Hudson Valley National Center for Veteran Reintegration

New York State is home to nearly 600,000 military veterans and welcomes an additional 4,000 each year who are transitioning from active duty into civilian life.

For new veterans, the transition from military service to civilian life can be an extra challenge, as they may also face relocation and a perceived loss of purpose. Despite challenges, veterans often do not ask for help until a crisis and may be reluctant to speak with someone they believe would not understand their circumstances; they can feel more comfortable opening up to a fellow veteran. That dynamic makes peer-to-peer programs an effective approach; peers are equipped to offer practical skills and information, as well as shared experience, social connection, and hope. In New York State, the most widespread peer mentor program for veterans is the State’s flagship Joseph P. Dwyer Peer Support Program; it reduces isolation, increases social connectivity, and connects veterans with community-based resources. In 2022, the State roughly tripled the overall program budget and paved the way for the program to expand statewide. In 2024, NYHealth awarded the Hudson Valley National Center for Veteran Reintegration (CVR) a grant to maximize the impact of the State’s investment, expand high-quality veterans’ peer-to-peer services, and formalize a statewide peer mentor coalition to spread best practices and educate policymakers about ways to sustain and spread effective programs. NYHealth is also supporting a complementary initiative with Clear Path for Veterans.

Under this grant, CVR will formalize its “We Are Dwyer” coalition, comprising more than 100 peer mentor programs, providers, and other stakeholders. It will host coalition meetings to identify regional goals and define a shared advocacy agenda; leverage federal, State, and local funding opportunities; educate members about best practices for communicating with policymakers; and share tools and resources for peer mentors. CVR will partner with Clear Path to raise awareness about evaluation findings and technical assistance opportunities. It will also create an online directory for local Dwyer Program providers to access centralized information. CVR will develop a shared policy agenda and action plan based on input from members, veteran service organizations, and Clear Path’s evaluation. It will also partner with Clear Path to educate policymakers about ways to strengthen the program through future policy and regulatory changes.  

Open Door Family Medical Center, Inc.

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. 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 Open Door Family Medical Center a grant to participate in this initiative. 

Under this grant, Open Door will conduct a feasibility study to open a federally qualified health center (FQHC) location to expand access to primary care in Delaware County, a rural shortage area. It will partner with existing social and health service providers and a community advisory group to identify sites suitable for an FQHC and forecast costs associated with site renovation and initial clinic operation. Open Door will engage Delaware County residents to understand their care needs, barriers to health care access, and acceptance of non-physician-led care teams, in light of health professional shortages in the region. To address these workforce shortages, Open Door and partners will investigate the feasibility of a nurse-led care model, in which nurse practitioners serve as the lead primary care providers. Open Door will also cultivate partnerships with training programs for nurse practitioners, registered nurses, and medical assistants to provide tailored education on rural, community-based primary care and create pipelines into the FQHC setting. 

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

Mental Health America of Dutchess County

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 Mental Health America of Dutchess County (MHADC) to expand access to suicide prevention services by increasing outreach to and engagement with veterans in the Hudson Valley. NYHealth is also supporting complementary projects across New York State with Homeward Bound USA, Black Veterans for Social Justice, and the Oneida County Department of Mental Health.

Under this grant, MHADC 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. MHADC 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. MHADC 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 MHADC to address challenges with lags in suicide data to evaluate success of on-the-ground efforts and assess annual reductions in suicide rates.

Make the Road NY

More than 100,000 migrants and asylum seekers have arrived in New York City since spring 2022.

Most migrants arrive with nothing but the clothes on their backs. Among them are children who need vaccines to enroll in schools, pregnant women needing immediate prenatal care, and people with a host of other physical health conditions, mental health issues, and trauma. In response, New York City has opened a central arrival center and several resource navigation centers where migrants can access necessities and be connected to community-based organizations. Additionally, NYC Health + Hospitals is providing emergency care, basic health care, and immunizations. Despite these resources, migrants face barriers when navigating the complex health system. The City’s safety net and housing systems have also been pushed to a breaking point, its emergency shelter population topping 100,000 in summer 2023. City officials have sought to relieve the pressure by busing more than 2,200 migrants to Western New York, Albany, and the Mid-Hudson region, with plans to relocate others to the Finger Lakes. But poor coordination has left those areas scrambling to meet demand for services and has contributed to growing tensions. In 2023, NYHealth awarded Make the Road NY (MRNY) a grant to address the urgent health and mental health needs of newly arriving migrants and asylum seekers settling in New York. NYHealth is also supporting complementary initiatives with the New York Immigration Coalition and Terra Firma at Montefiore Medical Center.

Under this grant, MRNY will engage migrants and reach 6,000 asylum seekers at arrival centers in New York City, Long Island, and Westchester to provide health screening and connect them with health and mental health services, using bilingual community health workers. It will help new arrivals enroll in health insurance, schedule medical appointments at NYC Health + Hospital’s care clinics, and travel to appointments. MRNY will also connect them with other services including food, transportation, English classes, and workplace safety training, and conduct monthly Spanish-language know-your-rights workshops. Lastly, it will organize community forums and use feedback to advocate with local and State officials for the needs of asylum seekers.

Doctors United

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 Doctors United a grant to participate in this initiative.

Doctors United is a multi-specialty physician practice in the Bronx and Westchester County that provides diagnostic, treatment, and pain management services across five sites. Under this grant, Doctors United will continue to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. It will also create bilingual patient education materials—including step-by-step guides on how patients can access notes—and support education with outreach and navigation efforts.

See a full list of grantees participating in this initiative.

Make the Road New York

Since April 2022, the governors of Texas, Florida, and Arizona have sent thousands of migrants by bus to New York City—pushing the City’s safety-net services to the breaking point and prompting Mayor Adams to declare a state of emergency.

Most migrants arrived with nothing but the clothes on their backs and are in need of urgent medical care. Among them are children who need vaccines to enroll in schools and pregnant women needing immediate access to prenatal care. But migrants do not know how to navigate the complex health system. New York City opened the Asylum Seeker Resource Navigation Center, where migrants can access basic necessities and connect with community-based organizations that provide specialized support services. Most recently, the flow of migrants has slowed down, but there are still many newly arrived migrants in need of health assistance. Make the Road New York (MRNY) has been onsite at the Center to help hold orientation sessions for migrants. In 2022, NYHealth awarded MRNY a grant to build on this work and connect migrants to health care access and other specialized services in New York State.

Under this grant, MRNY conducted outreach at key locations that migrants often attend, such as food pantries, schools, and health fairs, to provide information about available services, COVID-19 vaccines and treatments, and additional referrals. It also provided health care enrollment assistance and health care navigation by connecting migrants to NYC Health + Hospitals’ primary care program, ensuring that children have access to vaccines needed to enroll in schools and pregnant women receive prenatal services. MRNY also referred migrants to other vital services, including workforce training, adult education classes, and food pantries.