Clinical Services for Older Adults

The goal of this new area of funding is to improve the quality of care and reduce costs of clinical care and services to individuals age 65 and over in our community.


Jewish Senior Life received $480,895 between 2015 and 2018 to expand on their existing activities in end-of-life care with support from palliative care experts. The Center of Excellence for Palliative & End-of-Life Care will include advance care planning, assessment of patients’ mental and physical condition, and will include families in the review of care goals. Staff will also receive comprehensive palliative care training, including how to communicate on end-of-life issues and how to provide support services as part of an interdisciplinary palliative care team.

Lifetime Care was awarded $627,338 between 2015 and 2018 to build upon existing palliative care services to create a comprehensive, interdisciplinary team approach – Advanced Illness Support Program (AISP) – for older adults in Monroe County. AISP will assist primary care providers with the care of patients in need of pain and symptom control, and will engage in discussions related to treatment options, end-of-life decisions, wishes, advance care planning, and other palliative care support.

Livingston County Emergency Medical Services was awarded $599,393 between 2015 and 2018 to assist Livingston County residents over the age of 65 who are treated and discharged from emergency departments at Noyes Memorial Hospital and Strong Memorial Hospital back to their homes. The project will use the Coleman Care Transition Intervention (CTI), an intervention designed to improve hospital-to-home transition and decrease hospital re-admissions and costs. Trained emergency medical services providers will serve as CTI coaches.

The University of Rochester’s Flaum Eye Institute was awarded $574,903 between 2015 and 2018 to implement their Resilience Building Program (RBP) with the goal of strengthening seniors’ capacity to cope with current and future vision loss, preventing depression symptoms, and alleviating current depression due to vision loss. 300 patients across nine counties will benefit from the intervention and evaluation. The program will also focus on increasing patients’ quality of life and providing potential cost-savings to providers and insurers.

The University of Rochester Medical Center’s (URMC) Project ECHO® was awarded $645,787 between 2015 and 2018 to grow the existing Project ECHO® at URMC to build the capacity of community-based clinicians to deliver high-quality primary palliative care and geriatric mental health consultations across nine-county areas. The model improves access to complex chronic disease and specialty care in underserved communities through telemedicine technology to connect specialists in medical centers with providers in under-resourced regions.

The University of Rochester Medical Center (URMC) was awarded $600,095 between 2015 and 2018 to create a multi-disciplinary, virtual Parkinson Disease care center for the Greater Rochester area, known as the Regional Multi-Disciplinary Telemedicine Care Network for Parkinson Disease. The center will leverage existing expertise in multi-disciplinary Parkinson Disease care and telemedicine and bring care into the homes of 400 individuals who may not otherwise have access to care. With a Parkinson Disease Care Network, experienced physicians, nurses and telemedicine program coordinators can provide better access to care, increase patient quality of life, increase medication compliance, and decrease hospitalizations.

St. John’s Dementia Quality of Life Program was awarded $437,317 between 2015 and 2018 to recruit and train nursing staff to become Dementia Advocates. The program will use the Alzheimer’s Association dementia education training and curriculum and with the guidance of their Dementia Specialist, the advocates will lead neighborhood educational programs and provide necessary follow-ups to improve residents’ qualify of life as well as staff and family satisfaction. Project staff will also work to create “dementia enabling” physical work spaces.

Disease/Condition Improvement


The Center for Refugee and Immigrant Health received $298,871 between 2015 and 2018 to fund a pilot transitional program that will engage and prepare primary care providers to treat refugee patients and educate refugees on how to navigate their local health care system.

The University of Rochester Medical Center (URMC) received $600,000 between 2015 and 2018 to fund a center for adults with special care needs that will coordinate community outreach and coordination of services to transition patients from pediatric to adult systems scare, and provide inner-professional education.

