Finger Lakes Archives - Page 2 of 15 - New York Health Foundation

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 continued to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. Mosaic enhanced 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 created patient education materials in multiple languages, conducted outreach and navigation, and installed kiosks for patients to access notes on-site. It also sought 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 created a physical peer support drop-in center at its main location in Rochester. It assessed the community’s needs using proven methods like focus groups and “buddy check” phone calls. Building on earlier phases of work, it engaged high-risk populations, such as women veterans and veterans of color. The center was staffed by veteran peers and mental health professionals who provided crisis intervention, case management, and peer support groups. Using data and feedback collected from clients and partner organizations, VOC tailored services and hours of operation to best meet the needs of the veteran community. It served as a hub to connect veterans with housing, substance use disorder treatment, counseling, and referrals to VA health care and benefits. VOC compiled a report that outlines steps and lessons learned for other regions looking to expand suicide prevention efforts.

Common Ground Health

A core strategy for improving health and food security is developing and implementing local food systems plans that reflect regional and local circumstances, strengths, and deficits.

Local food systems plans tackle issues such as: engaging health care systems to advocate for and provide healthier institutional food; starting new farmers markets and urban farms; changing zoning to allow the establishment of new supermarkets and other food access points; strengthening farm-to-school programs; expanding nutrition assistance programs; establishing or scaling local food hubs; and educating government officials and community members about what the food system is and why it is important. Most local planning groups are run by volunteers and are loosely organized. Full-time dedicated staff and organizational structure are needed to accelerate and improve the development of local food systems plans. In 2022, NYHealth awarded Common Ground Health a grant to help develop a formal local healthy food plan tailored to the Finger Lakes region and advocate for policy changes to make healthy, local, and affordable food more available to New Yorkers.

Under this grant, Common Ground Health partnered with the Rochester Food Policy Council (FPC) to develop a local food action plan. FPC engaged in workshops, trainings, and visits to local food system sites to increase learning and build relationships and capacity. Common Ground Health expanded community engagement work and retooled its website to create more interaction with the public. By committing itself to equitable representation, compensation for resident participation, and robust community engagement, FPC developed policy decisions that were informed by and benefited communities of color. FPC worked with a wide range of partners on the food policy action plan, including businesses, farmers markets and food hubs, faith communities, the health care sector, academic institutions, and the urban agriculture sector. Residents were also deeply involved in the planning process. The project demonstrated successes in resident-led food policy decisions and provided models and practices that can be used in cities across New York State.

NYHealth also supported complementary food planning initiatives with Bedford Stuyvesant Restoration Corporation, Catholic Charities of the Diocese of Rochester Food Bank of the Southern Tier, Adirondack Health Institute, Equity Advocates, and Newburgh Urban Farm and Food Initiative.

Rochester Regional Health

Clinical visit notes are an important resource for helping patients and families remember and act on information discussed during a visit, including treatment plans, medication, and care coordination.

Shared visit notes, often referred to as open notes, are an important way to help consumers become active participants in their own care. The 21st Century Cures Act, which went into effect last year, includes a federal mandate that requires all health care providers that maintain electronic medical records 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 varies. For some hospitals, note-sharing is embedded into their practice, and they are ready to expand the types of notes and information they share and to test out innovative ways to meaningfully engage patients. For others, note-sharing is new territory, and they can benefit from adapting proven tools to their own settings and learning best practices from more experienced hospitals. In 2021, NYHealth issued a Request for Proposals (RFP) “From Good to Great: Improving Access to and Use of Patient Visit Notes,” to support hospital facilities in New York State in sharing open notes in compliance with new federal rules and in going beyond compliance to use open notes to more meaningfully engage patients. In 2022, NYHealth awarded Rochester Regional Health (RRH) a grant to participate in this initiative.

