Sullivan County - File #: ID-8723

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CHHA: Certified Home Health Agenc

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• Daily Census: Physical Therapy remains at capacity and is being evaluated daily to balance new referrals with available staffing.

• Referrals & Admissions: Referral activity remains strong, with 76 referrals and 67 new admissions, resulting in an 88% referral conversion rate. Admissions exceeded discharges during the reporting period, supporting continued census growth.

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Table 1 * based on billable visits entered in our system by all clinicians

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Increase and maintain the daily census of the CHHA Program to ensure consistent enrollment, maximize resource utilization, and support the growing demand for home healthcare professionals.	• Average daily census (ADC)	• ADC: 102
Increase the number of new patient admissions through enhanced referral partnerships, physician outreach, and digital marketing strategies.	• # of referrals o Referral Conversion Rate (RCR) (referrals → admissions) § Target RCR: 40-60% • # of new patients • # of discharges	• # of referrals: 76 • RCR: 88% • new patients: 67 • discharges: 57
Maintain Full Staffing Achieve an average of 5 points per day, per clinician while maintaining high-quality care, measured through patient satisfaction scores and clinical outcome improvements.	• # of staff for all CHHA positions • Staff Productivity • # of visits by type: • RN- Registered Nurse • PT- Physical Therapy • OT- Occupational Therapy • ST- Speech Therapy • HHA- Home Health Aid Visit	• Staff Productivity: 5.29 • See table below
Ensure timely and accurate completion of Patient Review Instrument (PRI) and Health Screens for Next Stage of Life Healthcare participants to support appropriate placement and continuity of care for individuals requiring nursing home or long-term care services. (PRI established by the NYSDOH, is used to assess the physical, medical, and mental characteristics of individuals who may require nursing home care, and to document the level of services needed to support their ongoing health and safety.)	• # PRI assessments	• # PRI assessments: 3
Ensure Personal Care Assessments (PCA) are completed thoroughly and in alignment with program standards to support effective care planning. (PCA is an evaluation used to determine an individual’s need for assistance with daily living tasks such as bathing, dressing, mobility, meal preparation, and medication support.)	• # PCA assessments	• # PCA assessments: 1

Maternal and Child Health Programming

• Sullivan County Public Health applied for a $20,000 Fidelis Care Maternal Health Grant to strengthen maternal and child health services, with a particular focus on increasing postpartum follow-up and postpartum depression screening. If awarded, funding will support a relationship-based approach that begins during pregnancy, allowing Public Health staff to connect with expectant mothers before delivery and build trust prior to the postpartum period.

• Labor & Delivery Outreach: Public Health is working with the hospital to establish regular access to the Labor & Delivery unit, allowing our LPN Community Health Worker to visit twice weekly and connect with new mothers who may be interested in postpartum services. This provides an important opportunity to reach families who were not engaged prenatally and connect them with support shortly after delivery, rather than waiting for birth certificate data used for our “New Baby” calls, which are approximately six weeks delayed.

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Decreasing maternal and infant morbidity • low birth weight = Less than 2,500 grams (5 lb 8 oz) at birth, regardless of gestational age) • newborn screenings = heel-stick blood test that screens for numerous genetic, metabolic, endocrine, and other disorders. SCDPH does not perform these tests, instead we follow-up with families when repeat is needed and refer back to Primary Care Provider (PCP). • newborn hearing screenings = checks for possible hearing loss, typically before hospital discharge; repeat needed is initial test is a fail. SCDPH is responsible for follow-up with families for failed tests and refer for retesting. • “New Baby” calls = MCH staff conduct outreach to families identified through recent birth certificate data to offer postpartum support, education, and connections to available services and resources. Birth certificate data are typically received approximately six weeks after delivery, so these calls represent follow-up to recent births rather than immediate postpartum outreach.	• # births for this month o # of low birth weight births this month • # of repeat newborn screening follow-ups • # of repeat newborn hearing screenings follow-ups • # of new baby calls initiated o # of new baby encounters o # of new baby home visits	• # births for this month: 56 o # of low birth weight births this month: 2 • # of repeat newborn screening f/u: 5 • # of repeat newborn hearing screening f/u: 0 • # of new baby calls initiated: 17 (July births) o # of new baby encounters: 9 o # of new baby home visits: 0

Child Passenger Safety Program (Car Seat Program)

• Sullivan County Public Health was awarded $29,000 in Child Passenger Safety funding to support car seat education, safety checks, and community outreach. Approximately $17,000 will be used directly to purchase car seats for distribution to eligible families, helping ensure children have access to safe, age- and size-appropriate restraints. The remaining funding will support car seat check events, educational activities, outreach materials, and continued training for Child Passenger Safety staff.

