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.

Oneida County Department of Mental Health

Veterans in New York die by suicide at nearly twice the rate of civilians.

Compounding these challenges is a shortage of mental health providers equipped to treat veterans. In response, the U.S. Department of Veterans Affairs (VA) created the National Strategy for Preventing Veteran Suicide, which use approaches such as reducing access to lethal means, increasing social connectivity, and expanding access to mental health treatment. Between 2018 and 2020, suicide rates stabilized, but newly released data show warning signs that rates are increasing again. Continued and more intensive action and resources are needed to build on the momentum of successful suicide prevention efforts. To address this need, VA awarded $174 million in federal grant dollars to 250 community-based organizations to implement suicide prevention services, 5 of which are in New York State. However, these funds cannot be used for outreach and community engagement activities or to provide services to veterans who are (1) ineligible for VA care or (2) deemed anything other than “high risk” for suicide. To maximize the full potential of the federal investment, in 2022, NYHealth awarded a grant to one of the federal funding recipients, Veterans One-Stop Center of WNY (VOC), to conduct outreach to veterans in Western New York. The success of VOC’s outreach efforts led NYHealth to further invest in the remaining four New York State grantees. In 2023, NYHealth awarded a grant to the Oneida County Department of Mental Health to expand access to suicide prevention services by increasing outreach to and engagement with veterans in Central New York. NYHealth is also supporting complementary projects across New York State with Homeward Bound USA, Mental Health America of Dutchess County, and Black Veterans for Social Justice.

Under this grant, the Oneida County Department of Mental Health will increase outreach to identify veterans at risk of suicide—including younger veterans, women, and those ineligible for VA services—through technology, in-person events, and social media. It will also build strategic partnerships with local organizations, including county veterans service officers, local New York State suicide prevention coordinators, leaders in tribal communities, veterans service organizations, and other mental health providers. The Oneida County Department of Mental Health will screen veterans to determine their risk for suicide, service needs, and VA eligibility, connecting them to suicide prevention services as needed. Additionally, it will provide case management services to connect veterans with community-based or VA health services and offer referrals to wraparound services. The Oneida County Department of Mental Health will help eligible veterans access benefits such as supportive housing, GI Bill education assistance, and disability compensation. It will also share demographic and screening information with partners and disseminate reports to identify areas for improvement and promising practices that can be replicated. Lastly, the VA and State government stakeholders will partner with the Oneida County Department of Mental Health to address challenges with lags in suicide data to evaluate success of on-the-ground efforts and assess annual reductions in suicide rates.

University of Rochester Medical Center

At the height of the COVID-19 pandemic, New York State saw an approximately 130-fold increase in telehealth use.

Although telehealth has tapered off, it is here to stay as an option for patients. Telehealth can expand access to care, especially in rural areas with provider shortages. However, uneven telehealth use during the pandemic has exacerbated—not reduced—disparities in health care access. Rural residents, people of color, people with low income, people who speak a primary language other than English, and older adults face barriers to telehealth use, including the digital divide, unfamiliarity with digital tools, and privacy and trust concerns. The University of Rochester Medical Center (URMC) has launched an on-demand telehealth service for primary care, but URMC’s rural patients—who stand to gain the most from telehealth—struggle to access it because they lack internet access at home. A regional bank, Five Star Bank, has emerged as a promising, non-traditional site to extend URMC’s reach in rural areas. Only 30% of URMC patients living in rural areas reside within 4 miles of its primary care clinics, yet more than 50% reside within 4 miles of a Five Star Bank branch. There is potential for strong foot traffic in these branches, as rural residents access banking services in person at much higher rates than urban residents. In 2023, NYHealth awarded URMC a grant to pilot a bank-based telehealth model throughout the Finger Lakes, Southern Tier, and Central New York regions in partnership with Five Star Bank, telehealth vendors, and internet providers.  

Under this grant, URMC clinicians will provide virtual services that lend themselves to telehealth: treatment for common problems like urinary tract infections, sore throat, tick bites, and flu, as well as diagnosis, medication prescription, testing, referrals to in-person and emergency care, and screening for health-related social needs. In the first year of the project, URMC and Five Star will pilot telehealth services in up to five branches. Through input from relevant stakeholders, URMC will understand perceptions, barriers, and facilitators of telehealth provided in banks; raise patient and provider awareness; and guide marketing and implementation. In addition, it will conduct education, outreach, and marketing to drive uptake. URMC will operate workgroups with partner organizations to develop and implement clinical protocols, data-sharing, bank renovation, community outreach, and evaluation. Impact will be evaluated by tracking process metrics and patient and bank staff satisfaction to continuously improve pilot implementation. 

