Improving care for a vulnerable population

Greater Rochester Health Home Network

The Greater Rochester Health Home Network’s (GRHHN) work is part of a coordinated effort to improve care among a vulnerable population, helping individuals with appointment setting, follow-up, access, and much more. This results in increased continuity of care, reduced system costs, improved outcomes, and reduced burdens in Emergency Departments.

As a lead health home, GRHHN provides tools and resources for care management agencies—connecting each patient with primary care providers, hospitals, behavioral health services, and community-based organizations.

GRHHN was acquired by FLPPS in 2018 and serves as a lead Health Home overseeing and administering the NYS Health Home program, which provides a care management NYS benefit for high-risk Medicaid patients.

With FLPPS infrastructure expertise and knowledge, the GRHHN improved operational efficiencies, quality, and care management agency satisfaction, expanding its geographic coverage beyond Monroe County, and growing enrollment.

GRHHN established a new Direct Care Management division to supplement the care management capacity in the region and support partner outreach and population health management for high-risk patients.

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“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

“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

“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

“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