DSRIP Innovation Funds

DSRIP Innovation Funds

The AHI PPS awarded more than $12.7 million in DSRIP funding to support 75 progressive health care projects involving more than more than 170 partner organizations through four rounds of innovation funding.

Each awarded project aligns with the overarching DSRIP goal of improving population health and creating an integrated delivery system. In addition to innovation, emphasis was placed on funding projects involving multiple partner organizations from diverse sectors and the ability to replicate initiatives in other regions.

Below is a list of awarded projects broken out by Population Health Network (PHN) region, round, project title, project summary, lead organization, lead contact, lead email address, and other participating organization(s). You can also use the search box to find projects related to a given term.

If you are interested in learning more about a particular project or replicating an initiative, we encourage to reach out to the project’s lead contact. If you have any general questions, contact [email protected].

PHN RegionRoundProject TitleProject SummaryLead OrganizationLead ContactLead Email AddressOther Participating Organization(s)Status UpdateSustainability Plan
Glens Falls2Care NavigationContinue funding of the organization's Care Navigator position.Council for PreventionAmanda West[email protected]
Glens Falls2Hope and Healing Recovery Community Outreach Center StaffingIncrease staffing in the Hope and Healing Recovery Center.Council for PreventionAmanda West[email protected]A staff member is now overseeing the Warren-Washington Suicide Prevention and Hometown vs. Heroin and Addiction Coalitions, and supervising the Adolescent Challenge Program. A number of training sessions have been held, including the 12-hour SBIRT course for Caleo Counseling Center staff and numerous Suicide Prevention training workshops. A number of program presentations and meetings have been held, including a discussion with BOCES principals about trauma, and Parsons Mobile about how to make referrals to the Adolescent Challenge Program. The program has also worked with Opioid Diversion staff at CFR to start making Health Home referrals. The program has shown the documentary “Angst," a film about anxiety and depression and how to see the signs, at four schools. Several schools have reached out requesting additional training.
Glens Falls2LPN ProjectExpand health services in the housing and programs WWAMH offers. This will assist patients in improving engagement and understanding of their chronic medical conditions.Warren-Washington Association for Mental HealthAndrea Deepe[email protected]Staff received training on such topics as nicotine replacement options and health monitoring. The organization's LPNs have been successful in addressing the social determinants of health. The organization has provided transportation to those who otherwise would have had a difficult time attending medical appointments. The agency has spent a good deal of time on patient advocacy and education.
Glens Falls2East Side Center After Hours ProgramExpand hours at the East Side Center, a supportive community program.Warren-Washington Association for Mental HealthAndrea Deepe[email protected]Hours at the facility have been expanded. Meals are served on a regular basis during the extended hours, allowing participants to socialize during meal preparation and while eating. The program has been successful in providing access to a counselor during 100 percent of its open hours. Trained peer specialists are on staff regularly and a case manager has been assigned to work in the program each evening. Transportation, linkages to community supports, activities, and social interactions have all provided positive benefits. Participation in all facets of the program has increased dramatically.
Glens Falls1Open Access ImplementationImprove the availability of treatment for mental illness by improving utilization and allowing open access scheduling, a patient-focused scheduling methodology.Warren-Washington Association for Mental HealthAndrea Deepe[email protected]The Center for Children is dealing with structural problems, limiting the organization's ability to start open access. There are further delays due to capacity issues for the Adult Outpatient Clinic and the Children and Family Clinic. Because they don't have enough medical staff, they haven't offered open access to the public for their Adult Outpatient Clinic. At this time, they have approximately 185 people waiting to get in for psychiatric services. They are looking at opening two small windows for open access.
Fulton3Fulton County Telehealth Expansion ProjectContinuation of the telehealth initiative, opening the platform up with an app and virtual visit licenses.Fulton County Public Health DepartmentAngela Stuart-Palmer[email protected]Nathan Littauer Hospital & Nursing Home, The Family Counseling CenterA new contract was executed to update the project scope in August 2019.
Fulton1Fulton County Telehealth Expansion ProjectAllow for increased access to care and integration throughout the county by leveraging and expanding technology.Fulton County Public Health DepartmentAngela Stuart-Palmer[email protected]The Fulton County telehealth pilot was initiated in March 2018 with telehealth stations set up at Fulton County Public Health, Fulton County Office for the Aging and Fulton Montgomery Community College. A provider training session took place at which time equipment was dispensed to Nathan Littauer Hospital & Nursing Home and St. Mary's Hospital providers. FCPH reached out to major insurance companies in the area providing medical coverage, resulting in a productive meeting with CDPHP which expressed interest in partnering on a countywide telehealth project in the primary care provider setting.FCPH will continue to follow up with additional carriers to facilitate additional participation in the countywide telehealth program, in efforts to ensure long-term sustainability. Development of the app. will continue based on measuring pilot utilization rates and outcomes data on metrics to then expand to the countywide initiative.