Syracuse Onondaga Food Systems Alliance (fiscal sponsor: Syracuse Grows)

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

NYHealth currently supports eight a cohort of food planning groups in New York State that develop tailored food systems plans designed to meet local and regional food needs. Syracuse Onondaga Food Systems Alliance’s (SOFSA’s) service area—the city of Syracuse, Onondaga County, and the Onondaga Nation—is home to communities experiencing concentrated poverty in the urban center and a large refugee population, as well as both urban and rural agricultural producers and other food businesses. Central New York is one of the most productive farming areas in the Northeast, and Syracuse has a long history of food processing and distribution, yet residents report poor access to healthy foods. Moreover, residents looking to pursue farming—including new immigrants with farming skills—struggle to access land. In 2023, NYHealth awarded SOFSA, through fiscal sponsor Syracuse Grows, a grant to add Central New York to the food policy planning cohort to advocate for policy changes that make healthy, local food more available across the region. 

Under this grant, SOFSA will develop a five-year strategic plan that expands upon existing projects and goals. SOFSA will deepen its local partnerships and cultivate relationships with influential statewide organizations to implement a campaign to bring back a grocery store and establish a farmers market in the lowest income neighborhood of Syracuse; convene school food service workers from across Onondaga County to share successes and identify ways to fill gaps; support schools to serve more locally produced food; and create a communications plan to educate stakeholders, policymakers, and the public about benefits of participation in the food system. SOFSA will implement a mini-grants program to support community-identified solutions to food access issues. In addition, SOFSA will convene food policy councils from across the State to share strategies and strengthen capacity, forging a coordinated statewide network.

Mosaic Health

Shared visit notes, often referred to as open notes, are an important way to help consumers become active participants in their own care.

When patients have access to their own visit notes written by health care providers, they better remember and act on information discussed during visits, improve communication with their health care team, and better manage their health. The 21st Century Cures Act, a recent federal mandate, requires health care providers to make clinical notes available to patients electronically and at no charge. However, the level of compliance and, most importantly, the proactive use of open notes to improve care vary among health systems. In 2022, NYHealth issued a Request for Proposals (RFP), “From Good to Great: Improving Access to and Use of Patient Visit Notes in Non-Hospital Systems,” to support non-hospital systems across New York State in sharing open notes in compliance with recent federal rules and using open notes to more meaningfully engage patients. In 2023, NYHealth awarded Mosaic Health a grant to participate in this initiative.

Mosaic Health is a federally qualified health center that serves Western New York, Central New York, the Finger Lakes, and Mohawk Valley; it offers comprehensive primary, dental, and behavioral health care to approximately 103,000 patients across 16 primary care clinics, 3 dental clinics, and 5 school-based health centers. Under this grant, Mosaic will continue to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. Mosaic will enhance the sharing and usability of notes through provider training, with an emphasis on writing patient-friendly notes. With a focus on improving note-sharing with its patient population, including refugees and rural residents, it will create patient education materials in multiple languages, conduct outreach and navigation, and install kiosks for patients to access notes on-site. It will also seek patient feedback on these patient engagement and provider training efforts.

See a full list of grantees participating in this initiative.

Syracuse Community Health

Shared visit notes, often referred to as open notes, are an important way to help consumers become active participants in their own care.

When patients have access to their own visit notes written by health care providers, they better remember and act on information discussed during visits, improve communication with their health care team, and better manage their health. The 21st Century Cures Act, a recent federal mandate, requires health care providers to make clinical notes available to patients electronically and at no charge. However, the level of compliance and, most importantly, the proactive use of open notes to improve care vary among health systems. In 2022, NYHealth issued a Request for Proposals (RFP), “From Good to Great: Improving Access to and Use of Patient Visit Notes in Non-Hospital Systems,” to support non-hospital systems across New York State in sharing open notes in compliance with recent federal rules and using open notes to more meaningfully engage patients. In 2023, NYHealth awarded Syracuse Community Health a grant to participate in this initiative.

Syracuse Community Health is a federally qualified health center in Syracuse that provides comprehensive primary care and dental care to approximately 68,000 patients annually across 6 clinics and 8 school-based health centers. Under this grant, Syracuse Community Health will continue to implement and improve the use of shared notes within its system, including its school-based health center, and participate in a technical assistance and peer-learning network. It will enhance the sharing and usability of notes through provider training and notes translation. It will also conduct patient education, outreach, and navigation and install kiosks for patients to access notes on-site. It will also seek patient feedback and upgrade its patient portal to facilitate easier note-sharing.

See a full list of grantees participating in this initiative.

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