Rochester Regional Health System received $391,400 between 2015 and 2018 to fund Building Healthy Pregnancies, which will work to decrease the number of babies born with low birth weight, premature birth rates, and Neonatal Intensive Care Unit (NICU) admissions for pregnant patients in the inner-city by integrating wrap-around services.

Action for A Better Community, Inc.’s Let’s Talk About it project was awarded $107,639 between 2015 and 2018 to fund a project utilizing the Black Barbershop Health Outreach Program model to combat prevalent diseases (diabetes, hypertension, and heart disease) in African American males ages 18 to 65.

St. Joseph’s Neighborhood Center received $325,000 between 2015 and 2018 to fund Addressing Oral Health Gaps in the Rochester Region. The program will hire a dentist to address gaps in dental services for uninsured individuals, veterans, individuals on Medicare and individuals on Medicaid.

Lifespan of Greater Rochester was awarded up to $600,000 in 2010 for a three-year program to address the issue of depression in older adults using the PEARLS/Plus program.

Eldersource was the lead agency for an evidence-based program to address depression in older adults in cooperation with Catholic Family Center, PeerPlace, and the University of Rochester’s Geriatric Psychiatry Program. The project was awarded $600,000 between 2010 and 2013 to implement Program to Enhance Active and Rewarding Living for Seniors (PEARLS/Plus) for clients with mild to severe depression.

Highland Family Medicine, part of the University of Rochester Medical Center, was awarded $421,511 between 2010 and 2013 for a project to identify and treat depression in low-income and minority patients at community health centers using an evidence-based IMPACT model. As a result of our funding, two additional years of funding have been secured through a Hospital-Medical Home grant funded by the Centers for Medicare and Medicaid.

Melissa’s Living Legacy Teen Cancer Foundation used a grant of $50,438 between 2009 and 2011 to establish Teens Living with Cancer, a project with a community-based peer support network in Rochester for young people who have been diagnosed with cancer.

Monroe County Department of Public Health was awarded $164,238 for a one-year program in 2010 for the Perinatal Home Visiting Program to improve outcomes for mothers and their children. An additional $247,250 in matching funds was received from New York State Community Optional Preventive Services.

Rochester General Health System was awarded  $599,370 between 2010 and 2013 to target Rochester General Medical Associates’ patients affected by hypertension and high blood pressure.

University of Rochester Medical Center was awarded $101,295 to develop a Community Education to Promote Anterior Cruciate Ligament (ACL) Injury Prevention program between 2007 and 2009 to reduce injuries in high school female athletes. They received an additional $160,969 for use between 2009 and 2011 to expand this program.

University of Rochester Medical Center was awarded up to $523,897 in 2010 for a three-year initiative at Culver Medical Group targeting patients with hypertension and high blood pressure with a goal to achieve a 25 percent improvement from baseline in blood pressure control rates.

Unity Health System was awarded $670,814 between 2010 and 2013 to fully implement the Patient Centered Medical Home model and apply the Chronic Care Model to focus on patients with hypertension.


Electronic Medical Records and Rochester RHIO


HealthVantics, LLC, a subsidiary of Rochester RHIO, received $298,302 between 2015 and 2018 to fund the Supporting Patient Care Network project, which will improve patient care coordination by creating a real-time network of all of a patient’s care providers. Monroe County Medical Society, Rochester Regional Health System, and University of Rochester Medicine are partners for this project.

Rochester Regional Health Information Organization (Rochester RHIO) was granted up to $600,000 in 2013 for a three-year project to help health care systems convert to a standardized set of lab codes. This will allow medical professionals to quickly understand a patient’s lab results regardless of where the tests were performed.

Rochester Regional Health Information Organization (Rochester RHIO) was awarded a two-year matching grant of $500,000 between 2008 and 2010 to support the acquisition and installation of electronic medical record (EMR) systems in community health centers and private physician offices via a state grant (HEAL 5). As a result of our match, they were able to secure an additional $6,700,000 from New York State.

Westside Health Services, now part of the Anthony L. Jordan Health Center, received $418,037 between 2007 and 2009 to implement a practice management system, enhance chronic disease management efforts and comply with government mandates.

