Rapid Engagement and Advocacy for Community Health (REACH)

Lead Organization

Trinity Alliance

Joint Applicants

Homeless and Travelers Aid Society (HATAS)

Radix Ecological Sustainability Center

AVilllage…, Inc.

Areas Project Intends to Serve

Capital District

Overview

Rapid Engagement and Advocacy for Community Health (REACH) is a Trinity Alliance initiative born out of the Alliance for Better Health’s 2017 cycle of Innovation Funds. The goal of REACH is to sustainably connect residents of the inner city of Albany to health and wellness supports through addressing social determinants of health (SDoH). This model is predicated on the foundation of health ‘hubs’ that foster a workforce of Community Health Workers and serve as an anchor for community members to recognize and access services. Through lessons learned during the first few months of operation, REACH is transitioning to a Community Health Worker model and is phasing out its Resident Outreach Worker (ROW) role. Training our existing ROWs to fulfill Community Health Worker higher level responsibilities will ensure that REACH achieves maximum impact.

The ultimate trio of REACH’s services include connecting each consumer to a) health insurance, b) a primary medical provider [who is trusted by the consumer and geographically accessible] and c) needed pharmacy supports. REACH’s focus on addressing SDoHs ensures that connection to the ultimate trio is sustainable for the individual (i.e. that the resident will be able to maintain these connections if discharged from REACH).

While REACH seeks to provide a direct, tangible service to the community, more subtly but notably, we will be expanding our collaboration with community partners AVillage and Radix Ecological Sustainability Center (Radix) to cultivate and mobilize the community in the context of enhanced social cohesion and community mobilization.

DSRIP Measures Addressed

  • Asthma
    • Asthma Control Scripts (50%+)
    • Asthma Control Scripts (75%+)
    • Potentially Preventable Admissions – Adolescent Asthma
    • Potentially Preventable Admissions – Pediatric Asthma
  • Preventative Health
    • Primary Care Visit (Age 20-44)
    • Primary Care Visit (Age 45-64)
    • Primary Care Visit (Age 65+)
    • Well Child Visit (Age 1-2)
    • Well Child Visit (Age 2-6)
    • Well Child Visit (Age 7-11)
    • Well Child Visit (Age 12-19)
  • Behavioral Health
    • Antidepressant Medication Management – Acute
    • Antidepressant Medication Management – Continuation
    • Antipsychotic Med Users with Diabetes Screening
    • Cardiovascular Disease Schizophrenics with CVD Monitoring
    • Diabetic Schizophrenics with Diabetes Monitoring
    • Engaged in Substance Abuse Treatment
    • Initiation of Substance Abuse Treatment
    • Discharge with Timely Follow-Up – 7 Days
    • Discharge with Timely Follow-Up – 30 Days
    • Potentially Preventable Emergency Visit
    • Schizophrenics with Antipsychotic Medication Adherence
  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Child
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Re-admissions