Annual Report 2023: Health Foundation for Western & Central New York

Reframing the

big picture

Bringing health equity into focus

Mission

To improve the health and health care of the people and communities of western and central New York.

Vision

A healthy central and western New York where racial and socioeconomic equity are prioritized so all people can reach their full potential and achieve equitable health outcomes.

Arthur R. Goshin, M.D., M.P.H. (Advisor)

Marybeth K. McCall, M.D., Secretary

Marnie Annese Senior Program Officer

Gwen Baggs Ito Storytelling and Advocacy Content Specialist

Jordan Bellassai Program Officer

Coralie Brown Grants Officer

Steve Copps Operations Manager

Roxanne Cuebas Program Officer

Leslie Daniel

Executive Assistant to the President

Kenneth M. Genewick Vice President of Programs

Kerry Jones Waring Vice President for Communications

Kristen Luppino-Gholston Program Officer

Nora OBrien-Suric, Ph.D. President

Diane Oyler, Ph.D.

Executive Vice President

Ann Marie Sava

Director of Finance and Administration

To our community partners

When we first embarked on our vision of racial and socioeconomic health equity, we knew that it would require more than the standard philanthropic approach to change. The impact we want to make goes beyond providing funding or starting programs—although we’re very proud of that work, too.

To truly improve the lives of the people we serve, we recognized that we need to use our resources to disrupt structural barriers and change the systems that have an impact on our community’s health.

These systems could be the way we access health care (and pay for it!); how we build communities for people of all ages; what defines a healthy childhood; or what health equity really looks like.

It’s how, together, we change the conversation around health.

This kind of change takes time and effort, but the results—as you can see in these pages—are worth it.

We’re proud to share these stories of progress and impact, the culmination of years of partnership and hard work.

We are grateful to our grantee-partners for trusting us to work together on these important issues. Together, we’re shifting mindsets, fueling momentum, and helping more people recognize that everyone deserves their best chance at a healthy life.

Thank you for collaborating with us to reframe the big picture.

Sincerely,

Nora OBrien-Suric, Ph.D. President

Changing the statewide conversation about doulas

A 2017 study showed that patients with access to a doula had a 39% reduction in the likelihood of cesarean birth and 31% reduction in reporting a negative birth experience.*

How doulas provide comfort and build trust

A doula is a trained, nonclinical professional whose services can improve pregnancy, birth, and postpartum outcomes. A doula isn’t the same as a midwife, who is clinically trained to deliver a baby. Instead, a doula is wholly focused on the physical, emotional, and psychological needs of the birthing parent.

As an extension of the care team, the doula becomes the person in the delivery room to provide moral support and advocate for the birthing person. Doulas can’t make any clinical decisions, but they can facilitate communication between the patient and the medical team and help navigate the emotional roller coaster of labor.

Learn more about the benefits of doulas in this related story.

Data show us that doulas can contribute to better maternal health outcomes, including fewer premature births and cesareans, and yet these professionals have traditionally been ignored by health care systems. The Health Foundation has funded programs in both western and central New York to help doula access for low-income parents. Thanks in part to the outcomes from those programs, along with ongoing work by advocates, New York State recently enacted policy changes that will make it easier for low-income people to access doulas.

New York State’s doula pilot program

In 2018, New York State’s Department of Health launched a pilot program for doula services in Erie County to expand maternal support for Medicaid-insured patients. At the time, doulas weren’t being compensated through Medicaid for their services.

The pilot was a resounding success. Doulas reported that the program allowed them to expand their capacity to serve more Medicaid members. They could support clients by advocating for a childbirth experience that considered their clients’ preferences. The number of families on Medicaid who used doulas increased. The number of vaginal births increased, resulting in lower insurance costs.

Previously ineligible for Medicaid reimbursements, doulas could now receive $600 per pregnancy (eight visits, labor, and delivery). The pilot was expanded statewide, and in 2023, under the leadership of Governor Kathy Hochul, Medicaid reimbursements for doulas more than doubled: $1,500 in New York City and $1,350 in upstate New York.

“A lot of people still don’t know what doulas are or that it’s an option for them.”

Kalia McCray, Birth Equity Project Manager, Erie Niagara Area Health Education Center

Doulas help build a healthy foundation for families

Training doulas in Erie County

After New York State’s doula pilot program began in Erie County in 2018, the Health Foundation awarded a grant to a local coalition that included March of Dimes NY and United Way of Buffalo and Erie County to help facilitate the program. The funds enabled the Erie Niagara Area Health Education Center (ENAHEC) to project-manage the county’s participation in the new pilot program. ENAHEC’s doula work continued to grow, and two years later, the organization established a doula training program within their Birth Equity Project to focus on training more Black women as doulas.

