Community Health Assessment & Improvement Plan

The Columbia County Department of Health and its community partners have worked collaboratively to develop the Community 

Health Assessment (CHA) and Community Health Improvement Plan (CHIP) for 2016-2018.  This CHA/CHIP summarizes county 

demographic and health data from a variety of sources and presents a community plan for making measurable improvements in the 

following health priority areas: 
  • Chronic Disease Prevention,
  • Mental Health Promotion and Substance Abuse Prevention,

We are very excited to share the information with you (attached below).  The plan will form the foundation of many community health

 improvement activities, which we hope will help the county to be a healthier, safer place to live, work, learn, and play.  As the county 

implements its Community Health Improvement Plan, New York State is also implementing its Health Improvement Plan (also known 

as the Prevention Agenda for 2016-2018).  We invite you to learn more about the state’s Prevention Agenda by visiting their website.


We encourage you to share the documents and information.  We welcome your questions, suggestions, and participation in the 

improvement process.  Please contact us at (518) 828-3358 or  Thank you!        

Executive Summary of the Community Health Assessment and Community Health Improvement Plan (2016-2018)

The Columbia County Department of Health (CCDOH) is deeply committed to the health, safety, and well-being of the community.  CCDOH works collaboratively with community partners to monitor the health status of populations, identify health problems, and make vital community health improvements.  To accomplish these activities, CCDOH regularly coordinates a Community Health Assessment (CHA), the results of which are used to develop a Community Health Improvement Plan (CHIP).  This CHA/CHIP for 2016-2018 was composed by the Healthy Capital District Initiative (HCDI) and summarizes Columbia County demographic and health data from a variety of sources and presents a community plan for making measurable improvements in health priority areas: Chronic Disease Prevention and Mental Health Promotion and Substance Abuse Prevention.   

Our CHIP addresses the priority areas listed above because they were identified and highlighted as priority areas in the data, presented by HCDI.  Both of the priority areas chosen were present in our previous CHIP cycle (2013-2017). This cycle will aim to focus more on youth when addressing the issue of unhealthy weight in Columbia County. In addressing Substance Abuse Prevention, the focus will be towards community education and mobilization. Not only reach those who are addicted to obtain the services they need, but also breaking the stigma so that available services are accessible. These are the areas in which the greatest health improvement impacts can be realized relative to the current health status of Columbia County residents. 

In the area of chronic disease, several examples of poor health outcomes among community members were identified in the CHA.  There are high rates of obese/overweight school aged and preschool children.  There are also high rates of heart disease, stroke, chronic lower respiratory disease/chronic obstructive pulmonary disease, and lung cancer.  Many of these diseases can be prevented through health behaviors such as physical activity, eating a healthy diet, abstaining from tobacco use and substance abuse, and by early preventive screenings. 

Within the Chronic Disease Prevention priority area of the CHIP, our focus is obesity prevention among children.  Obesity, considered a chronic disease, is a significant risk factor for other chronic diseases and conditions, including high blood pressure, type 2 diabetes, asthma, high cholesterol, stroke, heart disease, certain types of cancer, and osteoarthritis.  Overweight and obesity may also contribute to psychological distress, depression, discrimination, and prejudice.   Of Columbia County public school district students, 18.7% are obese (New York State: 17.3).  Among Columbia County children, overweight and obesity rates vary by school district.  Hudson City School district has the highest percentage of students who are obese (23.1%; Student Weight Status, 2012-2014). Hudson will be the focus for addressing the disparate population being impacted by Chronic Disease, Obesity. The Hudson area has high rates of poverty, higher rates of hospitalization and emergency department visits for many chronic diseases, and the largest percentage of minority populations.

The CHIP activities for obesity prevention focus on physical activity and healthy eating habits because of the important role that these lifestyle factors have on preventing and managing chronic diseases. The primary focus of the CHIP addressing youth obesity prevention will be an after-school-based obesity prevention initiative. Based on data reviewed, the Columbia County Public Health Leadership Team (Table 4) has selected 5-2-1-0 Evidence- based programming to move the dial on youth obesity in Columbia County. 5-2-1-0 is a policy level program that aims to promote daily healthy practices: 5 fruits and vegetables each day, no more than 2 hours of leisure screen time, at least 1 hour of physical activity and 0 sugary beverages.

There are seven options for implementation: K-5, Middle and High School, Out-of-School, Child Care, Health Care, and Healthy Workplaces. The Leadership Team has elected to implement the Out-of-School program for several reasons. Redistribution of students in the Hudson City School District, our focus area, has caused some upheaval in the schools in addition to pressure of standardized testing.  The out-of-school based component will introduce healthy living principles into existing after school programs, starting with the Hudson Youth Center (HYC) after school program. The staff at HYC are enthusiastic about their participants overall development and are continually interested in programs promoting health, wellness and life skills. HYC staff will largely be the front lines of implementation for this program with assistance from CCDOH, Columbia Memorial Health, and Cornell Cooperative Extension of Columbia and Greene Counties. Obesity prevention in after school programs will promote healthy living strategies into practice in a less structured environment. Additionally, the Hudson after school programs reach ages K-12, ideal in our efforts to promote healthy behavior changes and prevent/reduce obesity in Columbia County youth.

 In addition to our larger goal of reducing the prevalence of obesity among public school children by 10% from 18.7% to 16.8% by December 31, 2018, we will have several benchmark process measures to monitor progress of our initial implementation of 5-2-1-0 at HYC. By December 31, 2016 we hope to achieve the following: Begin implementation in HYC; Select two 5-2-1-0 strategies to be the focus of implementation at HYC; Implement 5-2-1-0 in two After School programs in the Hudson City School District and one in the rest of Columbia County. In addition to our process measures, the 5-2-1-0 evidence-based programming provides surveys and data collection tools to monitor progress. Columbia Memorial Health will also be providing BMI scales to track progress of program participants. Full list of process and outcome measures can be found in work plan (Attachment 5).

