1. 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

2. Outline Formal Request for Information (RFI) Process
Community Health Worker (CHW)
Logistics

3. 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

4. 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

5. 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

6. 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

7. 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

8. Logistics Referrals Client Plans
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