We successfully led the implementation of the very complex DSRIP Program. The program improved the design and delivery of healthcare for the Medicaid population by reducing avoidable hospitalization and improving population health, while lowering the cost of healthcare.

Community Navigation Program

Community Navigation has been a key focus area under DSRIP and began with Project 2.d.i Patient Activation that focused on training navigators across the region to use the Patient Activation Measure (PAM) to measure health literacy and assist individuals to better navigate the healthcare system. Nearly 80 partner organizations were trained on the PAM tool. In this initial project, Partners expanded their programs to address the outreach, coordination, and linkage needs of the individuals they engaged, developing a spectrum of care navigation programs based on the specialties of the Partner and needs of their population.

Since then, we launched two Community Navigation Programs and collaborated with dozens of Partners who connect individuals with food, housing, transportation, dental, behavioral health, and primary care services. These programs have demonstrated significant improvement in clinical outcome performance in the region. Further, the programs have improved collaboration between clinical and non-clinical agencies through the screening of social determinants of health and provision of culturally competent navigation services.

Community Navigation activities are critical in serving vulnerable populations. We identified six principles for a best-in-class navigation program and in the most recent program supported Partners in aligning with these principles and adopting best practices. The FLPPS Learning Management System was utilized to house program resources, e-Learnings, and other tools.

Our Community partners

“I am excited to see ‘equity in action’ through this partnership with FLPPS, who recognizes the importance of lived experience and elevating the parent and patient voice to bring change across our health and behavioral health systems.”

Sara Taylor, Founder of BIPOC PEEEEEEK

“For decades Regional Health Reach has been a leader in the community in providing healthcare and support services to those experiencing homelessness. Through our traditional clinic, mobile medical unit, and presence at shelters, our Healthcare for the Homeless program has touched thousands of lives. Health Reach is excited to partner with Finger Lakes Performing Provider System and MC Collaborative to expand our reach to unsheltered individuals, meeting them where they are, to provide the care they need.”

William E. Belecz, Executive Director of Regional Health Reach

“The key to the success of this menu of services is our ability to have a two-way dialogue with doctors and other medical professionals about both health and social support needs at home. We’ve proven this model can improve patient outcomes and reduce unnecessary ED visits and hospitalizations, and that’s a win for everyone. It also reduces both physician and patient/family caregiver frustrations.”

Ann Marie Cook, President and CEO of Lifespan

“By expanding our Person In Crisis teams to include certified peer specialists, we will be able to assist even more of our residents in need in a humane and compassionate manner. In addition, by assisting residents in this new way, we are expecting that there will be a reduced number of people calling the PIC team because they are getting connected to the services they need.”

Former City of Rochester Mayor Lovely Warren

“The Finger Lakes IPA, a partnership of the region’s community health centers, six behavioral health organizations, and the S2AY Rural Health Network, is very excited to be a part of this important initiative by FLPPS to support the critical need for access to developmental screenings for young children in our rural communities. This program will give us the ability to provide access to services that are often not available due to geographic and other barriers to care experienced by our patients.”

Mary Zelazny, Chair of Finger Lakes IPA and CEO of Finger Lakes Community Health