A Message From the CEO
Dear Reader,
Following the challenges we faced throughout 2024, our team committed to tackling difficult problems with ingenuity, resilience, and thoughtful action. As a result, 2025 proved to be an exceptionally prosperous year for our work in the nonprofit sector. We established new partnerships, expanded into additional geographic regions, and launched innovative programming that strengthened our impact.
A concept from Jim Collins, author of Great by Choice, continues to resonate deeply with me: productive paranoia It’s the discipline of remaining vigilant even in times of success the understanding that stability can be fleeting As Collins puts it:
“Even in calm, clear, positive conditions, we must constantly consider the possibility with 100% certainty that at some unpredictable point, and at a highly inconvenient moment, events will turn against us—and we must be prepared.”
This mindset reminds us that sustained success requires not just celebration of progress, but constant readiness for what lies ahead. We find ourselves in unprecedented times as we look to the funding landscape for the important work we do, which does not afford comfortability. At the same time, staying close to the mission and holding true to our company values must also remain a priority as we change and grow. As we look back on another year, I am proud to share just a few of the amazing highlights for 2025:
In January, we launched a new payroll system, Paylocity, which has enabled more efficient recruitment and onboarding processes, while also providing valuable trend data to support employee satisfaction and retention efforts
In May, we introduced Health-Related Social Needs Screening and Navigation Services through a partnership with Healthy Alliance, our regional Social Care Network, expanding our ability to address the broader needs of the communities we serve.
In July, we were awarded a new five-year contract with the Oneida County Department of Family and Community Services for the RIYS Program, which provides diversion services to at-risk youth to help prevent out-of-home placement.
In September, we expanded our Resiliency Project a child welfare prevention program into two additional rural school districts: Adirondack and Holland Patent, increasing access to critical support services for children and families
In October, we extended our Health Home services into Saratoga County, responding to a significant need to better serve the homeless population in that region.
In December, we delivered holiday assistance to more than 600 families and 1,500 children, helping to ensure a brighter season for those in need.
As we look ahead to 2026, we will continue striving to strengthen our agency’s brand, build upon the success of our current programming, and deepen partnerships with both funders and nonprofit organizations to achieve meaningful, lasting impact
Best Regards,
Chief Executive Officer CNYHHN, Inc.
JANE VAIL
A Message from our VP of Communications & Donor Development
Dear Friends and Supporters,
It is a privilege to join CNYHHN at such a pivotal moment in our organization’s journey. Stepping into the role of Vice President of Communications and Donor Development, I am fueled by a singular mission: to ensure that the vital work we do is not only recognized but championed by the community we serve.
Our mission is the heartbeat of this region, and my primary focus this year is to amplify our brand visibility and strengthen our fundraising infrastructure By telling the stories of the lives we touch and the barriers we break, we are doing more than just sharing information, we are building a movement of care and support
As we look toward the coming year, our goals are ambitious We are expanding our reach, refining our message, and creating new opportunities for you to engage with our mission. However, we cannot do this alone. Our ability to scale our services and provide a safety net for our neighbors depends entirely on the generosity of people like you.
Your contribution is an investment in the health and stability of our region. Whether it is a one-time gift or a monthly commitment, your support provides eep our community connected and thriving.
we will achieve together and welcome the any of you in the coming months to hear your stories uture
Meet our Senior Leadership Team
Kimberly Pecor Senior Vice President of Operations
Jillian Gross Vice President of Program Evaluation & Data Management
Vice President of Finance
Millie Occhionero Vice President of Communications and Donor Development
Vice President of HR & Administative Services
Jane Vail Chief Executive Officer, CNYHHN
Danielle Martin Executive Director, Connect Ed
Amy Osborne Chief Financial Officer
Kathleen Gaetano Vice President of Integrated Services
Holly Crandall
Amy Schmid
Kelley Bennett Divisional Director of County Programs
Danielle Falzarine Director of Care Management
Divisional Director of Community Schools
Jessica Julian Director of Quality Assurance
Robert Sroka Director of Employee Engagement & Safety
Colleen Matthews Divisional Director of Community Schools
Heather Shwamle Assistant Director
Linda Montemurro Director of Technical Assistance & Training
Matthew Hartwell
Board of Directors
Kristen Vennero, President
Dr Marybeth McCall, Vice President
Michael Giacobbe, Treasurer
Gilli Hachey
Caitlin McCann
James Weaver
Kate Weidman
Rob Wuest
Stephen Zogby
Mission & Vision
Vision
Mission
To promote, sponsor, and coordinate innovative programs that improve healthcare quality, access, and service delivery.
