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.