Oak Orchard Community Health Center received $525,000 between 2007 and 2008 for Expansion of Primary and Secondary Preventive and Disease Management Services, a project to advance the effective delivery of primary health care, health promotion, and disease prevention in a rural/semi-rural community.

Planned Parenthood of the Rochester and Syracuse Region (PPRSR) was awarded up to $465,133 in 2012 to implement an Electronic Practice Management / Electronic Health Records (EHR) network over a three-year period. The system will enable PPRSR to improve the quality of patient care by providing reliable, real-time access to health information and increase operational efficiency in appointment scheduling, inter-affiliate reporting, and benchmarking.

Rochester Regional Health Information Organization (Rochester RHIO) was awarded $237,000 between 2007 and 2008 to develop a strategic plan for the regional health information organization including the major health systems, community health centers and other providers of care for the nine-county Greater Rochester community.

Unity Health System received $200,000 from the Health Foundation and matching funds of $7,000,000 from New York State HEAL 17. The goal of Creating Connections for Patient Centered Diabetes Care was to support Patient-Centered Medical Home projects and to assist primary care physicians to use health IT to improve coordination of care for patients.

Health System Improvement


Anthony L. Jordan Health Center was awarded $537,505 between 2010 and 2013 to implement a Patient-Centered Medical Home model to provide comprehensive primary care to adults at risk for diabetes, hypertension, obesity, and cervical cancer in partnership with the Monroe Plan for Medical Care. The Center also received matching funds of $4,500,000 from New York State HEAL 17 for the optimization of technology projects to create a more streamlined approach to sharing patient information.

Anthony L. Jordan Health Center was awarded up to $135,000 over a three-year period, beginning in 2012, to absorb Threshold for Alternative Youth Services, Inc., (Threshold) under its umbrella. The long-term goal of this project is to achieve a smooth transition of services from Threshold to Anthony L. Jordan Health Center to maintain continuity of care for 5,340 urban youth.

University of Rochester Medical Center received $75,000 in 2012 to conduct an adult health survey.

St. Ann’s Foundation was awarded $207,990 between 2008 and 2010 to convert to an automated unit dose and barcode-scanning system to ensure the five “rights” of medication: right patient, right time, right medication, right dose, and right method.

Medical Motor Service of Rochester and Monroe County, Inc., received $278,816 between 2008 and 2010 for Access for Older Adults to provide a coordinated transportation service for non-emergency medical care for older adults with chronic medical conditions in cooperation with Catholic Family Center, Lifespan, Eldersource, and Monroe County Office for the Aging.

Anthony L. Jordan Health Center received $1,200,000 from the Health Foundation between 2009 and 2010 to help them acquire Westside Health Services, also a Federally Qualified Health Center, with no disruption to patients, and through which they were able to secure an additional $2,028,000 from a variety of organizations. See the report here.

Finger Lakes Health Systems Agency received $35,000 in matching funds from the Health Foundation and an additional $35,000 from Excellus Blue Cross/Blue Shield for a CMS Innovation Challenge project to identify new service delivery and payment models for Medicare and Medicaid beneficiaries.

Mt. Hope Family Center received $50,000 in 2009 to provide evidence-based interventions for families and children in the foster care system.

Keuka Comfort Care Home received $50,000 for use between 2007 and 2009 to develop a peaceful, home-like environment for terminally ill residents with a life expectancy of three months or less in Yates County.

Finger Lakes Health Systems Agency (FLHSA) received $240,205 between 2007 and 2009 for the African American and Hispanic Health Engagement project to engage leaders from disadvantaged communities to better understand and respond to local and regional health disparities.

University of Rochester Medical Center’s Rochester Primary Care Adolescent Immunization Program received $531,468 between 2007 and 2009 to improve rates of adolescent well-care visits and immunizations at nine primary care practices that serve the majority of Rochester’s poorest teens. Based on the success of this program, we awarded an additional $20,000 to enable them to receive matching funds of $70,000 from the Monroe Plan and $2,500,000 from the Agency for Healthcare Research and Quality.