Other goals include helping doulas navigate the complex Medicaid system and educating both health care providers and the community about the role and value of doula services. Once they’ve been trained and certified, the doulas can work independently or through the ENAHEC network as a Medicaid provider.

Jericho Road Community Health Center, a Health Foundation grantee-partner, which had already begun training doulas through the Priscilla Project, was also a participant in the NYS pilot program. Jericho Road caters to the unique cultural needs of immigrants and refugees. The Priscilla Project offers maternal support such as prenatal education, mental health screenings, mentoring, and language interpretation services.

Doulas are paired with clients who speak the same language, and when that’s not possible, an ondemand language interpretation service is used.

“I’d like to see us continue to grow the doula movement through these collaborations and partnerships.”

Shari Weiss, Ph.D., Director of the Cayuga Community Health Network

Central New York doula network

While the Erie County pilot project was underway, central New York groups focused on their own maternal health needs. A 2018 grant from the Health Foundation laid the groundwork for a new program in Cayuga County.

The program focused on training doulas to serve the unique needs of residents in Cayuga’s communities. Shari Weiss, Ph.D., Director of the Cayuga Community Health Network, soon invited groups from Cortland, Madison, and Herkimer counties to collaborate. Cohorts of doulas were trained and began helping with births through referrals from local health care providers and community organizations.

Today, the multi-county doula network continues to educate central New Yorkers about the value of doulas. In Cortland County, meet and greets have helped build strong working relationships with health professionals and community groups.

Gabrielle DiDomenico, who manages the Cortland doula network, explains that a key priority is to help OB/ GYN staff members at the local hospital and clinic understand the value of doula services for their patients. “Knocking down myths and misconceptions about what doulas do or don’t do was a big reason to create our referral network,” she says.

Medicaid recognition and reimbursement

In November 2023, Governor Kathy Hochul signed a law to create a statewide doula directory. In her 2024 State of the State address, Governor Hochul introduced a six-point plan to reduce the risks of maternal and infant mortality, including the continued expansion of doula services for low-income New Yorkers. Much of the plan builds on the groundwork laid by the 2018 pilot program that we helped fund. The ongoing work and advocacy of our grantee-partners has also raised awareness of doulas.

The newly increased Medicaid reimbursement rates are a significant first step in changing the statewide conversation around doula services. The rates should be even higher to help those who want to work full time and keep up with the cost of living.

While more work needs to be done to reimagine reproductive health, for right now, the growing doula movement gets us closer to the goal of making pregnancies as safe and healthy as possible for everyone—regardless of race or socioeconomic status.

Elevating the voices of rural health

“Our county has been near the bottom when it comes to health outcomes for a long time, because of the same problems—like lack of transportation, the health care workforce shortage, and high rates of obesity and smoking. These disparities have been well-researched and discussed for years. Now we need solutions.”

Barbara

Hastings, Cattaraugus County

“Dental is a public health crisis right now. Folks continue to struggle to recruit dentists at a rate they can afford to pay them. The wait lists are astronomical—hundreds, thousands of people. In some places they’re doing triage—only seeing people with emergencies—and it’s really hard for adults to get visits, because there’s such a short supply.”

Patty McMahon, Executive Director, Forward Leading Independent Provider Association (FLIPA)

A long history of economic disinvestment, under-resourcing, and other factors has led to poor health outcomes in many rural communities across New York State.

The Health Foundation launched the Transform Rural Health campaign in 2023 to uplift the voices and stories of the people who live in, work in, and serve the rural communities of western and central New York.

Disparities in rural health often mirror the systemic barriers that lead to poor outcomes in urban areas. By addressing these issues head-on, we can create a ripple effect that improves health equity for all.

“Medical transportation is becoming a nightmare. People need treatment for a medical condition, but their condition gets deteriorated because they miss so many appointments. Not because they choose to, but because they can’t get there.”

Ivette Quiñones, Chautauqua County

“Transportation, technology, housing, and food access—these are some of the big issues I see. You can ask your patient to eat more fruits and vegetables, but what happens when they tell you they can’t afford to eat any healthier than they are now?”

