Innovation Fund

2018 Innovation Fund: A Call for Collaboration

Innovation Award Program Overview

  • Purpose & Goal: As part of the evolution towards a value-based payment environment, Alliance for Better Health is launching a $4.6 million Innovation Award program on May 1, 2018. This program will support Alliance partners in designing and implementing innovative programs to improve the health of the patients and clients we serve and reduce avoidable use of the health care system
  • Encouraged components: In the spirit of the DSRIP program, Alliance strongly encourages collaboration among partners and a focus on social determinants of health
  • Eligibility: All partners with a signed Master Services Agreement (MSA) as of January 1, 2018 are eligible to submit as the lead applicant

Program Objectives

  • Encourage creative approaches towards positively impacting patients, clients, and communities served by Alliance partners.
  • Align partner efforts toward achieving DSRIP performance targets
  • Support collaboration among medical and behavioral health providers/systems and community-based organizations.
  • Address social determinants of health needs
  • Identify and assess programs with potential for significant long term and measurable impact to prepare partners for a value-based payment future

Application Process

  • Application will be live on this page on May 1, 2018
  • Applications are due by June 11, 2018

Selection Process

  • Selection Committee comprised of a multidisciplinary team of Alliance staff
  • Once finalists are selected, Alliance may reach out to the identified point of contact on the application to ask follow-up questions

