DSRIP Innovation Funds

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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)
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]
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]
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]
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]
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 Center
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]
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 Campuses
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 Country
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]
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]
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]
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]
Glens Falls2Provider Engagement ProjectImprove engagement and organization of the primary care network at the hospital.Glens Falls HospitalCathleen Traver[email protected].org
Glens Falls1TelepsychiatryIncrease access to psychiatric providers, via telepsychiatry, to better meet the needs of individuals in the region.Glens Falls HospitalCathleen Traver[email protected]
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]
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 Center
Plattsburgh2Patient Coaching for Navigation 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 AgingDarleen Collins[email protected]
Glens Falls2Emergency Food Access ProjectInitiate new programs to advance DSRIP and support emergency food access activities.Comfort Food CommunityDevin Bulger[email protected]
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 AdvocatesDonna Studlack[email protected]
Plattsburgh2School-Based Case ManagersSupport two school-based Case Managers.Behavioral Health Services NorthElizabeth Cole[email protected]
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]
Fulton2Coaching and Navigation ServicesExpand community navigation resources in the region.Nathan Littauer Hospital & Nursing HomeGeoffrey Peck[email protected]The Family Counseling Center
Fulton3Inpatient and ED Discharge Take-Home Meal ProgramTake-home meals will be distributed to patients in an effort to prevent readmissions and revisits.Nathan Littauer Hospital & Nursing HomeGeoffrey Peck[email protected]Johnstown Area Volunteer Ambulance Corp (JAVAC)
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 Care
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 Region
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]
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 Health
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 Transit
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 Prevention
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 North
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]
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]
Glens Falls2Patient Navigation ServicesContinue funding for the Patient Navigator position.Planned Parenthood Mohawk HudsonKim Atkins[email protected]
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]
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]
Plattsburgh2Exercise PhysiologistAdd a Registered Exercise Physiologist to the team of providers.Plattsburgh Primary Care PediatricsKymberlie Sweenor[email protected]
Glens Falls2Patient Coaching and Patient Activation Measure (PAM) ServicesContinue funding for patient coaching services.Alliance for Positive HealthLaurie Lanphear[email protected]
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 Services
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 Services
Saranac Lake4Mobile Farmer's 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 Charities
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 Transportation
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]
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 Hospital
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 Pediatrics
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]
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 Counties
Fulton2Building RenovationsMinor building renovations will transform existing space into two primary care rooms.The Family Counseling CenterMichael Countryman[email protected]
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]
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]
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]
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 Services
Plattsburgh2Tele-counselingPilot tele-counseling program for outpatient behavioral health settings.Clinton County Mental Health and Addiction ServicesRichelle Gregory[email protected]
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]
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]
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 Pediatrics
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 College
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]
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]
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 Hospital
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]
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 HealthTim Lamay[email protected]North Country Healthy Heart Network
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 HealthTim Lamay[email protected]
Saranac Lake2Heart Failure Education ProgramBuild an inpatient educational program that is guideline-based around the "self-management" needs of a patient who has chronic health 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 HealthTim Lamay[email protected]
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 Community
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 System
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]
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 NorthPaul Ferrari[email protected]
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]
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