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Tompkins County Whole Health Releases Updated 2022-2024 Community Health Assessment and Improvement Plan

(Ithaca, N.Y., February 7, 2023) – Tompkins County Whole Health, in partnership with Cayuga Health, is pleased to announce the release of the updated Community Health Assessment (CHA) and 2022-2024 Community Health Improvement Plan (CHIP). The plan’s vision captures the recent integration of the local health department and mental health services into one organization, Tompkins County Whole Health (TCWH).

The Tompkins County Community Health Assessment and Improvement Plan is a collaborative process with a focus on promoting health equity, when every person has fair and just opportunities for optimal health and well-being. The development of the CHIP is a requirement from New York State public health law, updated every 3 years, using focus areas outlined in NYS’s Prevention Agenda, a blueprint for “the healthiest state.”

The Prevention Agenda (PA) includes five Priorities: Prevent Chronic Disease; Promote a Healthy and Safe Environment; Promote Healthy Women, Infants, and Children; Promote Well-Being and Prevent Mental and Substance Use Disorders; and Prevent Communicable Disease. Each priority has two or more focus areas.

A Steering Committee was convened to review and coalesce all data, and to propose the PA priorities and Focus Areas most relevant to the Tompkins County community. The committee included representatives from Tompkins County Whole Health, Tompkins County Youth Services, Tompkins County Office for the Aging, Cayuga Health, Health Planning Council, Cornell University MPH Program, and Cornell Cooperative Extension of Tompkins County (CCE-TC). 

The Steering Committee identified three priority areas: Prevent Chronic Disease, Promote Heathy Women, Infants, and Children, and Promote Well-Being and Prevent Mental and Substance Use Disorders.


Objectives in the Prevent Chronic Disease focus area include addressing food security and healthy eating and addressing gaps in cancer screening. Activities to promote these goals include a focus on increasing the availability of fruit and vegetable incentive programs, screening for food insecurity, removing structural barriers to cancer screening, and promoting strategies to improve detection of hypertension and prediabetes.


Objectives in this focus area address equity of care for birthing families, infants, and children. The CHIP outlines strategies to reduce the percentage of births that are preterm, low birth weight, and/or receive late or no prenatal care. The data shows disparity across zip codes and race in Tompkins County for these factors. Strategies to address these goals include a community health worker home visiting initiative, the redesign of the Moms PLUS+ program providing nurse home visiting services for prenatal and postpartum care and increasing demographic data collection to improve our ability to identify and address disparities in maternal and child health outcomes.


Well-being relates to an individual’s physical, mental, and social sense of health and satisfaction, along with the influence that social determinants have on experiences and quality of life. The CHIP identifies activities to prevent mental and substance use disorders, including increasing access to medication-assisted treatment, access to overdose reversal training and kits, and integrating trauma-informed approaches in training and policy.

Tompkins County Whole Health Commissioner Frank Kruppa stated, “The integration of mental, physical, and environmental health allows us to envision a future where every person in Tompkins County can achieve wellness. This vision captures the recent combining of the local health department and mental health services into one organization, Tompkins County Whole Health. We look forward to working with partners and the community in this new capacity.”

Community Health Assessment Results

The Community Health Assessment (CHA) data demonstrates that disparities in Tompkins County are primarily across wealth and race. Inequity is also evident in housing and access to healthcare, with the latter often due to lack of transportation options. Secondary data shows an income gap between races. 

Secondary data for the CHA were primarily sourced from the U.S. Census and the NYSDOH. The DOH pulls data from a variety of sources and compiles key indicators in the PA dashboard and the NYS Community Health Indicator Reports (CHIRS).

Primary data was collected directly from the community through a community wide survey in which respondents were asked to rate their own health, identify choices and challenges, and weigh in on what makes a healthy community. In 2022, over 1,500 eligible responses to the survey were completed. The results clearly demonstrate the influence that social determinants of health have on an individual’s perception of their health. 

Evaluation of the Community Health Improvement Plan

The array of programs active in Tompkins County to address social determinants of health drive strategies that are evidence-based, promising/pilot programs, and/or programs planning an expansion to serve new populations. These activities are aligned with CHIP goals and objectives identified by the steering committee. CHIP. Tompkins County is ranked as one of the healthiest counties in New York State, and we hav

Cayuga Health’s CEO Dr. Martin Stallone stated, “Cayuga Health is pleased to partner with Tompkins County Whole Health on the development of this year’s CHA and e so many organizations in this community doing incredible work to address the social drivers of health. Still, we know that not everyone has the same opportunities, access, or outcomes. Our health system is committed to advancing health equity, alongside our community partners. We are actively working to improve our capabilities to gather data and use it to better understand how we can positively impact health for everyone in our community.”

Herb Alexander, Chief Diversity Officer at Cayuga Health, added, “We all benefit from collectively advancing health and well-being. And, we all suffer when there are structural barriers that block anyone’s opportunities to be as healthy as possible. If even one person doesn’t have the information, access, or opportunity to live their healthiest life, we still have work to do. This plan and ongoing data collection will outline pathways for us to understand and respond to the unique needs of individuals in our community to truly advance health equity.”   

Evaluating the impact of the goals, objectives, and interventions presented in this CHIP will take place through 2024. A steering committee will monitor short term process measures that track activities. Community partners will have access to a reporting matrix that will be updated quarterly and on an annual basis submitted to NYS. Further information about the CHA/CHIP can be found online at:  

Tompkins County Whole Health (formerly the Tompkins County Health Department): envisioning a future where every person in Tompkins County can achieve wellness. Find us online at, and follow us on Facebook at and on Twitter at @TCWholeHealth. Get Whole Health updates or other county announcements via email or text, sign up here.

Media contact: Shannon Alvord,