Since COVID-19 vaccinations first became available, FPHNYC has been at the forefront of the City of New York’s commitment to ensure fair and equitable access to vaccinations and boost vaccine confidence. Central to this work has been supporting the efforts of the Health Department and community-based organizations to increase the presence of community health workers (CHWs) in communities.

In the following article, Healthbeat New York’s Eliza Fawcett discusses how CHWs helped increase vaccine uptake in communities around NYC. We thank Healthbeat New York for allowing us to republish the article on our blog.

This story was originally published by Healthbeat. Sign up for their public health newsletters at healthbeat.org/newsletters

Community health workers increased Covid-19 vaccination in NYC, a new study finds. Here’s why their efforts worked.

Jun 6, 2025 at 12:47pm EDT By Eliza Fawcett, Healthbeat New York

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In the depths of the Covid-19 pandemic, community health workers played a significant role in increasing vaccine uptake in hard-to-reach New York City communities, a new study has found.

Community health workers are public health workers with close connections to the communities they serve, and often act as intermediaries between local residents and health systems or social services. Across the country, many regions invested in community health worker initiatives as part of pandemic response efforts. But the workforce is particularly vulnerable to public health’s boom and bust funding cycle.

Quantifying the impact of community health workers who don’t work in clinical settings has long been challenging, said Dr. Maureen Miller, an epidemiologist and contractor with the New York City Department of Health and Mental Hygiene. But the data that emerged from the pandemic — and the Health Department’s significant investment in community health workers — offered an unusual opportunity to show their value, she said.

In the study, recently published in the American Journal of Public Health, Miller and other researchers affiliated with the Health Department found that community health workers, in partnership with the agency and community-based organizations, helped drive sharp increases in vaccination levels among local residents.

In 75 ZIP codes targeted for public health interventions, residents were primarily Black and Latino — demographics that had experienced disproportionately high mortality rates in the early weeks of the pandemic. At the beginning of the initiative in July 2021, 44% of all residents had completed their primary series Covid-19 vaccination. By June 2022, vaccine uptake rose to 76%. The majority of those communities received high levels of engagement from community health workers, defined as interactions during at least 11 months of the year.

Over the course of that year, community health workers also provided vaccination information to local residents more than 18 million times and participated in more than 22,000 outreach events, according to the study. They made 800,000 linkages to Covid-19 vaccination appointments, created more than 200,000 referrals to testing sites, distributed 17 million face masks and handed out 73,000 at-home antigen tests. They also helped residents tackle other issues, from food insecurity to housing instability.

In an interview this week with Healthbeat, Miller discusses the study, the role of community health workers, and why their approach to community engagement proved so effective. This interview has been edited for length and clarity.

Take us back to where New York City was in the pandemic when this project began. What motivated this research?

I was hired just as [the Covid-19 variant] Omicron was taking off, as were all of my colleagues. It was a very crazy period in the pandemic. Although vaccines were increasingly available, they were kind of challenging to get in New York City. You had to make appointments through computers and online. Not everyone knows how to operate that, not everybody has access to that, and we were also in the communities that had been left behind already by vaccines, by treatments. People had already died.

The statistics are astounding: Almost half of the people who died in the pandemic in New York City died in the first month or two. That’s staggering, and I think we’ve swept that loss under the rug because it’s enormous. It has affected all of us.

Against that background, people were mistrustful. They said, ‘You want us to take this vaccine now, we don’t understand it. We hear bad things about it.’ There was already a great deal of misinformation and skepticism on the part of community members that we were working with. So the idea was not, as the city Department of Health, to go in and say, ‘Get vaccinated.’ It was to partner with community-based organizations who hire people who are centered in the community. We provided funding for the community-based organizations to hire community health workers who we would help train and keep updated on all the new variants, the new vaccines, the boosters.

The community health workers and the community-based organizations developed a lot of their own methods of interacting with the community. We would provide the information, but they would make up songs and get them on the local radio, they’d have flyers. They would do videos and put them on social media. We had biweekly meetings with community members and with community-based organizations. We had a series of trainings for community health workers. It was probably the largest effort that the New York City Department of Health has ever made to integrate community with government in the city.

How did you set up this study?

