Community Navigation & Patient Activation

The FLPPS Community Navigation Program was built upon the infrastructure of the DSRIP Patient Activation project. The Patient Activation project focused on encouraging individuals to more actively use the healthcare system. In this process a trained staff member would use the  Patient Activation Measure (PAM ®) tool to assesses an individual’s current health literacy and teach them how to better navigate the healthcare system.

Community Navigators were incorporated in this process to further connect individuals with clinical and non-clinical resources throughout their care network. A navigator often makes appointments, schedules transportation or accompanies individuals to their appointment.  The Community Navigator’s role is unique to the organization they serve and is often compared to the role of a Community Health Worker or Care Manager.  


Since 2015, FLPPS has invested in 50 partner organizations to support Community Navigation and Patient Activation. Twenty-six partner organizations continue to provide Community Navigation services throughout the Finger Lakes region. These partners represent diverse provider types, including health systems, Community Based Organizations, behavioral health offices, care management agencies and Federally Qualified Health Centers.  From January 2018 – January 2019, the Community Navigator program has supported more than 17,000 individuals to connect with food, housing, transportation, dental, behavioral health and primary care services.


The population impacted by this effort:

  • Demonstrated significant improvement in clinical outcome performance specifically, decreased Potentially Preventable Emergency Department (ED) visits and Potentially Preventable Behavioral Health ED visits, as well as increased access to primary care.

 The program improved collaboration between clinical and non-clinical organizations by:

  • Supporting Community Based Organizations to directly contract with primary care offices to provide culturally competent navigation services in a clinical setting.
  • Incetivizing clinical partners to more thoroughly address their patient’s social determinant of health needs.

More About Patient Activation

Patient Activation - Using Patient Activation Measures (PAM ®) the FLPPS Partners are able to activate Uninsured (UI), Non-utilizers (NU) and Low utilizing (LU) populations so they may benefit from the current healthcare transformation. PAM helps providers understand how much support a patient might need to be successful with their health outcomes. The PPS will formally train Partners and stakeholders on how to administer PAM ®, and regularly update the assessments of communities and individual patients.

Reducing the Financial Barriers to Healthcare - Getting individuals the resources they need to enroll in health insurance or connecting them with a health care resource that does not require health insurance.

Partnerships with Primary and Preventive Care Services - Looking holistically at the individual and determining which supports may be required to facilitate their active pursuit of their health outcomes. Supports could include partnerships with community based organizations that provide housing, childcare services, transportation, etc.