Healthcare Association of New York State, Inc. Healthcare Educational and Research Fund

Our health systems are not prepared for the complex health needs of patients ages 60 and older, who will make up 25% of New York State’s total population by 2040.

Older adults encounter barriers to care and experience avoidable harm from overmedication, preventable falls, and treatable cognitive concerns. The Age-Friendly model provides a standardized approach for providing high-quality care to older adults centered on the “4Ms”: What Matters, Medication, Mentation (i.e., care for delirium), and Mobility. When implemented together, the 4Ms result in significant improvements in patient experience and quality outcomes. In 2019, New York State set an ambitious goal to designate 50% of its health care sites as Age-Friendly. Recently, the Governor issued an executive order that mandates the establishment of a New York State Master Plan on Aging where the Age-Friendly Health Systems model is recognized as a cornerstone of the effort. In 2020, NYHealth awarded the Healthcare Association of New York State (HANYS) a grant to support the launch of the initial phase of a New York State Age-Friendly action community. In 2021, NYHealth awarded HANYS a second grant to build upon and continue this initiative. New York State is now more than halfway toward reaching its goal of achieving Age-Friendly recognition among 50% of health systems; however, under-resourced hospitals in upstate and rural regions have faced barriers to participation. In 2023, NYHealth awarded HANYS a third grant to continue scaling and operating the Age-Friendly Health Systems action community while laying the groundwork for statewide scaling and sustainability.

Under this grant, HANYS will work with at least 50 new and returning hospital systems, federally qualified health centers, and skilled nursing facilities across the State to achieve Age-Friendly recognition. HANYS will provide individualized technical assistance, group coaching sessions, and tools to put the 4Ms into practice. Sites will test out changes like prescription modifications, care coordination, and end-of-life conversations; use data to monitor outcomes; and submit required documentation to achieve recognition. HANYS will also facilitate partnerships among health care sites, area agencies on aging, and community-based organizations and establish a well-built referral network, including social services options, for older adults. Partners will craft joint strategic plans to improve care transitions and workflows. Finally, HANYS will work with sites to make the business case for sustained investment in the 4M framework. It will disseminate findings among health system leaders and policymakers to advocate for widespread adoption of Age-Friendly care across the State, including as part of forthcoming initiatives like the State’s Master Plan on Aging, Medicaid waiver, and value-based payment models.

The Legal Aid Society, Inc.

Inadequate dental care and poor oral health are linked to a range of physical, psychological, and quality-of-life issues.

Tooth decay and loss, gum degeneration, and mouth infections—when left untreated—can increase the likelihood of conditions like heart disease, diabetes, respiratory ailments, and malnutrition. New York State is 1 of 14 states that offer extensive dental benefits under Medicaid as an optional covered service, but it has historically limited coverage of dental implants, replacement dentures, root canals, and crowns.  Beginning in 2024, New York State’s Medicaid program will provide coverage that better reflects current standards of care and a comprehensive dental benefit. While the policy change is a big win, its impact depends on recipients, dentists, and advocates understanding the rule changes and recipients’ rights. In 2023, NYHealth awarded the Legal Aid Society (LAS) a grant to provide education and technical assistance to dentists and consumer advocates to ensure they understand the Medicaid rule changes, patients’ rights, and how to access newly covered services.

Under this grant, LAS will develop educational materials, provide in-person and virtual trainings, and monitor the rollout of expanded coverage. In consultation with the New York State Department of Health (NYSDOH), LAS will create training materials to inform dental clinic staff and Medicaid managed care plans about the new Medicaid coverage. The materials will provide clear information about how to interpret and implement the new rules, submit for coverage, and seek legal assistance for patients and what to do if Medicaid denies coverage. LAS will conduct training for all dental sites that serve Medicaid patients. It will partner with consumer advocacy groups and social service providers to raise awareness about expanded coverage and information about New York State’s dental provider network, and it will disseminate educational materials through a series of webinar trainings, media, and dental conferences. LAS will track and monitor information on the number and types of technical assistance requests and fair hearing topics and decisions. It will work closely with NYSDOH to create a feedback loop to share trends and information. NYSDOH will incorporate these findings into its ongoing training and oversight of Medicaid managed care organizations. LAS will operate its Access to Benefits helpline to respond to questions about coverage from providers and patients. It will also provide Medicaid recipients guidance on requesting hearings and appeals to challenge Medicaid denials of newly covered dental services.

