Project 2.d.i – Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care

Why FLPPS Chose this Project

The FLPPS region has a large number of uninsured individuals to be activated and educated in the appropriate use of the healthcare system. High rates of uninsured individuals can be attributed to gaps in services and resources, particularly in the rural counties. There is a significant need to expand existing healthcare infrastructure and navigator outreach in the FLPPS region. Resources available to the uninsured are disproportionately concentrated in urban Monroe County.

Percentage of uninsured can be as high as 36% in rural counties, compared with 7% in Monroe County and 15.1% nationally.

The PPS’s ability to appropriately engage these individuals will include effective cultural competence training, and recruitment of more health care/outreach workers that mirror the linguistic and cultural diversity of our population.

In Monroe County, the population is 62% white, 22% African American, 6% Hispanic, and includes over 5,200 refugees.

What Success Looks Like

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.

Partner Feature

Steuben County DSS

Steuben County Department of Social Services (SCDSS) is quickly becoming a leader in Project 2.d.i Patient Activation as they continue to surpass their initial targets for PAM (Patient Activation Measure) administration.

“DSRIP is an ongoing dialogue” says Kathryn Muller, SCDSS Commissioner, who attributes a portion of their success to their ability to be “forward thinking and prepared for the next level.”

SCDSS is a unique county department because it has a Behavioral Health unit within its office. The on-site team of social workers, psychologists, substance abuse counselors, and disability case managers make their office a natural fit for patient engagement and education. Dr. Ryan Peterson, SCDSS Psychologist, was one of their first staff to be trained in PAM administration and has since used the "train-the-trainer" model to spread this knowledge throughout the department. Both Commissioner Muller and Dr. Peterson feel the training has helped the staff in their offices understand the broader DSRIP goals, which can be shared with their clients.

“They are trailblazers for their community,” says Josh Jinks, 2.d.i Project Manager “their participation and engagement is incredible.”