James Wild, M.D., Cattaraugus County

“People do not associate rural areas with the same level of poverty and homelessness as cities. We’re constantly having to take evidencebased strategies that were developed with cities in mind and adapt them to work for a rural area. The rural voice needs to be heard.”

Shari

Weiss, Cayuga County

Reshaping outcomes on Buffalo’s East Side and beyond

Rev. George Nicholas, affectionately known in the community as Pastor George, is Chief Executive Officer of the Buffalo Center for Health Equity (BCHE), where he’s laser-focused on the health challenges facing Erie County, particularly Buffalo’s East Side. He looks forward to the day when it’s impossible to tell someone’s ethnicity, race, education level, socioeconomic status, and neighborhood just by looking at their medical chart.

He imagines a new reality, where explicit and implicit biases are no longer among the determining factors in a person’s health outcomes. And he insists that change is within our collective grasp. “The argument isn’t whether or not it’s possible. The argument is whether it’s a priority.”

Established in 2019, BCHE grew out of the African American Health Equity Task Force, thanks in large part to a grant from the Health Foundation. Made up of local clergy, university faculty, community leaders, and residents, the task force, which had formed in 2014, was doing unfunded research and introducing new ideas into the public dialogue about health care.

Pastor George says that when Nora OBrien-Suric, Ph.D., President of the Health Foundation, reached out to him, the Health Foundation became “the first foundation to step up and say, we want to invest in the work you’re doing.” With the initial grant from the Health Foundation and funds from Erie County, the group was able to establish BCHE, hire staff, and build capacity.

Five years later, the Center is more active than ever. Equal parts think tank and advocacy powerhouse, it conducts research, crafts policy recommendations, develops programs, collaborates with government, engages the community to collect valuable data, and elevates public discourse. BCHE helped Erie County establish its first Office of Health Equity and was also instrumental in creating the University at Buffalo’s Community Health Equity Research Institute.

Through research and events, the Center has delved into numerous areas, including maternal health, mental health, trauma, Black men’s health, menthol cigarettes, gun violence, and substandard housing.

Its annual Igniting Hope Conference invites national speakers to add to the community conversations. Just recently, the Buffalo Sewer Authority contracted with BCHE to create the Environmental Justice Corps, which provides paid job training for adults 18 to 30. Pastor George believes that to tackle health disparities, it’s imperative to address economic and educational inequities as well.

“Human beings have the amazing capacity to do big things, when it’s a priority.”

Rev. George Nicholas

None of the Center’s work would be possible without support from community partners. Pastor George explains how the Health Foundation’s initial investment helped BCHE “multiply organizationally and programmatically.” As BCHE has grown, high-profile projects have attracted additional private and public funders and partners.

Grateful for the early seed planted by the Health Foundation, Pastor George has advice for other philanthropic organizations that might want to support health equity work:

• Invest in people who started doing the work even before they received funding.

• Invest in ideas. Encourage people to explore a comprehensive, integrated approach. Simply expanding a service delivery system won’t address the root causes.

• Include people with the expertise to begin the hard conversations.

• Don’t expect immediate results.

Meaningful change requires focus, time, and patience. Both despite and because of this, the head of the Buffalo Center for Health Equity is as hopeful as ever.

“If you’re not optimistic in the work, then why are you doing it?”

Catalyst for Change: Buffalo Center for Health Equity

Expanding access to early childhood support across New York State

Being a parent of young children can be overwhelming. Why isn’t my baby crawling yet? What if I can’t afford diapers? Are they eating the right things? The pediatrician’s office can be a great resource, but not every parent has the same access to care.

Parents need an organized, barrier-free, centralized access point to connect them with the resources and support services they need. That’s why the Health Foundation brought the Help Me Grow model to western New York in 2011 with six pediatric primary care practices conducting developmental screenings of children from birth through age five.

The program offers families:

• Information on child development and parenting.

• Referrals to community resources through services like 211, such as early intervention agencies, family therapy, literacy support, mentoring, tutoring, parenting classes, recreational activities, and more.

• Questionnaires to help parents discover their child’s strengths and uncover any potential areas of concern.

Help Me Grow New York:

More than

20,000 children served

17 counties covered

In the years since the Health Foundation brought Help Me Grow to western New York, the program has spread to serve families in several other regions of New York State. In 2017, our partners at the Ralph C. Wilson, Jr. Foundation made a $1.8 million commitment to Help Me Grow in western New York. Help Me Grow networks have also been established in Long Island and Rochester. In 2018, with the Health Foundation’s support, Help Me Grow was brought to Onondaga County.

