Poster Presenters - Community Based Organization Category

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Q1 Please provide your contact information below.


Title and Organization


Address 2



ZIP/Postal Code

Email Address

Phone Number

Stephen Cook

Golisano Children´s Hospital @ URMC

601 Elmwood Ave

Box 777





Q2 Please describe your company or organizations overall goals and mission.

To be the premier children's health services organization for the upstate New York region. It serves as the referral center for all seriously ill or injured children from the 17 county Finger Lakes region and beyond. Our missions are to provider comprehensive care for children and families, educate future pediatricians and specialists, and perform progressive research that will lead to innovative care models and medical breakthroughs of tomorrow. We are also partnered with Foodlink, the regional food bank for the Finger Lakes, as well as Legal Assistance of Western New York (LAWNY, Inc.), the non–profit corp providing access to the justice system to low income people and other vulnerable populations.

Q3 Please indicate which category your organization falls under.

Health Care Provider,
Community Based Organization,

Other (please describe below: 150 character maximum):
We also include a regional food bank and regional legal assistance organization.

Q4 Innovation Executive Summary. Please describe the innovation, and how it addresses the social determinants of health. Please identify how the innovation addresses the 6 innovation criteria (i.e. ROI, scalability, feasibility, evidence–based support for innovation, relevance to the Medicaid population and speed to market).

The Fax to Food strategy, involves an active screening and referral process for families that identify food insecurity and need for food assistance during pediatric visits at the Golisano Children´s Hospital at UR Medicine. This involves routine screening for ~10 social determinants from the WE–CARE survey. For those families that respond "yes" to the question: "Do you need help in getting food by the end of the month", we provide passive and active referral strategies. For passive referral, we provide a handout on the Foodlink Curbside markets that are available 5 days a week throughout Rochester, we provide the link to the LAWNY webpage and the link to 2– 1– 1 Lifeline, the free & confidential to vital services within the community. The Active referral process has evolved through collaboration with Foodlink and LAWNY and ongoing negotiations with the hospital compliance team at UR–Medicine. We developed a 1–page consent and referral form with 2 questions about family needs. If families are interested, and provide written consent, we will fax and share their contact information with Foodlink staff and LAWNY staff. These organizations will reach back out to the families that are identified on the consent form, assess what needs they have around food and connect them with assets or services in our community. This project is scalable by virtue of developing partnerships with health care systems, providers or primary care practices with their regional foodbanks, their county–level NOEP or legal assistance organizations and with their local or community resource data base (2– 1–1). There are also cooperative extension services available through every county of New York who could partner in this strategy. The feasibility will be dependent on the local or regional champions that can be identified but the key community partners identified in our proposal should have a regional presence, in some form, through throughout the state. The scalability and feasibility of this project will be greatly improved or delayed by the vision and leadership of regional health care systems related to their providing resources to electronic medical records or IT solutions on the health care side of this. The evidence base for this work is taking from the American Academy of Pediatric Policy State from 2015 directing health care providers that serve children to screen for food insecurity and refer those who identify such needs. We are also building on work supported by the CDC´s Nutrition & Obesity network Policy Research & Evaluation.–safety–net/clinical–linkages/ This work is also based on a similar active referral process developed and implemented by Kaiser Permanent in Colorado who partnered with Hunger Free Colorado for a similar screening and active referral process. This is highly relevant to the Medicaid population (as well as Medicare) as the eligibility of Medicaid is nearly identical to those for WIC and SNAP. The families, as well as seniors, represent these key, vulnerable populations that have the highest rates of food insecurity. Speed to market, will depend on the current relationships in various regions throughout NYS, but the regional PPSs provide an ideal back drop for developing these regional strategies and partnerships. The other key to speed, again, comes back to the support and resources provided by either PPS or health systems to remove barriers and implement this screening and referral process. Even if active referral, like the Fax to Food form and strategy, an improved strategy for passive referral and embedding resources into the Electronic Medical Records of health systems is a highly feasible and scalable strategy.

Q5 Was your innovation implemented? If so, please explain when, the number of people impacted, and the results.

Yes (please specify when and the estimated number of people impacted):

Summer 2017, 3–8 families per week roughly with active referral but dozens with passive referral.

Q6 Please identify the SDH Domain that your innovation addresses. (Select all that apply.)

Health and Health Care,

Economic Stability

Q7 I give the Department of Health the right to share the information submitted in this application publicly (for example: on the DOH website). I understand that there is no monetary reward/reimbursement for my submission or for attending the summit should my innovation be selected.

I consent to have my innovation shared