The Community Health Improvement Plan (CHIP) identifies priority health needs based on a comprehensive review of quantitative and qualitative data gathered through the Community Health Assessment (CHA).
Findings from the Community Status Assessment, Community Partner Assessment, and Community Context Assessment were triangulated across multiple data sources, including population level indicators, community surveys, qualitative interviews, and stakeholder input, to identify shared concerns, disparities, and opportunities for collective action.
Based on this analysis, Issue Statements were developed in collaboration with the Steering Committee to reflect the most pressing health challenges facing the community. Each Issue Statement describes who is affected, the magnitude of the issue, contributing factors, and when and where impacts are most pronounced. This approach ensured that priority areas were grounded in evidence, informed by community voice, and aligned with opportunities for coordinated action through the Community Health Improvement Plan.
SDOH & Prevention Agenda Priorities
The Social Determinants, or Drivers, of Health (SDOH) are integrated into the 2025-2030 Prevention Agenda Priorities. This establishes a holistic approach to health by addressing root causes and health inequities. The PA “Domains” match the SDOH.
Social Drivers of Health and Prevention Agenda Domains
The 5 Priorities for Tompkins County’s CHIP 2025–2030
Economic Stability
Social and Community Context
Health Care Access and Quality
Table of CHA Indicators
Economic Stability
- Cost burdened households
- Severe housing problems X County
- Permanent supporting housing beds
- Health characteristics of CoC shelter population
- Food insecurity rate X year
- Food insecurity X year of children & by Race
- Individual requests at food pantries
Social and Community Context
- OASAS certified treatment programs enrollment rates X quarter
- Naloxone kit distribution X year
- Naloxone administration reports X quarter
- Overdose death rates X year (any drug and any opioid)
- Overdose incident rates X quarter (deaths and outpatient ED)
- Nicotine vaping middle and high school X year
Health Care Access and Quality
- Early prenatal care rate X year
- Early prenatal care rate X Race and X insurance coverage
- Birth outcomes X Race (preterm and LBW)
- Experiences of birthing parents in Tompkins County
- Leading causes of death X year
- Rate of women in Medicaid who had a mammogram X year
- Female breast cancer incidence rate X year and Late stage incidence rate X year
- Barriers to accessing healthcare services: primary care and cancer screening
- Diseases of the heart X Race: mortality, hospitalization, potentially preventable heart failure hospitalizations
- Diabetes incidence rates X year: mortality, hospitalization
- Diabetes indicators X Race: Mortality, potentially preventable short-term complications hospitalizations
Safe, stable, and affordable housing is essential for health, safety, and overall well being. Housing instability can increase the risk of poor physical and mental health, disrupt access to care and employment, and deepen existing inequities. In Tompkins County, rising costs, limited availability, and structural barriers continue to make it difficult for many residents to secure and maintain stable housing.
Issue Statement: Barriers to Stable Housing
Housing instability continues to be a challenge in Tompkins County, particularly for those with low income, young adults, single parents, and historically marginalized populations. Nearly one in three households (33%) spend half of their income on housing, higher than both the state (26%) and national (24%) averages. Homelessness affects 12.6 per 10,000 residents, the third highest rate among comparable Continuums of Care (CoC), and 54.5 per 10,000 residents use emergency or transitional housing annually. Waitlists for Section 8 vouchers and public housing range from 2-2.5 years, while the county’s rental vacancy rate remains critically low at 3.2%.
Racial disparities are evident. Within the county’s homeless CoC population, BIPOC residents represent 12.4% of the homeless population but make up nearly half of all shelter residents. Among those experiencing homelessness, 38.3% report a mental health disorder, 26.8% a substance use disorder, and 40% identify as survivors of domestic violence. Formerly incarcerated individuals face disproportionately high housing instability. Youth and young adults encounter unique risks: 11% of shelter guests are ages 18-25, youth homelessness has tripled since 2021, and no developmentally appropriate shelter exists locally.
