NCI Announces Outcomes of Three Promising Practices Fund Awardees

Projects Addressed Unmet Healthcare Needs in Tri-County Region

Watertown, NY —– North Country Initiative (NCI), a partnership of clinical and community-based organizations serving people in Jefferson, Lewis, and St. Lawrence counties, recently announced the successful outcomes of three healthcare projects that increased access to care, improved quality of care, and promoted positive health outcomes for patients served.

The projects were funded by NCI’s 2022 round of “Promising Practices” awards, an initiative to support established best practices and test innovative pilots to fill physical, social, and behavioral healthcare needs in the community. The 2022 funding marked the second year that NCI strategically invested in these priority areas through its Promising Practices Fund. The three projects were conducted over 12 months, from April 2022 through March 2023.

The first project, Bolton’s Pharmacy’s “Vaccines and Vitamins for Children,” provided free monthly supplies of multivitamins to more than 200 children in low-income households, secured equipment to administer vaccines for children, and provided more than 1,000 vital vaccine series to adults through Bolton’s Watertown location—an increase of more than 4,000% since the project began.

“Funding from NCI made it possible for us to apply to participate with New York State’s Vaccines for Children program, including purchasing a refrigerator and freezer combination and an exam table to provide our pediatric patients and their parents with a more private environment for vaccination,” said Shawn Signor, supervising pharmacist at Bolton’s Pharmacy. “Funding also allowed us to purchase two laptop computers to support administration of vaccines, particularly influenza vaccines, to patients in their home or community settings, and we have also obtained standing orders for 23 different types of vaccines to be administered, which further enhances our pharmacy’s ability to provide high-quality, convenient, and accessible care to the thousands of patients we serve.” Bolton’s Pharmacy indicated it will continue to offer free multivitamins to children and vaccines to both adults and children moving forward.

The second project, Complete Family Care & Laser Center’s “Bridging the Care Management Gap for Medicaid Patients” made it possible for the independently owned primary care practice located in Watertown to test an innovative pilot to provide clinical and social care management support to high-risk Medicaid-insured patients, as Medicaid does not reimburse providers for chronic care management services. NCI funds supported a Registered Nurse Care Manager and an Outreach Coordinator who collaborated to address identified high-risk patients’ clinical and social needs. Care management services took place over the course of several months and included regular, typically at least monthly, interactions with patients through a combination of face-to-face visits and phone calls; creation of a care plan based on the patient’s wellness goals; efforts to prevent avoidable hospitalizations and emergency department visits; facilitation of recommended services, such as breast cancer screening or colorectal cancer screening; referrals to specialty care and/or community-based social care organizations; and other services as appropriate.

Among the 106 patients that participated in the program, highlights of their outcomes include:

  • 54% reduction in emergency department utilization compared to the prior year
  • 40% reduction in inpatient hospitalizations
  • 94% completed a social determinant of health screening tool, with 69% of screenings resulting in at least one identified social need (e.g., housing, transportation, food insecurity, financial instability, etc.) and a resulting attempt to refer the patient to appropriate services in the community
  • 61 patients attended a same-day appointment with the practice for an acute need, which otherwise may have resulted in an emergency room or urgent care visit
  • 59% of the patients’ collective 752 identified care gaps were met (e.g., patient received a recommended cancer screening, immunization, diabetic eye exam, or other recommended service).

“This care management pilot has demonstrated success in reducing participants’ emergency department utilization and hospitalizations, engaging patients in primary care, and providing important preventive services like cancer screenings and immunizations,” said Dr. Karen A. Williams, owner and physician at Complete Family Care & Laser Center. “We have built a playbook of best practices for delivering chronic care management to the Medicaid population, and it is our hope that, together with NCI, we can reproduce and scale this program in other primary care practices in the region. Furthermore, we look forward to advocating for the incorporation of chronic care management within New York State’s Medicaid-reimbursable fee schedule so that Medicaid patients across the state can similarly benefit from this critically important service.”

The third project was the Watertown Family YMCA’s “Blood Pressure Self-Monitoring Innovation: A Partnership to Empower Low-Income High-Risk Individuals through Self-Monitoring for Successful Hypertension Control.” The Watertown Family YMCA enrolled 82 individuals with high blood pressure to participate in a four-month self-monitoring program in which they received a free blood pressure monitor to regularly check and track their readings at home and attended twice-monthly blood pressure check-ins and monthly nutrition education seminars led by YMCA staff. The seminars also incorporated healthy food tastings and “lunch and learns” whenever possible, promoting heart-healthy recipes.

“Because participants can enroll in the program at any time, we currently have 12 individuals who completed the program, with others midway through,” noted Michelle Graham, senior director of health and wellness at the Watertown Family YMCA. “The individuals who completed the program successfully managed their hypertension, with 58% experiencing a decrease in their overall blood pressure readings. The NCI grant has served as an incredible springboard to further enhance this important work, and we are dedicated to the continuation of the blood pressure self-monitoring program even after the grant has ended. We have enjoyed a strong collaboration with the North Country Family Health Center, whose team has facilitated referrals to the program, and we welcome referrals from all area providers.”

NCI Director Erika Flint concluded, “NCI is proud to have supported these three unique projects, each of which increased access to high-quality, patient-centered care for some of our region’s most vulnerable residents. We are equally pleased that each organization, after being boosted by NCI’s initial funding and seeing the positive health impacts that these projects have had on people in the region, has committed to continuing the projects into the future. Our community is fortunate to have an array of clinical and community-based partners who are passionate about improving the health and well-being of local residents.”

For more information about the three organizations whose projects were funded, please refer to their respective websites: