Population Health

At Evergreen Health, we don’t just care for one patient at a time: we also look at health data and trends to support the health of our entire community. We call this “Population Health.”

We track health trends impacting Western New Yorkers and use data to spot risks early and ensure people get the care they need, like screenings, vaccines, and follow-ups. Focusing on Population Health helps us close gaps in care, prevent illness, lower costs, and keep everyone healthier — not just when they’re sick, but all year long. By focusing on Population Health, we support you, your neighbors, and the whole community.

We address Population Health through:

  1. Chronic Disease Management: controlling high blood pressure, aspirin use, and Diabetes preventative measures like HbA1c Poor Control and Diabetes Retinal Eye Exam (DRE)
  2. Screenings: breast, cervical and colorectal cancer and HIV screening
  3. Behavioral Health Integration: depression screening and follow-up plans
  4. Preventative Care: physical exams, Medicare annual wellness visits, and childhood/adolescent well visits and immunizations

Critical Population Health Measures

We focus on addressing the key health measures that have the biggest impacts on the health of our community. Click on each title to expand and read more.

Immunizations & Vaccines

Vaccines are essential to keep our communities safe from preventable diseases like measles, whooping cough, and flu.

Whether you’re bringing your child in for back-to-school shots, updating your own immunizations, or catching up after a missed dose, Evergreen is here to help. Vaccines aren’t just for kids. Adults, pregnant people, and older adults also need certain immunizations to stay healthy and protect those around them.

Immunizations are safe, effective, and often fully covered by insurance, including Medicaid and CHIP. If you’re unsure what you or your child might need, we’ll review your vaccine history and create a personalized plan.

IMMUNIZATION MYTH: Natural immunity is better than vaccine-acquired immunity.

IMMUNIZATION FACT: While natural infection can sometimes provide immunity, it often comes with serious risks. Vaccines safely build protection without exposing you to the complications of diseases.

Call 716.847.2441 (option 5) to schedule an appointment today. Let’s stay protected, together.

Read more: Back-to-school starts at your doctor’s office

Breast Cancer Screening

Breast cancer is the most common cancer among people assigned female at birth in the U.S., with 1 in 8 expected to be diagnosed in their lifetime. It’s also one of the most treatable when caught early: the 5-year survival rate exceeds 90%.

The costs of late-stage breast cancer are not only personal, but also financial. Treatment for advanced breast cancer can exceed $100,000 per patient, while early detection through a mammogram is fast, low-cost, and often fully covered by insurance, including Medicaid.

If you’re age 40 or older, or have a family history of breast cancer, it’s time to talk with your provider about when to start regular mammograms. We can help you understand your risk and connect you to screening services.

BREAST CANCER MYTH: If I don’t have symptoms or a family history of breast cancer, I don’t need to get screened.

BREAST CANCER FACT: Most people diagnosed with breast cancer have no family history of the disease. Regular screenings can catch breast cancer early, before symptoms appear, when it’s most treatable. That’s why screening is recommended based on age and risk, not just symptoms or family history.

Call 716.847.2441 (option 5) to schedule an appointment with your primary care provider and discuss your options.

Read more: How preventative screenings protect your long-term health

Cervical Cancer Screening

Cervical cancer is highly preventable when caught early: 90% of cervical cancer cases are preventable with routine screenings and HPV vaccination. Regular Pap tests and HPV tests can detect abnormal changes in the cervix long before cancer develops. The earlier these changes are identified, the better the chance for successful treatment.

For most people with a cervix, screening should begin at age 21 and continue at intervals recommended by your healthcare provider. These screenings can detect cancer early, when it’s most treatable, and can reduce deaths by up to 70%. The HPV vaccine also provides powerful protection against cervical cancer and other HPV related cancers. Even if you feel well, routine exams are vital because early cervical changes often have no symptoms. Talk with your provider about whether vaccination or additional screening is right for you.

CERVICAL CANCER MYTH: If I feel fine and have no symptoms, I don’t need a Pap smear or HPV test.

CERVICAL CANCER FACT: Cervical cancer often has no symptoms in its early stages, which is when it’s most treatable. Routine screenings (like Pap smears and HPV tests) can detect precancerous changes before they turn into cancer, helping to prevent it entirely. Early detection saves lives.