St. Lawrence4Diabetic Retinopathy Screening ProgramDiabetic retinopathy education and screening will be offered at 13 facilities in the region.St. Lawrence Health SystemApril Grant[email protected]Community Health Center of the North Country Malone Clinic, Northern Lights Home Health Care, St. Lawrence County Health Initiative, United Helpers Maplewood and RiverLedge CampusesThe equipment has been received and staff training is in progress.
St. Lawrence4St. Lawrence County Access to CareAn authorized transportation service program will be created for Medicaid beneficiaries to travel to service destinations not eligible for funded transportation.St. Lawrence Health SystemApril Grant[email protected]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 CountryMore than 300 referrals have been processed.
St. Lawrence1Canton Enriched Housing ProgramAllow preventative measures to reduce unnecessary emergency department visits of the heavy-utilizing CEH residents.St. Lawrence Health SystemApril Grant[email protected]The Department of Health approved an application to increase the number of enriched housing apartments from 25 to 43. One full-time on-site manager, one full-time on-site medication coordinator, and one part-time caseworker were hired.Canton Enriched Housing received sustainability funding to help support day-to-day operations after this grant ended in May 2018.
St. Lawrence1Wellness and Prevention ServicesIntegrate behavioral health services in SLHS's Potsdam Primary Care Clinic to improve behavioral health outcomes.St. Lawrence Health SystemApril Grant[email protected]This project is on hold awaiting a waiver from NYS DOH/OMH to proceed.
Plattsburgh2Emergency Department High UtilizersSupport emergency department high utilizers to obtain/sustain independent functioning in the community.University of Vermont Health Network-Champlain Valley Physicians Hospital Medical HomeBrenda Stiles[email protected]The organization changed identifying criteria for a multi-visit patient to three or more visits in 30 days; five or more visits in 60 days; and continued notification of 10 or more visits in a calendar year. The number of targeted patients expanded under the new criteria, but multi-visits have dropped with the help of a peer navigator. Bi-monthly meetings continue to occur with community-based organizations to assist with community care plan creation. They continue to use the social determinants of health screening tool to assist with patient engagement and identification of needs/barriers. The project has prompted a deeper relationship between NAMI-Champlain Valley and UVMHN-CVPH which has expanded to the CVPH Care Management Team and led to the development of a Community Center at the RS Long Housing Center.
Plattsburgh2Data Output ExchangeCreate a data output exchange by way of Care Navigator and GSI Health.University of Vermont Health Network-Champlain Valley Physicians Hospital Medical HomeBrenda Stiles[email protected]This initiative is on hold due to AHI changing Health Home EMR vendors.
Glens Falls2Provider Engagement ProjectImprove engagement and organization of the primary care network at the hospital.Glens Falls HospitalCathleen Traver[email protected]GFH achieved stated project provider engagement goals and objectives. Funding received assisted Glens Falls Medical Group in establishing a foundation for physician engagement. Due to clinician feedback, they stopped printing a provider newsletter. Other types of communication tools are being evaluated.
Glens Falls1TelepsychiatryIncrease access to psychiatric providers, via telepsychiatry, to better meet the needs of individuals in the region.Glens Falls HospitalCathleen Traver[email protected]After an initial challenge of getting approval from OMH to launch the program, GFH determined the best and most expedient way to implement telepsychiatry was by piloting the services first as an Article 28-licensed service, rather than an OMH-licensed service (Cambridge Health Center) as originally proposed. The hospital will pilot the service within its Crisis Unit and Emergency Department utilizing GFH-employed providers.
Glens Falls1Crisis Care/Intervention CenterSupport a volume shift away from costly inpatient admissions, readmissions and emergency room visits, and focus on integrated and coordinated outpatient services for an extremely vulnerable patient population. Benefits will include expanded patient navigation services, development of coordinated ambulatory care services, improved admission vs. discharge decisions, increased staff support, enhanced safety for patients and staff, and improved patient satisfaction.Glens Falls HospitalCathleen Traver[email protected]The Crisis Center continues to see approximately 200 patients per month, with anywhere between 20-25 percent of those being children. The team continues to work with community-based organizations to connect patients back to their communities as appropriate. A current focus is on collaborating with a mobile crisis team (Northern Rivers) to market their services to the community. Engaging with schools and law enforcement to educate them about this service has also been a priority.
Glens Falls4Wellness Center for the Southern AdirondacksA centralized Wellness Center will increase access to services and positively improve overall wellness in the Southern Adirondacks.Hudson Headwaters Health NetworkCraig Leggett[email protected]Town of Chester, Turning Leaf Counseling Services, Office for the Aging, Chester Meal Site, Chester Library, Chester Food Pantry, YMCA Adirondack CenterThe Wellness Center opened on May 8, 2019, and is working on referrals.
