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Community Health Reports

Community Health Assessment & Community Health Improvement Plan, 2019-2024

 Focus Areas  |  Downloads  |  Exec. Summary  |  Appendices & Data Sources

THE PREVENTION AGENDA is the blueprint for state and local action to improve the health of New Yorkers in five priority areas and to reduce health disparities for racial, ethnic, disability, low socioeconomic groups, and other populations who experience them. (NYSDOH Prevention Agenda website)

Tompkins County mapThe Community Health Assessment (CHA) describes the health of the community by presenting information on the health status, community health needs, resources & assets, and health services infrastructure. It includes a socio-demographic profile of the county and identifies target populations that may be at increased risk of poor health outcomes. The CHA also assesses the larger community environment and how it relates to the health of individuals. New York State public health law requires all local health departments to produce a written community health assessment.

The Community Health Improvement Plan (CHIP) is a local-level, community-informed outline for addressing the most salient Prevention Agenda priorities in Tompkins County.

Read the Executive Summary here.
Download PDFs here.
Links to Prevention Agenda Dashboard and other data sources.

Prevention Agenda Priorities and Focus Areas

Tompkins County, 2019-2024

The NYS Prevention Agenda has five priorities: Prevent Chronic Disease, Promote a Healthy and Safe Environment, Promote Healthy Women, Infants, and Children, Promote Well-Being and Prevent Mental and Substance Use Disorders, and Prevent Communicable Disease. The structure within each Prevention Agenda priority is: Priority > Focus Areas > Goals > Objectives > Interventions > Measures. The following goals have been identified for inclusion in Tompkins County's CHIP:

NYS Prevention Agenda Priority Focus Area Goal At-Risk Populations Addressed
Prevent Chronic Disease CD-1: Healthy Eating and Food Security CD-1.1: Increase access to healthy and affordable foods and beverages
CD-1.2 Increase skills and knowledge to support healthy food and beverage choices
CD-1.3: Increase food security
Poverty/ low income; Town of residence/ geography
CD-4: Preventive Care & Management CD-4.1: Increase cancer screening rates for breast, cervical, and colorectal cancer screening Poverty; Residence/ geography; Race
Promote Healthy Women, Infants, & Children HWIC-4: Cross Cutting Healthy Women, Infants, & Children HWIC-4.1: Reduce racial, ethnic, economic, and geographic disparities in maternal and child health outcomes, and promote health equity for maternal and child health populations Poverty (Medicaid recipient); Race; Residence /geography
Promote Well-Being & Prevent Mental and Substance Use Disorders WB-1: Promote Well-Being WB-1.1: Strengthen opportunities to build well-being and resilience across the lifespan
WB-1.2: Facilitate supportive environments that promote respect and dignity for people of all ages
Poverty; Social isolation; Persistent mental illness

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Download all sections of the CHA & CHIP, and the CHIP Workplan Matrix

Table of Contents and Executive Summary (PDF, sections 1-2, pages 1-4, 97KB)

  • Sections 1-5 (PDF, pages 5-48, 1.1MB)
    • Section 1: Table of Contents
    • Section 2: Executive Summary
    • Section 3: Description of the Community
    • Section 4: Health Status of the Population
    • Section 5: Main Health Challenges
  • Sections 6-7 (PDF, pages 49-65, 170KB)
    • Section 6: Summary of Assets and Resources
    • Section 7: Process and Methods
  • Sections 8-10 (PDF, pages 66-81, 190KB)
    • Section 8: Identification of prevention agenda priorities; Goals, objectives, and intervention strategies and activities
    • Section 9: Hospital Actions and Impacts
    • Section 10: Local Health Department Actions and Impacts; Maintaining engagement, tracking progress, and making corrections; Presentation, access, and availability of the CHIP
  • Appendices & Sources

Download the complete CHA & CHIP narrative (PDF, 81pp, 1.3MB)

Previously released Tompkins County Health Assessments and Health Improvement Plans, 2005-2018

CHIP Workplan Matrix

The workplan matrix is entered into an Excel spreadsheet that has been pre-formatted by the NYSDOH. The matrix columns include PA goals and objectives, evidence-based interventions selected from the Prevention Agenda, process measures, projected intervention status for 2019, 2020, and 2021, and partners and collaborators.

A PDF file of the Workplan Matrix has been posted for each Priority Area identified in the CHA. Click the link to download.

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Executive Summary

Community Health Assessment & Community Health Improvement Plan

Tompkins County is located at the southern tip of Cayuga Lake in the Finger Lakes region of New York State, on Cayuga Tribal land. It is part of the Southern Tier Economic Development Region, and is grouped by the New York State Department of Health (DOH) in the five-county Southern Tier region, along with Broome, Chenango, Delaware, and Tioga Counties. Tompkins jurisdictions include nine towns, seven villages, and one city, Ithaca. About 30% of the county’s 104,000 population resides in the City of Ithaca.