One of the reasons that community-based community health workers get no respect is because it’s been extremely difficult to find a database that shows the impact of population-level change. We wanted to change entire communities, not just one person at a time. We didn’t interact with every single person in the community, yet our impact was felt, as evidenced by the huge increase in vaccine uptake over time.

We had an outcome: how many people had received the full series of vaccinations. We had that data, and it was collected on a weekly basis for everyone who became vaccinated. I can’t even tell you how unusual that is in the world of public health — but so is a pandemic. This provided a unique opportunity to look at the outcomes and then to see how our work with the community was impacting our objective, which was vaccine uptake.

We didn’t interact with every single person in the community, yet our impact was felt, as evidenced by the huge increase in vaccine uptake over time.

– Dr. Maureen Miller

The contracts were based on X number of outreach engagements, X number of handing out materials and documentation. You had to satisfy a minimum set of criteria in terms of engagement that you would then get paid for. That’s unique in my experience, but it was extremely effective, because the community-based organizations wanted to help the community in any way they could. So most of the time they exceeded [the goals].

What were the main findings of your research?

I was shocked — I hadn’t looked at the data until things started to settle down with the pandemic. I wondered: Well, how big of an impact did we have? And we had an enormous impact. I don’t know of vaccine uptake that has happened so quickly for any other disease.

Within one year, from the initiation of the project in July 2021 through June 2022, we had a 30% increase in vaccine uptake in a community that is under-resourced, marginalized, distrustful, and disinvested. People went out and got vaccinated.

One of the projects that we did was a storytelling project. We wanted to know, ‘Why did you get vaccinated? Why are you encouraging others to get vaccinated?’ And it was all about family. It was about, ‘I’m going to protect my family.’ It was about community. In an individualistic society such as ours, it was really heartening to hear that that was a fundamental reason why people were choosing to get vaccinated and to convince others to get vaccinated. Not only were our community health workers acting as advocates for vaccination, eventually so were community members.

How do community health workers’ efforts to help residents with other issues, like food insecurity or housing instability, connect to the broader goal of increasing vaccine uptake?

The Health Department wanted people to get vaccinated right away. And the community came back and said, ‘Listen, my kid doesn’t have diapers. I’m not getting a vaccine before I can get diapers.’ There was such a great deal of need — and there continues to be need — for food, for housing, for money for child care, for elder care. There is just so much need in these communities that they can’t afford to think about the Health Department’s priority of getting people vaccinated and not spreading Covid.

People really wanted help, and they didn’t necessarily want the help that we came in with — to provide vaccines. They wanted help with daily living needs that were not being met, and in fact, were exacerbated by the pandemic. So we started providing referrals. We pulled together a list of organizations where people could go to get food. We partnered with the Department of Homeless Services to provide vaccine information and opportunities to make reservations to get vaccinated, and also to find housing for people. Community-based organizations also corralled their networks of food pantries and other resources so that we could amplify their ability to refer others to these services.

That’s how we build trust. We need to pay attention to what it is you need and want; it’s not only about getting vaccinated. It’s dealing with community priorities to ensure that when we would like to do an important health intervention, we’ve already built up the trust.

Eliza Fawcett is a reporter covering public health in New York City for Healthbeat. Contact Eliza at efawcett@healthbeat.org.

Healthbeat is a nonprofit newsroom covering public health published by Civic News Company and KFF Health News. Sign up for their newsletters here.

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1. A Breast Cancer Patient Navigator Program that will increase timely breast cancer screening in Black women and offer continued support along the care continuum. Key elements of this program are to identify patients who are eligible for breast cancer screening, encourage timely screening, and follow up to be sure results are received. The program will also implement continual follow-up with patients who receive abnormal screening and ensure prompt and fair access for patients who need diagnostic and address barriers to care and treatment.

2. A Breast Cancer Coalition to build knowledge and understanding of the causes of higher breast cancer mortality among Black women in NYC, focusing on how our city’s healthcare systems can help address this inequity. The coalition, coordinated by the Health Department, would consist of hospitals and healthcare systems that provide cancer screening and treatment.

The Breast Cancer Patient Navigator Program and the Breast Cancer will benefit from the Health Department’s experience with the Citywide Colorectal Cancer Control Coalition, which has helped increase colonoscopy rates for adults 50 and older by 71% between 2003 and 2020. As part of NYC’s Women’s Health Agenda, the Health Department is committed to replicating similar success in screening and treatment for breast cancer.

