Care Management

Improving population health and reducing avoidable Emergency Room and Hospitalizations for high-needs populations. The initiatives in this domain provide for care management in response to patient-level of need through Patient-Centered Medical Homes, Community Navigation, and Health Homes. Activities include outreach and engagement with high-needs populations.

Expanding Services for Older Adults

Medicaid beneficiaries ages 50 and older and other individuals with Medicare or private insurance living in nine area counties can now access Lifespan’s comprehensive care management and healthcare coordination services.

We are partnering with Lifespan to expand access in Monroe, Livingston, Genesee, Wayne, Ontario, Steuben, Chemung, Seneca, and Yates counties. The goal is to improve health outcomes for individuals who have medical, behavioral health, and/or social needs by helping them coordinate their care and connect to supportive services.

Licensed Practical Nurse healthcare coordinators and social work care managers work in tandem with medical providers to coordinate care and help individuals navigate systems. They schedule and attend medical appointments with patients, coordinate transportation for appointments, conduct medication reconciliations at home, and provide health literacy training. Lifespan’s social workers visit people at home, assess needs, and link individuals and their families to supportive services.

These care management services are also part of a network of community-based care management agencies that work with individuals with serious and complex physical health, mental health, and substance use disorders to achieve better health outcomes and reduce costs. Greater Rochester Health Home Network (GRHHN) is a lead health home in this area, responsible for managing and supporting the network of care management agencies.

Our Community Partners


additional licensed practical nurses needed in the finger lakes region

OVER 550


*Based on data from 2015-2017 NYS DOH Vital Records.

“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.”

William E. Belecz, Executive Director of Regional Health Reach

“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.”

Former City of Rochester Mayor Lovely Warren

“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.”

Sara Taylor, Founder of BIPOC PEEEEEEK

“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.”

Mary Zelazny, Chair of Finger Lakes IPA and CEO of Finger Lakes Community Health

“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.”

Ann Marie Cook, President and CEO of Lifespan