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Car Seat Distribution and Education	• # of car seats distributed • # of education provided • # of car seats checks	• # of car seats distributed: 6 • # of education provided: 9 • # of car seats checked: 6

Healthy Families

• Families Served & Home Visiting: We provided service to 52 families throughout the month with a home visit achievement rate of 100%

• We currently have 56 families with the capacity of 80, but due to current staffing and HFNY case weight requirements, we aren’t able to increase capacity to much.

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Family Support Staff (FSS) will conduct at least 90% of scheduled home visits per month to ensure consistent family engagement.	• # of enrolled families (capacity = 60) • Total of 150 home visits expected per month. o Target completed home visits: 85%	• # of enrolled families: 52 • 100% completed home visits (115 out of 115)
Increase the number of new patient admissions through enhanced referral partnerships, physician outreach, and digital marketing strategies.	• # of referrals • # of assessments completed (Frogs) • # of referrals agreed to services and registered • Referral Conversion Rate (RCR) (how many referrals turned into admissions) o Target RCR: 17%	• # of referrals: 3 • # agreed to services and registered: 0 • RCR: 0%
Maintain Full Staffing	• # of staff for all HF positions

Early Care

(Previously: Children and Youth with Special Healthcare Needs / Early Intervention)

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Ensure that initial CPSE evaluations are completed within 60 calendar days of referral.	• # of active cases	• # of active cases: 298
Complete initial EI evaluation and develop Individualized Family Service Plans (IFSPs) within 45 days of referral.	• # of active cases o # of new referrals	• # of active cases: 226 o # of new referrals: 21
Early Intervention Ongoing Service Coordinators (EI OSC) will maintain an active caseload of 35-50 families, depending on case complexity and program capacity.	• EI OSC caseload o Recommended 26-60, best practice = 35.	• EI OSC caseload: average of 56
Increase outreach and engagement for Children and Youth with Special Healthcare Needs (CYSHN)	• # of active CYSHCN o # of new referrals • # of Education or Resource Events	• # of active cases: 41 o # of new referrals: 1 • # of Events: 2
	• % of parents receiving reimbursement • # of children on waitlist for bussing	• % of parents receiving reimbursement: o EI: 15% o CPSE: 3% • # of children on waitlist for bussing: 0
Authorized Services and Waitlisted	• EI Service Type, # children authorized to receive the service • EI Waitlist: # of children waitlisted for services

Community Education & Outreach

Health Education

• Of the 251 health kits distributed, 102 of them were distributed to 46 people at the scheduled response facilitated by Community Services at Federation for the Homeless.

• Community Wellness Day planning scheduled for October 15^th at the Government Center 10-2pm with health screening opportunities and service promotion.

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Education staff served as a liaison between the Center for Discovery (CFD) and Community Services for Nalox box installation at CFD

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Outreach/Education	• # of educational/outreach events o Outreach type & # of events o # of individuals reached • # of PH kits distributed by PH outreach • # of PH kits distributed by vending machines o Dental Hygiene ADULT o Dental Hygiene KIDS o Emergency Preparedness Kit o Hygiene Kit o Overdose Rescue Kit o Sexual Health Kit o Tick Removal Kit o Wound Care Kit	• # of educational/outreach events: 10 o Tabling: 9 o Educational Workshops (skill building): 1 o Education Lessons (prevention education): 0 *see table below for outreach topics and County location of participants • 106 individuals reached • # of PH kits distributed through outreach: 251 • # of PH kits distributed by vending machines: 124 o See table
Narcan Training	• # of Narcan trainings o # of participants • # of 1-on-1 Narcan trainings	• # of Narcan trainings: 1 o # of participants: 18 • # of 1-on-1 Narcan trainings: 8
Community Health Workers (CHW)	• # of CHW visits • # of referrals provided	• # of CHW visits: 0 • # of referrals provided: 0

