Innovative Resource Navigation and Referral Coordination Network, ADK Wellness Connections, Launches

Adirondack Health Institute (AHI), in collaboration with numerous community, social service, public sector, and health care provider organizations, has launched ADK Wellness Connections, a powerful, centrally-connected resource navigation and referral coordination network. ADK Wellness Connections aims to improve access to care and services to address unmet social and health-related needs for individuals and families in the greater Adirondack region. ADK Wellness Connections is part of a larger effort to increase collaboration and interoperability between clinical and social service providers, under the New York State Department of Health (NYS DOH) Delivery System Reform Incentive Payment (DSRIP) Program. A five-year program beginning in 2015, DSRIP was intended to transform care delivery to individuals who receive Medicaid with the goals of reducing avoidable hospital use, increasing access to primary and preventative care, and improving population health outcomes. Addressing social factors that impact health outcomes, such as housing, transportation, and access to nutritious food, has proven to be a key consideration in DSRIP initiatives.

ADK Wellness Connections utilizes Unite Us, a secure, HIPAA-compliant software platform, to support referral coordination, resource navigation, and the collection of social determinants of health outcomes data among network partners in Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren, and Washington counties. Network provider partners, from food pantry staff to hospital personnel, can communicate more effectively and efficiently around the care of a shared client, making it easier for that individual to get connected to what they need, when they need it.

“This new platform promises to be a real game-changer for our region, giving clinical and non-clinical service providers the ability to collaborate and share information in a much more coordinated, accountable, efficient manner,” stated Eric Burton, CEO, Adirondack Health Institute. “If we are going to truly address the social determinants of health and improve outcomes, a robust network of this sort will play a vital role in our success.”

ADK Wellness Connections’ network model allows for direct provider-to-provider referrals, while also offering referral facilitation through three regional Coordination Centers. Coordination Centers are assigned a service area to cover and are run by local community-based organizations familiar with the resources and services available in their designated region. Each Coordination Center is responsible for coordinating referrals that come from both network partners and individual community members. Community members can request assistance with connecting to service providers through a self-referral process on the ADK Wellness Connections website, or they can utilize the network’s resource locator to find services in their area. While a primary goal of the network is to increase access and improve health outcomes for individuals who receive Medicaid or are uninsured, there are no restrictions on who can receive referral coordination services within the network.

“ADK Wellness Connections links individuals in our region to services across a full continuum of care, addressing both social and medical needs,” said Jessica Chanese, Community Engagement Manager, Adirondack Health Institute. “It will make it easier for community members to access what they need to keep themselves and their families healthy. AHI and its partners are excited to bring this invaluable resource to our region.”

In addition, AHI is partnering with neighboring Performing Provider System (PPS), the Alliance for Better Health, to link their Unite Us-based network, Healthy Together, with ADK Wellness Connections. The Alliance for Better Health currently serves Albany, Fulton, Montgomery, Rensselaer, Saratoga, and Schenectady counties, expanding the combined network reach to a 13-county region. “The community referral network created by the collaboration between ADK Wellness Connections and Healthy Together allows network providers and individuals seeking services to have full access to both networks’ resources,” explained Kristen Scholl, Vice President, Population Health Programs, Alliance for Better Health. “This partnership will improve continuity of care and create a better user experience for both network providers and the population we serve.”

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