Transforming Health Care Together

AHI PPS Awards Nearly $1.7 Million to Partners for Innovative Health Care Projects

Nearly $1.7 million has been awarded by the AHI Performing Provider System (AHI PPS) to partner organizations in the region to undertake innovative health care projects. Innovation funding, part of the state’s Delivery System Reform Incentive Payment (DSRIP) Program’s efforts to fundamentally restructure the Medicaid system, will support the implementation of 14 progressive projects involving 70 regional organizations in nine North Country counties.

“Each of the awarded innovation fund projects aligns with the overarching DSRIP goal of improving population health and creating an integrated delivery system,” said Eric Burton, CEO, Adirondack Health Institute. “This is the fourth round of funding the AHI PPS has made available to partners. For this round, we placed an emphasis on supporting projects involving multiple organizations from a wide array of sectors working closely to positively impact community health.”

Demonstrating the Impact of Intensive Clinical Pharmacy Services and Education on Improved Patient Outcomes in Home Health Care and Outpatient Setting is a project in the Glens Falls region that has received funding support. Hudson Headwaters Health Network, Fort Hudson Health System, HCR Home Care, and Glens Falls Hospital aim to have pharmacists provide medication reconciliation for high-risk patients transitioning from a hospital to home care or a skilled nursing facility. “Studies show between 50-70 percent of patients do not take their medications properly, 44 percent of Medicare patients have at least one unnecessary drug after discharge, and one in three frail, elderly Medicare beneficiaries have one or more adverse drug reactions post-discharge from the hospital. It is thought that up to 50 percent of medication-related events can be prevented,” explained Linda Spokane, Vice President, Population Health Management, Hudson Headwaters Health Network. “This funding will be used to develop and implement efficient medication reconciliation workflows, conduct comprehensive medication reviews on high-risk patients, and serve as a means to identify and engage patients in additional care and services.”

A project in the Plattsburgh region receiving funding is Securing Better Health: A Collective Impact Food Security Initiative, an effort involving a myriad of regional partners. Clinton County Mental Health and Addiction Services is the applicant and they will work closely with Clinton County Public Health to implement the project. Leveraging the collective strength of clinical and community partnerships, collaborators will be able to better identify, address, and utilize local resources to help residents manage and overcome food insecurity. “According to the New York State DOH, one in five Clinton County residents are food insecure, a status that is strongly associated with the likelihood of developing chronic disease,” said Mandy Snay, Director of Health Planning and Promotion, Clinton County Public Health. “Traditional approaches have proved inadequate. This project aims to make cooperative system changes in how health care providers in the county identify, address, and utilize local resources to help residents manage and overcome food insecurity. Using new, more effective collective methods, we have a chance to make a real difference in the lives of our residents.”

One of the projects to receive funding in Franklin County involves 11 community organizations – Community Connections of Franklin County, JCEO, Franklin County Office for the Aging, Franklin County Public Health, The University of Vermont Health Network – Alice Hyde Medical Center, Franklin County Legislatures, Citizen Advocates, Cornell Cooperative Extension, North Country Healthy Heart Network, Akwesasne Housing Authority, and Catholic Charities – working together to expand a Mobile Farmer’s Market in Franklin County. Two state-of-the-art greenhouses will be constructed to grow fresh produce and lengthen the market’s growing season, while a full-time Mobile Market Manager and part-time Mobile Market Assistant will be hired to expand the capabilities and reach of the market. “With two new greenhouses, we can increase our growing season from three to nine months of the year and extend the market’s schedule from 10 to 14 weeks,” explained Lee Rivers, Executive Director of Community Connections of Franklin County. “With that four-week increase, coupled with a dedicated manager and assistant, we’ll be able to grow the presence of the market and serve another 800 people.”

In St. Lawrence County, St. Lawrence Health System (SLHS) will use funding to offset the cost of equipment to offer diabetic retinopathy screening at 13 regional facilities, including each of the nine SLHS Patient-Centered Medical Homes, Northern Lights Home Health Care, United Helpers’ Maplewood and RiverLedge campuses, and the Community Health Center of the North Country Malone Clinic. “Due to transportation, economic, and awareness challenges, nearly 72 percent of SLHS patients with diabetes have not had appropriate retinal screening and are at risk for developing blindness,” explained St. Lawrence Health System Chief Operating Officer Eric Burch. “Funding will help us to provide retinal exams at the same time a patient visits his or her primary care provider. By offering this exam, we significantly increase the odds of protecting a patient’s eyesight.”

