Social Determinants of Health
The initiatives in this domain support high-need patients and assist providers in providing care by addressing SDoH factors. The efforts include advancing health equity by working with sectors on the factors that influence health, including employment, housing, public safety and food access.
Social Determinants of Health
Street Medicine Program
We are partnering with Regional Health Reach and MC Collaborative to provide medical and dental care to unsheltered homeless individuals in the city of Rochester. Regional Health Reach is a federally qualified health center providing quality comprehensive medical and dental care to homeless individuals in the city of Rochester and the greater Rochester area. Services are provided at area homeless shelters, a mobile medical van, and a clinic located at the St. Mary’s Campus. MC Collaborative is a care agency that focuses on assisting individuals facing significant mental health, physical health, and addiction issues.
Regional Health Reach is collaborating with MC Collaborative to pilot a Street Medicine Program which brings services out of the clinic and provides care directly on the street, in encampments, parks, and under bridges. Regional Health Reach and MC Collaborative will deploy a mobile outreach team made up of a provider, medical assistant, and outreach worker to identify and engage with homeless individuals living on the streets or in high-risk areas.
As part of this collaboration, we are providing technical support to ensure the program meets its goals. This support includes consultation on data and analytics, and a program evaluation report.
The mobile outreach team will use telehealth to link individuals to care and the mobile medical van will also be available to provide medical and dental care. MC Collaborative will provide ongoing case management and coordinate health home care management services.
Our Community Partners
“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.”
“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.”
“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.”
“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.”
“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.”