In 2023, a group of agencies, including Oswego County Opportunities, Oswego County Early Childhood Alliance, Citi BOCES, the Richard S. Shineman Foundation, Oswego County government, and the New York State Office of Children and Family Services, convened to determine how Help Me Grow could be brought to Oswego County.

“The geographic composition of our county is so different from others—we have both small cities and very rural areas,” says Brandy Koproski, Executive Director of Integrated Community Planning of Oswego County.

“Our rural communities really struggle with accessing services, and early intervention workers may not be able to travel to people’s homes. We’ve seen high rates of developmental delays in children leading up to kindergarten.”

Enthusiasm among participating groups, plus support from the Richard S. Shineman Foundation and the Health Foundation, has helped spur momentum in the process.

“That support was the catalyst to get us off the ground.”

Brandy

Koproski, Executive Director, Integrated Community Planning of Oswego County

More funding followed, including from State Senator John Mannion, and American Rescue Plan funds that allowed the coalition to hire a coordinator through the Oswego County Early Childhood Alliance.

“What I have seen in community development is that partnerships and collaboration are the most effective way to create systemic change,” says Chena Tucker, Executive Director, the Richard S. Shineman Foundation. “I don’t know how you can do it without bringing groups together and having a shared vision of what we would like to achieve.”

30,000+ screenings completed

One of the key components of success for Oswego County Help Me Grow was their ability to learn from the counties that came before them, especially their neighbors in Onondaga County.

“Our coalition benefits from a close relationship with partners in Onondaga,” says Chena. “They’ve been so welcoming, saying ‘Let us help you!’ and sharing what they’ve learned in the process.”

Another long-term goal for Oswego County Help Me Grow? Influencing policy change. Chena notes that from the earliest conversations around bringing the program to Oswego, organizations that can influence systemic change—like county administration and rural health networks—have been at the table.

“The real return on investment will come down the road,” says Brandy. “Making sure families have what they need can lead to better health outcomes, higher educational attainment, and reduced poverty rates.”

Building bridges between social care and health systems

“I’ve always believed that social workers and community groups had an important place at the table as part of the medical care team.”

Nora OBrien-Suric, President of the Health Foundation for Western & Central New York

Nationwide, between 2017 and 2021, the percentage of community-based organizations contracting through a network doubled—from 20% to 40%

Source: Scripps Gerontology Center, Miami University

Shifting mindsets around social care

In 2010, the passage of the Affordable Care Act (ACA) accelerated a growing movement in health care: the recognition that social determinants of health—factors that affect people’s lives like access to food, housing, or transportation—can play a key role in health outcomes.

As part of this paradigm shift, health insurers and traditional health systems were encouraged to begin contracting for services with community-based organizations (CBOs) that provide social care.

The change presented an opportunity for CBOs to create more sustainable business models, build greater collaboration, and access new funding opportunities—not to mention work toward better health outcomes for the people they serve. But it also put strain on small organizations that lacked the time, staff, and resources to take on the administrative needs required by these new relationships, such as billing and contracts.

These challenges led to the creation of Community Care Hubs (CCHs), networks that ease the burden of doing business on participating social care organizations by providing shared access to services like billing, reimbursement, marketing, information technology, and more.

The CCH framework makes collaboration between social care organizations and health systems more cost efficient and streamlined on both sides, incentivizing new partnerships.

Health Foundation President Nora OBrien-Suric, Ph.D., was an early champion of this approach dating back to a previous role with The John A. Hartford Foundation. Under her leadership, the team at the Health Foundation has continued to advance programs and partnerships that encourage this approach to collaboration.

“We’ve always known that bringing ideas and groups together is the way to foster new solutions, especially for holistic health care,” Nora explains.

Today, Community Care Hubs are a growing force in 21st century care delivery.

Today’s Community Care Hubs

As the CCH model becomes more widely used around the country, the Health Foundation is supporting CCHs in our communities: Western New York Integrated Care Collaborative (WNYICC), headquartered in Buffalo and serving western New York, and Inclusive Alliance, headquartered in Syracuse and serving central New York. The two Hubs also belong to the National Learning Community (NLC) for Community Care Hubs, which allows them to tap into a broader network for deeper professional development and share resources more widely.

Breaking down silos

WNYICC (pronounced win-ee-ick) grew out of a Health Foundation program called Ready or Not. The program helped organizations build capacity and adapt to the economic and regulatory changes having an impact on health care at both the state and federal level.

