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.

Community Action of Orleans and Genesee Access to Healthcare Program

We collaborated with Community Action of Orleans and Genesee to increase access to healthcare for homeless and housing insecure families in Orleans County through a new program referred to as “Axis of Care.” Housing insecurity was a social determinant of health and a driving force of health inequities.

As part of this collaboration, we provided technical support to ensure the program met its goals. This support included process documentation, consultation on data and analytics, and a program evaluation report.

A health coach at Community Action of Orleans and Genesee connected and coordinated individuals with services, set and tracked goals and outcomes, improved health literacy among those in need, and coordinated transportation to healthcare facilities as needed. The health coach was part of the case management team and collaborated with a peer advocate from Genesee Council on Alcoholism and Substance Abuse (GCASA).

The agency established a telehealth hub in its Eastern Orleans Community Center located in Holley, NY, where community members experiencing homelessness or at risk of homelessness could access healthcare using telehealth services. The agency partnered with Orleans Community Health, Oak Orchard Health, and GCASA on telehealth services and had a mobile clinic onsite. The health coach connected individuals with needed services such as behavioral health treatments and services at the center or at healthcare facilities.

Our Community Partners

“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

“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

“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

“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

“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