Adirondack Health Institute (AHI), in collaboration with numerous community, social service, public sector, and health care provider organizations, launched ADK Wellness Connections last fall to address unmet social and health-related needs for people in the region. Officials say early results are positive.
“ADK Wellness Connections is working as planned to make it easier for community members to access what they need to keep themselves and their families healthy,” said Jessica Chanese, AHI community engagement manager.
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 available in their designated region. Each coordination center is responsible for coordinating referrals that come from both network partners and individual community members.
Family Service Association of Glens Falls, Inc. is the coordination center for Hamilton, Fulton, Warren, Washington and Northern Saratoga counties. Kim Sopsyzck, executive director of Family Service Association, said her team has “referred many clients in need of services, including transportation, childcare, housing, and mental health services. These referrals are being answered promptly by partners who have services to help with their specific need and the experience has been positive for our clients.”
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. 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.
Officials said in its first three months, the ADK Wellness Connections network has recruited 63 partner organizations with 91 service sites in Clinton, Essex, Franklin, Fulton, Hamilton, Saratoga, St. Lawrence, Warren, and Washington counties.
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 for a combined total of 180 network partners. Alliance for Better Health currently serves Albany, Fulton, Montgomery, Rensselaer, Saratoga, and Schenectady counties, expanding the combined network reach to a 13-county region.
ADK Wellness Connections is part of a larger effort to increase collaboration and interoperability between clinical and social service providers, under the state Department of Health 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.
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.
For more information, visit ADKWellnessConnections.org.
