In the Community

Health plans and their employees are a vital part of their communities. In addition to providing health care to their members, plans work in other ways to improve the health of their communities, and to provide innovative programs that support members and the community as a whole. Year after year, plans are also active participants in community activities and generous supporters of various organizations in the regions they serve. The following are examples of health plans’ innovative member support programs and other ways that plans give back to their communities.

Capital Roots

Two health plans, CDPHP and MVP Health Care, are working to reduce the impact of poor nutrition on public health in New York’s Capital Region. Both are teaming up with Capital Roots on efforts to get fresh, affordable food to underserved neighborhoods throughout the area.

Sponsored by CDPHP, Capital Roots’ Veggie Mobile is a mobile market that travels to inner-city neighborhoods throughout the services area. Since 2007 it has been bringing fresh, produce to residents with limited access to fresh food. The Healthy Stores program, sponsored by MVP Health Care since 2011, has been making sure that fresh, affordable produce and healthy alternatives are a daily presence in convenience stores throughout the region. Together, these programs support the goal of Capital Roots to nourish healthy communities and complement its other programs including organizing community gardens and urban greening programs and offering nutritional and horticultural education for all ages.

Pregnancy Notification Program

CDPHP’s pregnancy notification program identifies pregnant members to connect them to resources that support a healthy pregnancy, including breastfeeding support, healthy eating, staying active during pregnancy, mental health support, and the importance of prenatal and postpartum care. The program links pregnant members to the CDPHP Care Team, comprised of specially trained professionals including nurses, dietitians, and licensed social workers, to provide 1-on-1 support to individuals with high-risk conditions and resources to reduce barriers to a healthy pregnancy. This includes assisting members with arranging transportation for medical appointments, obtaining necessary pregnancy and baby supplies, finding and applying for affordable housing, and applying for applicable benefits such as WIC.

In 2022, CDPHP expanded the program, partnering with Ovia Health, a clinically-backed, digital health platform, to support members by providing personalized guidance, robust educational content and unlimited access to the Ovia Health coaching team. Compared to families not using the platform, Ovia Health reports: a 28% reduction in dangerous and costly preterm delivery and NICU stays; a 15% reduction in c-sections; and an 18% reduction in preeclampsia. Following delivery, 92% infant vaccination adherence and a 31% increase in perinatal mental health treatment utilization were reported.

Book Bikes

During the summer of 2022, CDPHP forged a partnership with the local not-for-profit organization Grassroot Givers to bring two “book bikes” to events across the City of Albany. With the support of CDPHP, Grassroot Givers’ book bikes are earth-friendly “mobile libraries” that pedal to local neighborhoods and events to share books and promote literacy and book ownership. The goal of the program is to ensure kids continue reading over the summer and avoid the so-called summer reading slump. The book bikes are also be equipped with toothbrushes, toothpaste and educational information on oral health, courtesy of Delta Dental. These are the first bikes of this kind in the Capital Region, making visits to Albany Department of Recreation Playstreets events each Friday, as well as several other camps, parks, and even splash pads. To date, Grassroot Givers has shared more than half a million books with people in the Albany.

Neighborhood Care

Beyond the role of providing health care to their members, health plans and their employees are also neighbors and part of the community. EmblemHealth developed the Neighborhood Care program with 13 centers around New York City and Long Island, with each offering in-person and virtual customer support, connections to local resources, and free programs to support community health and wellness tailored to the different neighborhoods. Each Neighborhood Care location also features Customer Care Navigators who live in the communities they serve, ensuring that they can help customers navigate barriers to health in a personalized way. Neighborhood Care classes, events and services are available to members and non-members alike.

Healthier Futures Health & Wellness Expos

At the height of the coronavirus pandemic, New York not only had the most cases in the country, but it also saw how the virus disproportionately impacted communities of color and low-income neighborhoods.  Seeing regular access to care in these communities decrease significantly throughout 2020, in 2021 EmblemHealth sought to eliminate health care disparities by bringing the doctor’s office directly to the people. The plan partnered with community organizations and local leaders to launch its inaugural Healthier Futures Health and Wellness Expos, a series of community health fairs that feature onsite health screenings, COVID-19 and flu vaccinations and family-friendly entertainment. In addition to providing thousands of New York residents with care services, the fairs also offer wellness and community resources, and fresh healthy food. Now an annual event, the Healthier Futures Wellness Expos have helped underserved neighborhoods across the city, from the Bronx to Brooklyn.