Plattsburgh2Patient Coaching for Navigation/PAM ImprovementProvide an additional cycle to conduct more outreach for navigation to services, administration of Patient Activation Measure (PAM) surveys, and coaching of patients to improve their PAM scores and health literacy.Clinton County Office for the AgingCrystal Carter[email protected]The organization has seen improved outcomes for many of its individuals. They have seen 268 people and have had 442 contacts with them. They are finding that many need help understanding they have control of their own health and can make changes. They started ER referrals in July 2018 and hired a new navigator in September 2018. They have had positive outcomes linking people with home health, primary care, and dentistry.
Glens Falls2Emergency Food Access ProjectInitiate new programs to advance DSRIP and support emergency food access activities.Comfort Food CommunityDevin Bulger[email protected]The project continues to administer PAM surveys to individuals, in some cases, asking them to take the survey a second time to evaluate progress. In those cases, most scores have trended upward. Interactions with participants have included connecting them to community resources, providing navigation, coaching for activation and counseling support, and offering produce samples and recipes. Information has been distributed to guests signing up for Empower, HEAP, Medicare, and NY State of Health health insurance coverage. They have also helped individuals find and connect with primary care providers, medical transportation services and prescription support programming, oftentimes using the ADK Wellness Connections referral network.The program will continue with funding from other sources.
Saranac Lake1Project InSHAPE (Self Health Action Plan for Empowerment)Provide health promotion coaching interventions in the areas of nutrition, fitness, social inclusion, and community engagement, for those with serious mental illness and at-risk for serious health conditions.Citizen AdvocatesKati Jock[email protected]Health coaches completed courses in Nutritional and Integrative Interventions for Mental Health Disorders and Corrective Exercise through the International Sports Sciences Association. The program has offered healthy cooking classes and held a weight loss challenge.
Plattsburgh2School-Based Case ManagersSupport two school-based Case Managers.Behavioral Health Services NorthElizabeth Cole[email protected]The organization hired two school-based case managers who have been working to build their caseloads. The two are working with school-based clinicians and partnering agencies to link their families to proper supports. They have noticed an increase in communication from families, with a higher engagement rate. They are continuing to educate the community on the services they provide.
St. Lawrence1Chronic Obstructive Pulmonary Disease (COPD)A comprehensive approach to the accurate identification of COPD patients and post-acute coordination to prevent readmissions and improve patient quality of life.St. Lawrence Health SystemEric Seifer[email protected]Canton-Potsdam Hospital has partnered with United Helpers Riverledge and Maplewood Skilled Nursing Facilities, Marra’s Home Care Agency, and Encore Healthcare for this endeavor. Since its launch, a respiratory navigator has seen patients, enrolling them to transition from inpatient status at the hospital to the Pulmonary Independence Program at either Riverledge or Maplewood’s SNF, and referred patients directly to Marra’s for in-home respiratory therapy services. The program also completed an educational video, “Dynamic Dialogues,” which is being used to assist health care professionals engage patients to obtain optimal outcomes. The program also hosted continuing medical education sessions with local primary care providers related to appropriately diagnosing and treating COPD.
Fulton2Coaching and Navigation ServicesExpand community navigation resources in the region.Nathan Littauer Hospital & Nursing HomeGeoffrey Peck[email protected]The Family Counseling CenterHealth coaches have assisted individuals in accessing appropriate levels of health care, and identifying and alleviating any social determinants of wellness. The hospital placed a coach part-time at their local YMCA transitional housing facility to assist those residents with their health care needs. Staff facilitated group trips to the Department of Social Services and other local resources that assist with housing, primary care, mental health, nutritional needs, pharmacy, etc.The initiative's goal is to demonstrate to health homes and insurance companies that the cost of implementing this program is far less than these individuals utilizing the emergency room or an inpatient hospital stay.
Saranac Lake3Antidepressant Medication Adherence ProgramKinney Drugs and Fidelis Care will collaborate on a pilot medication adherence program for behavioral health patients prescribed antidepressants.Adirondack HealthHeidi Bailey[email protected]Kinney Drugs, Fidelis CareA coordinator was hired. Follow-up on anti-depressants is now handled by health centers' resource navigators and a pharmacist will be working in all health centers to provide a collaborative drug management therapy program for patients.
Glens Falls4Community Health and Wellness ProgramMentally-ill and chemically-addicted individuals will be empowered to take control of their physical, social, and emotional health.The Baywood Center (820 River Street)Jacqueline Foster[email protected]Alliance for Positive Health, Family YMCA of the Glens Falls RegionThe program launched in late May 2019.
Glens Falls2Addiction-Related Treatment Services ListingCreate an accessible, accurate regional listing of all addiction-related treatment services in the Southern Adirondack/Capital region.Alcohol and Substance Abuse Prevention Council of Saratoga CountyJanine Stuchin[email protected]A listing of treatment providers in the seven-county region was completed. The listing includes information on payer coverage. It is updated two times per year.
