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.

DSRIP Projects and Workstreams

We worked with partners across the region to implement eleven innovative projects designed for system transformation, clinical management, and population health. Collectively, there were over 125 individual milestones! Our timeline/launch projections were incredibly aggressive, along with a solid implementation plan that spanned the entire FLPPS geography.

We implemented transformational work streams across the region related to Workforce, Social Determinants of Health, and Cultural Competency and Health Literacy. These work streams were integral to supporting the infrastructure and change management necessary to sustain project best practices.


122 FLPPS Partners connected to Rochester Regional Health Information Organization (RHIO) ​

937 Level 3 Primary Care Medical Home (PCMH) Certified Providers


17 Hospitals and 55,952 Patients engaged

7% ↓ Potentially Preventable Visits


34 Partners and 26,517 Patients engaged

2% ↓ Potentially Preventable Visits


20 New Beds, 26 Community-based Organizations and Hospitals

24% reduction in inpatient admissions

FLPPS was the only PPS to select this project

108,609 Patients engaged in Patient Activation Measure


40 Partners and 177,301 Patients engaged

4% increase in antidepressant initiation 


57 Partners and 40,654 Patients engaged

16% reduction in preventable ED visits for individuals with a behavioral health diagnosis


39 Skilled Nursing Facilities and 4,214 Patients engaged,

34% reduction in long term care resident reports of depression

27% reduction in antipsychotic medication use among residents with dementia

FLPPS was the only PPS to select this project

2,797 Patients engaged

29 Community Health Workers

3% reduction in low birth weight


46 Youth Mental Health First Aid Trainings

850 Individuals Certified

34 Clinicians trained in the ARC Model


7% ↑ Initiation and engagement treatment for alcohol and other drugs

“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

“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

“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

“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

“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