Innovation funding was provided to regional organizations for the following projects:

Grant Title

Organizations

Impact of Award

Transportation System Solutions The Baywood Center, Warren-Washington Association for Mental Health, Tri-County United Way, Greater Glens Falls Transit A transportation voucher system will be put in place so individuals in need can get to destinations that support their health and wellness.
Community Health and Wellness Program The Baywood Center, Alliance for Positive Health, Family YMCA of the Glens Falls Region Mentally-ill and chemically-addicted individuals will be empowered to take control of their physical, social, and emotional health.
Crisis Intervention Training for Law Enforcement First Responders The Baywood Center, Council for Prevention Law enforcement officers will learn first responder skills to improve outcomes in mental health crisis situations.
Clinical Pharmacy Services and Education Hudson Headwaters Health Network, Fort Hudson Health System, HCR Home Care, Glens Falls Hospital Pharmacists will provide medication reconciliation for high-risk patients transitioning from a hospital to a home care setting/skilled nursing facility.
Wellness Center Hudson Headwaters Health Network, Town of Chester, Turning Leaf Counseling Services, Office for the Aging, Chester Meal Site, Chester Library, Chester Food Pantry, YMCA Adirondack Center A centralized Wellness Center will increase access to services and positively improve overall wellness in the Southern Adirondacks.
Peer Engagement Support Program Behavioral Health Services North, Champlain Valley Family Center, Conifer Park, Alliance for Positive Health Certified Substance Use Peer Engagement Specialists will provide support to high-risk and sporadically-engaged individuals transitioning from behavioral health inpatient services to outpatient clinics.
Securing Better Health: A Collective Impact Food Security Initiative Clinton County Mental Health and Addiction Services, Clinton County Health Department, The University of Vermont Health Network – Champlain Valley Physicians Hospital, Adirondacks ACO, Behavioral Health Services North, Cornell Cooperative Extension, Champlain Valley Family Center, Clinton County Office for the Aging, Plattsburgh Housing Authority, Clinton County Department of Probation, Plattsburgh Primary Care Pediatrics, Mountain View Pediatrics, Plattsburgh Pediatrics Leveraging the collective strength of clinical/community partnerships and existing technology, cooperative system changes will take place in Clinton County to better identify, address, and utilize local resources to help residents manage and overcome food insecurity.
Essex County Transportation Collaborative Mental Health Association in Essex County, Essex County Department of Public Works, Essex County Mental Health Clinic, ACAP, Essex County Office for the Aging, Homeward Bound Adirondacks, Community Services Board Transportation will be maximized for the Medicaid population and those at risk for becoming an Asset Limited, Income Constrained, Employed (ALICE) household with the hiring of a Transportation Navigator (TN). The TN will assist consumers by linking them to volunteer drivers, providing travel training, managing vouchers, and handling gas card and other reimbursements among participating agencies.
Planned Parenthood Connects Planned Parenthood of the North Country New York, St. Lawrence County Health Initiative, Behavioral Health Services North Overall population health improvements and health disparities in Franklin and St. Lawrence counties will be achieved by addressing social determinants of health, such as access to affordable, quality health care and social support networks.
Mobile Farmer’s Market Expansion Community Connections of Franklin County, JCEO, Franklin County Office for the Aging, Franklin County Public Health, The University of Vermont Health Network – Alice Hyde Medical Center, Franklin County Legislatures, Citizen Advocates, Cornell Cooperative Extension, North Country Healthy Heart Network, Akwesasne Housing Authority, Catholic Charities Two state-of-the-art greenhouses will be constructed to grow fresh produce and lengthen Franklin County’s Mobile Farmer’s Market growing season. A full-time Mobile Market Manager and part-time Mobile Market Assistant will be hired to expand the capabilities and reach of the market.
Rides to Healthier Options Community Connections of Franklin County, The University of Vermont Health Network – Alice Hyde Medical Center, JCEO, Franklin County Office for the Aging, St. Joseph’s Addiction Treatment & Recovery Center, Franklin County Department of Social Services, Citizen Advocates, Adirondack Health, Franklin County Public Transportation Transportation services will be expanded for those in need in Franklin Country by way of the dissemination of bus tickets, gas cards, assistance with minor vehicle repairs and ride assistance from taxicab companies and other providers for non-medical needs.
Meeting the Substance Use Disorder Needs of Our Regional Citizens: A New In-Community Approach St. Joseph’s Addiction Treatment & Recovery Center, Community Connections of Franklin County, North Country Community College St. Joseph’s counselors will be on premises at Community Connections and North Country Community College to provide in-community services and referrals for those with substance use disorders.
Diabetic Retinopathy Screening Program St. Lawrence Health System (Canton-Potsdam and Gouverneur Hospitals), Community Health Center of the North Country Malone Clinic, Northern Lights Home Health Care, St. Lawrence County Health Initiative, United Helpers Maplewood and RiverLedge Campuses Diabetic retinopathy education and screening will be offered at 13 facilities in the region.
St. Lawrence County Access to Care St. Lawrence Health System (Canton-Potsdam and Gouverneur Hospitals), Community Health Center of the North Country, St. Lawrence County Department of Labor, St. Lawrence County Department of Social Services, St. Lawrence Health Initiative, St. Lawrence County NYSARC, St. Lawrence County Public Transit, Seaway Valley Prevention Council, Transitional Living Services, United Helpers, Volunteer Transportation Center of the North Country An authorized transportation service program will be created for Medicaid beneficiaries to travel to service destinations not eligible for funded transportation.

 

DSRIP is the main mechanism by which New York State implements the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. For more information, visit https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/.

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