“We’re always looking at it from the CBO perspective. How can we keep their administrative burden as low as

WNYICC was one of the first 12 in the country to be funded through the U.S. Administration for Community Living, and in November 2023, one of six from across the country to be profiled in Community Care Hubs: A Promising Model for Health and Social Care Coordination, a report released by the U.S. Department of Health and Human Services. WNYICC was highlighted for its ability to work directly with CBOs to provide vital services, such as hospital-to-home transition support, as well as meals and food security.

In 2023, WNYICC also secured a first-in-the-nation contract with a Medicare Advantage plan for a program called Health Coaching. The program earned WNYICC a Business Innovation award from The John A. Hartford Foundation.

How do CCHs help people in our community? Nikki describes an older adult who needed help with meals. The man agreed to work with a dietitian after receiving a referral to a nutritional therapy program. He confided to the dietitian that he was prone to falling. The dietitian enrolled him in a fall prevention program, which helped him improve his strength and balance. Some fall-proof adjustments were made to his home, too. There was no need for permission from the man’s health insurance plan to move him into these programs. The insurer had complete trust in WNYICC’s ability to assess their client’s needs, make the appropriate referrals, and integrate health and social care effectively.

that allow CBOs to enhance, expand, and strengthen their ability to reach folks in need and do that connecting work.”

Lauren Wetterhahn, Executive Director, Inclusive Alliance

region through its network of over 50 CBOs. In 2023, the Health Foundation provided funding to help Inclusive Alliance build and strengthen its technical infrastructure, including data storage.

Network Development Manager Nicole Hall describes the Hub’s new data warehouse for social care services. Her team can see how many people are being served by organizations across counties, as well as the type and breadth of available services. Eventually, this information will be overlaid with census data to uncover additional insights, like service overlaps and coverage gaps.

“We’re engaging with those smaller grassroots organizations and trying to elicit the data from them that they haven’t been able to showcase well before. Then we can demonstrate their impact across the community,” Nicole explains.

CBOs deserve to be compensated fairly for the important care they provide, but engaging with health insurers and public payers can be complex. To support them, a CCH like Inclusive Alliance guides CBOs on what billing for work entails, whether it’s Medicaid reimbursement for doula services, Medicare reimbursement for physical therapy, or something else. Inclusive Alliance leverages its knowledge of new social care payment models and billing codes from the health care sector to further support CBOs.

“Being able to tell organizations that something they’re already doing could be bringing in revenue is an essential part of what a CCH can do.”

Lauren Wetterhahn, Executive Director, Inclusive Alliance

Community Care Hubs offer invaluable services that will become increasingly in demand as more providers recognize how social determinants of health drive key outcomes. The Health Foundation is proud to have been at the forefront of supporting this transformative care delivery approach. We’ll continue to collaborate with our network of community organizations and help them strengthen their ability to innovate, collaborate, and meet the needs of our communities.

Reimagining age-friendly neighborhoods

How can we create neighborhoods that welcome residents of all ages, where growing older isn’t a barrier to living well? What does an age-friendly environment look like in our hospitals and medical facilities?

At the Health Foundation, we champion initiatives that support healthy aging by centering the needs and wishes of older adults. In our 2020 – 2025 strategic plan, we formalized our commitment in Midterm Goal 5: “Communities and health systems are working collaboratively to become age-friendly.” We’ve worked to bring the age-friendly approach to communities in several different ways—from hospitals to neighborhoods.

Our age-friendly work has included the funding of county-driven Age-Friendly Centers of Excellence and an evidence-based approach to geriatric care called Age-Friendly Health Systems. In 2022, we began funding Age-Friendly: Go Local, a program that offers financial support to organizations working to design age-friendly communities, with a particular emphasis on the safety and well-being of older adults.

Why a holistic approach to age-friendly work? Research has shown that creating livable communities benefits not only older adults and people with disabilities, but everyone else, too.

The passion and dedication of two grantee-partners— GObike Buffalo and Cayuga Health System—bring to life the strength and vitality of an age-friendly approach.

Enhancing safety for older adults

Our Mother of Good Counsel is a 43-unit apartment complex whose residents are older adults on fixed incomes. Located in Blasdell, a village within the Town of Hamburg, the building is situated on Lake Avenue between two main thoroughfares and less than a mile away from a busy thruway exit.

“It’s about getting where you need to go, regardless of mode and regardless of age and mobility.”

