Naturally Occurring Care Network (NOCN) Initiatives

In 2019, FLPPS NOCNs developed solutions and identified interventions to address key underperforming clinical outcomes specific to each NOCN region after performing a root cause analysis.

Partner Project Description
Family Services of Chemung County, Inc Promote Health Home services with marketing material for potential recipients and referral agencies, along with coordination of a Care Management Agency (CMA) Collaborative.
Finger Lakes Community Health (Finger Lakes Health) Dental case manager collaborations with local Emergency Departments.
Finger Lakes Area Counseling and Recovery Agency Embed a Substance Use Disorder (SUD) counselor in an Emergency Department.
Finger Lakes Area Counseling and Recovery Agency Formation of an Emergency Medical Service Diversion Workgroup for collaboration with local law enforcement.
Finger Lakes Area Counseling and Recovery Agency (Seneca County) Detox follow-up after discharge from inpatient admission.
Lake Plains Community Care Network Regional community navigation coordination to assess, train, and support existing navigation services.
McKinley & Carey Collaborative Homeless outreach and peer support program to hire engagement specialists and provide training to clinical practices servicing the homeless population while linking homeless patients to Health Home, Mental Health and/or Substance Use Disorder (SUD) services.
Recovery Coach University Peer Recovery Coach training for 30 peers and coordination of assignment to specific service providers to acquire hours to qualify for certification.
S2AY Rural Health Network Community navigation for high-utilizers and training for hospital staff on best practice Community-Based Organization (CBO) referral process enhancement.
S2AY Rural Health Network (Ardent Solution) Training and outreach to Primary Care and hospital providers to increase linkages to community-based services.