More Than $3.9 Million Awarded to North Country Organizations for Innovative Health Care Projects

More than $3.9 million has been awarded by the AHI Performing Provider System (AHI PPS) to ten partner organizations to undertake innovative health care projects in the North Country. Innovation Grant 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.

“All 14 of the awarded Innovation Grant projects align with the overarching DSRIP goal of population health and an integrated delivery system,” said Margaret M. Vosburgh, CEO, Adirondack Health Institute. “In addition, many of these initiatives will lead to a decrease in avoidable hospital readmissions.”

Many of the awards focus on improving behavioral health outcomes through a wide range of initiatives, including integrating behavioral health services directly into St. Lawrence Health System’s Potsdam primary care clinic; increasing the availability of psychiatric providers via telepsychiatry in the Glens Falls region; and implementing a mobile crisis team in Plattsburgh.

An innovative program being led by United Helper’s MOSAIC team in St. Lawrence County, will provide more comprehensive behavioral health services to children through an integrated community-based solution modeled after The New York State Office of Mental Health’s (OMH) Assertive Community Treatment (ACT) model. “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,” said Michele Montroy, MOSAIC Administrator.

Additional initiatives being funded through AHI’s Innovation Fund program include a comprehensive program to improve the accuracy of diagnosis and quality of life for Chronic Obstructive Pulmonary Disease (COPD) patients; the integration of palliative care services into home health; the implementation of open-access scheduling, a patient-center process whereby individuals are seen on the day they call for an appointment regardless of the reason for their visit; expanding health promotion and coaching interventions; and training of staff members at three Glens Falls-region partner organizations on LEAN methodologies so they can execute rapid cycle change with a focus on decreasing readmission rates in the area. “Implementing LEAN principles and processes is the cornerstone of our collaborative efforts to fundamentally transform the Medicaid system,” said Margaret M. Vosburgh, CEO, Adirondack Health Institute. “In order to attain DSRIP goals of significantly reducing emergency room utilization, unnecessary hospital readmissions, and other program metrics, improving efficiencies is required and introducing to our partners and implementing LEAN concepts is, without question, one of the keys to our success.

“We received applications from 25 partner organizations, each with compelling proposals and novel project concepts,” explained Vosburgh. “Each application was thoroughly reviewed by Population Health Network (PHN) leaders in the five regions we cover (Glens Falls, Plattsburgh, Saranac Lake/Essex County, Fulton County, and St. Lawrence County), along with the AHI executive team and an independent assessor. With so many worthy proposals, it was extremely difficult for the committee to narrow the list and select the awardees.” Vosburgh went on to explain that a second round of funding will be made available to partners in the future with an emphasis on projects that will drive success and sustainability for health care reform.

Findings and lessons learned from these initiatives will be shared across the AHI PPS so that successes can be replicated in other regions. “It is anticipated that these Innovation Grant projects will substantially improve population health in their respective communities, as well as create a blueprint for innovation across the entire PPS service area,” stated Vosburgh.

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. Up to $6.42 billion dollars are allocated statewide to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health. For more information, visit

Innovation Grant funding was awarded to organizations for the following projects:

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Grant Title,Organization,Impact of Award

Concurrent Care Project (CCP),Hospice & Palliative Care of St. Lawrence Valley,Decrease emergency department visits and hospitalizations of Medicaid patients by functionally integrating home health and palliative care services.,

Riverledge and Maplewood Campuses Integrated Delivery System (IDS) of Health Management,United Helpers – Riverledge and Maplewood,Improve the clinical diagnostic capabilities of each campus to stabilize the health of our residents and prevent unnecessary hospitalizations and outpatient visits.,

Canton Enriched Housing (CEH),St. Lawrence Health System,The 25 residents of CEH are heavy utilizers of the emergency department. The addition of a mid-level provider to round on these patients will allow preventative measures to reduce unnecessary emergency department visits.,

MOSAIC Integrated Delivery System (IDS) and Strong Mental Health Infrastructure for Children,United Helpers – MOSAIC,A collaborative approach between families and schools to provide 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.,

Chronic Obstructive Pulmonary Disease (COPD),St. Lawrence Health System,A comprehensive approach to the accurate identification of COPD patients and post-acute coordination to prevent readmissions and improve patient quality of life.,

Wellness and Prevention Services,St. Lawrence Health System,Integrate behavioral health services in SLHS’s Potsdam Primary Care clinic\, a certified Patient-centered Medical Home (PCMH)\, to improve behavioral health outcomes.,

Telepsychiatry,Glens Falls Hospital,Increase access to psychiatric providers to better meet the needs of the greater Glens Falls Region Population Health Network (PHN).,

Crisis Intervention Center,Glens Falls Hospital,Support 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.,

LEAN Training for Glens Falls Hospital\, Hudson Headwaters Health Network and Fort Hudson Health System,Hudson Headwaters Health Network,Train staff in three key Population Health Network (PHN) partner organizations on rapid cycle change with a focus on decreasing readmission rates in the area.,

Open Access Implementation,Warren-Washington Association for Mental Health,Improve the availability of treatment for mental illness by improving utilization and allowing open access scheduling\, a patient-focused scheduling methodology.,

County-wide Telehealth Initiative,Fulton County Public Health Department,Expand the current telehealth project in Fulton County for increased access to care and integration throughout the county by leveraging and expanding technology. Focus on reducing emergency department visits by 25 percent among the population participating in the project\, as well as reducing re-hospitalizations by 25 percent in Fulton County.,

Project “InSHAPE” (Self Health Action Plan for Empowerment),Citizen Advocates,Health promotion and coaching interventions in the areas of nutrition\, fitness\, social inclusion\, and community engagement\, targeting those with serious mental illness and high-risk health metrics.,

Mobile Crisis Team,Behavioral Health Services North,Stabilize and improve psychological symptoms of distress and engage individuals in person-centered treatment to ameliorate problems that may lead to a crisis.,

Pathway Home Project,The Open Door Mission,Expand the organization’s new location to include a training room\, day room\, resource and learning center\, and health clinic. This will have a direct\, positive impact on the social determinants of health in the community\, which is the single most significant factor in improving population health.

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