Private support is essential to launching the Breast Cancer Patient Navigator Program and the Breast Cancer Coalition. FPHNYC is engaging with foundations, corporations, and philanthropic individuals to help fund these critical initiatives. We welcome your partnership and support so that we can improve lives through more equitable prevention, screening, and treatment for breast cancer in NYC.

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Dr. Michelle Morse, the NYC Health Department’s Chief Medical Officer and Deputy Commissioner, and Assistant Commissioner Dr. Zahira McNatt, recently joined FPHNYC for a webinar discussion on Black Maternal Health in NYC.

The City of New York’s commitment to improving maternal health outcomes is not new; the Department of Health has been dedicated to this cause for decades. However, the inequitable outcomes for Black maternal health is an alarming crisis that demands urgent attention. In response, Dr. Morse’s office launched its Birth Equity Initiative (now the Maternal Home Collaborative) as an innovative umbrella effort to streamline, expand resources, and improve the impact of maternal health programs.  

The Birth Equity Initiative utilizes a collective impact approach to discern the key drivers of birth outcome inequities and explore both traditional and innovative solutions. Beginning in Brooklyn (the borough with the most Black pregnancies and births in NYC) and ultimately spreading to other areas of the city, the Birth Equity Initiative has been moving forward with three strategic components: the convening of diverse stakeholders to develop collective impact goals; developing a model to bundle Medicaid maternal home payments; and enhancing and expanding the integration of primary care services for underserved and at-risk birthing persons.

“Our goal is to reduce preventable mortality by 50% over the next five years. At present, 75% of pregnancy-associated deaths among Black mothers were preventable, compared to 43% in their white counterparts, and 65% in their Latina counterparts. “

To realize this goal, the vision is to work across sectors and create comprehensive strategies for support that encompass collaboration between government, philanthropy, and individuals. FPHNYC is the Health Department’s longtime and trusted partner for launching collaborative initiatives like the Birth Equity Initiative. These collaborations provide scalable and high-impact solutions to some of our most pressing public health issues like maternal health, as well as the opioid epidemic, and mental health. We welcome your collaboration and support! Contact us.

Wrapping up the webinar, FPHNYC’s CEO, Sara Gardner, stressed:

“Everybody needs to understand this issue and what they can personally do about it.  Improving public health and particularly eliminating the disparities between Black maternal mortality and other birthing people is going to take partnerships that bring together government, community, philanthropy, and our personal networks.”

Use your voice and connections to raise awareness about Black maternal health and the Birth Equity Initiative. Learn more about the community organizations assisting birthing persons in NYC and consider how you can best apply your talents and resources to address preventable racial and ethnic inequities in maternal outcomes. Also, explore the in-person and online events offered by the Health Department’s Center for Health Equity & Community Wellness for expectant and new parents.

By unifying government commitment, communal resources, and individual action, the Birth Equity Initiative can help transform the narratives surrounding maternal health, fostering a city – and ultimately a world – where every birthing person can experience safe and equitable care.

The post Black Maternal Health in NYC: A Discussion and Call to Action appeared first on Fund for Public Health in New York, Inc..

FPHNYC, in its long-standing role connecting the Health Department to the philanthropic community, organized a mid-March briefing for foundations to learn more about this transformative mental health plan and opportunities for partnerships. Commissioner Vasan and senior Department staff walked the attendees through the plan’s three pillars: Children, Youth and Families; People with Serious Mental Illness (SMI); and People at Risk of Drug Overdose. 

The briefing also focused on specific initiatives within the plan that the Department is eager to engage and partner with the philanthropic community, including the citywide Clubhouse expansion, telehealth mental health support for all NYC teens, and piloting a Supportive Place for Observation and Treatment (SPOT) program in NYC shelters.  As Dr. Vasan noted, “We started the premise of this plan with the idea and the knowledge that we (the city) can’t solve this all on our own.”

View a short overview of the plan below (and you can download a PDF of the complete plan). To learn more and support the initiatives FPHNYC is helping the City rollout, contact us. For mental health support, visit NYC Well; call 1-888-NYC-WELL (1-888-692-9355); text “WELL” to 651-73.