Under this grant, RRH continued to implement and improve the use of shared notes within its system, promoting greater information transparency and engaging patients in their care. RRH is an integrated health system that serves residents across the Western, Central, and Northern New York regions. With this grant, RRH supported patient education, improved portal communication, and increased health literacy and engagement among patients. RRH also participated in a 12-month learning collaborative led by OpenNotes staff to explore strategies and tools for note-sharing, including understanding the new federal mandate; sustaining clinician engagement; adopting effective communication strategies to introduce open notes to both providers and patients; and sharing notes in the context of adolescent, pediatric, inpatient, and behavioral health settings, among other areas.

See a full list of grantees participating in this initiative.

ETS Sponsorship Program

Each year, more than 200,000 service members transition from active duty to civilian life, 4,000 of whom resettle in New York State.

The transition from military service to civilian life can be challenging. The combined stresses of a perceived loss of purpose, geographic relocation, financial uncertainty, and underlying medical and psychological issues have led researchers to deem this period as the “deadly gap”—when new veterans face suicide rates more than two times higher than their civilian counterparts. A lack of communication and coordination at the federal, state, and local levels also hampers service members from getting a head start on their transition and being connected with the resources they need for a successful reintegration. New veterans are often left to navigate reintegration on their own. The Expiration Term of Service Sponsorship Program (ETS-SP) has created a scalable program that proactively addresses veterans’ needs before they leave active duty by using unique data dashboards and pairing veterans with peer mentors and resources in their destination communities. In 2022, NYHealth awarded ETS-SP a grant to expand its program within New York State and connect service members leaving active duty and transitioning to veteran status with peer mentors and community resources.

Under this grant, ETS-SP expanded the reach of its program into New York City and 13 counties in the Finger Lakes region. It established formal partnerships with local organizations to serve as community integration coordinators, which trained peer mentors to be paired with transitioning service members. Mentors received training through a VA-certified cultural competency/mentor training program that was previously supported by NYHealth. ETS-SP also conducted outreach to veterans leaving the military and with plans to settle in one of the identified regions. Finally, ETS-SP created virtual dashboard to provide a snapshot of data and information regarding transitioning veterans and the services most often requested in each region. Dashboards were also a secure way for veterans to share medical or discharge information with local providers. ETS-SP aggregated dashboard data to provide monthly needs assessments to each region and share vital information with the VA, the State, and each city’s Department of Veterans’ Services on the number and types of requests from transitioning veterans, demographics, and regional differences.

Finger Lakes IPA, Inc.

The Delivery System Reform Incentive Payment (DSRIP) program and other payment reform initiatives have shifted New York State’s health care landscape toward value-based payment models and increased market consolidation.

These shifts have spurred federally qualified health centers and other safety-net providers to implement strategies to remain financially sustainable and continue delivering care to medically underserved areas. Independent Practice Associations (IPAs), private networks formed by groups of providers, have emerged as a way to negotiate value-based contracts with payers and maximize new reimbursement models. In 2017, NYHealth supported the formation of the Upstate Community Health Collaborative (UCHC) IPA, which serves 100,000 patients in a 6-county area of Central New York. The Finger Lakes Independent Practice Association (FLIPA), located in the Finger Lakes and Western New York regions, was the first IPA in New York State committed to integrating primary care, behavioral health, and social service providers. FLIPA and UCHC have determined that merging into one IPA would better serve more than 200,000 patients with integrated primary care, behavioral health care, and social services, as well as allow them to negotiate together for value-based contracts with managed care organizations. In 2022, NYHealth awarded FLIPA a grant to support its work to operationalize this expansion, bringing together 18 organizations spanning 19 counties in New York State.

Under this grant, FLIPA assessed and finalized new corporate and governance structures for the combined entity. As needed, it restructured other systems such as accounting, contracting, and other technology platforms. FLIPA assessed existing managed care contracts and agreements to integrate UCHC providers. FLIPA also executed new data-sharing agreements to collectively manage and coordinate patient care across all networks. New providers used shared clinical protocols to access FLIPA’s population health management data platform to improve care coordination. Finally, FLIPA developed a business plan for its growth as a combined entity. With its expanded number of providers, FLIPA pursued more joint value-based contracts with Medicaid, Medicare, and commercial payers.

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