Back to School

As children and families got ready to go back to school this fall, EmblemHealth held a series of events for families and communities across New York City designed to help the 2022 school year get off to a good start. EmblemHealth’s back to school program provides children and families with free backpacks, school supplies and care packages, distributing more than 15,000 school bags and 7,500 school kits across the city this fall. In addition, EmblemHealth’s 14 Neighborhood Care centers, which are located throughout the New York City Metro Area and Long Island, provide free in-person and virtual services to all community members. The centers, offer health education and wellness classes, and connect individuals and families to community resources to address social determinants of health. Families also meet with AdvantageCare Physicians — EmblemHealth’s primary and specialty care medical office — to ask questions in preparation for September and beyond.

Scholarships for New York City’s Future

As part of a multi-year financial commitment to supporting and investing in New York’s future leaders, EmblemHealth is partnering with One Hundred Black Men of New York and Mount Sinai Hospital to provide scholarships to selected City University of New York students. Starting in the 2022 fall semester, the new scholarship program will provide five students with $5,000 each toward a bachelor’s degree. Additionally, recipients will be offered paid internships at either Mount Sinai or EmblemHealth, ongoing networking and mentorship opportunities, as well as consideration for full-time employment at EmblemHealth. CUNY schools such as Brooklyn College and the CUNY School of Medicine will recommend scholarship recipients. EmblemHealth, One Hundred Black Men of New York, and Mount Sinai Hospital will make final selections.

Empire BlueCross Blue Shield offers members an array of member support programs, including:

A partnership for a healthier community

For many families, putting fresh food on the table is a struggle. Working together, Empire Blue Cross Blue Shield and the Food Bank of New York City are helping provide access to fresh fruits and vegetables. When Empire announced it would be giving away fresh produce, the community reponded, with more than 200 people lining up two hours ahead of time. For vulnerable New Yorkers already grappling with high rents and other daily costs, receiving healthy produce is a welcome relief. The partnership between Empire and the Food Bank helps feed families and keep them healthy, and it helps feed the soul of the community.

Improving Maternal/Child Health

In partnership with Public Health Solutions, Empire/HealthPlus developed a referral pathway to support pregnant mothers and families with maternal-infant services and resources. Through the Jamaica Southeast Healthy Start initiative, members in Jamaica, Queens are screened to determine need for community services. The partnership has monthly check-ins on referral status and outcomes, with opportunities to discuss process improvements and program evaluation. Empire has referred 798 women to PHS, 88% of whom were contacted and screened. Of those screened, 59% were referred to home visiting (HV) programs and 26% were referred to other services, including SNAP/WIC application assistance or mental health support services. Of those referred to HV programs, 49% enrolled. The typical enrollment rate is 30%.

Post Discharge Management

Empire Blue Cross Blue Shield has developed a program that provides members with outreach following a hospital discharge to support and educate members to prevent a re-admission and improve understanding of disease process.

Asthma Outreach programs

The plan has care management specialists who educate members on management of this chronic disease. These efforts help to improve members’ overall health status to prevent serious asthma attacks, which also prevents emergency room visits.

Emergency Department outreach program

Through this program, Empire Blue Cross Blue Shield reaches out to members 23-48 hours post emergency room visit to assist with any follow up needs. This can include follow up appointments with primary care and other providers and social determinants of health needs, as identified.

Wellness and Recovery Support

A Wellness and Recovery Specialist (WRS) from the plan works with members in the hospital to help them strive toward recovery goals. WRS have experience working through treatment to recovery to develop a “peer” environment. They offer emotional and practical support, as well as informational resources.

Backpack Heroes

The annual Backpack Heroes campaign, a partnership between the Regional Food Bank of Northeastern New York, Fidelis Care and WRGB-TV (CBS-6), works to raise funding that helps fight childhood hunger in the Capital Region. The program, provides healthy foods for kids and families in need.