Glens Falls2Mobile Substance Abuse CounselorIncrease substance use services to the Warren and Washington County communities.The Baywood Center (820 River Street)Jennifer Neifeld[email protected]
Glens Falls3Transition CoordinatorFund a Community Re-entry Coordinator position to help individuals leaving the prison system access appropriate community services.The Baywood Center (820 River Street)Jennifer Neifeld[email protected]Warren-Washington Association for Mental HealthThe ABLE program is set up. The care coordinator is transitioning prisoners to the community and has connected them with services in multiple settings to assure they get the care they need. Their main focus is on assuring SUD, BH, and primary care services are quickly engaged upon release. The initiative is working well, taking referrals from both Warren and Washington County's justice systems (jails, probation, health service, etc.)
Glens Falls4Transportation System SolutionsA transportation voucher system will be put in place so individuals in need can get to destinations that support their health and wellness.The Baywood Center (820 River Street)Jennifer Neifeld[email protected]Warren-Washington Association for Mental Health, Tri-County United Way, Greater Glens Falls TransitThe YMCA was recently approved as a Medicaid transportation location and will assist with transportation barriers.
Glens Falls4Crisis Intervention Training for Law Enforcement First RespondersLaw enforcement officers will learn first responder skills to improve outcomes in mental health crisis situations.The Baywood Center (820 River Street)Jennifer Neifeld[email protected]Council for PreventionA training schedule has been developed.
Plattsburgh4Planned Parenthood ConnectsOverall 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.Planned Parenthood of the North Country NYKatie Ramus[email protected]St. Lawrence County Health Initiative, Behavioral Health Services NorthA new patient navigator was hired to make community connections.
Glens Falls2Arista MD-eConsult Test CaseAssist in determining if specialty care is needed so a primary care provider can manage the patient's care with a formal referral.Hudson Headwaters Health NetworkKevin Dougrey[email protected]HHHN clinicians have determined that consults are high quality, so they will open up the pilot to several more providers in efforts to decrease unnecessary referrals to specialty providers and assist with avoiding hospital use.
Glens Falls2Diabetic Retinopathy ProjectProvide diabetic retinal screening in the primary care provider office using special equipment that sends the test results to an ophthalmologist for evaluation.Hudson Headwaters Health NetworkKevin Dougrey[email protected]This initiative has been implemented at three sites: Ticonderoga, Warrensburg, and West Mountain. Of the 271 patients who received screenings, 32 identified with diabetic retinopathy. Reactions from clinicians and patients about the initiative have been very positive.
Glens Falls2Patient Navigation ServicesContinue funding for the Patient Navigator position.Planned Parenthood Mohawk HudsonKim Atkins[email protected]The organization is seeing patients regularly with positive results.
Glens Falls2Pathway Home ProjectSupport several programs at Open Door's new facility, such as a temporary housing program, facility for care management services, and programs for training both guests and the community on issues related to poverty, homelessness and food insecurity.Open Door MissionKim Cook[email protected]Furniture and a smart board for the Learning Center were installed. A coordinator was hired for the Community Resource Room and an internet cafe, complete with iPads, was opened in that room. The eight-bed emergency shelter hired supervisors and opened in June 2018 and has been full since. Code Blue started in November 2018. The organization continues to work on data collection regarding participant goal setting and attainment.
Glens Falls1Pathway Home ProjectExpand the organization's new location to include a training room, day room, resource and learning center, and health clinic.Open Door MissionKim Cook[email protected]The first floor is open. The Training and Resource Rooms are complete. Community providers are participating on-site at events and as needed.
Plattsburgh2Exercise PhysiologistAdd a Registered Exercise Physiologist to the team of providers.Plattsburgh Primary Care PediatricsKymberlie Sweenor[email protected]The exercise physiologist has been integrated into the care team. The physiologist has participated in pre-visit planning for patients being seen for annual preventive visits and return visits for behavioral health diagnoses. The physiologist has focused on meeting patients/families where they are, building rapport using evidence-based guidelines provided by the National Society for Health Coaching and Motivational Interviewing. Support tools such as goal setting, patient ambivalence, and patient agenda worksheets have been incorporated. Real-time documentation and communication between the provider and physiologist allows the provider to hit the ground running, reinforcing the physiologist's message.
Glens Falls2Patient Coaching and Patient Activation Measure (PAM) ServicesContinue funding for patient coaching services.Alliance for Positive HealthLaurie Lanphear[email protected]The organization has been administering PAM surveys to individuals, a number of whom have been provided coaching and/or enrolled in Health Home Care Management. Community outreach continues to expand with a focus on attempting to create connectivity between the county jails, short-term coaching, and Health Home Care Management.
Saranac Lake2Navigation and EngagementUtilize Peer Navigators in the emergency department of UVMHN - Alice Hyde Medical Center and at Franklin County Department of Social Services to further develop and maintain engagement of identified individuals who need ongoing support to assure their continued health and well-being.Community Connections of Franklin CountyLee Rivers[email protected]The University of Vermont Health Network - Alice Hyde Medical Center, Franklin County Department of Social ServicesThe program began tracking individuals utilizing the emergency department four or more times in 2018. Reporting done in July 2019 indicated 51 individuals who had a combined total of 400 visits in 2018, so far in 2019 had a combined total of 156 visits.The organization will continue to monitor the program's impact on ED utilization through the end of the funding cycle.
