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Community Needs Assessment and Service Plan

MMH Community Service Plan Executive Summary

Population health management focuses on understanding the health needs of the community, measuring and evaluating health status, and developing collaborative programs that will improve health outcomes. A shift is being made toward population health management by focusing on assessment, prevention wellness and chronic disease management.

Massena Memorial Hospital offers free screenings, community education, health fairs and primary care outreach clinics to ensure community members of all ages can benefit from prevention as much as possible. Furthermore, with the dramatic need for additional primary care providers throughout the North Country and New York State, Massena Memorial Hospital opened a Walk-In Clinic, open seven days a week, to ensure primary care and urgent care is available to all.

Effective population health management calls for building and sustaining strong partnerships. Rural hospitals such as Massena Memorial Hospital can work with their communities to create flexible and customized population health programs. The impact of these programs can be significant due to the strength of the relationship between the community and hospital.

By organizing our resources, Massena Memorial Hospital and its partner organizations in the local community and St. Lawrence County are working to establish successful community health initiatives and improve population health.

The St. Lawrence County Community Health Improvement Coalition, Bridge to Wellness, is an active committee with twenty-six participating organizations including Public Health, higher education, hospitals, Federally Qualified Health Centers and community based organizations. Meetings are facilitated by the Local Public Health Department, and the St. Lawrence County Health Initiative, Inc. The partners work collaboratively to plan, implement and oversee the St. Lawrence County Community Health Improvement Plan and Community Service Plan(s).

The Bridge to Wellness Coalition partnered with the Fort Drum Regional Health Planning Organization (FDRHPO) to develop an appropriate regional needs assessment that would guide a strong data driven Health Improvement Plan in St. Lawrence County, and be incorporated into a Health Assessment using State and National Data Sources. Considering the Assessment results, and the capacity of region, Bridge to Wellness Coalition identified priorities for the 2016-2018 plan as ‘Prevent Chronic Disease’ and ‘Promote Mental Health and Prevent Substance Abuse’. While these are the same priorities the coalition identified in 2013, the 2016 plan is streamlined and identifies additional opportunities to improve the health of targeted residents. The coalition-researched interventions grounded in evidence and activities include environmental, systems and policy change.

In each priority area, education and involvement from the community at large is integral to the success of each intervention. Bridge to Wellness Partners will disseminate regular reports to the community through online media, print publications, and radio and in person education. The Partners will oversee and govern the evaluation of this plan on a monthly basis.

Timeframe, measurement and evaluation is ongoing for all activities noted above and results will be reported annually to the New York State Department of Health and the hospital administration and Board of Directors.

Maintenance of Engagement with Local Partners Massena Memorial Hospital actively participates in a variety of coalitions and committees that work collaboratively to improve the health of St. Lawrence County. Each of these groups will meet regularly to share progress and relay any barriers that they are experiencing throughout the implementation of the Community Service Plan. Progress will be tracked through the work plans developed for each group using input from each participating organization to meet the objectives outlined within the work plan.

To read the complete service plan, please click here