New Initiative Connects Mohawk Valley’s Underserved Community with Primary Care to improve Chronic Disease Management

Utica, N.Y. - Mohawk Valley Health System (MVHS) and Excellus BlueCross BlueShield today announced an award from the health plan's Member and Community Health Improvement program to support MVHS's Mohawk Valley Partnership for Healthy Lifestyles Initiative. The three-year program will use community outreach to identify people living with chronic disease who lack access to primary care.

The Healthy Lifestyles Initiative is designed to expand access to care through a coordinated, patient-centered approach that includes education, screenings and referrals. It focuses on conditions such as diabetes, hypertension and obesity, with the goal of improving outcomes and quality of life through earlier intervention, particularly among underserved and minority populations.

"As a nonprofit health plan, our mission is to help people live healthier and more secure lives, and that means investing in the communities we serve," said Tony Vitagliano, Excellus BlueCross BlueShield's Utica regional president. "Partnering with MVHS helps advance health equity by providing the tools, support and access to primary care people need to manage chronic disease."

The role of primary care in chronic disease management

• Primary care providers support early detection, ongoing monitoring and coordinated treatment of chronic conditions such as diabetes and heart disease.
• Regular access to care helps prevent complications, reduce hospitalizations and lower health care costs, while improving overall outcomes.
• Access to primary care also supports patient education and self-management and helps address disparities in underserved populations.
• Oneida County ranks among the least healthy counties in New York and continues to see higher rates of preventable hospital stays and emergency department visits than the state overall.
• Oneida and Herkimer counties have high rates of diabetes and hypertension, with disproportionate impacts on racial and ethnic minority populations due to differences in social drivers of health.

About the Partnership for Healthy Lifestyles Initiative

The Partnership for Healthy Lifestyles builds on previous efforts to reduce chronic conditions such as hypertension, diabetes and obesity, with a focus on improving health equity in Oneida and Herkimer counties. The program uses community-based outreach to reach people where they live, including refugees, low-income families and minority populations.

The initiative emphasizes education, screenings and referrals, with a focus on improving blood pressure control among patients with diabetes. Primary focus areas include diabetes and chronic condition management.

Expected outcomes include increased awareness of hypertension prevention and management, leading to healthier behaviors, greater use of health care resources and earlier detection and treatment. The program will also expand the identification of at-risk individuals and improve access to primary care, resulting in earlier intervention, better disease management and fewer preventable complications.

Participants referred for hypertension care will gain a better understanding of blood pressure control and available treatment options. The initiative also aims to build a sustainable network of community partners to support long-term health improvements beyond the initial grant period.

Geographic focus: Oneida and Herkimer counties

Core strategies

1. Identify individuals with chronic conditions who lack access to primary care through community outreach
2. Expand access to care, with a focus on underserved populations, including refugees, low-income families and minority groups
3. Improve outcomes for patients with diabetes, hypertension and obesity through coordinated care
4. Provide education, screenings and referrals
5. Track outcomes, including A1C levels, blood pressure and quality-of-life measures

This work aligns with MVHS's priorities in chronic care management.

Contact:Scott Gwilt [email protected]