Supporting the community through programs that make a positive impact
System Transformation and Community Investment Program
Focuses on integrating community-based care into the healthcare delivery system, supporting community based organizations in programming designed to positively impact health outcomes, health equity, and the cost of healthcare.
Enabling integration between community and clinical providers in the following domains
Improving behavioral health outcomes and preparing Behavioral Health Care Collaborative networks and providers for Value Based Payment.
Improving the health and well-being of women, infants, children, and families.
Improving the quality and continuity of care for individuals by supporting social determinants of health connections and closed loop referrals.
Improving population health and reducing avoidable Emergency Room and Hospitalization for high-needs populations.
The Program domains were identified by a comprehensive data-driven, outcomes-based regional needs assessment that was conducted by FLPPS. This data analytic exercise provided key insights into performance of DSRIP outcome measures by domain and was leveraged to inform areas of need for system transformation efforts. There are twenty best-practice interventions and thirty partners were selected to establish or expand programming to address these outcomes over a two year project timeframe, with specific milestones and deliverables.
The projects are based on the United Hospital Fund “DSRIP Promising Practices: Strategies for Meaningful Change for New York Medicaid” Report, as well as FLPPS DSRIP promising practices, and represent targeted interventions which leverage community-based organization expertise to improve outcomes in a sustainable manner.
OVER 550
STUDENTS WILL BE PLACED IN
HEALTHCARE AND SOCIAL SERVICES FIELDS
FAMILIES IN ROCHESTER NEIGHBORHOODS NEED BETTER ACCESS TO PRIMARY AND BEHAVIORAL HEALTH SERVICES
CALLS A YEAR TO THE RPD ARE BEHAVIORAL HEALTH OR SUBSTANCE ABUSE-RELATED
*Published in Democrat and Chronicle January 2021
BLACK INFANT MORTALITY
NEARLY 3 TIMES THE RATE FOR WHITE INFANTS
*Based on data from 2015-2017 NYS DOH Vital Records.
“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.”
“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.”
“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.”
“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.”
“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.”
