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  • Improving Health Home Capacity to Serve Homeless Clients By: NYSHealth Priority Areas: Special Projects Fund Date: March 2017 Type: Grant Outcome Reports, Grantee Name: Corporation for Supportive Housing

    The Affordable Care Act gave states the option to provide coordinated services for Medicaid patients with multiple chronic conditions through “health homes”—networks of providers across communities that facilitate access to various medical, behavioral, and social services. Health homes have the potential to reorganize how care is delivered, managed, and coordinated for high-need and high-cost patients, which in turn could lead to lower emergency room use; reductions in hospital admissions and readmissions; reductions in higher health care costs; and improved quality of care. However, health home patients who are unstably housed often cycle through emergency rooms, detox facilities, hospitalizations, and shelters, resulting in enormous costs and poor health outcomes. To address this issue, NYSHealth awarded Corporation for Supportive Housing (CSH) a grant to improve coordination of care for health home patients with the supportive housing sector.

  • Developing the Community First Choice Program in New York By: NYSHealth Priority Areas: Special Projects Fund Date: March 2017 Type: Grant Outcome Reports, Grantee Name: New York Association on Independent Living

    In March 2011, New York State made an express commitment to implement the Community First Choice (CFC) an option under the Affordable Care Act that offers states enhanced Medicaid matching funds to enable people who would be eligible for institutional level of care to stay in their homes and get services in the community. This option was a win for both the State and its most vulnerable residents, with the potential to expand access to community-based services for approximately 1 million New York Medicaid recipients, generate an estimated $90 million a year in net Medicaid savings to the State, and rebalance incentives away from institutional care settings. NYSHealth awarded New York Association on Independent Living (NYAIL), in partnership with the Center for Disability Rights (CDR), a grant to work with the State on developing and adopting the CFC program in New York.

  • Accelerating Change Through 100-Day Challenges By: NYSHealth Priority Areas: Building Healthy Communities Date: March 2017 Type: Grant Outcome Reports, Grantee Name: Rapid Results Institute, Inc.

    NYSHealth launched the Healthy Neighborhoods Fund initiative to help New York State communities become healthier and more active places. Although all the communities are working toward the common goal of improving the health of their residents, each community may face particular challenges. In response, NYSHealth is supporting these communities with more specialized technical assistance (TA) to help them meet their goals. In 2015, NYSHealth awarded a grant to the Rapid Results Institute (RRI) to provide TA to the Clinton County Health Department (CCHD) to increase physical activity among its residents. Under this grant, RRI worked with CCHD on implementing RRI’s 100-day challenge plan, a methodology that challenges organizations to achieve radically ambitious yet tangible and measurable goals in 100 days. CCHD’s goal was to increase participation in senior walking programs by 300% and increase new participation by youth in physical activity programs by 50%.

  • Empowering Community School Directors By: NYSHealth Priority Areas: Building Healthy Communities Date: February 2017 Type: Grant Outcome Reports, Grantee Name: Coro New York Leadership Center

    Community schools serve as neighborhood hubs where students receive high-quality academic instruction, families can access social services, and communities congregate to share and address their common challenges. The New York City Department of Education (NYCDOE) began this initiative in an effort to provide a holistic and comprehensive approach to education in urban centers. At each community school, a community school director (CSD) identifies student needs and facilitates relationships with community-based organizations that can address those needs. As CSDs are not educators or NYCDOE employees, they face challenges in having the authority to lead changes in their schools as compared with traditional school leaders. In 2016, NYSHealth awarded Coro New York Leadership Center a grant to provide leadership training to 110 CSDs in New York City. The leadership training program aimed to equip CSDs with skills to implement and lead holistic practices at community schools, such as supporting the provision of in-school health and mental health services and bolstering community and parent engagement with schools.

  • Linking New York State Veterans and Their Families to Supportive Services By: NYSHealth Priority Areas: Veterans' Health Date: February 2017 Type: Grant Outcome Reports, Grantee Name: Iraq and Afghanistan Veterans of America, Inc

    In response to ongoing challenges facing veterans, the Iraq and Afghanistan Veterans of America (IAVA) launched its Rapid Response Referral Program (RRRP) for returning veterans and their families. The program was designed to link veterans and their families to case managers and veteran-specific resources across New York City, providing broader access to benefits in a community setting. Services range from helping veterans and family members deal with depression and stress to connecting them to health care, mental health, legal, housing, and employment services. In 2013, NYSHealth awarded IAVA a grant to double its capacity by expanding RRRP across New York State. In 2015, NYSHealth awarded IAVA a second grant to further build upon the program’s expansion.