Quality

Training & Quality

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Staff education	• # staff trainings offered • Topics covered • # of participants	• # staff trainings offered: 4 o Negotiating through conflict o NYS Quitline Community Connects Program training o Wound Vac Skills Training for CHHA Nurses o Patagonia Training for D&T and Early Intervention staff • 29 participants total
Quality Quality is the ongoing process of evaluating how well Public Health programs and services are performing and using data to make measurable improvements.	Quality Details External Affairs Committee items reviewed 4 Tic tracker for Early Intervention staff An excel spreadsheet for each EI service coordinator to track the amount of billable time. This supports the program’s initiative of going paperless, and will help eliminate human error when calculating billable time intervals. Emergency preparedness webpage updates To accurately reflect Public Health’s incorporation of Emergency Preparedness into all programs. Updated Extended Leave Request Form The department defines “extended leave” as 10 or more business days. The form required to be completed by staff prior to their time off request approval allows supervision to evaluate how agency, program, and community needs will be appropriately met while that staff member is out of office. This review process also allows for consideration of other staff member’s requests in the same time period.
Other/Events	Other/Events Details Hudson Valley Public Health Collaborative Putnam, Orange, Rockland, Westchester, and Sullivan Counties formed a collaborative partnership to launch a social media ad campaign with the goal of increasing childhood immunization rates to support community resilience to vaccine preventable diseases. Social media posts and ads focused on back to school vaccines began at the end of August. Baseline data for immunization rates has been documented in order to evaluate effectiveness of the campaign. In person Emergency Preparedness Coalition scheduled for October To clarify roles of partner organizations, expand partnerships to represent individuals with access or functional needs

*Examples of Hudson Valley Public Health Collaborative

Diagnostic & Treatment: D&T

(Previously: Disease Surveillance and Investigation - DSI)

• Bat exposures have increased, consistent with seasonal patterns typically seen in late summer and early fall. Increased human-bat encounters have resulted in a corresponding increase in rabies post-exposure prophylaxis (PEP) when indicated.

• Measles preparedness efforts remain ongoing. An increase in Legionella cases has also been observed; however, cases are sporadic and not epidemiologically linked, with no identified cluster at this time.

• Most frequently reported communicable diseases: Babesiosis, Anaplasmosis, Campylobacteriosis, and Legionellosis.

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Immunization Program	• Reoccurring Office Clinics - twice weekly o People immunized o # of doses (VFC, VFA) • Walk-In - outside of clinic hours o People immunized o # of doses (VFC, VFA) • Mobile/Community Clinics - outside of PH offices o People immunized o # of doses in the public • POD (Point of Distribution) Clinics o # of doses at Public Health o # of doses in public Totals • Total # of clinics • Total # of people immunized • Funding category
Rabies	• # of reported animal bites/incidents o Domestic o Wildlife • # animals tested o Domestic o Wildlife • # tested positive for rabies • # rabies vaccination clinics • # humans receiving post exposure prophylaxis (PEP)
Emergency Preparedness	• Integrated Preparedness Model: SCDPH continues to align its emergency preparedness structure with the intent of Public Health Emergency Preparedness (PHEP) funding which is to build and sustain preparedness and response capacity throughout the Public Health system. Preparedness is being incorporated across Department programs rather than operating as a separate, stand-alone department. Emergency preparedness responsibilities are being incorporated into program planning and staff development across Public Health, including communicable disease, nursing, maternal and child health, community health and outreach, early care, etc. This approach ensures that preparedness knowledge and resources are embedded within the programs and staff who would actually be responsible for carrying out response activities during an emergency. The Children and Youth with Special Health Care Needs (CYSHCN) program will be hosting an Emergency Preparedness Event in September for registered families. The event will provide practical education and resources to help families prepare for emergencies, with particular attention to the unique needs of children who may require additional medical, communication, sensory, mobility, or other supports. • Education, Training & Resources: PHEP funding supports the development of staff knowledge, training, planning, tools, supplies, and other resources necessary to strengthen the Department's ability to prepare for and respond to public health emergencies. These investments are intended to build capabilities that can be utilized across programs during both routine operations and emergency response.
Medical Reserve Corp. (MRC)		N/A
Lead	• # of Lead Tests • # of Positive Cases • # of Visits with DOH • # of open cases

Sexually Transmitted Infections (STI)	• # of lab reported cases • # of health care provider follow-up for + labs • # of confirmed disease type: o Chlamydia o Gonorrhea o Syphilis • # of rapid HIV tests completed • # of referrals made for HIV related services	• # of lab reported cases: 18 • # of confirmed disease type: o Chlamydia: 12 o Gonorrhea: 3 o Syphilis (early): o Syphilis (primary): o Syphilis (unknown duration): 1 o Gonococcal PID: 1 • # of rapid HIV tests: 0 • # of referrals made for HIV related services: 0
Tuberculosis (TB)	• # newly reported, Active TB cases • # of latent TB cases • # of reported by pending TB cases	• # newly reported, Active TB cases: 1 • # of latent TB cases: 3 • # of reported by pending TB cases: 0

General Communicable Reportable Diseases	• # of lab reported cases • # of confirmed disease type (varies monthly)	• # of lab reported cases: 244 (173 Lyme Disease) • # of confirmed disease type (varies monthly): table below

Legislation Details