For additional data and references, see: Magas, I., Norman, C. & Vasan, A. Premature Mortality and Health Inequality among Adult New Yorkers with Serious Mental Illness. J Urban Health 102, 641–649 (2025). https://doi.org/10.1007/s11524-024-00953-w

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FPHNYC quickly mobilized the philanthropic community to help support these efforts through the Vaccine Equity Partner Engagement Project (VEPE). Combining public and private funding, VEPE engages community and faith-based organizations (CBO/FBOs) as outreach partners for reaching people in neighborhoods identified by the Taskforce on Racial Inclusion & Equity (TRIE) as those most impacted by COVID-19. These neighborhoods also have a history of disinvestment and other disparities impacting health and well-being.  CBO/FBOs have also been crucial partners in the Health Department’s efforts to combat vaccine misinformation by disseminating accurate information through leaders and representatives trusted by local communities. 

Black Health is an example of a CBO/FBO which developed a COVID-19 outreach and education program incorporating faith and community-based organizations and youth ambassadors. Recognizing that COVID-19 health outcomes are often contingent upon one’s health status, Black Health focused its wellness outreach, education, and resource distribution efforts to include COVID-19 testing and vaccinations at its health hub locations in Bronx, Brooklyn, and Manhattan.

Efforts by CBO/FBOs like Black Health have greatly narrowed the vaccination gap between communities in New York City. There have been positive changes in vaccination rates in over 96% of zip codes served by the VEPE’s CBO partners between March 2022 (when disaggregated data became available) and October 2022. In fact, concerted outreach to NYC Housing Authority (NYCHA) residents by CBOs in 2022 brought the vaccination rate for NYCHA residents above the city-wide average.

Along with launching VEPE, FPHNCY provides administrative and program management for The NYC Public Health Corps (PHC), a city-wide effort to expand the public health workforce by partnering with community groups. The PHC is active in over 75 NYC Zip Codes and since September 2021, it has connected more than 1,057,577 people to vaccination sites. 

Moreover, according to research published in JAMA Network Open, every $1 invested in New York City’s COVID-19 vaccination campaign yielded, “…an estimated $10.19 in cost savings from lower infection and mortality rates, fewer productivity losses, and averted health care use.” Quantitative an qualitative evidence of how New York City’s targeted vaccine efforts to reach traditionally underserved communities appears is discussed in NEJM Catalyst.

The impact of VEPE and the PHC extends beyond numbers and statistics. The NYC Community Voices: COVID-19 and Beyond project makes available firsthand experiences of COVID-19 vaccine confidence and community resilience from communities served by the PHC. At the project’s online portal, anyone can listen to the real voices of community members as they describe their experiences with COVID-19, community, and vaccination, as well as view the analysis of common themes present in the 850+ highlights from these conversations. The fear and frustration of the COVID-19 pandemic are evident, but so too is an appreciation of the progress made to protect communities and allow people to find new hope. 

Sharing his thoughts with the Community Voices project, Mohammed from Queens said, “I feel like if there was another pandemic in the future, we’d be better equipped in this situation.” 

Read more about NYC’s place-based approach to address COVID-19–related health disparities in the American Journal of Public Health (AJPH). For an in-depth review of NYC’s public health response to the COVID-19 pandemic, see this discussion paper at the National Academy of Medicine website. The AJPH has more on the essential role of community health workers in increasing vaccine uptake in NYC.

The post COVID-19 Vaccine Equity and Engagement Update appeared first on Fund for Public Health in New York, Inc..

Baby Cafe meetings are open to breastfeeding/chestfeeding people, partners, and family​ members. Café facilitators often are International Board Certified Lactation Consultants (IBCLC) who can help with all aspects of breastfeeding, including assistance with latching and milk supply. While the big picture focus of the Baby Café program is to normalize breastfeeding and promote the health benefits to mother and child, the heart of the Baby Café experience is validating the realities and challenges mothers face and respecting the choices they make.

“We support, promote, and encourage breastfeeding as the optimal feeding choice for infants, but understand that this may not be possible for all families,” says Leticia Rios, an IBCLC who facilitates the Brownsville Baby Café. “It’s important to provide information on the benefits of breastfeeding and the risks of formula feeding to allow families the opportunity to make an informed decision. For some mothers, their first child was on formula, but they want to breastfeed with their second child. Each baby is different. We are there to support the family with goals for safe infant feeding.”

