Sullivan County - File #: ID-8669

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CHHA: Certified Home Health Agenc

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• Capacity & Census: Physical therapy remains at capacity, limiting the CHHA’s ability to accept referrals requiring PT services. These referrals are being directed to other CHHAs to ensure patients can access needed services. This continues to impact the CHHA’s overall census, which is currently lower than prior months.

• Pediatric Referrals: Continuing to see an increase in appropriate pediatric referrals, reflecting improved alignment of referrals with the CHHA’s scope of services and admission criteria.

• Electronic Medical Record (EMR) Transition: The contract with Homecare Homebase (HCHB) has been finalized. The CHHA is awaiting implementation and onboarding activities for the transition to the new EMR.

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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: 52 • RCR: 87% • new patients: 45 • discharges: 75
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: 4.91 • 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: 5
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

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.	• # births for this month • # of low birth weight births • # of repeat newborn screening follow-ups • # of repeat newborn hearing screenings follow-ups	• # births for this month: 72 • # of low birth weight births: 8 • # of repeat newborn screening f/u: 2 • # of repeat newborn hearing screening f/u: 1

Child Passenger Safety Program (Car Seat Program)

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: 22 • # of education provided: 2 • # of car seats checked: 16

Healthy Families

• Families Served & Home Visiting: Provided services to 53 families during June, achieving a 91% home visit completion rate. Home visits provide ongoing family support, parenting education, child development guidance, connection to healthcare and community resources, and assistance addressing identified family needs.

• Program Capacity: The program has an overall capacity of 80 families; however, current enrollment capacity is limited by available staffing and HFNY caseload weighting requirements. Caseloads are determined not only by the number of enrolled families, but also by the level and intensity of services required by each family. As a result, the program cannot safely increase enrollment to its full funded capacity until additional staffing is in place.

• Staffing: Effective July, one Family Support Specialist (FSS) was promoted to Program Supervisor. While recruitment is underway to fill two vacant FSS positions, the new Supervisor will continue carrying a caseload to maintain continuity of services and maximize the number of families the program can support. Filling these vacancies remains a priority and will allow the program to gradually increase enrollment toward full capacity.

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: 53 • 94% completed home visits (116 out of 124)
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: 7 • # agreed to services and registered: 1 • RCR: 0%
Maintain Full Staffing	• # of staff for all HF positions

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: 185
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: 210 o # of new referrals: 24
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 53
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: 40 o # of new referrals: 1 • # of Events: 2
	• % of parents receiving reimbursement • # of children on waitlist for bussing	• % of parents receiving reimbursement: o EI: 23% o CPSE: 8% • # 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

• Girls on the Run: Preparing to launch the Girls on the Run program at Liberty School this fall. The program promotes physical activity, confidence, healthy relationships, and positive social-emotional development among participating youth.

• CTRT Response: Distributed 118 resource kits through Community Trauma Response Team (CTRT) responses. Kits provide individuals and families affected by traumatic events with immediate supportive resources and connections to additional services when needed.

• Community Wellness Day: Planning is underway for an upcoming Community Wellness Day, bringing together Public Health programs and community partners to provide health education, prevention resources, screenings, and connections to local services.

Goal / Area of Focus	Key Performance Indicators	Update / Progress
Outreach/Education	• # of educational/outreach workshops o Outreach type & # of events o # of individuals reached • # of PH kits distributed 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 workshops: 8 o Tabling: 18 o Educational Workshops (skill building): 0 o Education Lessons (prevention education): 0 *see table below for outreach topics and County location of participants o 143 individuals reached • # of PH kits distributed through outreach: 132 total o See table
Narcan Training	• # of Narcan trainings o # of participants • # of 1-on-1 Narcan trainings	• # of Narcan trainings: 0 o # of participants: 0 • # of 1-on-1 Narcan trainings: 9
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: 5 o Latent TB Infection Training for Nurses; Communicating for Trust in a World of Confusion; Negotiating Through Conflict; Equitable Supervision; PRIN Screening Training • 15 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.	• Standardized Public Health Materials: Established standardized templates for outgoing flyers and public-facing materials to improve quality assurance, reduce staff time spent developing individual materials, and maintain a consistent and professional Public Health image across programs. • External Affairs Committee Review: The External Affairs Committee reviewed 6 external-facing items during the reporting period for accuracy, accessibility, consistency, and alignment with Department priorities and communication standards. • Early Intervention Quality Improvement: Developed a Plan of Correction in response to findings from the 2024-2025 Early Intervention audit. Improvement activities include strengthening communication processes with Ongoing Service Coordinators and expanding relationships with culturally appropriate providers to improve access and service coordination for children and families. • Quarterly Strategic Plan Review: Conducted a quarterly review of the Department's Strategic Plan using Monthly Program Review (MPR) data to assess progress toward established objectives, identify implementation gaps, and determine priorities and necessary adjustments moving forward.