To provide person-centered approaches and comprehensive supports that strengthen individuals and families so they can live healthier lives and fulfill their goals.
Lead Health Home
Description :
Central New York Health Home Network (CNYHHN) is a Medicaid-funded Health Home operating under New York State Department of Health. CNYHHN oversees a network of care management agencies, spanning across 10 counties, that aim to assist eligible individuals in managing, and ultimately becoming self-sufficient in managing their overall healthcare and/or the care of their children.
In 2025, our Lead Health Home Network received 3,126 incoming referrals and processed 3,052 of those received.
As a Lead Health Home Network in 2025:
Total Served
In 2025, our Lead Health Home Network served over 6,300 individuals
Adults
Children
In 2025, our Lead Health Home Network served 5,044 Adults In 2025, our Lead Health Home Network served 1,333 Children
Additional Highlights
Expanded into Saratoga County
Care Management
Description:
Care management in New York State, as overseen by the NYS Department of Health, refers to organized, person-centered services designed to help individuals, especially those with complex or chronic health conditions, access the coordinated care they need to stay healthy, reduce unnecessary hospital visits, and improve overall health outcomes
In 2025 we served:
Adults
Our team served 1097 Adults in 2025
Children
Our team served 229 Children in 2025.
Referrals from Internal Programs
We received 250 referrals from Internal Programs
As an active participant in the Social Care Network (SCN) in partnership with Healthy Alliance, FACT supports Medicaid members through systematic Health-Related Social Needs (HRSN) screenings.
FACT staff use the Accountable Health Communities Social Care Screening Tool to identify unmet needs that impact health outcomes, such as:
Housing instability
Utility access
Educational/vocational barriers
Food insecurity
Transportation barriers
Interpersonal safety
The FACT Program has completed more than 1,700 referrals to community services. Approximately 30% of these referrals directed individuals to Health Home Care Management and Enhanced Care Management (HRSN), ensuring that members with higher levels of need were connected to coordinated support.
Social Care Network Screenings and Referrals to HRSN Services:
Total HRSN Screenings Completed: 299
Individuals referred to HRSN services: 300
In 2025, FACT expanded its community partnership to include Hope House! Collaboration between CNYHHN FACT and Hope House has significantly improved the quality of care and access to resources for members by creating a more coordinated and holistic support system. Through shared expertise, referrals, and streamlined communication, members are able to access the services needed more quickly and with fewer barriers. As a result, collaboration with Hope House has enhanced outcomes, promotes continuity of care, and strengthens overall member well-being.
Referrals are streamlined through clear processes, shared communication systems, and established relationships between CNYHHN FACT and Hope House. Through the FACT universal referral form and agreed‐upon eligibility criteria, members are matched to appropriate services quickly and accurately. Direct points of contact between Hope House and CNYHHN FACT has reduced delays in connecting members to communitybased services, eliminates repeated referrals, and limits the need for members to retell their stories multiple times.
Annual Report 2025 CNYHHN, Inc
Critical Transitions:
In 2025, The FACT Program provided targeted support to individuals identified as having critical transitional needs These individuals are identified as transitioning across systems, particularly those experiencing homelessness, involvement with child protective services, or re‐entry from corrections settings. FACT continues to play a critical role in providing stabilization, navigation support, and rapid linkage to housing, behavioral health services, and community resources
In 2025, a total of 896 members with critical transitional needs were referred to FACT and 723 of those members were successfully linked to essential supports Among this group, 122 were identified as experiencing homelessness, requiring immediate stabilization and housing‐related interventions.
Program Impact
Breaking the Barrier of Language: Mohammad’s Story
Mohammad, a senior Medicaid member, faced significant challenges accessing and maintaining community supports due to his limited English proficiency and visual impairments These barriers often caused him to miss appointments, particularly when navigating Medicaid transportation To better understand his needs, his Community Support Coordinator met with Mohammad and a trusted interpreter of his choosing, using the HRSN screening process to identify the full scope of his challenges As a result, Mohammad was connected not only to improved transportation options but also to agencies that assisted him with food access, winter clothing, cold‐weather preparedness, and affordable housing resources.
Takeaway: When services are delivered in the language a community member is most comfortable with, providers can build trust, improve communication, and support healthier, more fulfilling lives.
Breaking the Barrier for Women and Children
Breaking the Barrier for the Homeless Population: Shamika’s Story
Shamika, a single mother with three young children, was experiencing homelessness and living in a rental vehicle after being evicted due to financial hardship With no existing service providers or community supports, she entered the program seeking stability Since enrolling in Care Management Services, Shamika has begun addressing her unmet social needs, including securing safe, supportive housing for her family She has also been connected to food resources to reduce her food insecurity and continues to work closely with long‐term providers who support her ongoing progress.