Justin Booth, Executive Director, GObike Buffalo

In recent years, pedestrians have been hit by passing cars while trying to cross the street in front of the apartments. After a fatality in 2019, the Town of Hamburg installed a pedestrian crossing signal and a yellow pedestrian crossing sign. Unfortunately, this safety step failed to prevent another tragedy: the death of a beloved resident in 2023. Despite a reduced speed limit of 35 miles per hour, most motorists fail to slow down when a person is entering the crosswalk.

To find a solution for these Blasdell residents, the Town of Hamburg partnered with GObike Buffalo on a Health Foundation-funded project, which became part of the Hamburg Active Mobility Action Plan. The addition of the Blasdell project to the plan was made possible by funding from the Health Foundation, in partnership with the New York Academy of Medicine, through Age-Friendly: Go Local. This unique hyperlocal program focuses on initiatives built on the principles of age-friendliness, livability, and equity to improve the lives and health of residents.

For Justin Booth, Executive Director of GObike Buffalo, and Randy Hoak, Hamburg Town Supervisor, the Go Local project is an opportunity to view the needs of the Blasdell community with a wide-angle lens. They’re inspired to explore ways to improve overall livability for the surrounding area—beyond fixing one treacherous crosswalk. GObike volunteers have conducted walk audits to study traffic patterns, driving habits, cracked sidewalks, commercial activity, and the demographic makeup of the area. “We wanted to look at how we can connect communities and give people safe opportunities to move about those communities,” Justin explains. Learn more about Age-Friendly Health Systems in New York State.

Justin and Randy have also met with Our Mother of Good Counsel residents to listen to their stories and concerns.

“We’re exploring all the options,” Randy says.

Once the Hamburg Active Mobility Action Plan is finalized, it will be presented to Erie County. Randy hopes to secure a county grant that will allow the Town of Hamburg to implement the entire plan, including the age-friendly component inspired by the lived experiences of Our Mother of Good Counsel residents.

Blasdell’s Go Local project is an example of how inclusive design solutions can improve the quality of life for older members of a community—and everyone else.

Small steps inspire big changes

The Health Foundation was the lead funder of the AgeFriendly Health Systems (AFHS) New York State Action Community led by the Healthcare Association of New York State and based on the model developed by The John A. Hartford Foundation.

The framework uses a set of four evidence-based elements to organize the care of older adults, known as the 4Ms: What Matters (understanding what’s important to older adults), Medication (knowing if medications are unnecessary or potentially harmful), Mobility (creating individual mobility plans), and Mentation (addressing conditions like dementia, delirium, and depression). When these 4Ms are implemented together, older adults experience stronger health outcomes and a better quality of life.

“The changes we’ve made haven’t just benefited the patients. Our care team has benefited, too.”

Emily Mallar, Senior Director for Care Transitions, Cayuga Health System

According to Emily Mallar, Senior Director for Care Transitions at Cayuga Health System, participating in the New York State Action Community with the Health Foundation’s support enabled their team to accomplish the following after an inpatient pilot project launched in October 2023:

What Matters. Because Cayuga Health’s recreational therapists routinely ask questions, they were already quite comfortable with getting patients to share goals and concerns. However, the therapists’ documentation wasn’t part of a patient’s care file. In formalizing a What Matters approach, these observations were integrated into the care files, daily case conferences, and overall care plans. The additional insights have enabled the rest of the care team to grasp a more holistic picture of each patient’s health. And the recreational therapists now feel like an integral part of the team.

Medication. Despite being well-versed in a traditional approach, one longtime provider was quick to adopt the new documentation standards for medication review. The new process included an IT enhancement to support documentation and tracking.

Mobility. “Mobility was the area where we were already doing well,” Emily explains. The Cayuga Health team had previously rolled out the Activity Measure for Post Acute Care (AM-PAC) mobility program before applying for AFHS.

Mentation. Previously, whenever a shift ended, it was customary for the outgoing nurse to record observations and sign out. The incoming nurse would then see the patient and record their observations. To achieve a more aligned approach, the outgoing nurse and the incoming nurse now observe the patient together during the bedside handoff. This collaborative approach has strengthened the validity of each assessment.

The AFHS approach has broken down the silos within the Cayuga Health team and inspired dynamic team meetings. Now every member shares their input on behalf of a patient’s care.

