As 2023 concludes, looking back on the achievements and the work ahead helps us frame our goals for 2024. The PPS continues to direct financial and strategic support for its partner organizations, implement population health and work force initiatives that focus on health equity in our community. Nearly 4 years post the DSRIP waiver, the PPS partner organizations continue to distinguish themselves in implementing innovative programs in the most challenging health domains like maternal health, substance use disorder, hypertension, diabetes, asthma, social determinants of health, Veteran and active duty programs, children’s health and prevention services.

The highlights for the PPS and its partners this year made a difference in many people’s lives. They include:

• Achieving an 81% reduction in overdose and overdose deaths for the 650 individuals engaged in the Hotspotting program, implemented by SIUH, RUMC, CHASI and RCDA team and funded by a grant from Secure Futures Project and Northwell Health funds. Year 2 is underway with very positive results.
• Becoming a Medicaid Innovation Collaborative grant winner for New York State to implement a program with Healthfirst and tech innovators, Ready Computing and Samaritan, to engage individuals disconnected from care, homeless with chronic disease.
• Receiving the first ever SAMHSA Grant of $1.6 million for diversion from justice involvement for individuals affected with co-occurring mental health and substance use disorder.
• Social Determinant of Health – completed 10,000 with 7,000 needs closed by partner CBOs’ and connecting 2000 back to primary and behavioral care. Financial, education and housing are among the highest needs and most difficult to fill. We need resources and innovative ways to close these gaps.
• Receiving the Community Health Worker Grant of $6 million from Health Resources and Services Administration (HRSA), in conjunction with Community Health Center of Richmond,  to train over 400 individuals in community health skills. We will add a Lay Counselor component in 2024 to expand community level behavioral health connections.
• Training over 100 individuals in apprenticeships roles in Certified Peer Recovery Advocate, Community Health Worker, Home Health Aide and Certified Nursing Assistants under the Apprenticeship Building America Grant of $4 million.
• Awarding grants, in partnership with the Staten Island Not for Profit Association, to 5 new partner organizations and welcomed them into the PPS network.
• Participating in community action to bring $12 million in settlement funds to Staten Island alongside Sam Pirozzolo, DA Mike McMahon, Borough President Fossella and our partner organizations.
• Flourishing  Veterans and active duty programming: In partnership with NYC Veterans’ Commissioner James Hendon and State Senator Jessica Scarcella Committee Chair, a Blue Star Families program at Fort Hamilton Coast Guard base currently provides food and supplies to 120 individuals representing 500 families. Thy Veterans Yoga Project provides weekly classes at the Staten Island Gold Star Post. There have been 9 webinars on Veteran suicide prevention. Our partner CHASI is being grant supported to do buddy checks on vulnerable veterans and food deliveries.
• A continued academic relationship with MIT, George Mason University, NYU, and CSI and are expanding with Columbia University and Wagner College.
• The 39-member class of Wagner College Physician Assistants (class of ’26), which has been a great addition to our community health work team. Kudos to Nora Lowy, Program Director for her vision.
• Several publications accepted in behavioral health, machine learning and quality improvement. PPS achievements have been highlighted in multiple media and staff has presented around the country and in the UK.
• Developing a learning collaborative with Leeds Integrated Care Board and visiting the UK for 3 days of intense workshops focused on improving quality, access and outcome with an incredibly dedicated team led by Tim Ryley. Many thanks to Martin Charters and Manraj Khela.
• Welcoming dynamic new partners, including, Mount Sinai Church, Super Health Pharmacy, Air-NYC Asthma Services, SI Not for profit Association, Blue Star Families, A Chance in Life Pantry, A Chance in Life, Celebrate Hope, Health 4 Youths, K Woods Foundation, COJO SI and a returning partner Make the Road NY.
• Expanding relationships with existing partners to include navigation services, including, Pride Center, PCCS, JCC and El Centro to bring capacity for the 1115 Waiver.

 

For 2024, the long awaited 1115 Waiver remains a priority, but the PPS has embarked on numerous initiatives that will also shape the direction of population health on Staten Island.

• In January, we will begin testing ways for patients to complete their own SDOH screening with ambulatory practices using mobile technology.
• We are working on implementing the Diversion Program for individuals with co-occurring conditions with the RCDA, Legal Aid Society, NYPD and clinical partners.
• Fair Start, Food as Medicine research project will be implemented in collaboration with Columbia University School of public Health and professor Heather Butts, a tireless advocate for Staten Island, and Wagner College focusing food insecurity in Veterans, College students and NYCHA residents.
• Expanding off of Staten Island is a priority and multiple efforts will come to fruition this year in Hotspotting, Lay Counselor training as part of the CHW curriculum, expansion of workforce efforts with Health and Welfare Council of LI, One Brooklyn Health, Air-NYC and others.
• We have the Safe Prescribing Pledge event scheduled for March 27^th where we expect over 250 prescribers to renew their commitment to judicious opioid prescribing and alternative paths to pain management.
• Medical support presence at food pantries is a goal of ’24, reaching people “where they are at” starts with consistent presence, coaching and health supports with those most in need.
• Veterans for Life, a food insecurity program focused on active-duty service members transitioning to civilian life is being launched on Staten Island at the Fort Hamilton Coast Guard base. The program developed in Texas is being piloted in New York on Staten Island in collaboration with Onwards Ops, a national suicide prevention program, Blue Families, a national program supporting military families and Shoprite.
• Healthy Start is a new initiative reaching into Head Start and other day care programs to develop trust, and create a path for healthy habits in nutrition, obesity prevention, vaccination awareness and active life style.

 

Many thanks to our friends and supporters who have worked with us to access resources, connect with new partners and expand the orbit of our work. There is much to be thankful for in 2023 and we are looking forward to a highly productive 2024 with the help of all our partners and supporters. This is especially so for our parent organization, Northwell Health. When many PPS were closed down in 2020, their commitment, along with the SIUH Executive Director, Brahim Ardolic, to keep the PPS efforts going in this community speaks louder than words.