Throughout the school year, hungry children can pick up a backpack filled with nutritious and easy-to-prepare food every Friday afternoon, so they have food to eat throughout the weekend. Started 15 years ago, more than $600,000 has been raised, which has helped the food bank’s backpack program reach 243 schools across 22 counties, supplying 188,900 backpacks to nearly 7,000 children in need.

Supporting Literacy Diversity

In 2018, at least 50 percent of children’s books published that year featured White characters, according to the University of Wisconsin-Madison School of Education Cooperative Children’s Book Center. The next most published characters, at 27 percent, were animals, meaning only about 23 percent of the books published that year had any other racial group represented and meaning many children don’t “see” themselves in books and can’t identify with the stories.

Fidelis Care has teamed up with Literacy Inc. (LINC), a nonprofit organization whose mission is to equip New York City families with foundational literacy skills, working together to change these statistics with Diversity through Literacy. The program, now in its third year, aims to increase diverse representation of children in books, which helps to cultivate unique perspectives on inclusion and equity while also helping families learn about the benefits of early literacy and its impact on children’s healthy development.

Member Support Programs

Expanding Telehealth

Fidelis instituted a new telehealth pilot program, looking to use telehealth services to engage members living in rural communities who are not currently seeing their assigned PCP. The plan targeted 15,000 rural members with no recorded PCP visits within at least the last 12 months and high potential risk. Reaching out to members through a large variety of channels – email, text, phone and mail – the program offers care management services that are specialized for the individual member. Success of the pilot will be measured by better health outcomes, lower urgent care utilization, and high member satisfaction. The following are examples of the program at work.

  • Addressing Challenges with Traditional Providers — One patient had a PCP in the community that they utilized to manage prescriptions but felt like their health needs were not being met otherwise. Fidelis co-managed the patient with their PCP services to get the patient’s health needs addressed, medications updated, and initiate a care management program. When the patient also indicated they had lost access to their mental health provider within the community, the program was able to establish a relationship with a telehealth mental health provider. The patient said this was the best healthcare experience they have had in their life, specifically mentioning how great it was to have someone call back when they indicated that they would and be able to quickly address their needs.
  • Addressing LGBTQIA+ community unmet needs in Rural Geographies — A patient, who struggles with a mental health condition decided to book a telehealth appointment after receiving mailers outlining the services offered by the Fidelis pilot program. Going to a PCP is especially uncomfortable for the patient and results in the patient not obtaining services. After the initial appointment with a telehealth PCP, the patient was able to refill prescriptions and have routine lab work ordered. The patient expressed that they have had a wonderful and comfortable experience with telehealth and felt that they were able to receive both preventive and routine medical care that they were not receiving through traditional medical systems.
  • Addressing Food Insecurity as a Social Determinant of Health Risk — A patient with a hormonal disorder does not have a support system that helps them make healthy lifestyle choices and changes. Fidelis’s Community Health Worker reached out to schedule an appointment to discuss government-funded programs such as SNAP that the patient may be eligible to enroll in that could assist them both financially and nutritionally. In order to educate the patient on healthier habits and promote an understanding of the components of a well-balanced diet and overall nutrition, techniques such as motivational interviewing were leveraged, as well as providing educational materials to the patient. Fidelis is continuing to meet with the patient to provide support and accountability during their health journey.

Timely Post-Partum Care

Healthfirst established a partnership with Mount Sinai to develop an intervention and payment redesign program to improve timely post-partum visits for low-income, high-risk mothers, age 18 and over, who spoke Spanish or English. The intervention provided education about health conditions (examples include gestational diabetes and depression) and health behaviors (such as nutrition and exercise), and additional engagement included education about common postpartum symptoms, taught self-management skills, provided enhanced social support and connected patients with community resources. The program included a cost sharing arrangement between the plan and the hospital to cover costs related to employing a social worker and community health worker, and provided financial incentives for completed postpartum visits (as defined by HEDIS guidelines).

