Investing in Pediatric Care to Build a Healthier New York

Grantee Name

Independent Health Foundation, Montefiore Medical Center

Funding Area

Special Projects Fund

Publication Date

November 2025

Grant Amount

Independent Health Foundation ($172,500) and Montefiore Medical Center ($239,378)

Grant Date:

Independent Health Foundation (2021) and Montefiore Medical Center (2022)

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The first three years of a child’s life are a crucial period for ensuring long-term cognitive, physical, social, and emotional development. Children growing up in poverty face many challenges that can impact healthy childhood development, and pediatric primary care visits can serve as powerful touchpoints for families in need. During routine pediatric well-visits, staff can identify childhood developmental delays, assess social and environmental factors, and make referrals for services that can address the emotional, social, and economic needs of children and their families.

In 2021, NYHealth awarded the Independent Health Foundation (IHF) a grant to support pediatric providers and families in meeting the physical and emotional development needs of children in Western New York. The grant supported a five-year pilot program called Growing Up Strong, which integrated HealthySteps (HS) – an evidence-based pediatric care coordination model – at six Erie County primary care practices and community sites, serving approximately 12,000 children (ages 0 to 3).

In 2022, NYHealth awarded Montefiore Medical Center a grant to pilot a pediatric care coordination model aimed at better meeting children’s physical and emotional development needs. The grant supported HealthySteps-trained staff in providing preventative interventions, referrals to community services, and ongoing follow-up for children between the ages of 0 and 5 years old living in the Bronx.

Both organizations worked with the clinics to measure the effects of their programs on the health outcomes of pediatric patients and created reimbursement payment models to ensure long-term sustainability of the services.

Outcomes and Lessons Learned

IHF successfully introduced HS to three Western NY health systems — Neighborhood Health Center, Kaleida Health, and Jericho Road Community Health Center — which resulted in standardized policies and protocol to conduct developmental screenings, coordinate referrals and follow-ups, and screen for family needs, including maternal depression.
Montefiore Medical Center partnered with Healthfirst, the HealthySteps National Office, Be-InCk, and NYC Health + Hospitals/Jacobi to implement a HealthySteps program at Tiga Pediatrics.
Analyses from both projects showed that children who received continuous HealthySteps services demonstrated higher rates of well child visits and continuity of care; a higher rate of emotional/behavioral screenings, and a higher incidence rate of mental and behavioral health care compared to those seen in non-continuous HS practices.
Financial strategies to sustain the work emerged throughout the project. In the fall of 2023, the NYS Office of Mental Health awarded additional funding to support the expansion of HealthySteps, and three of the participating sites in Western NY received a grant to continue their work. Additionally, initial findings from Montefiore’s value-based payment model estimate up to $30,000 of additional yearly reimbursement to the billing providers for a caseload of approximately 100 children.

There were several key lessons learned. Both IHF and Montefiore Medical Center noted that institutional buy-in at the participating hospital system and readiness of community partners were key to sustained success.

For both grantees, the staffing and workflow of the participating clinics presented unique challenges in the launch of HealthySteps. For example, Independent Health Foundation’s Western New York partner sites needed to modify staffing structures, salary scales, and clinical workflows before they could conduct a search for a new HS specialist. IHF learned that each clinic needed an extra six months in their program timeline. Workforce shortages also affected the ability of Montefiore’s project team to hire a HealthySteps specialist at Tiga Pediatrics. To overcome this obstacle, Montefiore leveraged the use of NYS Medicaid reimbursement for community health work and formed a partnership with the Institute of Community Living to hire one of their community health workers to work as a HS specialist.

Lastly, launching national models of care posed a challenge when working across multiple clinical sites. Differing practice sizes, workflows, and patient demographics led to varied uptake and implementation for both programs.

Co-Funding and Additional Funds Leveraged for IHF: Community Foundation for Greater Buffalo ($100,000); Garman Family Foundation ($25,000); Celia Lipton Farris and Victor W. Farris Foundation ($25,000); and Independent Health Association ($1,000,000).
Co-Funding and Additional Funds Leveraged for Montefiore Medical Center: Healthfirst ($100,000).

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