Good Food Buffalo Coalition (fiscal sponsor: Massachusetts Avenue Project)

Food systems planning is a collaborative process among farmers, retailers, consumers, nonprofits, health systems, and government to develop priorities and implement policies that shape how local or regional food systems operate.

Benefits of food planning include improving food procurement at public institutions, supporting local retail food businesses, and strengthening outreach and enrollment in benefits programs. NYHealth is supporting eight food planning groups in New York State that are developing tailored food system plans. Buffalo’s food planning group, the Good Food Buffalo Coalition, has chosen the adoption of the Good Food Purchasing Program (GFFP) as its priority. GFPP guides public institutions to make purchases that align with values including increased nutritional quality. GFPP also creates opportunities for small farms and suppliers who traditionally have had less capacity to compete for institutional contracts. In 2022, NYHealth awarded the Good Food Buffalo Coalition a grant to assess the readiness of local farmers for GFPP, publish a resource directory for farmers of color, and work with community members to develop a GFPP racial justice action plan. The Coalition also partnered with Buffalo Public Schools to complete a GFPP baseline assessment to understand how schools performed. With the support of the Good Food Buffalo Coalition, Buffalo Public Schools is now poised to implement GFPP. In 2024, NYHealth awarded the Good Food Buffalo Coalition a grant to implement a local food system plan to harness the collective purchasing power of schools to improve meal quality, lower costs, and support local agriculture.

Under this grant, the Good Food Buffalo Coalition will help secure Buffalo Public Schools’ implementation of GFPP. With the baseline assessment complete, it will work with district decision-makers to identify key opportunities to shift purchasing in line with GFPP. The Coalition will also partner with Buffalo Public Schools’ Office of Nutrition Services to maximize the potential of the district’s new centralized kitchen to prepare scratch-cooked, fresh meals for the district’s 30,000 students.. The Good Food Buffalo Coalition will also continue to strengthen its membership and to educate local and State policymakers about GFPP.

Home HeadQuarters, Inc.

Buffalo suffers from the highest rates of childhood lead poisoning in New York State and the country, largely because more than 90% of the housing stock was built before lead-based paint was banned.

Childhood lead poisoning can cause irreversible damage, resulting in issues with learning, development, and cognition. Lead poisoning affects communities of color and immigrant communities disproportionately. Children in Buffalo’s low-income neighborhoods and communities of color are 12 times more likely to be diagnosed with elevated blood lead levels than children who live in the city’s predominantly white neighborhoods. Refugee families, who make up a growing proportion of Buffalo’s population, are at a heightened risk. They are more likely to live in Buffalo’s substandard housing with lead exposure because they face limited affordable housing options and are unfamiliar with health and housing codes. Furthermore, language and cultural barriers and difficulties navigating health systems complicate the ability to mitigate lead exposure for refugee families. In 2024, NYHealth awarded Home HeadQuarters (HHQ) a grant to address high rates of childhood lead poisoning in Buffalo through community education, lead testing, housing remediation, and improved clinical follow-up.

Under this grant, HHQ will lead the Buffalo and Erie County Lead Safe Task Force. In 2023, the task force adopted a strategic plan to coordinate and deploy complementary community engagement and education, health care, early intervention, and code enforcement strategies. The task force partnered with Jericho Road Community Health Center, which serves many pediatric patients diagnosed with elevated lead levels. HHQ will expand upon Jericho Road’s Community Health Worker (CHW) program to facilitate health and social services for refugee and immigrant children with elevated lead levels. The program will connect children who test positive to a dedicated CHW who will help families navigate resources. CHWs will conduct home visits, offer case management, distribute lead safety cleaning kits, and assist with interpretation at home visits from Erie County Department of Health (DOH) inspectors. CHWs will also educate property owners about the harmful effects of lead, connect them to mitigation training through the Erie County DOH, and provide guidance on financing for lead remediation services. In addition, HHQ will coordinate a campaign to push for stronger rental housing regulations and increased resources for lead hazard remediation.

Integrity Partners for Behavioral Health IPA

There is a mental health crisis among youth and young adults, as well as a growing and related concern in adolescent substance use, including abuse of alcohol, tobacco, opioids, and other drugs that can lead to addiction.

In 2020, among 12–17-year-olds, more than 8% reported using drugs in the past month, 10% used alcohol, and nearly 3% met the criteria for illicit drug use disorder in New York State. More teens are also dying of drug overdoses, with the rate nearly doubling between 2019 and 2020 across the country. Substance use disorder often co-occurs with mental health problems, including anxiety, depression, and suicidal ideation, and it can trigger or worsen these symptoms. Studies show that one of the most effective treatments for substance use disorder integrates family into the treatment process—known as family behavioral therapy. This approach improves communication and problem-solving skills and enhances positive family interactions to foster a supportive and healthy environment for recovery. It often results in better long-term outcomes compared with other approaches. In 2023, NYHealth awarded Integrity Partners for Behavior Health IPA (IPBH) a grant to integrate family members into behavioral health care interventions for adolescents with substance use disorders in Western and Central New York.

Under this grant, IPBH will test the family behavioral therapy model at 21 rural behavioral health sites across 14 counties in Western and Central New York with the aim of creating a replicable and cost-effective model that promotes sustained substance use recovery. It will conduct a readiness assessment among participating practices to implement family behavioral therapy, training 24 licensed therapists on the model and treatment protocol. Clinical staff will recruit patients ages 10–19 with substance use disorder to participate in the family behavioral therapy program. They will offer 12–16 family sessions on topics such as communication, conflict resolution, problem-solving, and environmental factors. To track recovery of patients, IPBH will measure the frequency of substance use among adolescents and the changes in family functioning. Additionally, IPBH will educate health and social service providers across the 14 counties on family behavioral therapy practices. It will establish referral pathways for adolescents who need additional services, including other recovery services, education, health care, housing, and food, creating a holistic network to support young people and their families toward recovery. Lastly, IPBH will partner with the University at Buffalo to track activities and outcomes across the provider network. It will share findings and best practices through peer-reviewed publications and conferences to encourage other provider networks to integrate family-based therapies in rural communities.

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.

Jericho Road Community Health Center (Jericho Road Ministries)

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 Jericho Road Community Health Center a grant to participate in this initiative.

Jericho is a federally qualified health center in Buffalo that provides comprehensive primary care, specialty care, and health-related support services to approximately 24,000 patients annually across 5 primary care clinics, a safety-net dental clinic, and a pharmacy. Under this grant, Jericho will continue to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. With a focus on improving note-sharing with its patient population, including refugees, it will engage community health workers to lead patient education, outreach, and navigation efforts and install kiosks for patients to access notes on-site. Jericho will also upgrade its patient portal and website to facilitate easier note-sharing.

See a full list of grantees participating in this initiative.

Anthony L. Jordan Health 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 Anthony L. Jordan Health Center a grant to participate in this initiative.

Jordan Health is a federally qualified health center in the Greater Rochester area that provides comprehensive services—including primary care, obstetrics/gynecology, behavioral health, dental health, and medication-assisted treatment—to approximately 38,000 patients annually across 9 sites. Under this grant, Jordan Health will continue to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. Jordan Health will enhance the sharing and usability of notes through provider training, notes audit, and notes translation. It will also engage a patient advocate to lead patient education, outreach, and navigation efforts to increase use of shared notes and install kiosks for patients to access notes on-site. It will seek patient feedback on these patient engagement and provider training efforts.

See a full list of grantees participating in this initiative.

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