Partnering to restore hope to the homeless

Homeless patients discharged from the hospital and with nowhere to go are particularly vulnerable, and are four times more likely to be readmitted within 30 days. Amerigroup, which manages Highmark of Western New York’s Medicaid managed care programs, partnered with the Buffalo City Mission, enabling Highmark Medicaid members who are homeless to receive intensive, coordinated care at the time of discharge. Patients receive needed health care through Jericho Road Community Health Center, which has a clinic right in the mission. In addition to working to reduce readmissions, this innovative program is also improving overall health care for homeless patients by enabling them to receive post-discharge care in a safe and healthy environment. Patients in need receive mental health services from Spectrum Human Services. Through the partnership between the health plan and the mission, there’s also an onsite health care navigator who works with those that don’t have health insurance, connecting them with coverage within 24 hours. Working together, Highmark and Amerigroup are helping the Buffalo City Mission fulfill its mission of reaching those in need and getting them back into the community as full functioning individuals.


2022 was a difficult year for Western New Yorkers. The mass shooting at a community grocery store in May and a massive blizzard in December that trapped people in their homes for days and claimed dozens of lives left many people suffering both physically and emotionally. Following the December Blizzard, Highmark BCBSWNY connected with Mental Health Advocates to collaborate on a new initiative called #WeAreHope to identify ways to support the mental health needs of the community. Looking to address past tragedies and future response needs, with the health plan allocating community investment funding towards the effort, they worked together to offer an array of support services. A series of community events — including a Community Day of Hope and Healing and roundtable discussion about community trauma — and a new resource guide that provides a current list of crisis, treatment and community services available across Western New York, have reached well over a million Western New Yorkers in person and online so far. The #WeAreHope initiative has been so well received that Highmark plans to continue the project and is looking at ways to expand its reach.

Care For You

The Care For You program was created to assist members who have chronic health conditions get both the medical care and assistance they need without having to navigate the health care system alone. The personal care program offers a team of doctors, nurse practitioners, nurses, pharmacists, dietitians, and other providers who all work together with members’ doctors, helping provide patients services that go beyond what the physician’s office can provide. Care For You assistance can be advice from a pharmacist, help from a social worker, in-home evaluation, or connecting with community agencies. Care management and provider support is tailored to individual patient’s needs, with 24/7 access in various settings — from the patient’s home to the hospital or a nursing home, or in a clinic convenient to the member. Care For You works to ensure alignment among providers and care personnel to provide more efficient and effective care, resulting in fewer unnecessary treatments or hospital admissions. At the same time, an assessment of social determinants of health that may impact physical and mental health outcomes enables the care team to link patients with applicable community services. The program currently serves more than 2,400 members.

RedShirt Program

Independent Health’s RedShirt Program is focused on helping members who sometimes need a little extra – whether it be finding a provider for particular care needs, getting answers quickly and accessing benefit information, or forging a path to healthier life styles or staying active. For Steve M., after he had open heart surgery two years ago, the RedShirt team members were there to coordinate follow up care and provide motivation to keep up with exercise and diet, helping him to lose 40 pounds. The program also routinely connects patients with Independent Health’s Medication Therapy Management team who step in to help those patients who are non-compliant with their prescriptions, assisting them with proper drug utilization or managing multiple medications that often result in members realizing significant savings on their prescription costs. The RedShirt Program also partners with a variety of local organizations to offer programs designed to help Western New Yorkers get healthy and have fun at the same time.

Capital Roots

Two health plans, CDPHP and MVP Health Care, are working to reduce the impact of poor nutrition on public health in New York’s Capital Region. Both are teaming up with Capital Roots on efforts to get fresh, affordable food to underserved neighborhoods throughout the area.

Sponsored by CDPHP, Capital Roots’ Veggie Mobile is a mobile market that travels to inner-city neighborhoods throughout the services area. Since 2007 it has been bringing fresh, produce to residents with limited access to fresh food. The Healthy Stores program, sponsored by MVP Health Care since 2011, has been making sure that fresh, affordable produce and healthy alternatives are a daily presence in convenience stores throughout the region. Together, these programs support the goal of Capital Roots to nourish healthy communities and complement its other programs including organizing community gardens and urban greening programs and offering nutritional and horticultural education for all ages.