Integrity Partners for Behavioral Health IPA

There is a mental health crisis among youth and young adults, as well as a growing and related concern in adolescent substance use, including abuse of alcohol, tobacco, opioids, and other drugs that can lead to addiction.

In 2020, among 12–17-year-olds, more than 8% reported using drugs in the past month, 10% used alcohol, and nearly 3% met the criteria for illicit drug use disorder in New York State. More teens are also dying of drug overdoses, with the rate nearly doubling between 2019 and 2020 across the country. Substance use disorder often co-occurs with mental health problems, including anxiety, depression, and suicidal ideation, and it can trigger or worsen these symptoms. Studies show that one of the most effective treatments for substance use disorder integrates family into the treatment process—known as family behavioral therapy. This approach improves communication and problem-solving skills and enhances positive family interactions to foster a supportive and healthy environment for recovery. It often results in better long-term outcomes compared with other approaches. In 2023, NYHealth awarded Integrity Partners for Behavior Health IPA (IPBH) a grant to integrate family members into behavioral health care interventions for adolescents with substance use disorders in Western and Central New York.

Under this grant, IPBH will test the family behavioral therapy model at 21 rural behavioral health sites across 14 counties in Western and Central New York with the aim of creating a replicable and cost-effective model that promotes sustained substance use recovery. It will conduct a readiness assessment among participating practices to implement family behavioral therapy, training 24 licensed therapists on the model and treatment protocol. Clinical staff will recruit patients ages 10–19 with substance use disorder to participate in the family behavioral therapy program. They will offer 12–16 family sessions on topics such as communication, conflict resolution, problem-solving, and environmental factors. To track recovery of patients, IPBH will measure the frequency of substance use among adolescents and the changes in family functioning. Additionally, IPBH will educate health and social service providers across the 14 counties on family behavioral therapy practices. It will establish referral pathways for adolescents who need additional services, including other recovery services, education, health care, housing, and food, creating a holistic network to support young people and their families toward recovery. Lastly, IPBH will partner with the University at Buffalo to track activities and outcomes across the provider network. It will share findings and best practices through peer-reviewed publications and conferences to encourage other provider networks to integrate family-based therapies in rural communities.

Health Leads, Inc.

Nationally, Black women are three times more likely to die from pregnancy-related causes than white women; in New York State, they are five times more likely.

Most maternal deaths and complications are preventable, but they stem from a mix of complex factors, including bias and structural racism. Doulas have emerged as an innovative strategy to address inequities for birthing parents. Doulas are trained childbirth professionals who provide physical, emotional, and informational support during and after pregnancy. Use of doulas is associated with lower rates of preterm birth, low birthweight, and postpartum depression. Despite these benefits, doulas are underused, and people of color and with low incomes have limited access to them. One reason is that New York’s Medicaid program—which covers more than half of births in New York State—has historically not covered doula services. However, the New York State FY24 budget expanded Medicaid coverage for doula services for all pregnant and birthing people through 12 months postpartum, along with increased reimbursement rates. While this is a promising development, the State must take numerous steps to implement the coverage expansion effectively. In 2023, NYHealth awarded Health Leads a grant to promote broader use of doulas across New York State through effective implementation of the Medicaid coverage expansion for doula care and by establishing a set of standards for a statewide doula-friendly hospital designation.