Saranac Lake3Franklin County Community Education and PreventionSupport prevention education efforts in Franklin County.Community Connections of Franklin CountyLee Rivers[email protected]Franklin County DSS, Franklin County Community ServicesMeetings have occurred to develop the curriculum, identify agency partners, and communicate with school superintendents.Community Connections of Franklin County, Franklin County Department of Social Services, and Franklin County Community Services will partner on a sustainability plan.
Saranac Lake4Mobile Farmers' Market ExpansionTwo 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. Community Connections of Franklin CountyLee Rivers[email protected]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 CharitiesThe greenhouses have been constructed and one of them is currently being used to grow various types of produce for distribution to local food pantries.JCEO is currently seeking funding to outfit the second greenhouse with a hydroponic system. The system will allow JCEO to grow lettuce that will be sold to local food distributors. The sale of the lettuce will produce the income necessary to sustain the Mobile Farmers' Market and the provision of fresh produce for pantries.
Saranac Lake4Rides to Healthier OptionsTransportation 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 taxi cab companies and other providers for non-medical needs.Community Connections of Franklin CountyLee Rivers[email protected]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 TransportationThrough this initiative, 116 people received 548 rides; 141 people received 1,569 tokens; 50 people received gas cards; 19 people received assistance with their vehicle repairs; two people received assistance obtaining their driver's licenses; and one person received help with vehicle registration.The organization believes its data will show the state the full impact of the region's transportation problem, prompting them to allocate funding to support an innovative solution to address the issue.
Plattsburgh3Well-Fed Essex County CollaborativeBring on board health care organizations, community-based educators, farmers, retailers, and food pantries to improve access to fresh local foods.Essex County Public HealthLinda Beers[email protected]Well-Fed Essex County Collaborative workgroups meet bi-monthly, and subcontractors meet monthly. The Better Choice Retailer Program recruited four local retailers, and is working with new and current retailers to accept WIC and SNAP. In March 2019, UVMHN - Elizabethtown Community Hospital rolled out the Wellness RX Program. Cornell Cooperative Extension has met with food pantry directors to complete pre-assessments and discuss current processes for healthier choices. Renovations have been made to Keeseville Farmacy. The Farmacy 2.0 location has been identified. Equipment has been purchased for Essex County WIC for farm food donations. With the support of Essex County Office for the Aging, the collaborative is submitting an application to accept SNAP benefits at congregate meal sites and for home-delivered meals.The work completed during the latest quarter focused on Building partner connections, increasing capacity, and developing infrastructure has been the recent focus of the initiative to ensure identified projects are sustained beyond the innovation grant period.
Glens Falls4Clinical Pharmacy Services and EducationPharmacists will provide medication reconciliation for high-risk patients transitioning from a hospital to a home care setting/skilled nursing facility.Hudson Headwaters Health NetworkLinda Spokane[email protected]Fort Hudson Health System, HCR Home Care, Glens Falls HospitalThe program is working with mutual patients of Fort Hudson. The workflow has been developed.
Plattsburgh4Securing Better Health: A Collective Impact Food Security InitiativeLeveraging 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.Clinton County Mental Health and Addiction ServicesMandy Snay[email protected]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 PediatricsStaff members have been hired and training is in progress. They will begin to serve residents in the upcoming months.
Glens Falls2Community Check Program of the Mobile Health Care SystemVisit select patients in their home for additional support.Cambridge Valley Rescue SquadMark Spiezio[email protected]The project is on hold pending the identification of a safety net lead. Prior to that, NYS DOH BEMS had been receiving requested reports demonstrating the effectiveness of the program. As of September 2018, there were 32 active participants and 10 in holding (home nursing or rehab). Time had also been dedicated to updating existing policies and procedures. Hudson Headwaters Health Network made the CCP program available to all of its primary care practices. HCR Home Care and Fort Hudson Health System were partnering to create a collaborative working agreement.
Fulton2Transportation ProjectPurchase taxi cab vouchers, bus tokens, gas-only gift cards and pay for minor car repairs for individuals to get to such destinations as health care appointments, job interviews, school meetings, pharmacies to pick up prescriptions, and the grocery store.The Family Counseling CenterMichael Countryman[email protected]Nathan Littauer Hospital & Nursing Home, Planned Parenthood Mohawk Hudson, The Community Health Center, HFM Prevention Council, Mental Health Association of Fulton and Montgomery CountiesA part-time coordinator was hired. The program developed and distributed to partners a questionnaire for each voucher utilized to assess social needs being met and gaps this initiative is bridging.By utilizing and sharing questionnaire data, the program intends to demonstrate to insurance companies and/or private foundations that they are fulfilling unmet needs and thereby avoiding preventable hospitalizations.
