Funds Flow

Funds will be used to engage an evening and weekend hours Telemedicine Triage System for use with I/DD adults living at each of the six Able2 Enhancing Potential certified residences.

Targeted Clinical Outcome: Potentially Preventable Emergency Department Visits.

Funds will be used to expand the new Hospital to Home program to improve transitions for patients at high risk of re-admissions and avoidable hospital visits. With the intent to make primary and palliative care a priority, the team intends to provide more accessible support and symptom management by offering a higher level of care in patients homes within 24-48 hours of discharge from the hospital.

Targeted Clinical Outcomes: Potentially Preventable Re-admissions; Potentially Preventable Emergency Department Visits.

This new clinical position will offer more intensive patient-centric activities as well as a single point person for population Health. The new population health care manager will reach out to patients who are hardest to reach and provide the opportunity for a closer examination of barriers to access.

Targeted Clinical Outcomes: Potentially Preventable Emergency Department Visits, Monitoring of Patients with Schizophrenia Who Have Diabetes or Cardiovascular Disease, Children’s Access to Primary Care, Adult Access to Primary Care

Funds will be used to create an improved workflow that will lead clients to more effectively utilize primary care and behavioral health treatment as well as Health Home (HH) and /or Health and Recovery Plan (HARP) engagement.

Targeted Clinical Outcomes: Follow-up After Hospitalization for Mental Illness (within 7 days and within 30 days)

Develop a mobile outreach service delivery model which includes food pantries, rural community buildings, libraries, churches, and other non-profit sites, and home visits.

Targeted Clinical Outcomes: Adult Access to Preventive or Ambulatory Care 

The initiative will provide a collaborative approach for further respiratory assessment, education, support, exercise, nutrition guidance, smoking cessation, and pulmonary rehab as well as individualized goal planning, engagement and navigation to necessary services.

Targeted Clinical Outcomes: Potentially Preventable Re-admissions, Potentially Preventable Emergency Department Visits, Adult Access to Preventive or Ambulatory Care

Adult Access to Preventive or Ambulatory Care - This project will establish additional services most commonly needed, but typically not accessed, by patients by creating one point-of-contact location for diagnostic and screening services.

Targeted Clinical Outcomes: Adult Access to Preventive or Ambulatory Care, Children’s Access to Primary Care 

The Socks Room - Create a designated room for patients in perceived or real crisis related to a social determinant. Care teams will visit the patient in this room where they can be given a meal, blanket and warm socks while a diagnosis or referral is arranged.

Targeted Clinical Outcomes: Potentially Preventable Re-admissions, Potentially Preventable Emergency Department Visits

The Child Wellness Outreach Initiative will implement two central strategies. A Child Health Outreach Worker will identify Jordan Health children up to age two who are not current on immunizations and conduct vigorous outreach and education to help families complete their children’s immunizations. The outreach worker will work with families to identify and address barriers to immunization, lead screening and well-child visits. The second strategy includes outreach to children and families registering for school who are not linked to primary care and require both immunizations and physicals.

Targeted  Clinical Outcomes: Children’s Access to Primary Care 

This proposed project will develop community-based healthcare navigation services to assist adults ages 65 and above, in accessing preventive care and management including screenings, counseling, immunizations or medications used to prevent disease, detect health problems early, and prevent disease progression and complications.

Targeted Clinical Outcomes: Adult Access to Preventive or Ambulatory Care, Potentially Avoidable Re-admissions

This pilot will deploy expert transportation navigators, well versed in best practices in mobility management. The transportation navigators will work with transportation-challenged Medicaid clients to arrange their transportation to medical care and key non-medical services identified as contributing social determinants of health such as trips to obtain prescriptions and/or nutritious food and trips to participate in support groups and for DHS appointments.

The pilot will create a mobility management competency within the following
project partner’s clinical sites: Anthony Jordan Health Center,  Monroe County Nurse Family Partnership/URMC VNS, Finger Lakes Community Health, Pembroke Family Medicine, Oak Orchard Health Center

Targeted Clinical Outcomes: Adult Access to Preventive or Ambulatory Care; Children's Access to Primary Care

Funds will be used to develop and implement a Comprehensive Assessment of Risk scoring software tool; Educate, train and provide ongoing supervision for the Patient Activation model (PAM©) of Coaching for Activation for Health Home Care Managers and clinical staff; Expand access to opioid dependence treatment by adding a Harm Reduction Nurse onsite at Trillium Health, and; Expand the Transition of Care model used for medical inpatient discharges to psychiatric inpatient discharges.

Villa of Hope (VOH), in collaboration with East High School, Center for Youth (CFY), Eugenio Maria de Hostos Charter School (EMHCS), Monroe #1 BOCES – The O’Connor Academy (BOCES 1), and Monroe 2-Orleans BOCES Westside Junior/Senior High Academy (BOCES 2) proposes the Life of Hope Project. The goal of the project is to increase initiation and engagement for alcohol and other drug dependence treatment for youth, aged 13 and older by administering the GAIN-SS tool. All staff assigned to the project will be trained in administrating the GAIN-SS assessment and will administer the GAIN-SS with their student/client population.

Targeted Clinical Outcome: Initiation and Engagement of Alcohol and other Drug Dependence Treatment.