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.

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 will continue to implement and improve the use of shared notes within its system and participate in a technical assistance and peer-learning network. Mosaic will enhance 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 will create patient education materials in multiple languages, conduct outreach and navigation, and install kiosks for patients to access notes on-site. It will also seek patient feedback on these patient engagement and provider training efforts.

See a full list of grantees participating in this initiative.

Buffalo Go Green

Nearly one in ten New Yorkers is food insecure, and food insecurity jeopardizes health.

Veterans are twice as likely to be food insecure compared with the non-veteran population, with even higher rates among sub-groups like women and those with serious mental illness. More than half of eligible veterans are not enrolled in the Supplemental Nutrition Assistance Program (SNAP), and many of those who are enrolled still struggle to afford healthy foods. Recognizing the connection between food and health, health care systems are increasingly screening for food insecurity and implementing Food Is Medicine interventions. Food Is Medicine usually takes the form of prepared meals or food boxes that are medically tailored to an individual patient, often with a food “prescription” written by a health care provider. In 2023, NYHealth awarded Buffalo Go Green (BGG) a grant to expand a partnership between health care and community-based organizations to provide a suite of Food Is Medicine services to 1,500 food-insecure veterans in Western New York.

Under this grant, BGG will continue working with the Community Health Center of Buffalo to expand its signature fruit and vegetable prescription program, FVRx. BGG will coordinate with its partners to screen veterans and provide Food Is Medicine and enrollment services to at least 750 food-insecure veterans per year. A registered dietitian and social worker will work with each veteran to identify services to best meet their individual needs, such as one-on-one nutrition counseling; fresh food box deliveries; and enrollment in SNAP, Double Up Food Bucks, and the Farmers Market Nutrition Program. BGG will also work with the Buffalo Veterans Health Administration (VA) to integrate program services at VA sites and provide technical assistance to operationalize screenings and referrals throughout the program. In addition, BGG and the health center will partner with the University of Buffalo to evaluate the expanded program by assessing food-insecure veterans’ needs and experiences. The evaluation team will track the suite of services used by each veteran and use that data to tailor the program design. BGG will develop a financial sustainability plan that will enable the health center to bill insurance for counseling services.

caret-down