Special Projects Fund

Project Title

Reducing Barriers to Primary Care in the North Country

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

September 29, 2021


North Country






Delivering health care services in the North Country region of New York State is challenging; at least 25% of residents in rural Jefferson, Lewis, and St. Lawrence counties do not have a primary care provider.

Residents insured by Medicaid and/or Medicare also face barriers to access, including lack of transportation and long appointment wait times. As a result, approximately 35% of these residents have not had a primary care visit in the last year. The North Country’s rate for well-child visits for children also falls far below the State’s target. To create meaningful and effective solutions for the North Country, feedback from residents is needed, and new strategies must be implemented. In 2021, NYHealth awarded Fort Drum Regional Health Planning Organization (FDRHPO) a grant to develop and implement an action plan to improve access to primary care in the North Country counties of Jefferson, Lewis, and St. Lawrence.

Under this grant, FDRHPO designed and conducted focus groups with North Country residents, recruiting individuals who were insured by Medicaid and/or Medicare and who did not have a primary care provider. It also partnered with local community-based organizations and primary care provider organizations on recruitment. Residents in the region were surveyed on their primary care utilization, including experiences with a personal doctor and barriers to accessing care. The FDRHPO team and primary care partners also became certified to conduct the Bridges to Health & Healthcare training, a proven model that offers clinical staff a framework for understanding poverty and serving and communicating with low-income patients. Following the training, staff implemented the training in primary care settings. Findings from the project were synthesized to identify specific strategies for a regional action plan including outreach, patient engagement, and workflows that were more patient-centric. FDRHPO produced summary reports and hosted a virtual roundtable with primary care partners to discuss findings and an actionable implementation plan for improving primary care access.