 Actions to decrease the high obesity rates among children were included in the plan because instilling healthy habits in children is prevention at its best.  Including children will result in generating maximum impact on health status and can bring about positive health outcomes for generations. After school programs historically bridge the rigid structure of school with crucial decisions made surrounding physical activity and healthy eating at home.

(Executive Summary, continued)

Mental health issues and substance abuse are prevalent in Columbia County.  Problem areas of note are prescription and other drug abuse (Opioid Emergency Department 27.6 per 100,000 [2015]), alcohol abuse, binge drinking, underage drinking, alcohol-related motor vehicle injuries and deaths, suicide, mental disorders such as depression and anxiety, co-occurring disorders, self-inflicted injury, stigma, difficulty accessing mental health services and substance abuse services, and scarcity of preventive services.   

Within the Mental Health Promotion and Substance Abuse Prevention priority area of the CHIP, the focus is prescription and illicit drug abuse prevention.  It has been identified as a major problem in Columbia County and also a growing problem nationwide.  In 2014, 20% nationwide aged 12 and older reported using prescription drugs for nonmedical purposes (National Institute on Drug Abuse, 2016).  Prescription drugs are often easily accessible, and abuse of those drugs can lead to severe health consequences and even death. 

To accomplish the goals set forth for reduction in drug use, CCDOH, the Columbia Memorial Health Pain Management Committee and participating agencies of the Columbia- Greene Controlled Substance Awareness Taskforce (CSATF) will implement dimensions of Project Lazarus, an evidence-based initiative that assisted a North Carolina county in reducing opioid overdoses by 82%. This model promotes 1) Public Awareness, 2) Coalition Action, and 3) Data and Evaluation via seven dimensions of prevention: 1) Community Education, 2) Prescriber Education, 3) Hospital Emergency Department Policies, 4) Diversion Control, 5) Pain Patient Support, 6) Harm Reduction, and 7) Addiction Treatment. Many of these preventative measures are already being implemented by the CSATF. Our group will be working towards enhancing those initiatives that already exist and put into motion other dimensions of the model where local communities are lacking.

The Columbia-Greene Controlled Substance Awareness Task Force (see attachment 5: workplan for list of agencies involved) and the work groups associated (Prescriber work group and Prevention/Education work group) are working to rectify this public health crisis. Process measures for monitoring through CHIP implementation include increasing number of, and access to medication drop boxes in the county to remove unneeded prescription medications, the number of drug take back days held annually, amount of medication collected from drop boxes, the number of communities/ school districts hosting drug awareness/education forums, the number of participants in these events, the number of community members trained in Naloxone, and the number of Naloxone revivals in Columbia County. Full list of process and outcome measures can be found in work plan (Attachment 5).All agencies involved with the Columbia-Greene Controlled Substance Awareness Taskforce will have a hand in implementing the activities of Project Lazarus as well as collecting data for evaluation.

Aside from health issues in the priority areas, the county experiences other health concerns.  Columbia County has the second highest rate of Lyme disease in New York State. There is a high infant mortality rate and a high percentage of pregnant women with late or no prenatal care.  Other community issues include lead exposure, motor-vehicle related injuries, shortage of affordable housing, economic instability, and lack of widely-available public transportation.

Although the county experiences these problem areas, there are areas in which the county is doing well.  For example, there is a low violent crime index, and compared to the state, the county has a lower breast cancer mortality, lower diabetes hospitalization rate, lower diabetes mortality, lower teen pregnancy rate, and lower rates of many sexually transmitted diseases.

Columbia Memorial Health has been an important partner as both of our agencies are working collaboratively to address the health needs of Columbia County residents in the hospital’s Community Services Plan and in CCDOH’s CHIP.  Numerous other agencies and individuals have also contributed their expertise, time, and passion to this planning process, and they will continue to be invaluable partners in developing and implementing community health improvement activities, and in evaluating and measuring community health improvement outcomes.  Various other community and regional agencies are also equipped and experienced to tackle Columbia County’s health issues.  Agencies such as those in the local public health system and those listed in Attachment 3: 2015 Columbia-Greene Interagency Yellow Pages have been, and will continue to, strategically address community health concerns and work to prevent of disease.  Collaboration and team work will be necessary in tackling health improvement activities. 

Maintenance of collaborative efforts will be overseen by the Columbia County Public Health Leadership Team. This group meets bimonthly to discuss implementation efforts of the CHIP, discussing updates, barriers and successes as they arise. Meeting of this group will act as a reminder for CHIP partners for their role in CHIP implementation and tracking responsibilities.

Thank you for taking the time to review this Community Health Assessment and Community Health Improvement Plan.  This plan will form the foundation of many community health improvement activities, helping Columbia County to be a healthier, safer place to live, work, learn, and play.  The Columbia County Department of Health and partners welcome your questions, suggestions, and participation in the improvement process; please contact us at (518) 828-3358 or       


Victoria McGahan,
Jun 8, 2017, 7:56 AM
Victoria McGahan,
Jun 8, 2017, 7:56 AM
Victoria McGahan,
Jun 8, 2017, 7:56 AM
Victoria McGahan,
Jun 8, 2017, 7:56 AM
Victoria McGahan,
Jun 8, 2017, 7:56 AM
Victoria McGahan,
Jun 19, 2017, 10:34 AM