While facilitators of the Baby Cafes have topics of focus ready for each meeting, the events often unfold organically with wide-ranging conversations about parenting. This helps new mothers build confidence and connect to a supportive community of peers. It is also an opportunity for participants to share information and resources, including about the complimentary services and support available through the Family Wellness Suites at the Neighborhood Action Centers. The Family Wellness Suites host the Baby Cafes and offer a variety of other parenting classes, as well as provide free supplies to new parents such as car seats and safe cribs. 

“Mothers need connections and information beyond what they might get in a visit to a pediatrician,” says Jacklyn Vingan an IBCLC who facilitates the East Harlem Baby café. “For example, we recently had a mom join who just got out of a shelter. Her case worker knew about the Baby Café. Now we’re getting the mom and her baby resources through the Family Wellness Suite. The mother did the hard and scary thing of showing up and asking for help and we want to be as welcoming and supportive as possible.”

Attend upcoming maternal and new family health events.

Watch a short video of moms talking about their experiences with Leticia at the Brownsville Baby Café, and follow @NYCbaby on Instagram. Read about how the Baby Cafes and support for mothers continued even during the onset of the COVID-19 pandemic.  

Related journal article of interest:
Pierre, J., Valdez, J., Marshall-Taylor, S. et al. Fostering Community Support for Breastfeeding: Implementation of a Neighborhood Level Breastfeeding Initiative in Brooklyn, New York. J Community Health (2025). https://doi.org/10.1007/s10900-025-01446-w

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Dr. Michelle Morse is the Health Department’s first Chief Medical Officer, appointed in February 2021. She leads the agency’s work in bridging public health and health care, including reducing premature mortality, increasing an understanding of health inequities, and ending racial inequities in the leading causes of preventable death. This places her at the forefront of the Department’s commitment to address health inequities and end systemic racism in public health and medicine.

“There’s a natural nexus between public health and healthcare delivery,” Dr. Morse said. “It’s something we need to continue building on…bringing more visibility to the biggest health equity challenges and moving resources to the places, spaces, and programs that address those challenges in a way that is place-based and as well as city-wide.”

A landmark resolution by the New York City Board of Health in 2021 declared racism a public health crisis and directed the Health Department to expand its anti-racism work. In her Public Health Talk presentation, Dr. Morse outlined three pillars of the vision and goals for the Office of Chief Medical Officer: Bridging Public Health and Health Care, Anti-Racist Health Policy, and Accountability.

As an example of the Department’s anti-racism initiatives, Dr. Morse spoke about the newly formed NYC Coalition to End Racism in Clinical Algorithms (CERCA). Clinical algorithms are tools used by clinicians to guide their decision-making. These algorithms often use “race adjustment,” which can negatively impact the treatment and care for persons of color. The 12 institutional members of CERCA have pledged to end race adjustment and create plans to evaluate racial inequities and patient engagement. [September 2022 update: read the Inaugural Report on CERCA’s first year progress]. [May 2024 update: video highlights from CERCA convening]. [October 2024 update: NEJM Catalyst article “New York City’s Public Health Approach to Reexamining Race-Based Clinical Algorithms.”] [April 2025 update: Toolkit for improving clinical decision-making].

Addressing inequities in maternal health is another area of particular concern for Dr. Morse. She spotlighted the disturbing statistic that Black, non-Latina women in NYC are 9.4 times more likely to die during and after childbirth than White, non-Latina women. The Health Department is committed to improving maternal health for people throughout NYC, but it has identified Brooklyn as the epicenter of the maternal equity crisis.

“Brooklyn is the biggest borough by population and has the highest number of births in the City,” Dr. Morse explained. “What we’re trying to do is use a data-driven, anti-racist, and a place-based approach over four years to improve birth equity in the borough.”

Regarding the COVID-19 pandemic, Dr. Morse pointed out that Black and Latino New Yorkers still make up a disproportionate number of cases of infection, hospitalizations, and deaths. She acknowledged how facts like this could make it hard for people to have confidence in the City’s commitment to addressing health disparities —  even though actions like the Board of Health’s declaration of racism as a public health crisis are, she said, a “strong signal of progress.” However, the extent to which systemic racism permeates many aspects of American society remains a formidable contributor to the health inequities of Black and Latino people.

