New York Health Foundation

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Region: Long Island

Organización Latino Americana (OLA) of Eastern Long Island

Eastern Long Island, or the East End, is commonly associated with luxurious beachside properties, but this wealth masks the economic and racial disparities in this region.

Thousands of Latinos live in the area year-round working in essential industries like landscaping, farming, and hospitality. Many are immigrants, face food and housing insecurity, and have limited access to health and social services. In some school districts in the region, up to 40% of students are Latino and up to 60% live below the federal poverty level. Like their peers across the country, these teens are struggling with mental health challenges that have been exacerbated by the COVID-19 pandemic. In the East End, access challenges are compounded by a shortage of culturally and linguistically appropriate mental health providers, stigma about behavioral health disorders, and cost-prohibitive private treatment. As a result, Latino youth have historically had no one to turn to for help. In 2023, NYHealth awarded Organización Latino Americana (OLA) of Eastern Long Island a grant to expand access to bilingual crisis counseling and mental health services for middle and high school students in five towns on Eastern Long Island.

Under this grant, OLA scaled up its successful pilot, Youth Connect, at five East End school districts. The program used clinical social workers to provide crisis counseling to middle and high school students and partners with Family Service League, the only nonprofit that provides mental health services on the East End. OLA increased access to the Youth Connect helpline, a free and anonymous platform that allows teens to communicate with bilingual crisis counselors who, if needed, referred teens for ongoing care at Family Services League. OLA also worked with school counselors and administrators to develop referral systems to connect students with ongoing mental health support. It collaborated with youth-serving community organizations, houses of worship, and local government agencies to complement school-based services; delivered educational workshops at parent/teacher conferences; and trained youth ambassadors to conduct peer outreach and develop social media content. OLA also advocated at the State and local levels for additional mental health services for Latino families.

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 engaged migrants and reached 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 helped new arrivals enroll in health insurance, scheduled medical appointments at NYC Health + Hospital’s care clinics, and traveled to appointments. MRNY also connected them with other services including food, transportation, English classes, and workplace safety training, and conducted monthly Spanish-language know-your-rights workshops. Lastly, it organized community forums and used feedback to advocate with local and State officials for the needs of asylum seekers.

Health and Welfare Council of Long Island, Inc.

New York State’s approximately 7,000 community health workers (CHWs) are frontline public health workers who are trusted members of their communities.

More than half of them are people of color. CHWs have been proven to improve access to care and health outcomes, address housing and healthy food access, and lower health care costs. Increasing support for these workers in the primary care setting is one way to expand patients’ access to primary care, advance team-based care, and enhance health equity for CHWs themselves through career ladders. With a recent increase in State and federal support, primary care practices are looking to recruit more CHWs but require assistance to integrate them into care teams. Practices also need support in designing updated clinical workflows and supervisory models to help these workers productively contribute to patient care. In 2023, NYHealth awarded the Health and Welfare Council of Long Island (HWCLI) a grant to integrate community health workers into primary care practice teams by providing technical assistance to clinicians across Long Island. NYHealth is also supporting a complementary initiative with Montefiore Medical Center.

Under this grant, HWCLI will create a repository of resources to support practices across Long Island in hiring and integrating CHWs. These resources will be informed by national best practices; interviews with primary care practices and CHWs; and engagement of a workgroup that includes community health centers, hospital outpatient practices, and Medicaid managed care plans. Resources will include job descriptions, interview guides, onboarding materials, and professional development options for community health workers. Tools will also provide guidance on effective referral mechanisms between primary care and community-based organizations. Additionally, HWCLI will engage 12 primary care practices, covering a broad swath of Long Island, to help them put the tools into practice by conducting group training sessions and one-on-one technical assistance. To ensure proper implementation, HWCLI will track outcomes including successful hiring and retention; integration into care teams; and effective referrals between clinicians, CHWs, and social services. Finally, HWCLI and workgroup members will develop a regional CHW policy advocacy agenda in response to on-the-ground needs.

Advantage Care Health Centers (Advantage Care Diagnostic and Treatment Center)

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 Advantage Care Health Centers a grant to participate in this initiative.

Advantage Care is a federally qualified health center in Nassau County that provides primary care, specialty care, and health-related support services to approximately 2,500 patients annually through 2 community health centers and the Fay J. Lindner Center for Autism and Developmental Disabilities. Under this grant, Advantage Care continued to implement and improve the use of shared notes within its system and participated in a technical assistance and peer-learning network. With a focus on improving note-sharing with its patient population, which includes children, adolescents, and adults with intellectual or developmental disabilities, Advantage Care enhanced the sharing and usability of notes through provider training, notes audit, and notes translation. It also conducted patient education, outreach, and navigation to support use of shared notes and sought patient feedback.

See a full list of grantees participating in this initiative.

Parker Jewish Institute for Health Care and Rehabilitation

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 Parker Jewish Institute for Health Care and Rehabilitation a grant to participate in this initiative.

Parker Jewish Institute is a health care and rehabilitation center and skilled nursing facility for older adults providing inpatient programs, community health services, and medical house call services across New York City and Long Island. Under this grant, Parker Jewish Institute continued to implement and improve the use of shared notes within its system, particularly its medical house call program, and participated in a technical assistance and peer-learning network. It enhanced the sharing and usability of notes through provider and patient education, with a focus on improving note-sharing for its patient population of homebound older adults. It also upgraded its patient portal to facilitate easier note-sharing and sought patient feedback.

See a full list of grantees participating in this initiative.

St. John’s Medical Group (Episcopal Health Services)

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 St. John’s Medical Group a grant to participate in this initiative.

St. John’s is a hospital-affiliated physician network in the Rockaways and the Five Towns in Nassau County that provides comprehensive primary, pediatric, mental health, specialty, and wellness care to approximately 17,000 patients at multiple outpatient locations. With this grant, St. John’s will continue to implement and improve the use of shared notes within its system, particularly its pediatric and mental health practices, and participate in a technical assistance and peer-learning network. St. John’s will enhance the sharing and usability of notes through provider training on writing patient-friendly notes and the creation of new note-sharing workflows. It will also conduct patient education and outreach, including marketing campaigns and in-person workshops.

See a full list of grantees participating in this initiative.

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