Takeaway: Meeting individuals exactly where they are both physically and emotionally is a compassionate, person‐centered approach that respects their readiness, acknowledges their unique challenges, and supports meaningful change
A young mother of four, living with paralysis on one side and using a wheelchair, expressed concern that the meals prepared for her children were not as healthy or suitable as she hoped. After completing an HRSN screening, the FACT team connected her to Nutritional Supports tailored to her family’s needs She began receiving three medically tailored meals each day, seven days a week, delivered directly to her home To further empower her independence, she also received cookware and kitchen tools to support easier and safer meal preparation
Takeaway: HRSN screenings can uncover additional supports that individuals may not know are available. By connecting families to these services, community providers can help them achieve better health and stability.
Overcoming Challenges For a Better Future
Our Mission
We provide person-centered approaches and comprehensive supports that strengthen individuals and families so they can live healthier lives and fulfill their goals.
Our Vision
To promote, sponsor and coordinate innovative programs that improve healthcare quality, access and service delivery
Our Values
Integrity Understanding Appreciation Resiliency
Board of Directors
Paul Muench, Chair
Dr. Joanne Joseph, Vice Chair
Jody Kehl, Treasurer
Jill Heintz
Maria Lindsay
Patricia Roach
A Message from our Executive Director
Our mission and vision are not just guiding statements they are a promise A promise to remain steadfast in meeting the evolving needs of children and families within our community, and to do so with compassion, integrity, and purpose Everything we do is grounded in the belief that when families are supported and children are given opportunities to thrive; entire communities are strengthened
I have had the distinct honor of serving as Executive Director alongside an incredible team of innovative, passionate, and deeply committed individuals. This team shares a common set of values and an unwavering belief in our mission. Together, we have worked to reimagine what is possible, adapting to challenges, embracing innovation, and continuously striving to meet people where they are with dignity and respect.
Recognition, Innovation, and Growth in 2025
The year 2025 marked a period of meaningful recognition, continued innovation, and sustained growth for our organization We are proud to highlight several accomplishments that reflect the strength of our partnerships and the impact of our work across the community
The Connected Community Schools Initiative was honored as the 2025 Nonprofit of the Year at the Rome Chamber of Commerce Annual Event. This recognition underscores the Initiative’s critical role as an anchor organization, particularly in its collaborative response to the Rome tornado, where coordinated resources and services were mobilized to support individuals and families in need.
In the spring of 2025, the Resiliency Project received national recognition from the American Federation of Teachers and the University of California, Irvine for its leadership in advancing the “Support vs. Report” Child Welfare Model. The AFT research team commended the strength of the collaborative framework and its measurable impact on students and families. They noted that this model stands out as one of the most effective approaches they have encountered.
As a result, opportunities for expanded partnership have emerged, including participation in future research and evaluation grants We look forward to contributing to ongoing national research on the model’s efficacy while continuing to strengthen this promising collaboration.
Additionally, Connect Ed established a new partnership with Vanta Esports, further expanding our engagement within schools and communities. This collaboration creates new pathways for students through esports programming that supports civic engagement and workforce development In partnership with the Rome City School District and Utica University, Connect Ed and Vanta were honored to receive funding from the Upmobility Foundation to launch a pilot esports program within the Rome City School District during the 2026–2027 school year.
Together, these achievements reflect our ongoing commitment to innovation, collaboration, and expanding opportunities for the communities we serve. From expanding services to strengthening partnerships and responding to emerging community needs, our work has always been guided by listening first and leading with purpose. We remain focused not only on delivering services, but on creating a lasting, meaningful impact for the children and families who place their trust in us
I am profoundly grateful to our staff, board members, partners, and supporters who make this work possible. Your dedication fuels our momentum and ensures that our mission is more than words it is lived out every day.
As we look ahead, we remain mission-driven and vision-focused, committed to growth, innovation, and equity Together, we will continue building a stronger, healthier community one child, one family, and one partnership at a time.
With gratitude and optimism,
Danielle Martin Executive Director Connect Ed NY, Inc.
Connect Ed Program Highlights
A Community School, figuratively or physically, is a hubbing of all your community services and resources into your school building. Our mission as Connected Community Schools is to create Community Schools that ensure students and families have their basic needs met, that they are inspired and supported by the community
A Partnership Between: Connect Ed, NY | CNYHHN,Inc. | Rome Alliance for Education
Impact Metrics 2025:
Received 6,818 LINK Referrals.
