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.

Legal Assistance of Western New York, Inc.

Social determinants of health such as food, housing, and employment can affect up to 80% of patients’ health outcomes.

For many low-income people, related legal problems affect their physical and mental health. In response, Legal Assistance of Western New York’s (LawNY) medical-legal partnership (MLP) programs provide legal services to patients experiencing poverty who receive care at local hospitals. Through this work, LawNY has identified a growing need among women and families in Monroe County—where women are the largest demographic living in poverty, with the highest rates of poverty among mothers and pregnant women of color and female-led households. Additionally, the maternal and infant mortality rate is three times higher for Black women and babies than for their white counterparts. Through its decade-long partnership with Rochester Regional Health (RRH), LawNY has an opportunity to expand services and better support Monroe County. In 2023, NYHealth awarded LawNY a grant to launch a replicable MLP program to improve maternal health by addressing factors that contribute to disparities in infant and maternal mortality, pre-term births, and maternal mental health.

Under this grant, LawNY will expand its onsite presence at several RRH medical clinics to provide easy access to support for mothers and pregnant patients at varying stages during their care. It will assign patients to legal advocates who can assist with needs like housing, employment and educational programs, paid family leave and short-term disability, space and time for lactation, childcare subsidies, postpartum health insurance and children’s health insurance coverage, spousal responsibility income, and SNAP and WIC benefits. LawNY aims to connect at least 100 women and families with legal services for complex cases. In addition, LawNY will partner with clinicians and social workers to screen for needs related to social determinants of health and make referrals to the MLP team. To promote sustainability and broaden reach, it will hold biannual multidisciplinary RRH staff trainings and engage with other MLP networks to share practical strategies to replicate the model throughout the region and State.

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. 

The Institute for Human Services, Inc.

Mental health challenges are the leading cause of disability and poor life outcomes in young people.

The pandemic exacerbated these challenges as youth faced instability of daily routines, educational loss, isolation from loved ones, fear, and trauma. In 2021, rates of depression and anxiety rose significantly; compared with 2019, emergency room visits for suicide attempts were 50% higher for adolescent girls and 4% higher for adolescent boys. Nearly two-thirds of teens in the United States who experience mental health challenges don’t seek help. Teens who do seek mental health services often face barriers or delays, particularly in areas with a shortage of mental health providers. Young people are also more likely to turn to their friends for support before approaching a parent, sibling, significant other, teacher, or online service. In 2023, NYHealth awarded The Institute for Human Services (IHS) a grant to provide teens, schools, and community partners in Chemung and Steuben counties with an evidence-based program that teaches high schoolers to identify, respond to, and get help for mental health and substance use challenges. 

Under this grant, IHS, through its Steuben Rural Health Network, will train high school students in a nationally recognized, evidence-based Teen Mental Health First Aid curriculum to prepare them to cope with mental health challenges and support their peers. IHS will conduct a pilot in two high schools in Steuben and Chemung counties, engaging students, teachers, and school staff in a community-based approach. Certified Teen Mental Health First Aid instructors from IHS and ProAction of Steuben & Yates will conduct trainings and workshops for students, staff, and community partners to become mental health “first aiders.” Each school will have a safety plan protocol to follow up immediately with any teen deemed to be at risk of suicide. IHS has identified more than 50 local partners positioned to ensure that wraparound services are available for students. IHS and schools will raise awareness about its 2-1-1 Teen Helpline, a hotline that assists with referrals to local services in a five-county area. In addition, it will use results from the pilot to plan a broader Teen Mental Health First Aid training effort and discuss the sustainability plan with rural health network partners, who will determine how to institutionalize the program across counties.  

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.

Veterans Outreach Center

For nearly two decades, suicide rates rose among both veterans and civilians in the United States.

In New York State, veterans die by suicide at nearly twice the rate of civilians. In response, both the U.S. Department of Veterans Affairs (VA) and New York State have made significant efforts to prevent suicide among veterans, such as reducing access to lethal means and expanding access to mental health treatment. Continued and more intensive action and resources are needed to build on the momentum of these suicide prevention efforts. NYHealth supported the Veterans Outreach Center, Inc. (VOC) in 2021 to provide community-based mental health and peer support to veterans across Monroe County. In 2023, NYHealth awarded VOC a grant to expand peer support and suicide prevention services for veterans in crisis throughout the Rochester region.

Under this grant, VOC will create a physical peer support drop-in center at its main location in Rochester. It will assess the community’s needs using proven methods like focus groups and “buddy check” phone calls. Building on earlier phases of work, it will engage high-risk populations, such as women veterans and veterans of color. The center will be staffed by veteran peers and mental health professionals who will provide crisis intervention, case management, and peer support groups. Using data and feedback collected from clients and partner organizations, VOC will tailor services and hours of operation to best meet the needs of the veteran community. It will serve as a hub to connect veterans with housing, substance use disorder treatment, counseling, and referrals to VA health care and benefits. VOC will compile a report that outlines steps and lessons learned for other regions looking to expand suicide prevention efforts.