Under this grant, Health Leads will educate providers, payors, patients, and doulas about the State’s new Medicaid benefit and hold regular coalition meetings with the New York State Department of Health. Health Leads will train community-based doula organizations to meet enrollment requirements of State-approved Medicaid providers, to bill for doula services, and to create systems to integrate doulas into care teams. Additionally, Health Leads will work with coalition members to create standards for a doula-friendly hospital designation. Standards will cover criteria such as laboring techniques that support doulas, systems to track patients’ birthing experiences, staff training about a doula’s role, and referral systems. It will identify a hospital that has already developed initial doula standards to pilot the model. Health Leads will also create a compendium of resources and share best practices to help foster the adoption of doula care. Lastly, Health Leads will partner with Columbia University to track the project’s impact.

Organización Latino Americana (OLA) of Eastern Long Island

Eastern Long Island, or the East End, is commonly associated with luxurious beachside properties, but this wealth masks the economic and racial disparities in this region.

Thousands of Latinos live in the area year-round working in essential industries like landscaping, farming, and hospitality. Many are immigrants, face food and housing insecurity, and have limited access to health and social services. In some school districts in the region, up to 40% of students are Latino and up to 60% live below the federal poverty level. Like their peers across the country, these teens are struggling with mental health challenges that have been exacerbated by the COVID-19 pandemic. In the East End, access challenges are compounded by a shortage of culturally and linguistically appropriate mental health providers, stigma about behavioral health disorders, and cost-prohibitive private treatment. As a result, Latino youth have historically had no one to turn to for help. In 2023, NYHealth awarded Organización Latino Americana (OLA) of Eastern Long Island a grant to expand access to bilingual crisis counseling and mental health services for middle and high school students in five towns on Eastern Long Island.

Under this grant, OLA will scale up its successful pilot, Youth Connect, at five East End school districts. The program uses clinical social workers to provide crisis counseling to middle and high school students and partners with Family Service League, the only nonprofit that provides mental health services on the East End. OLA will increase access to the Youth Connect helpline, a free and anonymous platform that allows teens to communicate with bilingual crisis counselors who, if needed, will refer teens for ongoing care at Family Services League. OLA will also work with school counselors and administrators to develop referral systems to connect students with ongoing mental health support. It will collaborate with youth-serving community organizations, houses of worship, and local government agencies to complement school-based services; deliver educational workshops at parent/teacher conferences; and train youth ambassadors to conduct peer outreach and to develop social media content. OLA will also advocate at the State and local levels for additional mental health services for Latino families.

Make the Road NY

More than 100,000 migrants and asylum seekers have arrived in New York City since spring 2022.

Most migrants arrive with nothing but the clothes on their backs. Among them are children who need vaccines to enroll in schools, pregnant women needing immediate prenatal care, and people with a host of other physical health conditions, mental health issues, and trauma. In response, New York City has opened a central arrival center and several resource navigation centers where migrants can access necessities and be connected to community-based organizations. Additionally, NYC Health + Hospitals is providing emergency care, basic health care, and immunizations. Despite these resources, migrants face barriers when navigating the complex health system. The City’s safety net and housing systems have also been pushed to a breaking point, its emergency shelter population topping 100,000 in summer 2023. City officials have sought to relieve the pressure by busing more than 2,200 migrants to Western New York, Albany, and the Mid-Hudson region, with plans to relocate others to the Finger Lakes. But poor coordination has left those areas scrambling to meet demand for services and has contributed to growing tensions. In 2023, NYHealth awarded Make the Road NY (MRNY) a grant to address the urgent health and mental health needs of newly arriving migrants and asylum seekers settling in New York. NYHealth is also supporting complementary initiatives with the New York Immigration Coalition and Terra Firma at Montefiore Medical Center.

Under this grant, MRNY will engage migrants and reach 6,000 asylum seekers at arrival centers in New York City, Long Island, and Westchester to provide health screening and connect them with health and mental health services, using bilingual community health workers. It will help new arrivals enroll in health insurance, schedule medical appointments at NYC Health + Hospital’s care clinics, and travel to appointments. MRNY will also connect them with other services including food, transportation, English classes, and workplace safety training, and conduct monthly Spanish-language know-your-rights workshops. Lastly, it will organize community forums and use feedback to advocate with local and State officials for the needs of asylum seekers.