“We can’t stand to see another six decades of inequity in household income, life expectancy, incarceration rates, college graduation, unemployment rates, and homeownership rates,” Dr. Morse said. “If we are serious about racial justice and declaring racism a public health crisis, these are the kinds of trends that we have to turn around.”

Resources

Download Dr. Morse’s Presentation (PDF)

Board of Health Resolution Declaring Racism a Public Health Crisis.

Coalition to End Racism in Clinical Algorithms (CERCA).

The Bridge: newsletter of the Chief Medical Officer.

Book: Killing the Black Body, by Dorothy Roberts.

Book: Medical Apartheid, by Harriet A. Washington.

Report: Racial Inequities in COVID-19 Hospitalizations During the Omicron Wave in NYC.

The post A More Just Future for Medicine and Public Health appeared first on Fund for Public Health in New York, Inc..

After two years of a global pandemic, it’s hard sometimes to remember that public health is not just about responding to crises. Public Health is also proactive, working to realize visions of improving people’s overall health and well-being — visions that are usually well-grounded and evidence-based. They are visions of what may temporarily be just beyond our grasp but can be possible through collaboration and partnership.   
 
Here, in visual form and short text, are some of FPHNYC’s visions for the future and what we are doing to turn vision into reality.   

Ending Racism and Promoting Health Equity 

Racism is a public health crisis, and there is a long history of structural racism impacting health services and care. FPHNYC supports the priorities of the Health Department to advance anti-racism public health practice, reduce health inequities, and strengthen NYC’s collective approach to ensuring that all New Yorkers can realize their full health potential.  

Controlling COVID-19  

Widespread vaccination against COVID-19 is New York’s path to recovery, and FPHNYC is at the forefront of helping the City of New York and community partners provide fair and equitable access to vaccination.  

Improving Birth Outcomes 

Black women in NYC are eight times more likely than white women to die of pregnancy-related causes. In partnership with the Health Department, FPHNYC is piloting solutions to address inequities and transform programs so that pregnant New Yorkers and their babies in our city’s most vulnerable communities receive the support they need to thrive.  

Providing Healthy Choices

Good nutrition is important to an individual’s overall health, as well as a crucial part of managing chronic illnesses such as diabetes and heart disease. From programs to subsidize the cost of healthy food options at supermarkets and farmers markets to providing community-based health education about chronic illness, FPHNYC and our partners are helping New Yorkers take steps to improve their health. 

Preventing Overdose Deaths 

Opioid and substance misuse is a complex public health challenge, and drug overdoses have become one of the leading causes of death in NYC. FPHNYC is working closely with the Health Department to test and implement creative strategies to decrease the rate of opioid overdose deaths and remove barriers to care and resources for people with substance use disorder.   

Supporting Mental Health  

One in five New Yorkers struggles with a mental health condition. Together, FPHNYC and the Health Department are working to improve New Yorkers’ access to mental health support and enhance workforce development for mental health professionals. Anyone in need of immediate mental health assistance can reach out to NYC WELL. 

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Dear Friends,

Progress is rarely a straight path forward, especially during a global pandemic. The roll-out in a record time of highly effective vaccines to protect against the worst effects of COVID-19 is progress worthy of celebration. However, as we continue the fight against COVID-19, the parallel pandemics of racism, mental illness, drug overdose, and food insecurity threaten our wellbeing and demand renewed attention.

Our nearly 20-year partnership with the New York City Department of Health and Mental Hygiene has never been more vital. As FPHNYC turns to 2022, we build on years of progress partnering with and serving the public to innovate and scale public health solutions designed to meet our most formidable public health challenges.

FPHNYC’s Board Chair and NYC Health Commissioner, Dr. Dave A. Chokshi, has repeatedly stressed that New York’s recovery from COVID-19 will only be possible if ALL New Yorkers have an equal opportunity to participate in and benefit from our response to the pandemic. To this end, we are facilitating partnerships for the Health Department with dozens of community and faith-based organizations in all five boroughs to enhance vaccine confidence and access in historically underserved and marginalized neighborhoods.

While these efforts initially focus on increasing COVID-19 vaccinations, we will leverage this network of community organizations to address what Dr. Chokshi terms “slower-moving health disasters,” such as diabetes, mental illness, and the prevention and treatment of many chronic diseases. The health of nearly 9 million New Yorkers is everyone’s business, and it is dependent on the strategic collaboration of the public and private sectors.

