Independence Care System

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. In 2023, 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 Independence Care System (ICS) a grant to participate in this initiative.

Under this grant, ICS will establish a Center of Excellence for primary care for people with disabilities at Woodhull Hospital, evaluate its impact, and support replication across the New York City Health + Hospitals (H+H) system and beyond. ICS will conduct focus groups in Brooklyn with 100 patients with physical disabilities to identify specific care needs and experiences with primary care providers. It will adjust care protocols based on patient feedback and evidence-based practices, and it will improve Electronic Medical Record documentation to better identify patients’ needs for accommodation. ICS will train primary care providers, clinical staff, and administrative staff and offer on-site consultation to support the delivery of more accessible and equitable care. In partnership with leading national researchers, ICS will analyze the model’s impact on enhancing uptake of screenings and preventive care, reducing hospitalization, and improving patient health outcomes. It will create resources to enable replication across H+H, including policies and procedures, disability competency training curriculum, and continuing education opportunities. It will also disseminate learnings through peer-reviewed publications and online patient and provider educational resources.

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

EngageWell IPA

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. In 2023, 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 EngageWell IPA a grant to participate in this initiative.  

Under this grant, EngageWell will connect residents living in emergency shelters and supportive housing across New York City to virtual medical and behavioral health services, aiming to reduce racial health disparities in primary care use and health management. EngageWell will facilitate a planning process with input from shelter and supportive housing residents to create a virtual, trauma-informed medical care experience that increases access to and trust in routine preventive care. EngageWell will seek to provide residents with 700 virtual primary care, urgent care, and mental health visits in home and congregate settings at up to 7 housing agencies. Residents will receive support and technology navigation from community health workers and referrals to follow-up care with EngageWell’s health care provider network. EngageWell will prioritize care to residents of color, residents with chronic conditions, residents who have not seen a primary care doctor in the past year, and residents who frequent the emergency department. EngageWell will evaluate the impact of this model on reducing emergency department use and share project findings through fact sheets, policy briefs, or conference presentations. It will disseminate best practices and lessons learned to stakeholders including national and statewide housing and health care provider networks; university partners; and digital health vendors.  

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

Jewish Board of Family and Children’s Services

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. In 2023, 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 the Jewish Board of Family and Children’s Services a grant to participate in this initiative.  

Under this grant, the Jewish Board will integrate primary care services into its Certified Community Behavioral Health Clinics (CCBHCs) in Brooklyn, the Bronx, Manhattan, and Staten Island to increase access to care and decrease care fragmentation for individuals with co-occurring primary care, mental health, and substance use disorder needs. It will embed primary care teams of clinicians and patient navigators to provide services like vaccinations and immunizations; diabetes, cardiovascular, hepatitis, and cancer screenings; medication management; health counseling; and family planning services. The Jewish Board will create and disseminate a framework on how to effectively and sustainably integrate primary care into CCBHCs to support other CCBHC agencies in meeting new regulations. It will also advocate for regulatory and funding changes to better enable primary care integration into CCBHCs.  

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

Strong Children Wellness Medical Group

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. In 2023, 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 Strong Children Wellness Medical Group (SCW) a grant to participate in this initiative. 

Under this grant, SCW will scale and evaluate a model of pediatric care embedded within community-based organizations designed to address inequities in health outcomes. This innovative model integrates pediatric primary care with mental health, substance use disorder, early head start, and social service programs. It is designed to provide two-generational and trauma-informed support for children and families from historically marginalized communities through care teams comprising clinicians and navigators. SCW will expand its integrated model, originally piloted in the Jamaica and Flushing neighborhoods of Queens, into the Woodside neighborhood, with co-located clinical and social services at The Child Center of New York.  SCW will engage a community advisory board in project design and evaluation to ensure services are culturally and socially responsive and reflective of community need. SCW will evaluate its wraparound model to assess impact—relative to traditional sources of pediatric primary care—on health outcomes such as vaccinations, developmental screenings, behavioral health management, and childhood obesity, among other metrics of engagement and patient experience. It will also create a toolkit to disseminate its pediatric integrated primary care model with health care providers, social service professionals, and policymakers across New York State.  

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

Black Veterans for Social Justice

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

Under this grant, BVSJ 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. BVSJ 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. BVSJ 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 BVSJ 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.

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