A master plan for aging

We believe age-friendly solutions are achievable, but success requires an intentional, committed approach. Thanks in part to our advocacy, New York State is in the development stage of an important effort that builds on previous agefriendly work: the Master Plan for Aging. We look forward to continuing to help shape this plan with the goal of creating a New York State where older adults—and all residents—have what they need to live healthy lives.

Amplifying respite opportunities through community

What does it take for a project or program to grow to the next level of impact and scale? If you asked the team at West Falls Center for the Arts, they’d tell you it takes a great idea, an engaged community, and funders that serve as learning partners.

West Falls’ Musical Memories Café is a place for caregivers and their loved ones to come together to enjoy socializing, refreshments, and entertainment by local musicians. In 2020, the café was part of the first cohort of Exhale, the Family Caregiver Initiative, a funding partnership between the Health Foundation and the Ralph C. Wilson, Jr. Foundation to help boost respite opportunities in western New York.

Participants with dementia, hearing familiar music from their younger years, overwhelmingly respond positively, while their caregivers enjoy their loved one’s company in a stress-free and joyful environment. But it’s not just about the music; attendees also find a community to rely on and get connected to other services that can help them.

“When I see that we are at max capacity every time, and that we could do this every day of the week, it shows me how valuable this program is and how it needs to continue to grow,” says Carolyn Panzica, Executive Director of West Falls Center for the Arts.

Carolyn notes the café now has a community of “regulars,” including a frequent attendee, Flo, who takes pictures of the families at each table, prints the photos and gives them to each family to keep.

The program has already spread to an additional four locations in western New York. The team has plans to keep that momentum going by building a model for replication that will help other community organizations launch Musical Memories Cafés of their own.

• 100 percent of participants would recommend the memory café.

• Caregiver needs dropped during the evaluation period.

• 100 percent of the caregiver experience outcomes that were measured improved.

• The number of caregivers with ‘red flag’ status— meaning very high levels of need or stress—decreased through participation.

If you talk to the caregivers and other participants at West Falls, the impact is clear.

Flo, who has attended the café since its earliest days, says the live music adds a special element for participants.

“The music brings their inner being out,” Flo says.

“This is a chance to see your loved one in a different light,” explains Mary Carol, who attends with her husband and his uncle, and brings her mother to a different café location.

Flo, a Musical Memories café regular, with some photos of her fellow attendees

“This program builds resiliency among the participants,” says Steven Harvey, who works with Musical Memories Café on their evaluation and replication efforts. “We’re helping them clarify the future and access community resources. We do a lot in the background to support families and build community.”

These impressive outcomes caught the attention of caregiver experts nationally when ARCH National Respite Network and Resource Center named the Musical Memories Café as one of four Innovative and Exemplary Services for 2024 in the U.S. In addition to this exclusive recognition, the team also presented their achievements at ARCH’s national conference in May 2024.

“The support from Exhale did a number of things to help the program,” explains Steven. “The funders did not act as ‘big brother’ looking over our shoulder. It was a partnership.”

For Nancy, a caregiver to her partner Frenche, the café was life-changing after only two visits.

“This program made me feel alive again,” Nancy, a participant, shares. “It’s a miracle.”

2023

grants at a glance

Alzheimer’s Disease and Related Disorders

Association, Inc.

Southern Tier Alzheimer’s and Dementia Community Forum

$3,000

Ardent Solutions

Co-Creating Well-Being Trauma Informed Care Targeted Expansion Pilot

$89,000

Ardent Solutions

Rural Health Equity Initiative 2023

$75,000

Bertrand Chaffee Hospital

Age-Friendly Health SystemsNew York State Action Community Phase 2Participant Stipend

$10,000

Boston Foundation, Inc. dba

The Philanthropic Initiative WNY Memory Café Initiative

$300,000

Cattaraugus County Health Department

Cattaraugus County 100th Anniversary

$5,000

Cayuga Community Health Network, Inc. Doula Partnership of Cayuga, Cortland, Herkimer, and Madison Counties

$520,000

Cayuga Community Health Network, Inc.

Rural Health Equity Initiative 2023

$75,000

Cayuga Medical Center at Ithaca Age-Friendly Health SystemsNew York State Action Community Phase 2Participant Stipend

$10,000

Central Current, Inc.

Reporting on the gaps in the Syracuse lead system

$10,000

Child Care Solutions

PEDALS CNY Hub Support & Expansion

$548,507

Community Health Center of Buffalo, Inc.

Age-Friendly Health SystemsNew York State Action Community Phase 2Participant Stipend

$10,000

Community Service Society of New York Keep New York Covered

$105,000

Compeer West, Inc.

