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Population Health

What is Population Health?

Population Health is a strategy used by health providers to improve the health outcomes of a specific population, group of people or a community. Population health emphasizes prevention and wellness; the reduction or elimination of waste and the eradication of health disparities based on race, ethnicity, language, income, gender, sexual orientation, disability and other factors. The reasoning is that good health belongs to the whole, not just an individual. SJEH is committed to working with the community to identify and reduce the gaps in care, coordination of care, reduce health disparities and increase access to health care.


To improve the quality of life and empower the community by providing access to care, leading to optimal healthcare outcomes. To serve by bridging any gaps in the care continuum with high quality services, community engagement and contemporary standards.


Population Health will synergize the health, wellness and social needs of the community in an inclusive person-centered and culturally sensitive manner.

Population Health Disease Focus:

  • Cancer – Breast, Cervical, Colorectal, Lung and Prostate
  • COVID-19
  • Diabetes
  • Drug and Alcohol Related
  • Heart Disease, Hypertension, Hypercholesterolemia & Congestive Heart Failure
  • Obesity
  • Pulmonary disease – Asthma and COPD

Our Programs

Monkeypox Services

Cancer Services Program

St. John’s Episcopal Hospital is a credentialed provider of the NYSDOH Cancer Services Program and implements free breast and cervical cancer screenings, diagnostic follow-up services and referrals to treatment for uninsured and underinsured women and men who are at or below 250% of the Federal Poverty Level (FPL) and meet other program requirements.

To learn more about the Cancer Services Program or to schedule an appointment, please contact Antonio Handy at 929-928-2039.

Cancer Screening Navigation Program

The Cancer Screening Navigation Program is a proactive approach to guide patients through and around barriers in the complex cancer care system to help ensure timely diagnosis, treatment and support. The program focuses on reaching people in the community, and educating and directing them to screening.

To learn more about the Cancer Screening Navigation Program or to schedule an appointment, please call 718-869-7100.

Mobile Health Unit Outreach Program

The Department of Population Health at St. John’s Episcopal Hospital has embarked on an aggressive mobile health outreach project, using a branded hospital vehicle that is stationed at strategic locations within the community, at or near community based organizations, high foot traffic areas (shopping centers, beach entrances, transit depots) local churches, schools, and at community events, holiday celebrations, and health fairs. Through the Mobile Health Unit, we strive to bring health care to the community in their own settings.

To learn more about the Mobile Health Unit Outreach Program, please click here or contact the Population Health Department at 718-869-7100.

Weight Management Program

Overweight and Obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. Obesity can lead to type 2 diabetes, high blood pressure, depression, stroke, heart disease, cancers, gout, sleep apnea, osteoarthritis, gallstones among others.

We offer a culturally sensitive comprehensive program to work with you and to meet your goal of weight loss and improved health. Under physician supervision, our program offers:

  • Appetite Control
  • Exercise
  • Lifestyle & Behavioral Counseling
  • Nutrition Therapy
  • Surgery

Our medically-supervised weight management program for adults is managed by a multidisciplinary team of endocrinologists, registered dietitians, and nurse practitioners who are highly trained in providing treatment and support to overweight and obese patients.

Benefits of weight Loss : Reduces the risk factors for some diseases, particularly heart disease, and cancer, lower blood pressure, lower blood sugar, Improved cholesterol, Improved mobility, physical endurance, and self esteem.

To learn more about our Weight Management Program, or to enroll in the program, please contact the Population Health Department at 718-869-7100.

Diabetes Self Management Education Program

More than 30 million Americans have diabetes, and every 21 seconds another person is diagnosed with diabetes. Diabetes is a highly complex disease that requires continuous daily care to effectively manage blood glucose levels and help reduce and avoid deadly and costly complications. Diabetes self-management education and support (DSMES) is a vital component of care for all people with diabetes, as well as for people who are at risk for developing diabetes.

St. John’s Episcopal Hospital is accredited by the American Association of Diabetes Educators as a Diabetes Self-Management Education (DSME) Services Program. As a DSME, we offer a 6-week workshop with focus on:

  • Healthy Eating
  • Being Active
  • Diabetes Monitoring
  • Taking Medication
  • Reducing Risks
  • Problem Solving and Healthy Coping

To learn more about the Diabetes Self-Management Education Program or enroll in our upcoming six session workshops, please call 718-869-7954 or 718-869-7100.

Emergency Department (ED) Navigation Program

The ED Navigation program focuses on patients who are not connected to a patient-centered medical home and/or have no funding for healthcare. The ED Navigation team consists of a patient navigator located in the ED. Our patient navigator lives in the community and understands the cultural beliefs and practices of the population. Through shared life experiences with ED patients, the patient navigator builds trust, provides peer-level support and teaches individuals how to navigate the healthcare system.

To learn more about the program, please contact Karen James at 718-869-5763.

Health Literacy Program

Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Patients are often faced with complex information and treatment decisions such as:

  • Accessing Healthcare
  • Communicating with healthcare providers
  • Disease specific education modules
  • Education regarding the role of the primary care doctor
  • Education on medication use and precautions
  • Education on self-management
  • Interpreting test results
  • Locating healthcare resources
  • Understanding and accessing health insurance

St. John’s Episcopal Hospital has partnered with Wellness Network to standardize education, improve patient centric care and raise the level of patient self-management in outpatient and inpatient settings. The goal of this program is to engage, educate and empower patients to improve their overall health outcomes.

To learn more about the program, please contact Carolyn Blocker at 718-869-5349.

Addressing Food Insecurity on the Peninsula

Each Thursday, St. John’s teams up with The Campaign Against Hunger for a fresh food giveaway to help address food insecurity on the Rockaway Peninsula. Over 5,000 boxes of fresh produce and non-perishables have been distributed as of date. Read more in HANYS.

Every Thursday | 12:00 pm – 2:00 pm
Located in the Visitor’s Parking Lot in front of St. John’s Episcopal Hospital
327 Beach 19th Street Far Rockaway, NY 11691

New Programs Coming Soon!

  • Smoking Cessation Program
  • Substance Use Disorder Support Group
  • Caregiver Support Group
  • Women’s Health Forum
  • Men’s Health Forum
  • Nutritional Educational Program
  • Substance Use Disorder Program
  • Support Groups