Nearly $5.2 Million Awarded to 27 North Country Organizations for Innovative and Transformative Health Care Projects

Nearly $5.2 million has been awarded by the AHI Performing Provider System (AHI PPS) to partner organizations in nine North Country New York counties to undertake innovative and transformative health care projects. Innovation and Transformation funding, two parts of the state’s Delivery System Reform Incentive Payment (DSRIP) Program’s efforts to fundamentally restructure the Medicaid system, will support the implementation of 37 progressive projects involving 27 organizations in Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren and Washington counties.

“Each of the awarded Innovation and Transformation projects in the Glens Falls region align with the overarching DSRIP goal of improving population health and creating an integrated delivery system,” said Eric Burton, CEO, Adirondack Health Institute.

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

Innovation and Transformation funding was provided to organizations for the following projects:

Grant Title


Impact of Award

Value-Based and Sustainable Palliative Hospice Program Hudson Headwaters Health Network Evaluate options for the growth and sustainability of hospice in our area.
Population Health Data Management Hudson Headwaters Health Network Explore the next generation of population health data analytics to adequately evaluate the effectiveness of improvement initiatives and identify areas of potential opportunities.
Arista MD-eConsult Test Case Hudson Headwaters Health Network A physician-to-physician consulting service to assist in determining if specialty care is needed so a primary care provider can manage the patient’s care with a formal referral.
Diabetic Retinopathy Project Hudson Headwaters Health Network Diabetic retinal screening in the primary care provider office using special equipment that sends the test results to an ophthalmologist for evaluation.
4.a.iii Funding Continuation Council for Prevention Continued funding of the organization’s Care Navigator position.
Hope and Healing Recovery Community Outreach Center Staffing Council for Prevention Increase staffing in the Hope and Healing Recovery Center to bridge the increased hours and services while they wait for funding from OASAS next year.
Mobile Substance Abuse Counselor 820 River Street Funding this position will increase substance use services to the Warren and Washington County communities.
Provider Engagement Project Glens Falls Hospital Improve engagement and organization of the primary care network at the hospital.
Peer Transition Wellness Team Projects to Empower and Organize the Psychiatrically Labeled (PEOPLe, Inc.) with Glens Falls Hospital (GFH) PEOPLe, Inc., a peer support service organization, is partnering with GFH to assist in improving the warm handoff from inpatient psychiatric services to the community.
LPN Project Warren-Washington Association for Mental Health Expand health services in the housing and programs WWAMH offers. This will assist patients in improving engagement and understanding of their chronic medical conditions.
East Side Center After Hours Program Warren-Washington Association for Mental Health Expand hours at the East Side Center, a supportive community program.
Continuation of Patient Navigation Services Planned Parenthood Mohawk Hudson Continuation of funding for the Patient Navigator position.
Value-Based Payment and Personal Care Home Assistants Fort Hudson Home Care Training for home health aides to assist in understanding population health and the value-based payment (VBP) system.
Patient Coaching and Continuation of PAM® Services Alliance for Positive Health Continuation of funding for patient coaching services.
Emergency Food Access Project Comfort Food Community of Washington County Initiate new programs to advance DSRIP and support emergency food access activities.
Continuation of the Community Check Program of the Mobile Health Care System Cambridge Valley Rescue Squad Community Check program uses EMS and rescue staff to visit select patients in their home for additional support. Patients are referred by their primary care physician.
Addiction-Related Treatment Services Listing The Alcohol and Substance Abuse Prevention Council of Saratoga County Create an accessible, accurate regional listing of all addiction-related treatment services in the Southern Adirondack/Capital region. This listing will include insurance information for each agency.
Pathway Home Project Open Door Mission Support 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.
Coaching and Navigation Services for Fulton and Hamilton Counties Nathan Littauer Hospital & Nursing Home and The Family Counseling Center This new collaborative effort of the FCC and NLH will expand community navigation resources in the region for the next two years.
Transportation Project The Family Counseling Center Funding will be used to purchase 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.
Building Renovations The Family Counseling Center Minor building renovations will transform existing space into two primary care rooms.
Emergency Department High Utilizers University of Vermont Health Network-Champlain Valley Physicians Hospital Medical Home Support emergency department high utilizers to obtain/sustain independent functioning in the community.
Data Output Exchange University of Vermont Health Network-Champlain Valley Physicians Hospital Medical Home Creation of data output exchange by way of Care Navigator and GSI Health.
Community Liaison Position Hospice of the North Country Develop the new position of Community Liaison to educate health care providers and the community on end-of-life decisions and planning.
Pediatric Obesity Project Mountain View Pediatrics To decrease the rate of obesity in the pediatric population by integrating a Nutritionist, Social Worker, and possibly an Exercise Physiologist into the Food Security Project.
School-Based Case Managers Behavioral Health Services North Support two school-based Case Managers.
Wellness Transformation Grant (WHAM) Behavioral Health Services North To increase the organization’s ability to improve nutrition and exercise-based knowledge through various sources and possible partnerships.
Telecounseling Clinton County Mental Health and Addiction Services Pilot telecounseling program for outpatient behavioral health settings.
Exercise Physiologist Plattsburgh Primary Care Pediatrics Add a Registered Exercise Physiologist to the team of providers.
Primary Care Application Planned Parenthood of the North Country NY Serve 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.
Patient Coaching and Navigation – PAM® Improvement Clinton County Office for the Aging Provide 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.
Chronic Disease Coach Adirondack Health Develop 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.
Patient Navigators Adirondack Health To support 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.
Heart Failure Education Program Adirondack Health Build an inpatient educational program that is guideline-based around the “self-management” needs of a patient that 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.
Navigation and Engagement Mental Health Association of Franklin County d/b/a Community Connections of Franklin County Utilize Peer Navigators in the emergency department of UVMHN – Alice Hyde Medical Center and Franklin County Department of Social Services to further develop and maintain engagement of identified individuals that need ongoing support to assure their continued health and wellbeing.
Transition of Care Coordinator St. Lawrence Health System (Gouverneur Hospital) Enables the hiring of a new Transition of Care Coordinator, which was identified during a recent Medicaid Accelerated eXchange New York (MAXny) Series workshop as a crucial component of reducing preventable emergency department visits.
COPD Population Health Project United Helpers, Inc. Funded 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 workflow for the RRT to implement COPD protocols into the sub-acute pathway.

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 the New York State Department of Health website.

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