  • Improving Outcomes and Reducing Costs for Medicaid Managed Care Patients By: NYSHealth Priority Areas: Advancing Primary Care Date: February 2017 Type: Grant Outcome Reports, Grantee Name: Refuah Health Center

    Refuah Health Center is a federally qualified health center that serves low-income residents in the Hudson Valley region. NYSHealth awarded Refuah a grant to partner with Fidelis Care, one of the largest Medicaid managed care plans in New York State, and Health Management Associates (HMA), to collect and then analyze claims to identify unnecessary utilization and costs. At the time, Refuah lacked information on the utilization patterns of its patients outside of its center, such as costs of emergency, specialty, and hospital care. Under this grant, it aimed to use the data collected to implement new payment schemes for lowering health care costs and improving quality of services for its patients.

  • Exploring the Role of Hospitals in Improving Population Health By: NYSHealth Priority Areas: Building Healthy Communities Date: February 2017 Type: Grant Outcome Reports, Grantee Name: Cornell University Weill Cornell Medical College

    There has been increasing attention to the concept of population health—the health of all the people in a geographic community. Population health comprises more than medical care; it also includes factors such as socioeconomic status, the built environment, and education. Hospitals and accountable care organizations can play important roles as key drivers of population health, but medical professionals often have a much narrower definition of this concept. Creating a common definition of population health is essential both to assess the extent to which hospitals are working to improve population health and understand what resources are (or are not) being allocated to this important work. In 2014, NYSHealth awarded Weill Cornell Medical College a grant to gather and analyze information on the current and future role of New York State hospitals in improving population health.

  • Addressing Social Determinants of Health Through Medicaid By: NYSHealth Priority Areas: Advancing Primary Care Date: January 2017 Type: Grant Outcome Reports, Grantee Name: Milbank Memorial Fund

    Social factors, such as income, access to food and housing, and employment status, have a significant impact on the health and health outcomes of Americans, particularly lower-income populations. Faced with mounting evidence on the importance of these social factors, state Medicaid agencies are looking for ways to integrate social interventions into their coverage, payment, and delivery models to improve the health of Medicaid beneficiaries, who are often the costliest and most complex patients. As they do so, states must decide which social interventions Medicaid should cover, recognizing that Medicaid is not a social services program and that there are limits on how it can be used. Although New York State’s interest in responding to these issues is strong, policymakers lacked actionable information on when and how Medicaid can play a role. NYSHealth joined with the Milbank Memorial Fund to develop an issue brief that provides State officials with practical guidance on how Medicaid can be used to address social determinants of health.

  • Scaling Up a Model to Prevent HIV Transmission in New York City By: NYSHealth Priority Areas: Special Projects Fund Date: January 2017 Type: Grant Outcome Reports, Grantee Name: Housing Works, Inc.

    Despite advances in medicine, the AIDS epidemic continues to be a major public health concern—especially in New York City, which remains an epicenter of the disease. During 2013, New York City recorded 2,832 new HIV diagnoses and 1,784 new AIDS diagnoses. Currently, more than 117,000 people are living with diagnosed HIV infection in New York City, many of whom come from vulnerable populations. Federal guidelines recommend antiretroviral (ARV) medication for all people living with HIV. ARV treatment suppresses the level of HIV in the blood to an undetectable level, which enables HIV-positive people to live healthy lives while making it virtually impossible to transmit the virus to others. Although ARV is highly effective and is now the established standard of care, only 43% of HIV-positive New York City residents have achieved viral suppression. In 2015, NYSHealth awarded Housing Works a grant to scale up a successful viral load suppression model, The Undetectables, to help those living with HIV manage the disease and prevent its further transmission. This evidence-based model has been shown to successfully suppress the virus in 82% of participants. Under this grant, Housing Works aimed to expand The Undetectables model and form a consortium to collectively adopt, refine, and scale up the model throughout New York City.

  • Developing a Wholesome Foods Pop-Up Market By: NYSHealth Priority Areas: Building Healthy Communities Date: January 2017 Type: Grant Outcome Reports, Grantee Name: Field & Fork Network, Inc.

    NYSHealth launched the Healthy Neighborhoods Fund initiative to help six communities across New York State become healthier and more active places, one of which is Niagara Falls’ North End neighborhood. As part of this initiative, NYSHealth awarded Create a Healthier Niagara Falls Collaborative a grant to improve access to affordable, healthy food in the community by expanding pop-up farmers’ markets. Pop-up markets are a convenient and affordable way for residents to purchase fresh, healthy foods in neighborhoods with limited or no access to such food options. In 2015, NYSHealth awarded Field & Fork Network a modest grant to provide technical assistance to the Collaborative in the development of a wholesome foods pop-up market.

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