Independence Care System

Primary care is often a patient’s first and most regular point of contact with the health care system.

High-quality primary care provides ongoing, relationship-based care that meets the health needs and preferences of individuals, families, and communities, according to the National Academies of Sciences, Engineering, and Medicine. It is a rare “win-win” in health care that improves individual and community health, enhances health equity, and saves money. Despite the benefits, too little is invested in primary care and too many New Yorkers, especially New Yorkers of color, have difficulty getting care when and where they need it. In 2023, NYHealth issued a Request for Proposals (RFP), “Primary Care: Expanding Access and Advancing Racial Health Equity,” to test replicable models to improve the accessibility, quality, and equity of primary care in regions across the State. NYHealth awarded Independence Care System (ICS) a grant to participate in this initiative.

Under this grant, ICS will establish a Center of Excellence for primary care for people with disabilities at Woodhull Hospital, evaluate its impact, and support replication across the New York City Health + Hospitals (H+H) system and beyond. ICS will conduct focus groups in Brooklyn with 100 patients with physical disabilities to identify specific care needs and experiences with primary care providers. It will adjust care protocols based on patient feedback and evidence-based practices, and it will improve Electronic Medical Record documentation to better identify patients’ needs for accommodation. ICS will train primary care providers, clinical staff, and administrative staff and offer on-site consultation to support the delivery of more accessible and equitable care. In partnership with leading national researchers, ICS will analyze the model’s impact on enhancing uptake of screenings and preventive care, reducing hospitalization, and improving patient health outcomes. It will create resources to enable replication across H+H, including policies and procedures, disability competency training curriculum, and continuing education opportunities. It will also disseminate learnings through peer-reviewed publications and online patient and provider educational resources.

See a full list of grantees working to expand access to and advance racial health equity in primary care across New York State.

The Johns Hopkins Center for a Livable Future (fiscal sponsor: Farm to Table, Inc.)

Food systems planning is a collaborative process among farmers, retailers, consumers, nonprofits, health systems, and government to develop priorities and implement practices that shape how regional food systems operate.

It can result in improvements like changes in food procurement at public institutions, revisions to urban gardening codes, and better access to local food, which in turn have a positive impact on food security and health. NYHealth is supporting eight food planning groups in New York State that are developing tailored regional food systems plans. The funding enables these alliances to put plans into action by hiring dedicated staff, speeding up coalition building, seeking community and resident input, and communicating to stakeholders about the positive impact of food planning on local food systems. In 2023, NYHealth awarded The Johns Hopkins Center for a Livable Future a grant to provide capacity building and technical assistance to the eight food planning groups.

Under this grant, Johns Hopkins will accelerate the development of local food system plans, support the regional planning groups to secure funding for sustainability, and position the cohort as a collective voice to influence statewide policy change. It will provide individual and group technical assistance to the eight regional food planning groups to ensure planning and strategies are action-oriented. Johns Hopkins will match each food planning group to a peer food policy council and facilitate discussions, site visits, and sharing of best practices. It will also support the cohort in developing a shared policy agenda to advocate for State and federal policy changes and make recommendations for a statewide food plan.

 

Rochester Food Policy Council (fiscal sponsor: Finger Lakes Health Systems Agency, dba Common Ground Health)

Food systems planning is a collaborative process among farmers, retailers, consumers, nonprofits, health systems, and government to develop priorities and implement practices that shape how regional food systems operate.

It can result in improvements like changes in food procurement at public institutions, revisions to urban gardening codes, and better access to local food, which in turn have a positive impact on food security and health. NYHealth is supporting eight food planning groups in New York State that are developing tailored regional food systems plans. The funding enables these alliances to put plans into action by hiring dedicated staff, speeding up coalition building, seeking community and resident input, and communicating to stakeholders about the positive impact of food planning on local food systems. Two of these eight groups are now ready to put their plans into action. In 2023, NYHealth awarded Rochester Food Policy Council (ROC) a grant to support the implementation of local food systems plans to make healthy, local food more available. NYHealth is also supporting a complementary initiative with the Adirondack Food Systems Network.