2017 Innovation Awardees

Organization Activity Innovation funds awarded
Samaritan Hospital Hire a readmissions clinical care coordinator to help prevent avoidable readmissions. $100,000
Katal Center for Health, Equity and Justice Expand the existing Law Enforcement Assisted Diversion (LEAD) project from the City of Albany to Rensselaer and Schenectady counties, to divert eligible offenders to case management as opposed to law enforcement. $69,519
Samaritan Hospital dba Capital Region Health Connections Health Home Hire a staff member to support outreach bedside for Health Home appropriate members and facilitate care transitions for members already enrolled in the Health Home Program. $57,000
Upper Hudson Planned Parenthood Hire two care coordinators to meet with patients needing additional behavioral health services, assess their needs, and connect them to trusted providers in the community. $113,167
Upper Hudson Planned Parenthood Hire a consulting firm to integrate new telemedicine technology with UHPP’s electronic medical record. $9,250
Unity House of Troy, Inc. Create a short-term behavioral health crisis/hospital diversion residence with 6-8 beds to serve individuals aged 18 and older diagnosed with a mental illness. $125,680
Community Health Center Expand the provision of tele-monitoring services for at-risk and high-utilizing patients in Fulton and Montgomery counties. $122,166
Ellis Hospital’s Asthma Education Program Hire a Community Health Worker intern and Respiratory Therapist/Certified Asthma Educator to support a school-based asthma program pilot with 3 elementary schools in the Schenectady City School District. $26,730
Catholic Charities Care Coordination Services Develop a person-centered single point of access in Schenectady County and Rensselaer County, modeled after Project Safe Point's existing Health HUB, for people who use drugs, are chronically homeless, struggle with issues related to poverty and/or issues related to mental illness. $350,000
Interfaith Partnership for the Homeless Support IPH’s Drop-In Center, Health and Wellness, Safe Haven in providing a safe setting where homeless individuals can access services that meet their basic needs. $181,937
Bethesda House Hire social workers and intensive case managers for an overnight emergency shelter. $232,310
Hometown Health Centers Purchase Vitalograph Aerosol Inhalation Monitor (AIM) to assist patients in training to appropriately use their inhaler. $4,800
Schenectady Works, The City Mission of Schenectady Expand its geographical service area for patient outreach, engagement and care coordination, connecting patients to services throughout the community. $350,000
Trinity Alliance Creation of a neighborhood hub located in the West Hill and South End neighborhoods of Albany to provide services through the Wellness Engagement Activation Resource Centers and the Refugee Community Health Partnership Program. $466,348
Albany Family Medicine Residency Hire a full time mental health provider for one year to diagnose depression and anxiety through screening tools, triage and coordinate referrals for patients with a mental health diagnosis, provide short term counseling, follow-up with patients with mental health diagnosis from hospital admissions and emergency department visits, and coordinate with pharmacists to promote medication adherence. $80,000
St. Mary's Amsterdam Hire a full time mental health provider for one year. $80,000
St. Mary's Amsterdam A digital media campaign that targets health care providers and one that targets Lower income/Medicaid recipients who smoke with a goal that they will quit. Digital marketing programs utilize the best platform and tactics to promote messages in primary market areas to key demographics through pre-roll video and display ads. $10,000
Planned Parenthood Mohawk Hudson To expand their scope of primary care to include the integration of preventive behavioral health services, preventive substance use services, and a comprehensive care coordination model that addresses the social determinants of health. $344,497
Interfaith Partnership for the Homeless' (IPH) Medical Respite program. Case coordination. The Medical Respite program opened in March 2017 and provides emergency respite shelter to individuals who are homeless and being discharged from inpatient hospitalizations or are homeless and have a recent history of overutilization of emergency departments, hospitals, and other emergency services due to chronic health conditions and/or illnesses. The ten-bed facility, located within St. Mary's Hospital in Troy, NY, provides a setting, accommodations, and intensive case coordination services not offered through traditional shelter facilities. Case coordination services focus on connecting individuals with community-based health care resources that will provide increased health stability and overall improved health. Case Coordinators meet with Medical Respite guests regularly to discuss each guest's unique set of medical needs as well as any needs that have led to and perpetuated their homelessness and inhibited their housing stability. $319,630
New Dimensions in Health Care Registered Nurse Care Coordinator position. $104,578
New Dimensions in Health Care Enhance patient communication for non-English speaking/hearing impaired patients via purchase and use of video interpretation. The implementation of the video interpreting device will allow patients to see an interpreter with the goal to improve care and care management. Additionally, forms used by the clinic will be translated into other languages to improve patient comprehension. $8,950
Healthy Capital District Initiative Employ a Project Coordinator to provide consumer research and engagement services. Targeted consumers include: Non-Initiators: consumers referred to home-based asthma services; initial visit not completed: Partial Participants: consumers dis-engaged after initial visit; no follow-up visit(s) completed. $84,500
Community Health Center (CHC) Educate primary care physicians about the new CHC Interact-like Zone Triage Phone call program. $10,000
Parsons Child and Family Center Expand mobile crisis unit hours. Mobile crisis services stabilize children and adults experiencing behavioral health crises in Albany (children only), Rensselaer, Schenectady, Saratoga, Warren and Washington Counties. These crisis services are currently available between 11:00 a.m. to 9:30 p.m., Monday-Friday. Parsons will expand the service hours to start at 8:00 a.m. on weekdays and 11:00 a.m. to 7:00 p.m. on weekends. This expansion is intended to divert patients from unnecessary hospitalization and keep them safe in the community. The expanded service hours will increase the number of crisis evaluations performed in the community and reduce avoidable ED-based crisis evaluations, with a positive impact on the overall DSRIP metric of reducing preventable ED visits. $343,000
Second Chance Opportunities, Inc. Establish a Recovery Community Center. This is a place where community members can safely go to seek recovery resources and options for themselves or for family and friends that have been impacted by substance use disorders. Second Chance will provide recovery focused programs and services including peer supports, family supports and programs, to promote a life centered on healing and recovery. $293,000
Center for Disability Services Install a Welch Allyn CardioPerfect Software based ECG/Spirometry system. With this device the Center can do Pulmonary function testing in house to treat asthma and COPD patients and no longer have to refer outside the practice, thereby helping patients to be more compliant and to have better outcomes. Also the ECG that work with our EMR GE Centricity. $7,252