Thanks to our philanthropic partners, in our 2021 fiscal year FPHNYC secured funding for more than two dozen projects to protect and improve the health and wellbeing of all New Yorkers. The work of public health cannot function without public trust and cooperation. We are grateful and proud to have yours as we meet the challenges of the moment and work to ensure a safe and healthier life is in every New Yorker’s future.

Most Sincerely,

Sara Gardner
Executive Director

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The U.S. incarcerates more individuals than anywhere in the world, with its prison population tripling to 2.3 million since the 1970s and disproportionally impacting people of color. Persons with criminal legal system involvement (CLSI) face systemic racism and restrictive barriers in accessing healthcare and social service resources to meet basic needs when re-integrating into the community. Many of these individuals struggle with high rates of heart disease, hypertension, behavioral health conditions, and the likelihood of premature mortality.

Recognizing that addressing public health outcomes is an essential part of the creation of a fairer and efficient justice system, the Criminal Justice Investment Initiative of the Manhattan District Attorney’s office funded an innovative pilot program: the New York City Health Justice Network (HJN). Developed and overseen by the New York City Department of Health and Mental Hygiene, the HJN focuses on Northern Manhattan and brings a public health and racial equity approach to the re-entry landscape. The grant is managed and administered by FPHNYC as part of a longstanding partnership with the Department of Health to launch and scale new projects.

HJN offers voluntary, wrap-around health and social services to persons with CLSI, including trauma and resiliency-informed approaches to engagement in healthcare and reentry support services. Community health workers (CHWs) with lived experience of the criminal legal system are paired with participants recently released from incarceration. CHWs, embedded in community-based health and social service organizations, work with participants to identify and address needs by linking them to healthcare and social services and serve as trusted mentors, peers, and coaches along the way.

According to Dorian Bess, a Senior CHW in the HJN, “Having the ability to identify with our participants and their experiences helps us to build a trusting relationship to encourage and support their positive re-entry. Working to build their autonomy and confidence from our first encounter and always meeting them where they are, that is our role as Community Health Workers.”

Participation in the HJN is open to any NYC resident at least 18 years old who has come home from jail or prison in the last three years. Since the program opened for enrollment in September 2019, CHWs have worked with over 750 participants; averaging six interactions with each participant (interactions increased by 50% as the program shifted to remote operations due to COVID).

Preliminary findings show that the HJN has been able to work with participants in meeting self-identified needs. In a review of 417 cases closed between June 2020 through May 2021: 95% of participants (398) had at least 1 need addressed, 70% of participants (291) had 3 or more needs addressed, and 34% of participants (143) had more than 5 needs addressed.

“With re-entry, you can’t take basic things for granted; for example, many participants are released without access to phones which creates barriers to establishing social connections, and to accessing health and social services that are offered online,”

Mari Carlesimo, Senior Director of Transitions to Community at the Health Department’s Bureau of Health Promotion for Justice-Impacted Population.

A core component of the HJN’s mission is to counter the systemic racism and discrimination, which act as barriers to successful community re-entry. As part of the pilot HJN program, a team of six CHWs is available to work with participants. To provide broad community coverage, CHWs are embedded in three well-established community organizations: Osborne Association, Fortune Society, and Center for Court Innovation; and three Federally Qualified Health Centers: Community Healthcare Network, The Institute for Family Health, and the Sydenham Site of Health + Hospitals’ Gotham Health Center.

“The shortest distance between two points is a straight line and the HJN is that straight line in the re-entry landscape,” says Christina Green, Director of the HJN. “The HJN makes direct connections between health and reentry services and gives our participants the many tools and support to be successful along the way.”

HJN has established an all-participant community advisory board to engage with and learn from the insights of community members impacted by the criminal legal system. Similarly, the HJN has launched a Learning Collaborative to incorporate and share lessons that emerge from the program. By filling key gaps in the re-entry landscape and lowering barriers to successful re-entry, the HJN is emerging as an important model for successfully re-integrating persons with CLSI experience into the community and ultimately enhancing the wellbeing and public health of all New Yorkers. The Department of Health and FPHNYC look forward to securing additional funding to continue this important reentry and public health program.

To hear more about the Health Justice Network you can watch a recording of our Public Health talk on our webinars page.

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