Millennium Planting New SDOH Seeds; Growing Healthy Communities

“Planting New SDOH Seeds; Growing Healthy Communities” was the title of Millennium Collaborative Care’s exhibit at the 2019 NYS Learning Symposium held Feb. 11-13, 2019 in Saratoga Springs, NY.

On the “sharing” side, the Millennium Team showcased how a “Whole/Plant-Based Eating Initiative”; including the actual prescription of “Food as Medicine” by Millennium’s Western New York Partners; is driving positive outcomes for patients among 270,000 Medicaid clients living in WNY’s eight counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming).

In addition to a special issue of Buffalo Healthy Living Magazine explaining the health benefits of whole/plant-based foods ; Millennium also showcased a video tour of Buffalo-based Urban Fruits & Veggies; and poster pages detailing successful outcomes being driven by innovative providers including Evergreen Health (THRIVE); Greater Buffalo United Accountable Healthcare Network (G-Health); and Rapha Family Medicine (Diabetes Prevention Program). (See Outcomes Below)

To “illustrate” the initiative and involve fellow PPS colleagues in the celebration of healthy whole/plant-based eating; Millennium invited attendees to pose as Symposium “Pictures of Health” by donning “farmer’s gear” and hoisting a basket of vibrant vegetables in front of a life-size “Healthy Living Magazine Cover”. The result was a glorious gallery of magazine cover photos featuring Millennium’s newest whole/plant-based foods advocates!

“We harvested a ton of new knowledge… and hope we planted a few new seeds ourselves,” said Millennium Executive Director Al Hammonds, CSSBB, who was joined at the Symposium by MCC team members Kimberly Backey, EMBA, Cultural Competency & Diversity Initiatives Manager; Christine Blidy, Chief Network Officer; Joe Eberle, Chief Analytics Officer; Michele Mercer, RN, MSHSA, Chief Clinical Integration Officer; Jordon Rabey, Health Care Analyst; and Liz Thelen, Project Administrator.

On the “Learning” side; just a few of Millennium’s new knowledge takeaways included:
• Techniques for designing pathways and processes that meet community needs/concerns and desires.
• How to build the case for partnership to achieve multiple goals.
• The spectrum of MCO and CBO partnerships… What worked and what did not.

“Thanks again to our fellow attendees for their enthusiastic participation in our ‘Picture of Health’ magazine cover selfie opportunity,” said Michele Mercer, who is leading Millennium’s whole/plant-based food initiative. “Our team had great fun at our exhibit. We also thoroughly enjoyed visiting the other creative exhibits and brought home many new learnings from the Symposium overall.”


Heart Disease education group on average:
• 7.5% drop in cholesterol
• 1-2% drop in blood pressure
• 1.2% drop in body weight

Diabetes education group on average:
• 9.7% drop in cholesterol
• 9% drop in A1c (their average blood sugar reading over 3 months)
• 1-3% drop in blood pressure
• 1% drop in body weight

Art Therapy patients have reported an average:
• 27% reduction in symptoms of depression and anxiety
Check In/Check Out Wellbeing surveys:
• Acupuncture: 323 surveys completed, average reported reduction in
mental health symptoms of 59%
• Guided Imagery Meditation and Yoga: 311 total surveys completed,
average reported reduction in mental health symptoms of 35%
• 188 PHQ9 pre-tests have been completed


• .3% drop in HgbA1C was measured for diabetic participants
• 7.5 points systolic and 6 points diastolic average drop in blood
pressure among the general participating population
• These outcomes contributed to the BP Gold status that was awarded
to Urban Family Practice (UFP) by the American Heart Association.
This award recognized the ability of the practice to control blood
pressure for more than 70 % of its patients.


• About 85% of Prediabetic Patients that enrolled in Rapha’s Diabetes
Prevention Program achieved 5% or more weight reduction within a
• Stable A1c levels (It’s important to note that all participants were
able to reduce their risk of developing type 2 diabetes.)
• Majority of the patients reported that they “feel more positive in
general about life and more energetic.”


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The Erie County Medical Center (ECMC) is the lead entity in the Millennium Collaborative Care Performing Provider System.

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