Call 716.847.2441 (option 5) to schedule an appointment or speak with your primary care provider about your cervical cancer screening options.

Read more: Preventing cervical cancer: what can I do?

Colorectal Cancer Screening

Colorectal cancer is one of the most common and deadliest cancers in the U.S. and is highly preventable with regular screening and healthy lifestyle choices.

There’s more than one way to screen for colorectal cancer, and lifestyle choices like a balanced diet, regular exercise, and avoiding smoking and excessive alcohol use can help lower your risk.

COLORECTAL CANCER MYTH: Colorectal cancer screening is only necessary if I have symptoms or a family history.

COLORECTAL CANCER FACT: Most people diagnosed with colorectal cancer have no symptoms or family history. Screening starting at age 45 (or earlier if you’re high risk) with colonoscopies or stool-based tests (like FIT or Cologuard) can catch cancer early or even prevent it altogether by removing precancerous polyps.

Talk to your primary care provider today or call 716.847.2441 (option 5) to schedule an appointment.

Screening Made Simple: Ask About Cologuard

Did you know you may not need a colonoscopy to get screened for colorectal cancer? Cologuard is a convenient, non-invasive, at-home stool test that checks for early signs of colon cancer. It’s a great option for adults 45 and older at average risk.

Talk to your provider to see if Cologuard or another stool-based test is right for you. Early detection saves lives, and it can start from the comfort of your home.

Read more: How preventative screenings protect your long-term health

Depression Screening

Depression affects over 21 million U.S. adults and 5 million teens each year, often without warning or visible signs. Depression screening is a simple yet powerful tool to protect your mental health.

DEPRESSION MYTH: If I’m not visibly struggling or talking about my feelings, I don’t need a depression screening.

DEPRESSION FACT: Depression can be invisible and silent, and many people don’t show obvious signs. Symptoms can include fatigue, irritability, sleep changes, or loss of interest in daily life. Routine screenings help catch it early, even when symptoms are mild or unspoken, so people can get the support they need.

Screening is quick, confidential, and just the first step. If needed, we’ll work with you to develop a personalized care plan, whether that means therapy, medication, or supportive follow-up. You’re not alone, and help is available.

Let’s break the stigma around mental health. Schedule a visit today to talk about depression screening or talk to your provider at your next visit. A few minutes could change your life.

Call 716.847.2441 to make an appointment.

Read more: Depression screening helps you understand your mental health

Diabetes Prevention and Care

Diabetes is a chronic condition that affects over 34 million Americans. Even more concerning, 1 in 5 people with diabetes don’t even know they have it.

If you have diabetes, you should get your A1c checked every 3 to 6 months to monitor your blood sugar control and adjust your treatment as needed. If you have diabetes, it’s important to get regular lower extremity exams to check circulation, nerve function, and prevent complications like foot ulcers. If you’re taking antipsychotic medication, it’s important to have your A1c levels checked regularly to monitor for diabetes and stay on top of your health.

DIABETES MYTH: Only people who are overweight or eat too much sugar get diabetes.

DIABETES FACT: Diabetes can affect anyone and managing it doesn’t mean giving up the foods you love. It’s about balance, and our on-staff dietician is here to guide you every step of the way.

Whether you’re living with diabetes or trying to prevent it, early detection and healthy lifestyle choices make a big difference. A balanced diet, regular exercise, and routine check-ups are key.

We offer in-house Diabetic Retinal Exams (DRE): a quick, painless photo of your eyes that’s reviewed by an ophthalmologist, with results sent directly to your primary care provider.

Our THRIVE Wellness Center also offers activities like healthy cooking classes, art therapy, yoga, and more, designed to support your whole-person health.

Schedule an appointment with your primary care provider or call 716.847.2441 (option 5) to learn more.

Read more: Living with diabetes is easier with unconditional support

Heart Disease Prevention

Heart disease is the leading cause of death in the U.S., claiming a life every 33 seconds. Nearly half of American adults live with some form of cardiovascular disease (CVD), and locally in Erie County, the impact is even more pronounced with higher than average death rates.