Disease Surveillance and Investigation

• Health & Safety Extravaganza: Successfully participated in the Health & Safety Extravaganza on July 24^th held at SCDPH, providing community education, prevention resources, and opportunities for residents to engage directly with Public Health staff and services.

• TB/LTBI Follow-Up: Coordinating follow-up for one refugee referred with possible latent tuberculosis infection (LTBI). Additional medical assessment is needed to clarify the diagnosis and determine appropriate next steps. The individual is scheduled for evaluation at Sun River Health on August 13, 2026, with Public Health continuing to monitor and coordinate as appropriate.

• Communicable Disease Surveillance: A total of 343 infectious disease cases have been reported/investigated. Frequently reported general communicable diseases include anaplasmosis, babesiosis, Legionella infection, campylobacteriosis, and yersiniosis. Tick-borne illnesses continue to represent a significant component of communicable disease activity and remain an area of ongoing surveillance and prevention education.

• Measles Preparedness: Continuing active measles surveillance and preparedness in response to cases and outbreaks occurring in other jurisdictions. Public Health remains in communication with NYSDOH, monitors regional activity and potential exposures, reviews local vaccination and surveillance data, and maintains readiness to initiate case investigation, exposure management, vaccination activities, and public communication if local risk increases.

Goal / Area of Focus	Key Performance Indicators		Update / Progress
Immunization Program	• OFFICE CLINICS -VFC, VFA, FLU, COVID o # PEOPLE IMMUNIZED o # OF DOSES (VFC, VFA) • WALK-IN - VFC, VFA, FLU, COVID o # PEOPLE IMMUNIZED o # OF DOSES (VFC, VFA) • PUBLIC CLINICS o # PEOPLE IMMUNIZED o # OF DOSES in the PUBLIC • POD (Point of Distribution) CLINICS o # of DOSES@ PH o # of DOSES In public TOTALS • TOTAL # CLINICS • TOTAL #PEOPLE IMMUNIZED VFC, VFA, COVID office & walkin • TOTAL # DOSES @ PHS • TOTAL # DOSES (Public) • COMBINED TOTALS OF ALL DOSES		• OFFICE CLINICS: 1 o # PEOPLE IMMUNIZED: 1 o # OF DOSES: 1 • WALK-IN: 0 o # PEOPLE IMMUNIZED: 0 o # OF DOSES: 0 • PUBLIC CLINICS: 0 o # PEOPLE IMMUNIZED: 0 o # OF DOSES in the PUBLIC: 0 • POD (Point of Distribution) CLINICS: 0 o # of DOSES @ PH: 0 o # of DOSES In public: 0 TOTALS • TOTAL # CLINICS: 1 • TOTAL #PEOPLE IMMUNIZED: 1 • TOTAL # DOSES @ PHS: 1 • TOTAL # DOSES (Public): 0 o COMBINED TOTALS OF ALL DOSES: 1
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)		• # of reported animal bites/incidents: 37 o Domestic - Cat Incidents: 10 o Domestic - Dog Bites: 16 o Wildlife - Bat: 10 o Wildlife - Racoon: 1 • # animals tested: 7 o Domestic - Cat Incidents: 2 o Domestic - Dog Bites: 3 o Wildlife - Bat: 2 • # tested positive for rabies: 0 • # rabies vaccination clinics: 1 o 62 vaccinated • # humans receiving PEP: 9
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		• Total labs drawn: 111 • # of Positive cases: 0 • # of visits with DOH: 0 • Lead Education: 0

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: 30 • # of confirmed disease type: o Chlamydia: 18 o Gonorrhea: 5 o Syphilis (early): 2 o Syphilis (primary): 1 o Syphilis (unknown duration): 4 • # 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: 2 • # of reported by pending TB cases: 0
Hepatitis	• # of lab reported cases • # of health care provider follow-up or + labs • # of confirmed disease type:		• # of lab reported cases: 19 • # of health care provider follow-up or + labs: 19 • # of confirmed disease type: table below •

General Communicable Reportable Diseases	• # of lab reported cases • # of confirmed disease type (varies monthly)		• # of lab reported cases: 368 (267 Lyme Disease) • # of confirmed disease type (varies monthly): table below

Outreach Location		Outreach Topic
SCDPH Health & Safety Extravaganza : July 24		• Topics of Outreach: Immunization/Lead, Tickborne illness, Skin cancer prevention, Rabies Prevention, car seat, Healthy Families, CYSHCN, vision • 45 families in attendance (20 with car seat appointments, 2 for vaccinations) • Other organizations in attendance (or supported by): SunRiver Health, Lions See, SC Sheriff’s Department, SC Public Safety, and Cochecton EMS.

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