There are three large post-secondary institutions within the county, Cornell University, Ithaca College, and Tompkins Cortland Community College. Total enrollment in college or grad school is 29,300, 28% of the county population. As a result, the county population is young, well educated, transient, and includes a significant foreign-born population. Nearly half of all households are non-family, and nearly half of all housing units are renter-occupied. The poverty rate among individuals living in non-family households is twice that of those in family households.

The Prevention Agenda (PA), New York State’s blueprint for “the healthiest state,” includes five Priorities: Prevent Chronic Disease, Promote a Healthy and Safe Environment, Promote Healthy Women, Infants, and Children, Promote Well-Being and Prevent Mental and Substance Use Disorders, and Prevent Communicable Disease. Each priority is divided into two or more Focus Areas.

Tompkins County selected two Focus Areas in the Prevent Chronic Disease priority, one in Promote Heathy Women, Infants, and Children, and two in Promote Well-Being and Prevent Mental and Substance Use Disorders. Objectives address food security and healthy eating, gaps in cancer screening, equity of care for women and infants, and opportunities to build and strengthen well-being.

Disparities are primarily across wealth and race. Inequity is also evident in housing and access to healthcare, with the latter often due to lack of transportation options. Focus groups conducted for the Community Health Assessment (CHA) indicates that healthcare is less accessible for people of color, and secondary data shows an income gap between races.

Secondary data for the CHA were primarily sourced from the U.S. Census and the NYSDOH. The DOH pulls data from a variety of sources and compiles key indicators in the PA dashboard and the NYS Community Health Indicator Reports (CHIRS). These same sources have been the references for all editions of the Tompkins CHA.

Collecting primary data directly from the community was new with the 2019-2024 CHA. Key among these was a community wide survey in which respondents were asked to rate their own health, identify choices and challenges, and weigh in on what makes a healthy community. Thirteen hundred surveys were initiated, and the median response rate across all questions was close to 1,100. The results clearly demonstrate the influence that social determinants of health have on an individual’s perception of their health.

To further support the survey results and add personal stories to the analysis, in depth interviews were held with 29 key stakeholders, and 32 community members participated in four focus groups, representing four constituencies: mothers, African Americans, college students, and rural residents.

A Steering Committee was convened to review and coalesce all data, and to propose what PA priorities and Focus Areas were in the best interest of the Tompkins County community. The committee included representatives from County Public Health, Mental Health, and Office for the Aging, Cayuga Health Systems, Health Planning Council, consultant Horn Research, Ithaca College, Cornell University, and Cornell Cooperative Extension of Tompkins County (CCE-TC).

The array of programs active in Tompkins County to address social determinants of health drive strategies that are evidence-based, promising/pilot programs, and/or programs planning an expansion to serve new constituencies. These activities are aligned with CHIP goals and objectives identified by the steering committee. The Fresh Snack Program, Farm to School, and Universal Breakfast are evidence-based programs that target food security among school children. Health care providers are implementing the Fruit & Vegetable Prescription program to adults with a chronic disease. Structural barriers to cancer screening will be met by improving how patients are reminded to act, and by adding clinics, using mobile clinics, and increasing clinic hours.

Well-being relates to an individual’s physical, mental, and social sense of health and satisfaction, along with the influence that social determinants have on experiences and quality of life. The CHIP outlines strategies to strengthen well-being, including in the home to support parents and young children in families at risk, in a clinical setting to teach individuals with persistent mental illness ways to build skills, and bring together those living with a chronic disease to learn and practice techniques to better manage their disease in a safe, social setting. These programs are SafeCare, PROS, and Harmonicas for Health, respectively.

It takes a supportive community to build well-being, and the CHIP specifies that Mental Health First Aid (MHFA) courses be taught to an ever widening audience throughout the county, including at workplaces in all sectors. While MHFA builds personal awareness and understanding of mental illness, the social environment must match and reinforce a culture of support without stigma. The CHIP intervention to “use thoughtful messaging…” will be implemented through social media, an anti-bullying taskforce, and County Youth Services’ Action Plan.

Evaluating the impact of the goals, objectives, and interventions presented in this CHIP will take place through 2021. A steering committee will monitor short term process measures that track activities such as numbers of children served, schools involved, courses taught, and availability of certified practitioners. Community partners will have access to a reporting matrix that will be updated quarterly.

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Cover image of Horn Research reportActivities and final reports prepared by Horn Research, Slaterville Springs, NY

  • Community Survey (PDF): A Community Health Survey of Tompkins County residents age 18+ was conducted via Survey Monkey, Feb. 25-Apr. 15, 2019. There were 1,210 eligible respondents, and the average number of responses across 32 multiple choice questions was 1,088. Analysis of the results was by Lisa Horn of Horn Research, Slaterville Springs, N.Y.
  • Key Informant Interviews (PDF): In March 2019, 29 key informant/ stakeholder interviews were conducted by Horn Research. The stakeholders included community leaders, and non-profit organization and agency directors.
  • Focus Groups (PDF): Four focus groups were held with Tompkins County residents during the month of July 2019, with a total of 32 residents participating. Each participant received a $30 VISA gift card in appreciation for their assistance.

Data Sources

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