Supported families though 195,228 outgoing referrals to supports and services.
Provided over 14,500 hygiene products to students and families
Over 10,500 before/after school meals for students were provided Food Insecurity continues to be the largest identified need this year.
The RIYS Program (Restorative Integrated Youth Services) was established in December 2020. It is an Oneida County youth diversion program, supported by the collaboration between the Oneida County Department of Family and Community Services, CNYHHN Inc , and Safe Schools Mohawk Valley
A Partnership between: CNYHHN, Inc | Connect Ed, NY | Oneida County Department of Family and Community Services | Safe Schools Mohawk Valley
Impact Metrics 2025:
67 youth referred to RIYS services
79% family engagement rate, maintaining consistent in-home contact and case planning.
62% youth engagement in mentoring services.
167 community-based referrals connecting families to needed supports.
Our RIYS Program has been renewed for another five years!
The Resiliency Project’s mission is to deliver prevention services to students and families in the Adirondack, Holland Patent, Rome City and Camden Central School Districts by creating interdisciplinary teams that offer specialized interventions, services and supports in the home, school and community to address barriers to learning and chronic absenteeism.
A Partnership between: CNYHHN, Inc. | Connect Ed, NY | Oneida County Department of Family and Community Services | Rome Alliance for Education | Safe Schools Mohawk Valley | Adirondack Central School District | Camden Central School District | Holland Patent Central School District | Rome City Schools
Impact Metrics 2025:
Received 237 referrals across four participating school districts
Successfully graduated 131 families
Resiliency coordinators conducted 7,695 direct engagements with students and families
847 outgoing referrals to community providers and support services
We are pleased to announce our expansion of the Resiliency Project into the Adirondack and Holland Patent School Districts!
SOCIAL EMOTIONAL ACADEMIC LEARNING (SEALS)
The SEALs initiative, along with the Connected Community Schools model, embodies the vision of the “Whole Child Design”. The SEALs programming addresses the daily mental health needs of students with a traumainformed preventative & proactive approach to addressing barriers preventing students from fully engaging in their education.
The SEALs Program initially was implemented through the McKinney Vento grant directly with the Rome CSD, prioritizing services and support at Bellamy Elementary School. The expansion in the 25-26" School year has embraced the district's strategic planning of alignment in all 9 Schools throughout the District, allowing us to expand our team's support to students, families and our Educators
Impact Metrics 2025:
3,309 LINK Referrals for Rome CSD
Of the 3,309 referrals, 434% of students and their families were identified with housing needs (homeless and/or unstable housing)
Connected Rome CSD supports approximately 350 students identified as being covered under McKinney-Vento Act protections.
Herkimer County System of Care
Herkimer County System of Care is a coordinated network of community-based services that support Herkimer County youth from birth to 21 years old, and their families. Herkimer County System of Care provides linkages to accessible services for youth who have, or are at risk of developing, mental health challenges Our network of partners helps youth and families get connected with counseling, peer support and advocacy, psychiatry, medication management, care management, home and communitybased support services, and more.
The SOC is a collaborative with the following organizations providing services: Herkimer County Public Health, ICAN, Catholic Charities of Herkimer County, Upstate Caring Partners- CHBS, Herkimer BOCES, Mosaic Health, The Neighborhood Center, View Point Clinical Therapy Services, and Connect Ed (Connected Community Schools) Herkimer Co SOC is funded by SAMHSA, currently in year 3 of the 4 year grant
Impact Metrics 2025:
Staff attended specialized training to facilitate Girls and Mother/Daughter Circles Groups
Successful stakeholder engagement Participated in multiple outreach events including the 4 Annual Mental Health Awareness Walk th
The Growth Opportunities (GO) Program, funding 100% by a $51 million grant awarded by the US Department of Labor (DOL)’s Employment and Training Administration, seeks to bridge the gap between at-risk youth and the workforce, equipping them with the skills, experience and support needed to secure stable and decent work opportunities.
4 Principal objectives
Support Services - Life skills training, guidance and one-on-one support to help youth stay on track.
Paid Work Experience - Real job opportunities where participants earn pay while gaining hand-on experience
Mentorship & Leadership - Supportive mentors who help build confidence, leadership skills and workplace readiness
Education & Training Pathways - Help connecting to school, job training programs, internships and next steps.
Passport to success training 12 weeks | 36 classes
Passport to Success is a 12-week training program made up of 36 interactive classes The program is designed to help young people build confidence, learn practical skills, and prepare for the workplace.
Throughout the program, participants focus on skills they can use right away - at work, school and in everyday life.
