Fort Drum Regional Health Planning Organization (FDRHPO) and the North Country Initiative (NCI), a partnership of clinical and community-based organizations serving people in Jefferson, Lewis, and St. Lawrence counties, strategically pinpointed several unmet healthcare needs in the North Country. NCI then awarded grant funding to seven healthcare-related organizations for their projects to address these needs. This unique partnership resulted in successful outcomes that increased access to care, improved quality of care, and directly impacted the health and wellness of patients.
Funded by NCI’s 2023-24 round of “Promising Practices” awards, an initiative developed to support best healthcare practices and test innovative pilots to fill physical, social, and behavioral healthcare needs, NCI strategically invested in three priority areas: preventing and/or managing chronic disease, increasing preventive/primary care, and behavioral health and/or substance use prevention and management. The projects were active from April 2023 through March 2024 and awards were selected by a community review committee.
The seven healthcare-related organizations and their projects included:
ARC Jefferson-St. Lawrence - Reducing Fall Risk of Intellectually/Developmentally Disabled Residents - Provided training to staff, purchased 100 gait belts, 102 slip-resistant mats, 15 wheelchairs, and two sit-to-stand trolleys which resulted in a 13% fall reduction and two new certified balance and fall specialists.
Bolton's Pharmacy - Diabetes Self-Management Education (DSME) & Support Program - Reconfigured space to allow for 10-15 DSME participants; purchased a bariatric weight scale, blood pressure machine, projector, classroom material, and take-home blood pressure monitors; provided participant incentives (gas cards, water bottles) and blood glucose monitoring kits; and created marketing and outreach plans which resulted in Bolton's becoming a Medicare-approved DSMES site with 6 payor contracts pending, 40 patients having Continuous Glucose Monitoring and 4 patients participating in 1:1 DSMES with one experiencing a 1-point A1c decrease.
Credo Community Center (now known as “THRIVE Wellness and Recovery Inc.”) - Targeted Case Management for High-Risk Individuals - Targeted Case Manager (TCM) provided care management & coordination to high-risk patients resulting in 364 completed health-related social needs screenings, TCMs engaged with 482 patients (discharge follow-ups, referrals to clinical & social services), one patient with high volume of ED visits not having any since the engagement, and 2 TCM staff who continue work post-award.
Pediatric Associates of Watertown - Improving Quality of Care in the Pediatric Population - Acquired resources to increase outreach to Managed Medicaid patients due for a well-child visit and overcome the barriers to attending the visit which resulted in 440 well-child visits complete (29% of total Medicaid population).
Pediatric Wellness of NNY (formerly “Watertown Pediatrics”) - New Home for Pediatric Wellness of NNY - Added four new exam rooms, a conference space, providers, an in-house lead and hemoglobin testing machine, a sensory room, interactive toys, and a reading corner which resulted in a 30% patient visit increase, 100% lead screening rate, longer visit time for children who required a nebulizer and in the future they plan to incorporate a mental health counselor and purchase a spirometer and bilirubin blankets.
South Jefferson Rescue Squad - Fall Prevention Program – Engaged with patients at high risk for future falls in Southern Jefferson communities and conducted home inspections; rearranged cords, decluttered walkways, installed mobility equipment/night lights, demonstrated exercises; and connected to services. This resulted in working with 50 people ages 56-94 who have a fall history; 24 group sessions with patients/caregivers; a 38% decrease in 911 fall calls among patients with a history of them, and a 62% decrease for patients who experienced their first fall call during the grant period.
Watertown Urban Mission - Addressing Social Determinants of Health through the CARE Center - Provided/connected under-resourced individuals with services to address social & healthcare needs. This resulted in 457 individuals engaged in the CARE Center, each with social determinant of health screening; 90% who screened positive received referrals for services they otherwise were not aware of; seasonal events and 3 blood drives; and 9 people have become stably housed, have health insurance and SNAP benefits after using the drop-in center in the winter.
“We are honored to have been able to support these seven partner organizations and their projects,” said Erika Flint, NCI Director. “The awardees span a range of health & wellness provider types, including social care, primary care, behavioral health, emergency services, pharmacy, and intellectually/developmentally disabled services. This is a testament to the diversity of services in our region, and to the utility in involving multiple service types in projects that seek to impact health and wellness across populations. These projects demonstrate measurable impacts in those they served, and we look forward to seeing their work continue post-award.”
For more information on NCI visit www.northcountryinitiative.org.
Comments