The good news is that heart disease is often preventable. By making simple lifestyle changes like eating a balanced diet, staying active, quitting smoking, and managing stress you can significantly lower your risk.

HEART DISEASE MYTH: Heart disease only affects older people.

HEART DISEASE FACT: Heart disease can affect adults of all ages, and factors like high blood pressure, smoking, diabetes, and obesity can increase your risk even if you’re young.

Know your numbers! Regular screenings for blood pressure, cholesterol, and glucose are essential. If you’re over 45 (or 55 for females), have a family history of heart problems, or are managing conditions like obesity or high blood pressure, now is the time to act.

Our THRIVE Wellness Center offers activities like healthy cooking classes, art therapy, yoga, and more, designed to support your whole-person health.

Call us at 716.847.2441 (option 5) to schedule a heart health check-up. Together, we can build a stronger, healthier community, one heartbeat at a time.

Read more: How preventative screenings protect your long-term health

HIV Screening

Evergreen Health is committed to keeping our community informed, healthy, and supported. Routine HIV screening is part of your overall wellness.

HIV SCREENING MYTH You only need to get tested if you have symptoms or think you’re at high risk.

HIV SCREENING FACT: Many people with HIV have no symptoms for years, so regular screening is important for everyone aged 13 to 64 to detect HIV early and start treatment if needed.

HIV screening is recommended for all adults at least once, regardless of perceived risk. Early detection leads to better health outcomes, reduces transmission, and connects individuals to life-saving treatment and support.

Screening is quick, confidential, and typically covered by insurance. If you’ve never been tested, now is the time to take control of your health.

Call 716.847.2441 (option 5) to schedule a visit or ask your provider at your next visit to add an HIV screening to your labs.

Read more: Our services for people living with HIV

Aspirin Use

Patients aged 50–69 that meet certain criteria may benefit from low-dose aspirin to reduce their risk of heart attack or stroke. If you’ve had a heart attack, bypass surgery, or other cardiovascular event, or if you’re at higher risk due to factors like diabetes, high blood pressure, or smoking, aspirin might be part of your prevention plan.

ASPIRIN MYTH:  Everyone should take aspirin daily to prevent heart attacks.

ASPIRIN FACT: Daily aspirin is not recommended for everyone. It can lower the risk of heart attack or stroke only for people at higher risk, and even then, it must be prescribed by a provider. For people at low risk, aspirin may actually increase the risk of serious bleeding without providing much benefit. Always talk to your healthcare provider before starting or stopping aspirin. At Evergreen, we review your full medical history and use clinical data to guide safe, personalized decisions about your care.

Call 716.847.2441 (option 5) to schedule an appointment today. Let’s stay protected, together.

Read more: How preventative screenings protect your long-term health

High Blood Pressure Prevention and Care

Nearly half of all U.S. adults live with high blood pressure, and many don’t even know it. Often called the “silent killer,” hypertension usually has no symptoms but is a leading risk factor for heart disease, stroke, and kidney failure. Evergreen Health encourages all patients to get their blood pressure checked and talk with their provider about heart health.

HYPERTENSION MYTH: If you’re young, you don’t need to worry about high blood pressure.

HYPERTENSION FACT: Hypertension can affect people of all ages, including young adults. Lifestyle factors like diet, stress, and physical activity play a big role. And early detection is key to preventing long-term damage.

Managing your blood pressure doesn’t always mean medication. A healthy diet, regular physical activity, stress reduction, and limiting alcohol and tobacco can all help keep your numbers in check. Our team can help you create a personalized plan, and we have an in house Registered Dietitian available to support you with heart-healthy nutrition.

Our THRIVE Wellness Center offers activities like healthy cooking classes, art therapy, yoga, and more to support your whole-person health.

Early detection saves lives. Don’t wait until it’s too late: take a proactive step toward a healthier heart today. Schedule your blood pressure screening at Evergreen Health or ask about it during your next visit.

Call 716.847.2441 (option 5) to make an appointment.

Read more: Stay in the know with your yearly blood pressure screening

Lung Cancer Screening

Lung cancer is the leading cause of cancer related deaths worldwide. The good news? Early detection through screening can save lives.