Community members and service providers describe barriers to stable housing, including high rental costs, long waitlists, discrimination, and difficulty navigating fragmented systems. Affordable units are scarce while higher-priced rentals remain vacant, and emergency shelter often cannot accommodate “pets, partners, or possessions.” Transportation and communication barriers further limit access to housing assistance.
Of surveyed organizations and agencies, 49% responded they are working on housing stability.
Housing Insecurity Indicators
Cost burden: Percent of renter households that spend 50% or more of their income on housing, and percent of median household income spent on childcare.
Percent of households experiencing at least one of listed housing problems compared across 9 counties.
Trend in number of permanent supportive housing beds, and the health of the shelter population.
Access to affordable, nutritious, and culturally appropriate food is a fundamental component of health and well being. Food insecurity reflects broader social and economic conditions and can contribute to chronic disease, stress, and reduced quality of life. In Tompkins County, persistent inequities and rising demand for food assistance highlight ongoing challenges in ensuring that all residents can reliably meet their basic nutritional needs.
Issue Statement: Food Insecurity
Food insecurity continues to affect residents across Tompkins County, with rising demand for assistance and widening disparities across populations. In 2023, 13.1% of residents were food insecure, slightly below the state average (15%) but trending upward from 9% in 2021. In 2024, one in eight adults (12.5%) and one in eight children (12.5%) lacked reliable access to nutritious food. Racial disparities persist with 33% of Black residents and 28% of Latino residents experiencing food insecurity, compared to 12% of White residents.
Local food systems are under increasing strain. Only half of eligible residents receive SNAP benefits, and 5% of residents live in low-income areas without nearby grocery stores. Requests for food assistance grew 21% between 2023 and 2024 and 121% since 2019, highlighting growing reliance on emergency food programs. Older adults are also affected, with 12% reporting challenges having enough to eat.
Community members and service providers identify persistent barriers including affordability, transportation, stigma, lack of culturally appropriate foods, and income limits that exclude working families from public assistance. About one-third of food-insecure households earn too much to qualify for benefits but still struggle to afford food. Chronic food insecurity contributes to poor health outcomes, higher stress, and reduced educational and employment opportunities.
Of surveyed organizations and agencies, 55% responded they are working to improve nutrition and food security.
Food Insecurity Indicators
Percent insecure overall, of children, and by race and ethnicity, and comparing Tompkins County with NYS: yearly trend, 2019-2023.
Trend at food pantries: number of individual requests, 2019-2024
Substance use and overdose continue to affect the health and well being of Tompkins County residents, reflecting complex and evolving challenges in prevention, treatment, and recovery. While local efforts have expanded access to harm reduction and treatment services, gaps in access and persistent barriers continue to place some individuals at higher risk.
Issue Statement: Primary Prevention
Substance use and drug overdose continues to impact Tompkins County, with mixed trends across populations and settings. In 2023, the overdose mortality rate involving any drug was 26.1 per 100,000, lower than the New York State rate of 32.3 but failing to meet the NYS 2030 objective of 22.6. Overdose deaths involving opioids specifically were 3.9 per 100,000, below both the statewide rate (8.9) and the 2030 target (14.3). Emergency department visits tell a broader story where the 2022 rate for all drug overdoses was 167.8 per 100,000 (compared to 191.9 statewide), while opioid-related ED visits were higher than average at 42.5 per 100,000 (vs. 26.1 statewide).
Treatment and response systems remain active. In 2024, 811.5 per 100,000 residents were enrolled in OASAS treatment programs for opioids as their primary substance, compared to 775.5 in 2023. Naloxone access has also expanded, with community kit distribution rising from 1,284 in 2020 to 6,264 in 2024. EMS naloxone administrations, however, have fluctuated over time, peaking in 2021-2022 at 8 per 1,000 dispatches before dropping to 4.7 in 2023. Access to treatment medications has grown, with 587 per 100,000 residents receiving at least one buprenorphine prescription for opioid use disorder, above both the state rate (446) and the NYS 2030 objective (490.6).