Topics covered include:
Exploring career interests and setting goals
Building communication and personal skills
Learning how to apply for jobs and succeed in interviews
Understanding workplace expectations and managing money
Accolades/Recognition
The Connected Community Schools Initiative was honored as the 2025 Nonprofit of the Year at the Annual Rome Chamber of Commerce Event, recognizing its significant contributions for being the anchor organization to collaborate and provide resources/services to individuals during the Rome Tornado
In the Spring of 2025, The American Federation of Teachers and Berkeley Irvine University provided National recognition to the Resiliency Project for it’s impact on the Support vs Report Child Welfare Model. The AFT team expressed that they were impressed with the collaborative model and the collective impact on students and families, as they embrace the support rather than report campaigns with Educators across the country. They expressed that they have not seen a model that has been this successful in their time of research They proposed to partner on additional research/evaluation grants, and future opportunities to support our work at the local level.
We look forward to participating in a research project on the efficacy of this model and a strong partnership on future research/evaluation grants to support our work
Our Connected Districts
Adirondack Central School District
Herkimer Central School District
Rome City School District
Camden Central School District
Canastota Central School District
Central Valley Central School District
Dolgeville Central School District
Holland Patent Central School District
Madison Central School District
Mount Markham Central School District
New Hartford Central School District
Our Boces Partners
Delaware-Chenango-MadisonOtsego BOCES
Herkimer-Fulton-HamiltonOtsego BOCES
Sherburne-Earlville Central School District
Waterville Central School District
Madison Oneida BOCES
Oneida-Herkimer-Madison BOCES
2025 Financial Highlights
2025 Revenue by Source
Expense by Category
Our Network Agency Providers
ACR Health
Bridging the Gap
Building Blocks
Center for Family Life and Recovery
Children’s Home of Jefferson County
Helio Health
Integrated Community Alternatives Network (ICAN)
Mohawk Valley Psychiatric Center
New York State Department of Health
New York State Department of Mental Health
Oneida County Department of Family and Community Services
Presbyterian Home & Services
Rome Alliance for Education
Safe Schools Mohawk Valley
St. Catherine’s Center for Children
St. Lawrence County Community Services
St Lawrence County Government
The ARC Jefferson - St Lawrence New York
The Neighborhood Center
The Salvation Army
THRIVE Wellness & Recovery
United Helpers Care
Whitney Young Health
2025 Donors
We are thankful to the many individuals and businesses who supported us throughout the year.
Individuals and Families
George & Joanne
Amendolare
Geno DeCondo
Malcom Gaines-Parker
Michael Giacobbe
Gilli Hachey
Timothy Hammond
Bjorn Solli
Brett LaSalle
Caroline Levitt
Joseph Mazzara
Dr Marybeth McCall
Caitlin McCann
Daniel Vail
Katie Weidman
Elizabeth Worth
Rob Wuest
Stephen Zogby
Business & Organizations
Barclay Damon, LLP
Caruso McLean & Co.
FoxPointe Solutions
Gilroy, Kernan & Gilroy
Harris Beach Murtha, PLLC
Michael’s Foundation
NBT Bank
Scalzo, Zogby & Wittig, Inc.
Strategic Financial Services
Employee Giving
MaryBeth Amendolare
Jessica Julian
Lindsey Shibley
Lisa Shuford
Heather Shwamle
Jane Vail
Betsey Weaver
If you are interested in learning more about ways to support CNYHHN and its affiliated programs, contact Millie Occhionero at millie.occhionero@cnyhealthhome.net. To make an immediate donation, please scan the QR Code.
2025 Agency Highlights
In 2025, we successfully hosted our second annual Manager Bootcamp These trainings strengthen our management team by enhancing leadership skills, strategic thinking, and team development practices
We experienced meaningful growth this year, hiring 29 new staff members to further our work in the community.
Each year, we are lucky to have the opportunity to send cohorts of staff through leadership training with Coach Michael Sgro This training provides staff with an opportunity to strengthen
key leadership skills, enhance communication, and build confidence in guiding teams. Through engaging discussions and practical strategies, participants gain tools to support professional growth and create a positive effective workplace culture. We look forward to the upcoming cohort
CNYHHN, Inc. & Connect ED NY, Inc. participated in the third annual Mohawk Valley Gives Event. The Community Foundation of Herkimer and Oneida Counties hosted a 24-hour community wide day to benefit nonprofit organizations serving the two counties Together, the two
organizations raised over $10,000 to support the individuals, youth and families that we serve!
CNY Stuff the Bus annual event helped support the Giving Tree initiative for the sixth year in a row. We received toys, books and games for all ages to provide to the families enrolled in our programs.