Fulton2Building RenovationsMinor building renovations will transform existing space into two primary care rooms.The Family Counseling CenterMichael Countryman[email protected]Renovations are complete. They are waiting on waivers for the integration of NLH primary care into the Family Counseling Center behavioral health setting.
St. Lawrence1Integrated Delivery System of Health ManagementImprove the clinical diagnostic capabilities of each campus to stabilize the health of residents and prevent unnecessary hospitalizations and outpatient visits.United Helpers - RiverLedge and MaplewoodMichele Montroy[email protected]The organization continues to hold 40-hour training classes, including skills labs that are being heavily utilized by certified and licensed staff. The clinical and diagnostic educator has received infection control and IV training and is now providing both IV hydration and antibiotic therapy. The organization has taken evidence-based educational materials developed through the Pulmonary Independence Program and integrated care pathways into their clinical education program. Data analytics are being used to evaluate outcomes and performance, including internal QA tracking of incidence of infections compared to emergency room and acute admission utilization. In addition, they've been analyzing publicly-reported data for 30- and 90-day readmission rates. Both facilities have attained an overall 5 out of 5 stars in quality measures reported through CMS.
St. Lawrence1Integrated Delivery System and Strong Mental Health Infrastructure for ChildrenProvide an integrated community-based solution for children with severe behavioral needs. Modeled after the Office of Mental Health's adult Assertive Community Treatment (ACT) program, the goal of this Pillar Program is to break the cycle of disability and dependence and move toward independence for some of New York's neediest youth and their families.United Helpers - MOSAICMichele Montroy[email protected]The organization provided presentations to the St. Lawrence County Department of Social Services, Child Protective/Preventative Services, Foster Care, PINS, local community services providers, school districts, hospital emergency rooms/staff, SPOA, and the Regional Planning Council Child and Families Committee in order to obtain referrals for the Pillar Program, a wrap-around service for children. MOSAIC hired a therapist, psychiatric nurse practitioner, and care coordinator to support the program. The care coordinator is embedded in one of the local schools.
Plattsburgh2Community Liaison PositionDevelop the new position of Community Liaison to educate health care providers and the community on end-of-life decisions and planning.Hospice of the North CountryNatalie Whitehurst[email protected]
Plattsburgh4Peer Engagement Support ProgramCertified Substance Use Peer Engagement Specialists will provide support to high-risk and sporadically-engaged individuals transitioning from behavioral health inpatient services to outpatient clinics.Behavioral Health Services NorthPeter Trout[email protected]Champlain Valley Family Center, Conifer Park, Alliance for Positive Health
Plattsburgh1Mobile Crisis TeamProvide prompt, community-based triage of clients' medical and mental health status to minimize risk to self and others in the least restrictive, person-centered, trauma-informed environment possible to circumvent the need for more intensive crisis services.Behavioral Health Services NorthPeter Trout[email protected]The Crisis Team has served a myriad of adolescents and adults. Only 10 percent of those who have engaged with the team required transport to the emergency department. The team continues to work with county leadership and emergency services to increase referrals and market the service aggressively to the community.The coordinator has been data collecting to develop a sustainability plan in conjunction with agency leadership.
Glens Falls2Value-Based Payment and Personal Care Home AssistantsTraining for home health aides to assist in understanding population health and the value-based payment (VBP) system.Fort Hudson Home CareRhenda Campbell[email protected]North Country Home ServicesFort Hudson Home Care trained RNs and PCAs on how care planning can address value-based payment (VBP) priorities such as avoidable hospitalize use. The trained RNs and PCAs then reviewed plans of care for high-risk clients and adjusted them to assure the patient could be sustained in their home safely. Follow-up training has been incorporated into their annual staff education program.
Plattsburgh2TelecounselingPilot telecounseling program for outpatient behavioral health settings.Clinton County Mental Health and Addiction ServicesRichelle Gregory[email protected]Clinton County Mental Health purchased equipment and installed it at the jail and in the nursing home. They have put in place a referral process and agreed-upon protocols. Two clinicians conduct on-site initial assessments at the nursing home and schedule individuals, as appropriate, for teleconsulting.
Plattsburgh3PAX/DIRPurchase the PAX Good Behavior Game (PAX GBG) instructional classroom management tool and provide staff support.Clinton County Community Services Board Mental Health and Addiction ServicesRichelle Gregory[email protected]Coaching sessions for the first component of the program, Developmental Individual Differences and Relationship-based Intervention Practitioner (DIR), were held at Clinton County Mental Health for classroom teachers, teaching assistants, and administrative staff members. The DIR practitioner continues to receive referrals from pediatric offices. A training session for the program's second component, the PAX Good Behavior Game (PAX GBG), was held at Champlain Valley Education Services.
