Data-Driven Equity Interventions

Conducts triennial Community Health Needs Assessments (CHNAs) using quantitative and qualitative data, stakeholder input, and public feedback, and develops CHNA Implementation Strategies and Community Service Plans to guide hospital and community benefit programming in the Capital Region.

Provides 3T MRI services at outpatient locations including the Walmart Plaza on Route 4 in East Greenbush and at St. Peter’s Hospital in Albany, enhancing patient access and comfort.

Offers same-day evaluation and diagnostic testing for non-life-threatening cardiac symptoms, including echocardiogram, electrocardiogram (EKG or ECG), and stress testing.

Offers multidisciplinary breast care through certified mammographers, radiologists, pathologists, oncologists, surgeons, nurses, and nurse navigators, with facilities accredited by the National Accreditation Program for Breast Centers and designated as a Breast Imaging Center of Excellence by the American College of Radiology in Albany and Troy.

Delivers accredited home infusion therapy services, administered in patients' homes and accredited by the Community Health Accreditation Partner (CHAP).

Implements trauma-informed community initiatives through structured programming and convenes the Trauma-Informed Communities committee every other month to promote awareness and systemic change in Livingston County.

Operates an integrated rural health network with participation from approximately forty multi-sector organizations, hosting quarterly general membership meetings (in person and via Zoom), annual membership meetings with Board elections each November, and monthly community meetings in Lima Town Hall to advance collective health goals in Livingston County.

Provides suicide prevention education and support through initiatives such as Lock and Talk Livingston, Safe Talk, and the Out of the Darkness Walk; offers presentations, outreach materials, and access to the 988 Suicide & Crisis Lifeline. Convenes the Suicide Prevention Task Force monthly and operates Step by Step, a monthly peer support group for those affected by suicide or sudden loss.

Implements the Be Well in Livingston program across communities such as Nunda and Mount Morris, promoting improved nutrition, physical activity, and stress reduction through community-wide engagement and healthier practices in worksites. Includes hosting quarterly committee meetings and providing access to a calendar of health events.

Conducts and publishes annual reports in 2023, 2024, and 2025 to document progress, outcomes, and activities related to community health initiatives in Livingston County.

Provides free care management services to Medicaid recipients, including those dually eligible for Medicare and Medicaid, by coordinating medical appointments and connecting patients to community supports such as housing, food, and legal services.

Operates two urgent care locations in Fulton and Central Square, along with a multi-specialty medical group of over 100 physicians and providers, delivering primary and specialty care services to patients aged 3 months and older across Central New York.

Annually provides $24 million in free medical care to uninsured, underinsured, and indigent individuals as part of a community investment initiative, ensuring accessible quality healthcare regardless of ability to pay.

Offers Continuing Medical Education, Cultural Competency, and Health Literacy training for providers and supports over 1,000 network practices in care management using RHIO and EMR systems.

Conducts daily PHQ-9 and GAD-7 mental health screenings across 900 practices and offers mental health education, support groups, and psychosocial services to promote community well-being.

Designs and implements participatory research and multi-year communication campaigns informed by community needs, including the 'Invisible: State of Latino Health' and 'MisUnderstood: State of Chinese Health' studies.

Provides screening and personalized support to Medicaid members for access to healthy food, housing assistance, transportation to medical appointments, and other social services to address social determinants of health.

Established the SOMOS Community Care Collaboration Hub as part of the New York 1115 Waiver Social Care Network to integrate clinical and social services for underserved populations.