If you’re between the ages of 50 and 80 and have a history of smoking, even if you quit years ago, you may qualify for a low-dose CT scan. This quick, painless, and non-invasive test can detect lung cancer at an early stage, when it’s more treatable.

LUNG CANCER MYTH: Lung cancer screening is dangerous because it exposes you to too much radiation.

LUNG CANCER FACT: The low-dose CT scans used for lung cancer screening use a very small amount of radiation, much less than a standard CT, and the benefits of early detection far outweigh the minimal risk for people at high risk.

Think you’re not at risk? Even non-smokers with exposure to secondhand smoke or other risk factors should talk to their provider. Many people with early lung cancer don’t have symptoms, so screening is vital.

Evergreen Health, in collaboration with Roswell Park, offers personalized support through a dedicated lung cancer screening navigator, helping guide you through every step of the process.

Talk to your provider or call 716.847.2441 (option 5) to schedule an appointment today.

Read more: How preventative screenings protect your long-term health

Influenza Vaccination

Flu season is just around the corner and the best time to protect yourself is now. A flu shot can reduce your risk of illness, complications, and missed work or school.

FLU SHOT MYTH: Getting a flu shot can give you the flu.

FLU SHOT FACT: The flu vaccine cannot cause the flu. It contains inactivated virus that help your body build immunity safely. Flu vaccines are safe, fast, and effective and they’re available for patients of all ages. Whether you’re managing a chronic condition, caring for young children, or simply want to stay healthy this fall, the flu shot is a simple step that makes a big difference.

Evergreen Health can provide a flu shot during your regular primary care appointment or at our pharmacy.

Call 716.847.2441 to schedule your visit or ask about upcoming flu shot dates. Let’s stay healthy together before flu season hits.

Learn more: The Pharmacy at Evergreen is full-service and open to everyone

Pediatric Well Visits

Pediatric wellness visits are a vital part of your child’s growth, development, and success in school. These check-ups go far beyond vaccines: they help catch potential health or developmental issues early, support emotional well-being, and provide personalized guidance for parents on everything from nutrition to behavior.

PEDIATRIC VISIT MYTH: Missing well child visits won’t affect my child’s ability to go back to school.

PEDIATRIC VISIT FACT: Well child visits are where you fulfill your child’s school’s requirements for immunizations and health screenings, ensuring your child is ready for the school year. Missing visits can delay this process.

If your child is heading to daycare or school this fall, beat the last-minute rush and get us your school and daycare forms now so we can complete them well before August deadlines. Forms often require a current physical exam and up-to-date immunizations, so scheduling early ensures your child is ready for school when they need to be.

Requirements for Your Child to Return to School After Summer Break

  1. Completed Registration – Make sure your child is enrolled or re-enrolled for the school year.
  2. Updated Immunizations – Submit proof of required vaccines or exemption forms.
  3. Physical Exam (if needed) – Some grades may require a recent health or dental check-up.
  4. School Supplies – Bring all necessary supplies listed by the school or teacher.
  5. Emergency Contact Info – Update phone numbers, allergies, and medical details.
  6. Proof of Residency – Some districts may ask for an updated address document.
  7. Transportation Plans – Confirm how your child will get to and from school.

Parent’s Checklist: What to Bring to your Visit

  • Immunization records (if switching doctors)
  • Growth chart (if you keep one at home)
  • Any medical history or reports
  • A list of medications, vitamins, or supplements
  • Questions or concerns about behavior, sleep, eating, etc. (write them down ahead of time!)
  • Notebook or phone to take notes

What to Expect at your Visit

  • Height, weight, head circumference (in babies/toddlers)
  • Vital signs (heart rate, temperature, etc.)
  • Developmental screening
  • Physical exam (heart, lungs, ears, eyes, skin, reflexes)
  • Vision & hearing tests (age-dependent)
  • Immunizations (based on age schedule)
  • Fluoride treatment (for kids with teeth, if needed)

Call 716.847.2441 (option 5) or visit evergreenhs.org to schedule your child’s wellness visit today. Let’s grow healthy, together.

Read more: Back-to-school starts at your doctor’s office