Finger Lakes Health Systems Agency received $203,276 between 2007 and 2009  for a study of Ambulance Diversion of Non-Emergency Patients to address the problem of low-income people obtaining primary health care through the emergency department.

Wyoming County Health Department received $42,939 between 2008 and 2009 for the development of a county-wide health and wellness strategic plan.

Unity Health System received a one-year award of $150,000 between 2008 and 2009 to employ Lean Six Sigma principles to improve quality of care and patient safety.

Via Health (Rochester General Hospital) received $56,354 between 2007 and 2008 for a Lean Six Sigma Deployment Project that focused on the leadership roles of employees in transforming their culture to one that was customer focused and built on a foundation of highly talented, motivated, diverse, and engaged people to create a culture that was “best in class.”

Rochester Business Alliance received $25,534 between 2007 and 2009 for the Rochester Health Care Initiative Lean Six Sigma to employ lean six sigma principles and practices within the health care system to positively impact cost and quality.

Rochester General Health System received a one-year grant of $120,050 in 2009 in support of its Lean Six Sigma initiatives, including reducing overall patient length of stay, increasing capacity in surgical services, and decreasing patient wait times within the medical group.

Rochester General Health Foundation received a two-year grant of up to $449,904, beginning in 2011, for a Remote Simultaneous Medical Interpretation project for real-time interpretation between patients and their health care provider through a bank of medically trained interpreters, resulting in far fewer medical errors and improving compliance with treatment directions.

University of Rochester Medical Center received $57,807 for a Symposium to Discuss Unwarranted Variations in Medical Care in 2007 that focused on the cost and quality of health care, unwarranted variation, evidence-based medicine, and the application of Lean Six Sigma in health care.

University of Rochester Medical Center was awarded up to $800,000 in 2011 for a three-year initiative for the Stroke Treatment Alliance of Rochester (STAR). Members of the Alliance also include URMC, Unity Health System, Highland Hospital and Rochester General Hospital to work together to increase the rate of acute interventions for stroke, improve practices for stroke prevention and establish more cost-effective systems of care.

Westside Health Services, now part of the Anthony L. Jordan Health Center, received $27,000 for urgently needed medical supplies in 2009.

St. Joseph’s Neighborhood Center was awarded $299,956 between 2007 and 2008 to begin a strategic planning process to formalize initiatives of the Advisory Board of Directors to create a five-year development plan, open pathways to technology and research, and increase community involvement and partnerships.

Preventing Readmissions to the Hospital


Unity Health System was awarded up to $558,000 in 2013, over three years, to implement a program to improve secondary prevention for patients with stroke or transient ischemic attack (TIA). The one-year target goal is a reduction of 30-day stroke readmissions to <10 percent, with a two-year target of <8.5 percent.

University of Rochester Medical Center’s (URMC) Strong Memorial Hospital was awarded a three-year grant of close to $600,000 in 2013 to pilot a “virtual care center” (VCC) working with Visiting Nurse Service. The goal is to improve the quality of care to patients and reduce hospital readmissions by 20 percent.

St. Ann’s Foundation has been awarded up to $484,000, beginning in 2013, for a two-year program to reduce hospital readmission’s for patients with heart disease. Patients will participate in a well-researched training program to better manage their disease, and interdisciplinary teams will provide clinical services with the goal of reducing readmission’s to 15 percent.

St. Ann’s Foundation and Visiting Nurse Service received a two-year grant of $210,000 between 2007 and 2009 to create a five-bed unit to provide end-of-life care, called the Palliative Center for Caring.

Home Care of Rochester received a grant of $421,268 between 2007 and 2008 to develop ¡EXITO! a unique home care model for Hispanics that incorporated cultural norms to improve health outcomes including a reduction in rehospitalizations and emergency room visits.



