Lead Organization

City Mission of Schenectady

Joint Applicants

Mohawk Ambulance

Hometown Health Centers

Areas Project Intends to Serve



The City Mission of Schenectady, Mohawk Ambulance, and Hometown Health Centers are going to use Mohawk’s in-home access to a large population of Medicaid recipients to environmentally survey homes for potential issues related to social determinants of health. Such issues include safety concerns, such as fall risks, nutrition concerns, hygiene concerns, need for chronic disease self-management education, or medication concerns. Data from Mohawk’s surveys will then be shared with Empower Health, a program of the City Mission, whose coaches will then conduct follow-up visits to address what concerns the surveys found. Furthermore, Hometown Health will help to plan this intervention, specifically by tailoring the environmental survey used by Mohawk Ambulance.

DSRIP Measures Addresses

  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Child
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Re-admissions







Alliance for Better Health

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