CNYCC Develops Resources and Customized Reports to Support Healthcare Providers and Community Based Organizations During COVID-19 Crisis

Local Nonprofit identifies more than 319,000 Central New York residents considered to be high risk for COVID-19

The Central New York Care Collaborative (CNYCC), a partnership that connects more than 2,000 healthcare and community-based service providers in six counties across Central New York, has been working behind the scenes to provide their partners with resources and customized reports to assist during the COVID-19 pandemic.

As the virus made its way to Central New York, CNYCC went to work leveraging their data, IT tools, and healthcare expertise to become a resource for their partners during the time of need. After the Center for Disease Control (CDC) identified several medical conditions which place patients at higher risk for complications of COVID-19, including Hypertension, Cardiovascular and Pulmonary Diseases and Obesity, CNYCC used that information to build reports that identified any patients who met the CDC criteria for high risk.

Utilizing proprietary clinical data from Electronic Medical Records integrated into IBM Watson Health, along with New York State Medicaid Claims data, CNYCC built 66 customized reports for their partner organizations that contained more than 319,000 patients across Central New York considered to be high risk for complications of COVID-19 based on the CDC identified medical conditions.

“By providing our partners with their customized COVID-19 High Risk Patient Roster, we are hoping to help inform each partner’s strategy for the extra care required in protecting this vulnerable population,” said Dr. Joseph Maldonado, Chief Medical Officer at CNYCC. “At a time when we are facing a nationwide Pandemic, we feel it is vital to do everything possible to help protect those who are most vulnerable and who have the highest risks for poor outcomes.”   

Compassionate Family Medicine (CFM) of Syracuse is one of the partners who received a custom report that included a roster of susceptible patients for COVID-19. The healthcare provider plans to have their HealthCare Coordinators use the report to further categorize those who have the greatest risks of having complications if infected and proactively contact them to do a TELEMEDICINE encounter with the purpose of assessing, educating, and reassuring those patients.

CFM will reach out to patients based on age and social determinants such as: those 60 years or older, patients who live in poor neighborhoods with high hospitalization rates,  patients who have had transportation difficulties, patients with mental health conditions such as anxiety and depression, patients who suffer from alcohol and/or drug use, lack social support, or have language barriers.

Along with working directly with their patients, CFM will collaborate with the pharmacies that deliver medications to their patients’ homes, as well as the insurance companies to assist anyone who may have co-pays that would be a barrier to receiving proper healthcare.

“The list provides us with the patients who have immunocompromising health conditions and gives us a tremendous head start.” said Ted J. Triana, D.O., Chief Executive Officer of Compassionate Family Medicine. “CFM, our staff and our patients continue to be grateful for the support and empowerment provided to us by CNYCC.”

In addition to the customized reports, CNYCC created a COVID-19 resource center on their website that shares information directly from the Centers for Disease Control (CDC), World Health Organization (WHO), New York State Department of Health (NYS DOH), and other medical sources.

CNYCC also provided their Partners with an opportunity to ask COVID-19 related questions to a public health official when they hosted a live special question-and-answer webinar with Dr. Jiancheng Huang, Public Health Director for Oswego County.

About CMF

Compassionate Family Medicine (CFM) is a primary medical care provider with four locations in Central New York including Downtown Syracuse, North Syracuse, Baldwinsville and Lyncourt. CMF provides competent and compassionate medical care to all our patients regardless of their race, cultural or economic backgrounds and is proud to be recognized by the National Committee on Quality Assurance (NCQA) as a New York State Patient-Centered Medical Home. For more information on Compassionate Family Medicine, visit



The Central New York Care Collaborative (CNYCC) is a partnership that connects more than 2,000 healthcare and community-based service providers in six counties across Central New York--Cayuga, Lewis, Madison, Oneida, Onondaga and Oswego. The primary goal of the collaborative is to serve the population by improving the coordination of services, enhancing the quality of performance outcomes, and creating an overall better system of care. Since 2015, CNYCC has worked closely with over 150 network partners in developing programs to address the physical, behavioral, and social needs of patients across the region.

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