population health

Population Health refers to the health outcomes of a group of individuals, including how those health outcomes are distributed throughout each group. In this case, “groups” of people are defined by geography, gender, race/ethnicity, socio-economic status, or health status. Additional groups could include employees, disabled persons, or prisoners, among others. Our work in population health focuses on identifying the specific health needs of the community and addressing social determinants of health to eliminate health inequities.

population health
FDRHPO was one of 11 Population Health Improvement Programs in New York State (shown by the grey and red sections) and remains one of 32 rural health networks (indicated by stars).

Here at FDRHPO, our work within the realm of population health began in 2013, when we were awarded a New York State Department of Health grant to serve our three-county region as a Rural Health Network Development Program. We currently remain one of 32 Rural Health Network Development Program in NYS.

Our efforts to improve health outcomes were enhanced in 2015 after securing a five-year NYSDOH Population Health Improvement Program (PHIP) grant, making us one of 11 PHIPs in the State.

Thanks to a third NYSDOH grant, Linking Interventions for Total Population Health (LIFT), we further expanded our efforts in 2017 to include work in addressing obesity and diabetes.

While grant-funded projects come and go, our commitment to the overall health and wellness of the region, through our work in these four key population health strategy areas, remains strong:

  1. Data collection & analysis
  2. Stakeholder engagement
  3. Infrastructure development & support
  4. Health messaging & promotion

What are our Population Health Priorities?

Our approach to improving population health in the North Country is multi-faceted. To gauge the unique health concerns of our region, we conduct thorough community health surveys every few years. Then, we assess the results and form a community health improvement plan.

Currently, our region’s priority areas are:

Colorectal Cancer
Colorectal cancer is one of the most common diagnoses in our region, eclipsed only by lung and bronchus cancer, prostate cancer (among men), and breast cancer (among women). More than 100 new cases of colorectal cancer are diagnosed every year in the North Country. Fortunately, 71% of adults in our region ages 50-75 have had a colorectal cancer screening within the past 10 years.

Cultural Competence
Cultural competence is a measure of how well healthcare providers and community organizations treat the social, cultural, and linguistic needs of their patients. FDRHPO believes that all patients — regardless of where they were born, how they live, or what language they speak — deserve access to quality healthcare services that respect their way of life. To help further this concept, we work with our healthcare partners to implement cultural competence into their daily operations, using recognized strategies such as Bridges Out of Poverty and others.

Click here to view our Health Literacy & Cultural Competency training video.
More than 1 in 10 adults living Jefferson, Lewis and St. Lawrence counties report having diabetes, including 24% of adults over age 65. Those who have diabetes are at an increased risk of other conditions, such as high blood pressure, mental health concerns, obesity, and heart disease. To prevent and decrease rates of diabetes in the North Country, FDRHPO is working with several local partners to increase screening levels and promote evidence-based diabetes prevention and self-management programs.

Health Literacy
The U.S. Department of Health and Human Services defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” As we work with partners and community members to improve population health, we keep health literacy in mind to ensure all members of our community have access to the information and guidance they need. Since health literacy is closely tied to cultural competency, FDRHPO embeds health literacy and cultural competency into all committee discussions and project planning.

Click here to view our Health Literacy & Cultural Competency training video.
Maternal & Infant Health
Our region has a markedly higher birth rate than the state, especially in comparison to other rural areas. Military families stationed at Fort Drum account for a large share of these births. Statewide, less than 1% of newborns in hospitals are covered by TRICARE or other Department of Defense payers, but in our tri-county region these payers cover 29.1% of newborns, including 48% at Samaritan Medical Center and 37% at Carthage Area Hospital.

Access to prenatal care is a need for the region. According to 2013-2015 Vital Statistics Data, 71.7% of mothers were receiving adequate prenatal care, but in two of our region’s three counties this percentage was in decline. In St. Lawrence County, the percentage of births with adequate prenatal care fell from 78.2% in 2009 to 62.5% in 2015. Jefferson County’s decline is more recent, falling from 80.9% in 2013 to 73.8% in 2015. Goals in the region include increasing the proportion of children who receive comprehensive well-child care in accordance with American Academy of Pediatrics (AAP) guidelines and reducing the prevalence of dental caries among children. FDRHPO is partnering with North Country Prenatal/Perinatal Council to achieve these efforts.

Mental Health
The mind is a part of the body. When a person’s mental wellness is strained, this pressure can lead to anger, anxiety, depression, or chronic stress. These symptoms will then begin to impact that person’s physical health, causing side effects such as headaches, bowel problems, life-threatening chronic diseases and even heart attacks or strokes. To see more of FDRHPO’s work in the mental health field, visit our Behavioral Health page.

Obesity affects one-third of adults and one-fifth of children in the North Country. Obesity is a direct risk factor for many chronic diseases, including type 2 diabetes, heart disease, cancers, and musculoskeletal disease, and a leading cause of premature death. Obesity also harms quality of life by limiting mobility and other functions. FDRHPO is helping to address this issue with the help of the Linking Interventions For Total Population Health (LIFT Population Health) grant, which focuses on local school wellness policies, Complete Streets, and other physical activity initiatives.

