DSRIP Projects and Highlights

  • Creating Integrated Delivery Medicine and Population Health Management
  • ED Care Triage: +8,000 connected to Primary Care, lowering ER readmissions.
  • INTERACT Project: 51 Skilled Nursing Facilities throughout the 8 counties of WNY have implemented the Interventions to Reduce Acute Care Transfers program.
  • Hospital/Home Care Collaboration: Certified Home Healthcare Agencies (CHHA) have adopted similar “INTERACT-like” evidence-based care protocols and tools, performed hospitalization tracking and root cause analysis, trained staff on new communication forms and techniques, and rolled out use of enhanced patient and family education materials.
  • Patient Activation Activities to Engage, Educate and Integrate Uninsured/Non-utilizer Populations:
  • Over 91,400 individuals have received a Patient Activation Measure® (PAM®) assessment to identify the motivations to seek health care. Five community-based organizations are collaborating with Primary Care providers and the Medicaid managed care organizations to connect low- and non-utilizers of health care services back to Primary Care.
  • Integration of Primary Care and Behavioral Health
  • The Chautauqua Center in Dunkirk, NY has added staff Behavioral Health professionals.
  • ECMC has launched a rebranded “Primary Care Access Center.”
  • BestSelf has partnered with ECMC to create the “ECMC Behavioral Health Bridger Program” whereby a BestSelf team member serves as the “Bridger.”
  • Niagara Falls Memorial Medical Center has implemented an ED-Based Screening of Behavioral Health Patients and has begun Behavioral Health Home Visits.
  • Behavioral Health Crisis Stabilization Services
  • Achievements include:
  • JustTellOne.org prevention initiative
  • Development and implementation of new Mental Health Triage Tool
  • Supported additional Crisis Intervention Training (CIT) for officers serving “hotspot” zip codes in Erie County

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