Flaum Eye Institute was awarded up to $600,000 in 2012 for a Rochester Area Tele-I-Care program to link primary care providers with ophthalmologists using telemedicine to diagnose and treat vision-threatening eye disease. The three-year initiative is a partnership of the University of Rochester Medical Center’s Flaum Eye Institute, Rochester General Health System, and Rochester Institute of Technology, and will serve about 1,000 patients.

Visiting Nurse of Rochester and Monroe County, in collaboration with the Finger Lakes Visiting Nurse Service, MVP Healthcare, and the Anthony L. Jordan Health Center, received up to $562,159 in 2011 to expand its Telemedicine Program designed to monitor patients’ vital signs and symptoms using in-home monitoring equipment to immediately alert medical personnel of health status changes in home care patients. Their initial grant of $110,395 between 2008 and 2010 was to pilot this project.




Anthony L. Jordan Health Center received $582,943 between 2009 and 2011 for renovation of its existing eight dental operatories and the addition of four new operatories to maximize the center’s ability to meet the needs of low-income patients.

Wayne County Rural Health Network and Wayne County Department of Heath received $330,585 for use between 2008 and 2011 to establish two free dental clinics to serve Wayne County residents who are uninsured or underinsured.

Western New York Rural Area Health Education Center, Inc.(R-AHEC) was awarded up to $599,997 in 2012 for a Rural New York TeleDental Initiative to reduce the prevalence of tooth decay in 3,900 children of migrant and seasonal workers in eight counties. Over a three-year period, R-AHEC will work in partnership with Finger Lakes Community and Migrant Health, Oak Orchard Community Health Center and Agri-Business Child Development.

University of Rochester Medical Center was awarded $253,990 between 2008 and 2010 to increase accessibility to oral health care and improve health care outcomes for residents living in poverty. Funds were used for expansion of an extension clinic of the Eastman Dental Center.

Health Workforce Development and Healthy Workforce


Catholic Family Center Services, in partnership with Monroe Community College, received $211,452 between 2007 and 2008 to develop a Medical Interpreter Training Partnership to train medical interpreters to assist patients with limited English proficiency.

Unity Health System received $164,505 between 2007 and 2009 to develop a Deaf Community Home Health Aide Program to improve both the quality of services to this population and link deaf, elderly home care patients with staff fluent in American Sign Language.

Rochester Business Alliance (RBA) received $149,350 between 2007 and 2008 for a Workplace Wellness Strategic Planning Project to improve the physical activity and eating habits of area employees.

University of Rochester Medical Center was awarded $82,591 for On-Site Medical Education in Rheumatology for Primary Care Providers between 2007 and 2008 to provide enhanced training to primary care physicians in rheumatology to improve their skills at helping their patients with rheumatologic problems.

Other Health Care Delivery


The Children’s Institute’s GROW Rochester program received $600,000 between 2015 and 2018 to increase the number of three-year-olds in Rochester who receive developmental health screenings and subsequent needed services. Early childhood providers will be trained to provide screenings and communicate results and available services to parents and caretakers.

Cayuga Centers, a partnership of Cayuga Centers and North East College Preparatory High School, was awarded up to $49,500 in 2013 to implement an evidence-based Functional Family Therapy program and determine the feasibility of establishing a mental health clinic satellite at the school to reduce physical altercations, suicide, and mental health arrests.

Jewish Senior Life was awarded up to $552,306 for a three-year program, beginning in 2012, to expand its successful Physician House Calls program to provide primary and palliative home-based care to homebound, chronically ill older adults.

St. Joseph’s Neighborhood Center was awarded up to $487,033 for a three-year project, beginning in 2012, for a Health Access Navigation System (HANS) to expand its cost-effective pilot program to identify the best community resource for people having difficulty finding health-care and/or public insurance. The process takes an integrated biological/psychological/social/spiritual approach to care and expects to assist 3,500 individuals annually.