Despite these resources, challenges persist. Community survey data indicate that 12% of residents reported using substances more than they would like, while 6% cited barriers to accessing treatment. Reported barriers include lack of providers, cost, and difficulty making appointments. Community partner engagement in this area includes 28% of surveyed organizations working on overdose prevention.
Youth substance use also raises concern. Vaping increases steadily through adolescence, with current nicotine vape use rising from 2% in middle school to 9% in high school, and marijuana vaping increasing from 1% to 8% across the same grades. Lifetime use follows similar patterns. Perceptions of risk and coping behaviors influence these trends where 26% of students perceive little or no risk from nicotine vapes and 72% report using substances “to feel better.” Students report that younger adolescents often begin vaping due to curiosity or peer pressure, while older youth more often cite stress and coping. Community engagement in this area specifically includes 17% of surveyed organizations working in the domain of tobacco and e-cigarette use.
At the national level, recent changes in SAMHSA’s strategic priorities raise concerns about the future of harm reduction and voluntary, health-led crisis response. Local progress in naloxone distribution, medication-assisted treatment, and community-based prevention may be affected if federal support shifts away from harm reduction strategies toward more abstinence-based or coercive approaches, underscoring the importance of sustaining local investment and cross-sector collaboration.
Primary Prevention Indicators
OASAS-certified opioid use treatment programs: trend in quarterly enrollment rates, 2021-2024.
Naloxone kit distribution: number distributed by Tompkins County Opioid Overdose Prevention Programs (OOPPs)
Number of times Naloxone was administered by EMS, law enforcement, and registered Community Opioid Overdose Prevention (COOP) programs, quarterly trend 2021 Q3–2025 Q1.
Overdose Incident Indicators
Substance overdose rate trends by year: deaths, 2014-2023.
Opioid overdose incident rate trends by quarter: deaths and outpatient Emergency Department (ED) visits, 2021-2025.
Youth Vaping
Vaping nicotine among Tompkins County students grades 7–12
Timely and equitable prenatal care is critical for supporting healthy pregnancies and improving outcomes for birthing people and infants. In Tompkins County, gaps in access and persistent disparities limit the ability of all individuals to receive early and consistent prenatal care, contributing to inequities in maternal and infant health outcomes.
Issue Statement: Timely & Equitable Prenatal Care
In Tompkins County, access to timely and equitable prenatal care remains a public health concern, with only 76% of birthing people receiving prenatal care in the first trimester, falling short of the Healthy People 2030 target of 81%.
Racial disparities are evident, only 65% of Black/African American individuals receive early prenatal care compared to 78% of White individuals. These disparities may contribute to worse outcomes, including higher rates of preterm birth (13% among Black individuals compared to 8% among Whites) and low birth weight (13% for Non-Hispanic Black infants vs. 6% for Non-Hispanic White).
Community interviews highlight limited provider availability, poor continuity of care, and difficulties navigating insurance and payment systems as key barriers. These gaps add stress during a critical time and contribute to unequal maternal and infant health outcomes in the county.
Community partner engagement in this area includes 21% of surveyed organizations working on prenatal care and maternal health.
Early Prenatal Care Indicators
Percent receiving early prenatal care, 2017-2024, Tompkins County compared with the NYS 2030 target rate.
Maternal Child Indicators by Race
Rates of prenatal care received by race and insurance coverage.
Birth outcomes by race
Community Context Assessment Report
Community Context Assessment
Experiences of Birthing Parents in Tompkins County
Despite performing well in aggregate statistics, when disaggregated by person and place, Tompkins County continues to have disparities related to maternal care access and outcomes. The stories and experiences of parents in Tompkins County with regard to whether and how existing care and programming addresses barriers to care is also limited. To address these gaps, there was a need to evaluate the barriers to and facilitators of health programs used by birthing parents in Tompkins County.
This publication was prepared July/August 2025 by the Cornell Public Health Community Context Assessment team in collaboration with Tompkins County Whole Health. It draws from the Integrated Learning Experience capstone and additional analyses completed by the authors.