Plattsburgh2Reducing Pediatric ObesityDecrease the rate of obesity in the pediatric population by integrating a Nutritionist, Social Worker, and an Exercise Physiologist into the Food Security Project.Mountain View PediatricsRobert Moore[email protected]The organization has two full-time registered dietitians seeing patients. They see more than 85 percent of all well-visit patients and have extended appointments for those who need further assistance. Currently, insurance coverage is not existent for the services they provide. They are reaching out to provider reps to try to negotiate RD billing into contracts.
Plattsburgh3HealthySteps SpecialistSupport a full-time HealthySteps Specialist to promote healthy early childhood development and effective parenting.Clinton County Community Services Board Mental Health and Addiction ServicesRobert Moore[email protected]Mountain View PediatricsThe Healthy Steps Specialist has seen more than 480 families. The practice has incorporated the ACE rating scale into all well-visit appointments.The organization is concerned about sustainability as this is still not a billable service.
Saranac Lake4Meeting the Substance Use Disorder Needs of Our Regional Citizens: A New In-Community ApproachSt. 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.St. Joseph's Addiction Treatment & Recovery CenterRobin Gay[email protected]Community Connections of Franklin County, North Country Community CollegeSt. Joseph's has a full-time clinician in Tupper Lake providing individual and group counseling. They are currently in the process of setting up telehealth for MAT options.St. Joseph's plan is to maintain the full-time clinician in Tupper Lake and have a 2020 budget in place to do so.
St. Lawrence1Concurrent Care ProjectDecrease emergency department visits and hospitalizations of Medicaid patients by functionally integrating home health and palliative care services.Hospice and Palliative Care of St. Lawrence ValleyRuth Fishbeck[email protected]Canton-Potsdam Hospital signed on to the grant to provide patient data for program evaluation. The hospital and Hospice have connected to HealtheConnections. The project is collaborating with Northern Lights to ensure medication reconciliation and progress note sharing are completed. The program is averaging a census of 150-160 patients.
St. Lawrence2COPD Population Health ProjectFund the hiring of a new Registered Respiratory Therapist (RRT) to treat patients at several United Helpers' facilities, as well as the cost of software to provide clinical pathways and a directed work flow for the RRT to implement COPD protocols into the sub-acute pathway.United HelpersStacey Cannizzo[email protected]A full-time respiratory therapist is on staff providing clinical support and direct care for their two skilled nursing facilities, RiverLedge and Maplewood. An RN is on staff providing clinical education and program development for each facility. The RT has conducted education for the PT/OT and nursing staff members at the two facilities and Northern Lights Home Health. The RT performs spirometry testing for sub-acute populations transitioning home, as well as long-term care populations with COPD. The RT evaluates and treats patients with a change in condition, and also provides one-on-one patient education for those transitioning home.
Glens Falls2Peer Transition Wellness TeamAssist in improving the warm handoff from inpatient psychiatric services to the community.Projects to Empower and Organize the Psychiatrically Labeled (PEOPLe, Inc.)Steve Miccio[email protected]Glens Falls HospitalThe project was restarted at Glens Falls Hospital due to new leadership in psychiatry. PEOPLe, USA has been working on referrals and in the community with peer services. The peer advocates have been seeing several direct referral patients in the community.
Plattsburgh2Primary Care ApplicationServe as a primary care provider by engaging an Associate Director for Primary Care, train staff and equip their health centers with necessary primary care supplies and equipment.Planned Parenthood of the North Country NYTess Barker[email protected]The organization has trained providers and staff members, developed policies and protocols, and worked with the EMR vendor to implement and develop the templates necessary for primary care documentation. Due to Patient-Centered Medical Home (PCMH) work, the organization has experienced improvements in documentation, test tracking, and reporting capabilities.
Saranac Lake2Chronic Disease CoachDevelop a program that will provide coaches for individuals with chronic diseases. Coaches will help with ongoing disease education and support. The goal is to keep individuals out of the hospital/emergency department and increase their quality of life by helping them to self-manage their health needs.Adirondack HealthHeidi Bailey[email protected]North Country Healthy Heart NetworkWellness coaches are trained in motivational interviewing techniques. They are leading the next National Diabetes Prevention Program (NDPP) in Spring 2020. Adirondack Health has received accreditation from the Centers for Disease Control and Prevention for this program. They are working toward implementing the national "Baby & Me Tobacco Free" program with the support of the North Country Healthy Heart Network, addressing the NYS Prevention Agenda priority areas of Promoting Healthy Women, Infants and Children and Preventing Chronic Disease. Tobacco treatment specialists have received training and are working toward certification. They are working with the employee wellness program to offer services that incentivize Adirondack Health employees to lose weight/quit smoking.
Saranac Lake2Patient NavigatorsSupport two Patient Navigator positions in the emergency department with the goal of reducing visits. Navigators will serve as advocates and liaisons for the patients and their needed services.Adirondack HealthHeidi Bailey[email protected]ED navigators are busy making referrals for high-utilizers (HU) to address individuals' access to care, lack of a primary care provider, transportation, etc. Efforts have resulted in a sharp decrease in ED visits for super HUs (those with 12 or more visits within a 12-month period).
