Support for Care Coordination Teams
IAN GRANT, MPH, CPH
POPULATION HEALTH PROGRAM MANAGER
FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION
Care Coordination Collaborative | May 18, 2017
Outline

Formal Request for Information (RFI) Process

Community Health Worker (CHW)

Logistics
RFI Process

The PPS released two Requests for Information (RFIs) on November 4, 2016

Each RFI was developed to support community needs and existing DSRIP
project deliverables:


Request for Information – Community Health Worker / Patient Navigator

Request for Information – Behavioral Health Peer Support
Closing date for submitting a proposal for each RFI was December 2, 2016
RFI Criteria (summary)

Offeror must:



CHW RFI

have documented experience providing both Community Health Worker and
Patient/Insurance Navigation services

have a service area that encompasses all three counties (Jefferson, St.
Lawrence, and Lewis Counties) in the Tug Hill Seaway Region
BH Peer Support RFI

have documented experience providing Behavioral Health Peer Support
Services

have the ability to collaborate with organizations across the tri-county region
have experience providing Patient Activation Measure (PAM) services
Community Health Worker

A frontline worker who is a trusted member of and/or has an unusually close
understanding of the community served

Based on trusting relationship, CHWs:

Serve as a link between health/social services and the community

Facilitate access to services

Support improvement in the quality and cultural competence of service delivery

Build individual and community capacity

By increasing health knowledge and self-sufficiency through outreach, community education,
informal counseling, social support and advocacy.
American Public Health Association 2017
PPS Partner Resources
Community Health Workers, Patient/Insurance Navigators
• Administer PAM and coach clients to improve patient activation
• Coordinate client access to care across multiple settings
• Connect clients to evidence-based prevention programs
• Ensure uninsured clients receive insurance navigation
Behavioral Health Peer Supports
• Serve as CHWs/Navigators with their peer population
• Serve as liaison between health/social services and their
community/peers
PPS Partner Resources
Community Health Workers,
Patient/Insurance Navigators
• North Country Prenatal/Perinatal Council
(NCPPC)
Behavioral Health Peer Supports
• Northern Regional Center for Independent Living
Logistics


Referrals

Both NCPPC and NRCIL have a single point of entry for all referrals

Referral forms are being finalized (NCPPC) or are already distributed (NRCIL)
Client Plans

NCPPC: individual wellness plan

NRCIL: independent living plan