Get the full publication(PDF, 6MB)
Chronic diseases remain a leading cause of illness and death in Tompkins County, with inequities in prevention, early detection, and management contributing to avoidable health disparities. While overall indicators in some areas appear favorable, gaps in access, structural barriers, and differences in care utilization continue to disproportionately affect communities harmed by racism and social injustice.
10 Leading Causes of Death, Tompkins County
Cancer, heart diseases, diabetes, and related chronic conditions remain major contributors to illness and premature mortality in Tompkins County. Over the ten-year span from 2013 to 2022, cancer and heart disease have evenly shared the #1 cause of death in Tompkins County. However, while cancer was the leading cause for 2019, 2020, and 2021, the rate of cancer deaths per 100,000 has decreased from 126.8 in 2019 to 122.7 in 2022. Heart disease, cancer, unintentional injury, Chronic Lower Respiratory Diseases (CLRD), COVID, diabetes, and cerebrovascular diseases are the top seven for 2022, the most recent data available (Vital Statistics, Data as of August 2024).
Issue Statement: Cancer Prevention
Despite relatively high overall cancer screening rates in Tompkins County, significant disparities persist, particularly among Black/African American women and underserved populations.
In 2021, 83.5% of residents received breast cancer screenings, exceeding the Healthy People 2030 target of 80.3%. However, only 53.1% of Medicaid eligible women aged 50–74 received a mammogram between October 2019 and December 2021, placing the county in the state’s “high concern” category. Racial disparities are particularly notable where only 33% of Black/African American women received mammography screenings compared to 46% of White women.
Barriers such as long wait times, limited provider availability, lack of in-network coverage, and the absence of evening or weekend screening hours continue to limit access. These challenges may contribute to delayed detection and poorer outcomes. Late-stage breast cancer incidence rate is 44.9 per 100,000 which is classified as high concern, and the breast cancer mortality rate is 19.6 per 100,000 not meeting the Healthy People 2030 target of 15.3.
Community partner engagement in this area includes 26% of surveyed organizations working on chronic disease and cancer domain.
Breast Cancer Indicators
Trend in mammogram uptake, percent of Medicaid recipients across years, 2013-2022.
Trend in rate of breast cancer incidents, 2012-2021.
Barriers to accessing healthcare services, percent of 2025 survey respondents.
Issue Statement: Cardiometabolic Disease Prevention
Cardiometabolic diseases, including diseases of heart and diabetes) remain a major public health concern in Tompkins County, with persistent racial and access-related disparities in both outcomes and prevention. Although the overall heart disease mortality rate in the county (144.8 per 100,000) is lower than the state average (230.3), Black residents experience higher mortality rates (178.1) compared to White residents (125.4). Diabetes shows similar inequities, where the mortality rate among Black residents (42.8 per 100,000) is more than double that of White residents (20.2), and the overall county rate (27.8) fails to meet the Healthy People 2030 target of 13.7.
Heart disease and diabetes share overlapping risk factors and preventive strategies, as both are strongly tied to metabolic and lifestyle factors. Preventive care efforts are also falling short. Only 63.2% of adults aged 45+ have been tested for high blood sugar in the past three years which is below the state goal of 71.7%. Among Black residents, only 57% have controlled blood sugar, compared to 72% of White adults. Multiple factors contribute to these outcomes including limited provider availability, restrictive insurance coverage, high costs, and transportation barriers. These are compounded by behavioral factors where 21% of adults report no leisure-time physical activity, and 34% consume no fruits or vegetables daily. While recreational spaces are available, rural and low-income residents often face access challenges due to poor walkability and geographic isolation.
Of the community organizations surveyed, 26% are working on chronic disease prevention activities. Recent federal funding cuts and the absence of chronic disease self-management programs further limit community capacity to address these issues.
Heart Disease Indicators
Heart disease rates by race: mortality and hospitalization rates by race, and potentially preventable hospitalization.
Diabetes Indicators
Trend in rates of diabetes deaths and hospitalizations by year.
Diabetes rates by race: mortality and potentially preventable hospitalizations.
3/13/2026