Saranac Lake2Heart Failure Education ProgramBuild an inpatient educational program that is guideline-based around the "self-management" needs of a patient who has chronic heart failure. The program will also provide ongoing outpatient support and follow up on these patients with the goal of decreasing emergency department visits and hospital admissions for this patient population.Adirondack HealthHeidi Bailey[email protected]Adirondack Health has seen a sharp decrease in the number of chronic heart failure patients visiting the ED. Patient compliance and access to care are a big focus of the initiative.
Glens Falls3Farmacy ProgramConduct a preventive care engagement study to address diabetes and food insecurity through a produce prescription and education program.Hudson Headwaters Health NetworkTrip Shannon[email protected]Comfort Food CommunityFarmacy services launched in mid-March 2019 at several Hudson Headwaters Health Network sites.
Glens Falls1Lean TrainingTrain staff in three key partner organizations on rapid cycle change with a focus on decreasing readmission rates in the area.Hudson Headwaters Health NetworkTrip Shannon[email protected]Glens Falls Hospital, Fort Hudson Health SystemAll Lean events have been executed.The organizations will continue to evaluate the results of PPR from SNF. They are in the process of expanding to other local SNFs.
Glens Falls2Value-Based and Sustainable Palliative Hospice ProgramEvaluate options for the growth and sustainability of hospice in the area.Hudson Headwaters Health NetworkTrip Shannon[email protected]High Peaks Hospice
Glens Falls2Population Health Data ManagementExplore the next generation of population health data analytics to adequately evaluate effectiveness of improvement initiatives and identity areas of potential opportunities.Hudson Headwaters Health NetworkTrip Shannon[email protected]Configuration and data transformation occurred. Daily files are sent from the electronic medical record data warehouse to CHS and CHS, in turn, prepares the data to populate the Wellscore tool. Training was provided to key Hudson Headwaters staff, including care managers, on the Wellscore reporting portal. Staff validated output and made recommendations on the weights/values incorporated into the configuration of the tool. The tool has been incorporated into the care management workflow and reports are used to drive focused interventions.
Plattsburgh4Essex County Transportation CollaborativeTransportation 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.Mental Health Association in Essex CountyValerie Ainsworth[email protected]Essex County Department of Public Works, Essex County Mental Health Clinic, ACAP, Essex County Office for the Aging, Homeward Bound Adirondacks, Community Services Board
Plattsburgh2Wellness Transformation Grant (WHAM)Increase the organization's ability to improve nutrition and exercise-based knowledge through various sources and partnerships.Behavioral Health Services NorthWade Sullivan[email protected]WHAM peer support training was held at BHSN. The organization has contracted with Cornell Cooperative Extension for their PT nutritionist to meet with their clients. They are working with the YMCA to explore technical assistance provision. WHAM has been incorporated into its Healthy Body, Healthy Minds module. The program continues to expand its WHAM services.
Saranac Lake3CHESS AppImplement and utilize the CHESS app to support residents throughout their treatment and aftercare regimen.St. Joseph's Addiction Treatment & Recovery CenterZachary Randolph[email protected]The organization finalized an eRecovery workflow and system configuration for specialty and outpatient programs, completed champion and on-site training for specialty programs, finalized a train-the-trainer plan for outpatient rollout, and completed on-site go-lives for Joe's House, Rose Hill, and the Veteran's program, and later Saranac Lake/Tupper Lake OPC. They are engaging referral partners interested in using the application. They identified an ongoing adoption plan and base metrics to be reviewed between CHESS and St. Joseph's. On-site demos for eIntervention were held with multiple referring partners. The organization is preparing to implement the application in Permanent-Supportive Housing Programs by Q1 2020.
St. Lawrence2Transition of Care CoordinatorEnable the hiring of a new Transition of Care Coordinator, which was identified during a Medicaid Accelerated eXchange New York (MAXny) Series workshop as a crucial component of reducing preventable emergency department visits.St. Lawrence Health SystemApril Grant[email protected]The transition of care coordinator has been working one-on-one with patients to assist them with establishing a connection with a primary care provider, or connecting them with a representative who can assist them with securing health insurance. The coordinator helps to identify whether a patient meets the criteria for home health services, a referral to Health Home for care management services. The coordinator averages between 20-25 patients monthly. She has a list of high-utilizers that she follows and shares with the Gouverneur Hospital ER.
Fulton3Inpatient and ED Discharge Take-Home Meal ProgramTake-home meals will be distributed to patients in an effort to reduce readmissions and revisits.Nathan Littauer Hospital & Nursing HomeGeoffrey Peck[email protected]Johnstown Area Volunteer Ambulance Corp (JAVAC)Nutrition is working on menus. They are waiting for final quotes to order equipment.
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