Oral Health
Oral health is an important part of a person’s overall health and well-being, affecting ability to speak, eat, and communicate, as well as self-esteem, school or work performance, and social life. Poor oral health can cause immense pain and significant functional problems and necessitate costly treatment. The CDC notes that oral health has been linked with other chronic diseases, like diabetes and heart disease. Oral health is also linked with risk behaviors like using tobacco and eating and drinking foods and beverages high in sugar.

More than two-thirds of North Country residents have visited a dentist or a dental clinic for a routine cleaning within the past year (68% in the North Country; 70% in Jefferson County; 73% in Lewis County; 64% in St. Lawrence County), while more than 75% of local residents visited a dentist or a dental clinic for a routine cleaning within the past two years. It is recommended that adults receive dental check-ups every six months, or more frequently if suggested by a dentist.

The average poverty rate in our region is about 17%, which exceeds the New York State average of 15.5%. People who live in poverty, whether chronic or temporary, are on average exposed to different and more pronounced risk factors for poor health.

Poverty limits access to healthy food, safe neighborhoods, quality housing, transportation, and adequate education. Poverty can also be isolating, removing people from networks of social support and participation in community life.

FDRHPO is involved in the North Country Bridges Steering Committee, a collaborative effort among many community sectors that aims to create community systems that alleviate poverty and improve quality of life for all North Country residents. The committee is leading the formation of a Bridges community that utilizes Bridges Out of Poverty concepts. Please refer to the committee’s charter for more information about current community representation and core initiatives. You can also follow the North Country Bridges Facebook page for news and updates!

North Country Bridges Steering Committee Charter
North Country Bridges Steering Committee — May 2019 Meeting Minutes
North Country Bridges Steering Committee — July 2019 Meeting Minutes
North Country Bridges Steering Committee — October 2019 Meeting Minutes

Substance Abuse
Drug overdoses are a growing cause of death across the United States. Over the past five years, drug and alcohol overdoses have killed 147 residents of Jefferson County, 38 residents of Lewis County, and 125 residents of St. Lawrence County. In 2017, nationwide drug- and alcohol-induced deaths increased to 109,813, and the death rate has increased by 65% over the past decade. To learn more about FDRHPO’s work to prevent substance abuse, click here.

Suicide is among the top 10 causes of death for adults in the United States. Over the past five years, there have been 157 suicide deaths in Jefferson, Lewis, and St. Lawrence counties. In 2016, the region’s residents visited emergency departments nearly 500 times because of suicide attempts or suicidal ideation. Suicide has lasting harmful effects on individuals, families and communities. Furthermore, survivors of suicide attempts may experience serious injuries and long-term health issues such as brain damage, organ failure, depression, or other mental health problems. For more information on how you can help prevent suicides in your community, visit suicidepreventionlifeline.org/participate.

Tobacco Use
Nearly 1 in 4 (24%) of adult residents in the North Country use tobacco, and another 22% are former tobacco users. Rates of current tobacco use rise to 32% among men, 34% among adults age 18-34, 36% among adults in active military households, and 40% among Medicaid households. Tobacco use is a risk factor for lung cancer, COPD, and other chronic diseases, and a leading cause of premature death in the United States.

Health Compass

To achieve our goals, FDRHPO relies heavily on strong partnerships with the North Country community.

population healthIn 2013, we convened North Country Health Compass Partners to assist and inform our work around population health in Jefferson, Lewis, and St. Lawrence counties. North Country Health Compass Partners is a collaborative of local hospitals, public health agencies, behavioral healthcare providers, prevention councils, education institutions, insurance providers, and community-based organizations. The group meets monthly to discuss, brainstorm, and review the community’s population health priorities.

This three-county region is the most sparsely populated but geographically largest in New York State with over 250,000 people residing in over 5,000 square miles of land mass. This region is dedicated as a Health Professional Shortage Area (HPSA). The area is unique in that the region’s community healthcare system supports Fort Drum, the only installation in the US Army with a division of Soldiers and families without an on-post hospital. Most specialty care and all inpatient care for the 40,000 Tricare beneficiaries in the region is provided by community hospitals and healthcare providers.

Regional healthcare data, including interactive charts, graphs, and dashboards for all of our population health priority areas is available upon request. Please click HERE to let us know what information you need; we’re happy to assist.

OUR MISSION: To develop, implement, and evaluation a regional health improvement initiative through research, data analysis, community engagement, and collaboration among public health departments, hospitals, healthcare providers, community-based organizations, and the general public.

OUR VISION: Improved system for health for all residents of the North Country region.


Want to learn more?

If you have questions about FDRHPO’s population health priorities or initiatives, our population health team can help you out! Get to know us below to see who might be your best contact.

Pat Fontana
Deputy Director
Kayla Burns
Population Health Coordinator