Under this grant, ROC will undertake a range of activities to implement its plan. It will form a partnership with the City of Rochester to launch a healthy food grant and loan program to fund retail food businesses. Together with the City, ROC will also create a community food system plan that prioritizes healthy food access and nutrition-centered food procurement goals in public institutions. Additionally, ROC will work to expand public gardens and support a youth-led advocacy campaign for healthier food options at recreation centers.

Adirondack Food Systems Network (fiscal sponsor: AdkAction.org, Inc.)

Food systems planning is a collaborative process among farmers, retailers, consumers, nonprofits, health systems, and government to develop priorities and implement practices that shape how regional food systems operate.

It can result in improvements like changes in food procurement at public institutions, revisions to urban gardening codes, and better access to local food, which in turn have a positive impact on food security and health. NYHealth is supporting eight food planning groups in New York State that are developing tailored regional food systems plans. The funding enables these alliances to put plans into action by hiring dedicated staff, speeding up coalition building, seeking community and resident input, and communicating to stakeholders about the positive impact of food planning on local food systems. Two of these eight groups are now ready to put their plans into action. In 2023, NYHealth awarded Adirondack Food Systems Network (AFSN) a grant to support the implementation of local food systems plans to make healthy, local food more available. NYHealth is also supporting a complementary initiative with the Rochester Food Policy Council.

Under this grant, AFSN will work to make it easier for rural areas with smaller populations to compete for funds and implement local programs. AFSN will also implement a regional outreach and enrollment plan for nutrition incentive programs like Double Up Food Bucks and Fresh Connect to maximize enrollment and efficiency. It will partner with local food producers to secure contracts with and supply food to local schools and health care institutions. In addition, AFSN will consolidate regional data from food system producers and distributors, retail locations, composters, nutrition programs, and health and funding information into an online repository to identify patterns and benchmarks and to evaluate progress.

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 Food Pantries for the Capital District

People with uncertain access to food have lower diet quality, higher rates of diet-related disease, and higher health care costs.

Medically supportive food and nutrition services, known as Food Is Medicine (FIM) services, can reduce the severity of these problems, improve health outcomes, and reduce food insecurity. FIM services include a spectrum of interventions that provide tailored food assistance to people living with certain chronic illnesses or risk factors and that serve as a link to the health care system, typically through a referral or prescription. In New York State, existing FIM programs are limited in reach, scale, and range of services covered. However, there is growing interest from a variety of stakeholders to expand and study FIM interventions. Many commercial health plans have designed and launched their own FIM coverage models; New York State Medicaid is also taking steps. Under a pilot program, New York Medicaid has allowed health plans to pay for non-medical services like meals when medically appropriate and cost-effective. In September 2022, the State submitted a proposal to the federal government for a multibillion-dollar Medicaid demonstration waiver that would allow Medicaid to pay for social service coordination, including FIM. The Food Pantries for the Capital District (Food Pantries) FIM coalition played a lead role in advocating for the integration of FIM services into the waiver and for Medicaid to cover registered dietitian services. Groups across New York State are preparing to make the most of broader Medicaid coverage for FIM services; however, many of these organizations need better understanding of FIM best practices for launching, operating, collecting data, and demonstrating return on investment. In 2023, NYHealth awarded Food Pantries a grant to support organizations in designing and researching medically tailored grocery programs that can be scaled and reimbursed across New York State.

Under this grant, Food Pantries will launch an accelerator program to help organizations learn the operational, policy, and contracting mechanisms needed to run and scale up medically tailored grocery programs. It will recruit community-based organizations operating feeding programs across a range of populations. Food Pantries will provide organizations with technical assistance to standardize practices for implementing medically tailored grocery programs. It will train participating organizations on technology, referral systems, and security measures. Participating organizations will track the outcomes of their FIM grocery programs, including foods distributed by type, volume, and source. Health care partners will share data to help determine the effectiveness of the program models, and Food Pantries will analyze the data. Food Pantries will disseminate findings among the New York State FIM coalition, New York State government agencies, and social and health care partners.

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