DEI Advancement at Compeer

$4,000

Council of Senior Centers & Services of New York City, Inc., doing business as LiveOn NY

Reframing Aging MPA Advocacy

$20,000

Early Childhood Alliance of Onondaga Co-Creating Well-Being Trauma Informed Care Targeted Expansion Pilot

$81,000

ECMC Foundation, Inc.

Age-Friendly Health Systems - New York State Action Community Phase 2Participant Stipend

$10,000

Family Help Center “GRAND-Families”

$11,000

Grantmakers Forum of New York Inc. dba NY Funders Alliance Initiatives Fund

Nonprofit Support Group Supplemental Grant

$15,995

Greater than the Sum Health Leadership Fellows Social System Map

$15,000

Healthcare Educational & Research Fund, Inc.

Age-Friendly Health System: New York State Action Community 3.0

$144,640

Healthy Community Alliance, Inc. Rural Health Equity Initiative 2023

$75,000

Holy Cross Head Start, Inc.

CFK - Holy Cross Head Start

$3,500

Ignite

Health Leadership Fellows Cohorts 8 and 9 Evaluation

$8,500

In His Name Outreach Inc.

Outreach and Educational Training

$5,000

Inclusive Alliance IPA Inc.

Inclusive Alliance: A CNY Community Care Hub

$180,000

Integrated Community Alternatives Network

Healthy Connections from the Start Renewal

$81,376

Integrated Community Planning of Oswego County Inc.

Help Me Grow Affiliate Training

$12,000

InterFaith Works of Central New York Expansion of Senior Companion Program

$5,000

Lakeshore Connections

Co-Creating Well-Being Targeted Expansion

$10,000

Lakeshore Connections

Live Well Erie RBA

$2,475

Lakeshore Connections

SDOH and Health Equity Conference

Support

$6,500

Leukemia and Lymphoma Society

LLS Local Travel Assistance Initiative

$10,000

Madison County Rural Health Council

Rural Health Equity Initiative 2023

$75,000

Mental Health Advocates of WNY 4th Annual Family Engagement Conference

$5,000

Most Valuable Parents of Buffalo Violence Prevention Program

$4,000

Mount St. Mary’s Hospital of Niagara Falls Age-Friendly Health Systems - New York State Action Community Phase 2Participant Stipend

$10,000

New York Academy of Medicine

Age Friendly: Go Local 2.0

$75,320

New York State Association for Rural Health, Inc.

CNY Rural Health Scan

$5,000

New York State Association for Rural Health, Inc.

Child Advocacy Center Advocacy

$25,000

New York StateWide Senior Action Council, Inc.

StateWide Health Task Force and Advocacy

$150,000

Police Athletic League of Buffalo, Inc.

Healthy Living - Farm to Fork WBLK

Sponsorship

$24,600

Public Policy and Education Fund of New York Inc.

End Medical Debt

$10,000

Research Foundation for SUNY on behalf of the University at Buffalo (UB)

University at Buffalo Kickstart Foot Care Program

$22,000

Research Foundation for SUNY on behalf of the University at Buffalo (UB) Stop the Bleed Educators Program

$5,600

Schuyler Center for Analysis and Advocacy Inc.

Educating Communities on Medicaid

$25,000

Seven Valleys Health Coalition, Inc.

Rural Health Equity Initiative 2023

$75,000

Southern Tier Health Care System, Inc. Rural Health Equity Initiative 2023

$75,000

The Osborne Association Safeguarding Children of Arrested Parents Training

$3,000

United Way of Buffalo and Erie County Co-Creating Well-Being Trauma Informed Care Targeted Expansion Pilot

$84,000

Universal Primary Care Care Team of the Future

$30,000

Western New York Integrated Care Collaborative, Inc.

Chronic Disease Self Management Program

$15,000

Western New York Public Broadcasting Association

WBFO Older Adults News Desk

$30,000

Western New York Public Broadcasting Association

WBFO May 14 Special Report

$3,000

YWCA Jamestown

Healthy Housing

$5,000

Learn more about our financials here.

Our grantmaking by the numbers

Total $2,744,168 Western $1,349,810 Central Grants by Region

$4,093,978

Grants by Focus Area

An additional $500,000 was granted through the Transform Rural Health campaign from MacKenzie Scott’s gift. Children $1,805,712

Adults $812,907 Other $250,921 Community Health Capacity $1,224,438