Fitness Courts

With a goal of funding free outdoor fitness spaces within a 10-minute bike ride of every American by 2030, MVP Health Care and the National Fitness Campaign are teaming up to build healthier communities. Working together, so far 21 state-of-the-art outdoor Fitness Courts have been created across communities in New York and Vermont, each sited in easily accessible public spaces to support fitness, wellness, and an overall active lifestyle. The Fitness Courts are designed to provide outdoor workout space and exercise programs for all ages and fitness levels.

Treatment in Place

MVP Health Care and UCM Digital Health recently launched Treatment in Place, a new initiative that provides MVP members with access to combination of hands-on and virtual care, to assure a patient receives appropriate, high-quality, cost-effective care, without the need to go to the emergency room. The program is activated when a member calls 911, and an EMS provider is dispatched. EMS providers can rapidly assess the patient’s vital signs, perform a physical exam, assess social determinants of health, or conduct a diagnostic test from the comfort of the patient’s home. EMTs and paramedics in partner organizations have access to the UCM team, including their medical staff and care coordinators, and work with a UCM emergency medicine-trained physician via telemedicine to quickly treat patients with non-life-threatening conditions. In addition to benefitting patients, the program also allows EMS organizations to utilize their resources appropriately and focus on true emergencies. UCM’s Treatment in Place program is currently available to MVP members across 18 counties in New York.

Elder Law Assistance Program

Without the assistance of an attorney to understand and protect their rights, it is common for older adults to be unable to access services or lose assets that could have been preserved. To address this, MVP Health Care and The Legal Project recently partnered to create the Elder Law Assistance Program to offer older adults free legal assistance on a variety of issues. Powered by a grant from MVP, it helps people over the age of 55 navigate complicated legal questions, draft living wills, assist with guardianship determination, support estate planning, assist with end-of-life document preparation, understand Medicaid and Medicare eligibility, and many more legal issues. The free legal assistance is available to those who meet the age and income eligibility in Albany, Schenectady, Rensselaer, Saratoga, Columbia, and Green Counties.

Virtual Primary Care

MVP Health Care and Galileo have a groundbreaking partnership to offer all MVP members access to virtual comprehensive care including primary care, chronic disease management, and multispecialty health care. The program enables members to use an app to connect with a primary care physician (PCP) at any time, day or night, within minutes and without making an appointment. Galileo’s highly experienced and culturally inclusive, bilingual providers can quickly address a wide range of patient needs, delivering fully integrated primary and behavioral health care, providing faster access to multispecialty care, improving chronic condition management, and avoiding unnecessary ER visits.

Therapy Dog Program

Therapy dogs, which are specially trained to provide affection, comfort and support to people, are often found in settings such as hospitals and hospice, retirement homes and nursing homes, schools and libraries. Thanks to a substantial donation from MVP Health Care, the Albany Police Department was able to stand up its own therapy dog program. As a result of the donation, the Department received three therapy dogs to build meaningful relationships and bring positive health benefits to the Albany community and members of the Albany PD. The therapy dogs have been deployed in emergency situations to help provide comfort to traumatized children who have been involved in car accidents and helped citizens who are at risk of hurting themselves from harm. This therapy dog program, supported by MVP, has been so successful that it has been replicated in other parts of the state and the country.

Patriot Plan

In October 2021, MVP Health Care expanded the offerings of its innovative Patriot Plan that adds an extra layer of health care to complement veterans’ existing VA benefits and empower veterans to have more freedom and control over their health and wellbeing. MVP’s expansion provides individuals who have served in the military with access to free on-demand transportation to and from the VA, free meals after an inpatient hospital stay, free mental health support, and an “over-the-counter allowance” of more than $100 per year veterans can use to help pay for basics such as aspirin, antacids or similar medicine cabinet necessities. Ken A, a Vietnam War Veteran and MVP Medicare Patriot Plan member, credits the programs with giving him “flexibility, choice, and management beyond the services that I am receiving from the VA,” adding that without the Patriot Plan’s additional transportation coverage, it would have been difficult for him to get to follow up appointments with specialists that he accessed through MVP.