|Able 2 Enhancing Potential, Inc.
|Offer evening and weekend hours for Telemedicine Triage System focused on care for individuals with Intellectual and Developmental Disabilities (l/DD) adults living in one of six certified residences.
|Expand the new Hospital-to-Home program that manages the transition of care from the hospital setting to reduce readmissions and set patients up for long-term health.
|Canisteo Valley Family Practice
|Hire a Population Health/Care Manager (PH/CM) for more intensive patient-centric activities to reach patients for clinical outcome gap closure.
|Catholic Charities Community Services
|Improve workflows for people living with HIV/AIDS by aligning New York State (NYS) Office of Mental Health (OMH) consultation on future opportunities for Value-Based Payment (VBP) and Home and Community Based Services (HCBS) in the future.
|Catholic Charities of Steuben
|Develop a mobile outreach service delivery offering to expand Social Determinant of Health (SDH) care at food pantries, rural community buildings, libraries, churches, and home visits.
|Geroulds Professional Pharmacy
|Targeted care management of those with Chronic Obstructive Pulmonary Disease (COPD) or other chronic respiratory illness to provide respiratory assessment, education, support, exercise, and pulmonary rehab to assist in managing their disease to mitigate hospitalization and emergency care.
|His Branches, Inc.
|Improve patient experience by providing a safe space for medical, social, and behavioral interventions for those in crisis, and Increase patient’s awareness and skills to manage their personal health and wellness.
|His Branches, Inc.
|Remove barriers to care and establish lab and diagnostic services most commonly needed but proven difficult for patients to access.
|Immunize, screen, and link children using a Patient-Centered Medical Home (PCMH) model in partnership with Rochester City School District (RCSD) to reach children and families registering for school who are not linked to Primary Care and require both immunizations and physicals.
|Community-based healthcare navigation services assist older adults (ages 65+) to access preventive care and coordinate care, including screening tests, counseling, immunizations, medications, early detection, and slowed disease progression.
|Rochester-Genesee Regional Transportation Authority
|Transportation intervention pilot in collaboration with Jordan Health, Monroe County Nurse-Family Partnership, UR Home Care, Finger Lakes Community Health, Pembroke Family Medicine, and Oak Orchard Health to test the value of a “mobility management system” for the identification of patients with transportation barriers and then linking them to appropriate services.
|Develop the tools and processes to identify high-risk, high-utilizing patients in real-time and more effectively link appropriate services and interventions for these patients. Foster and maintain effective Coaching for Activation skills in all direct care staff to be better equipped to work with these complex patients for beneficial behavior change.