Promesa Inc Camino Nuevo Support an education program for pregnant women and mothers of 0-3 year old toddlers that work with the organization. The program will consist of the following: "The Incredible Years", "Parents & Babies" and the "Toddler" curriculums. Each part is roughly 2 hours worth of curriculum that would be administered over a 2-week session making the Parent and Babies program a 12 week series and the Toddler program a 16 week series. The curriculum will be adapted as needed. $5,000
The Albany Damien Center Albany Damien Center will create an adherence support program designed to help persons diagnosed with HIV/AIDS reach HIV Viral Load Suppression. Upon enrollment in Albany Damien Center's "Undetectables" program, each person will be supported so that they are able to keep their primary care physician appointments and take their medications as prescribed. Each enrollee will be paid $25 per month that they have an undetectable HIV viral load. They will also receive personalized support to help with their treatment adherence. This will include a legal check up (performed by Legal Aid), medication adherence support (provided by specialty pharmacies), housing, nutrition, employment training, & social support (provided by Damien Center programming). $108,345
Marras Pharmacy Marras Pharmacy will reduce the number of potentially preventable hospital readmissions of identified high utilizers and also improve asthma medication adherence. Reduction of readmission will occur through a collaborative effort of pharmacy, hospital discharge staff, home health agency, primary care physician, case manager and/or medical home organization. The formation of this bridge program of care will provide discharge medications to the patient, either at the pharmacy or via home delivery, within 24 hours of discharge. $68,500
Four Corners Pharmacy Four Corners Pharmacy will reduce the number of potentially preventable hospital readmissions of identified high utilizers and also improve asthma medication adherence. Reduction of readmission will occur through a collaborative effort of pharmacy, hospital discharge staff, home health agency, primary care physician, case manager and/or medical home organization. The formation of this bridge program of care will provide discharge medications to the patient, either at the pharmacy or via home delivery, within 24 hours of discharge. $68,500
Catholic Charities, Tri-County Services Tri-County Services is a safety net for the targeted Medicaid population whose socioeconomic and psychosocial needs often are barriers to accessing health care. This project will implement the hiring, training, and placement of two (2) Case Managers. Staff will increase access to primary care, prevent high utilization of emergency room services and reduce unnecessary hospital admissions within the target population. Case Management services will be provided throughout our service area in Rensselaer and Albany Counties. Expanded case management has the potential to broaden service availability and provide the opportunity to obtain consents and linkage with providers to the parents and other children. $111,997
Catholic Charities Catholic Charities, Fulton County branch will use this funding to to provide crisis case management and referral services to individuals who had, at one time, been receiving services via the certified mental health community residence program in Fulton County, thereby potentially preventing unnecessary ED and/or inpatient utilization. The connections afforded to these individuals by having been a part of Catholic Charities and the CR program in the past have allowed for them to feel safe to reach out in a time of crisis, as an alternative to going to the ED or engaging in other unsafe behavior. Catholic Charities will use the funds to further establish the efficacy of this service. $9,750
START START will create a meaningful and effective partnership between the Child Advocacy Center, START Team members including Developmental Pediatrics and the SAFE Nurse program. This partnership will enable START to identify children who experience a traumatic event or are diagnosed with a life altering medical condition and provide notification to local schools regarding this concern (with parental permission). The school will be notified that the child’s experience may impact their school functioning and that school personnel should take this into consideration when dealing with the child. The school will be notified before the start of the school day that the child experienced a trauma. The Liaison will then be available to work with the school to put a plan in place to notify essential school personnel and provide a plan to manage the child's reaction, with the goal to provide support instead of consequences. This program would also work for children who receive a diagnosis or have family members who receive a life altering medical diagnosis such as cancer etc. A plan would be provided to connect the child to resources and provide support and education to school personnel regarding the diagnosis. $52,335
Bethesda House Bethesda House will hire a community outreach case manager (COCM) who will work collaboratively with the existing behavioral health team at Bethesda House, in an effort to provide case management services to coordinate care and connect individuals to community resources, primary care, behavioral health and substance abuse services. The COCM will operate under the same policies and procedures as the existing Bethesda House behavioral health team. The community outreach case manager would meet every morning with the existing team to discuss cases and service plans for the day. The COCM will spend most of the day out in the community, providing home visits, counseling and case/care management services to the most vulnerable individuals. The COCM will follow up on individuals the team has not been able to connect and will attempt to re-engage individuals and ensure that their care is managed and coordinated as needed. The COCM will ensure appointments are attended, follow-up appointments are scheduled, and data shared between community providers. Coordination of services in the community and integration of care will be of primary concern. BH staff will make contact with each individual's providers a minimum of two times monthly.. $45,000
Bethesda House A Psychiatric Nurse Practitioner will be available on site with the potential for non-conventional hours. Individuals that are in crisis will have the ability to come in and be seen immediately for evaluation for possible medication adjustment and/or other treatment options as appropriate. The Psychiatric Nurse Practitioner will complete regular medication reviews and an assessment of therapeutic efficacy of medication regime will be completed in order to make changes accordingly. The Psychiatric Nurse Practitioner will be an active member of the treatment team, aware of all aspects the person and services received in order that a holistic approach may be taken to an individual's behavioral health status. The psychiatric nurse practitioner will also work with community providers to ensure oversight of all treatments processes and will institute compliance support protocols. Coordination of services in the community and integration of care will be of primary concern to reduce hospital admissions and prevent potential crises. $111,208
Parsons Child and Family Center Mobile crisis services stabilize children and adults experiencing behavioral health crises in Albany (children only), Rensselaer, Schenectady, Saratoga, Warren and Washington Counties. These crisis services are currently available between 11:00 a.m. to 9:30 p.m., Monday-Friday. Parsons will expand the service hours to start at 8:00 a.m. on weekdays and 11:00 a.m. to 7:00 p.m. on weekends. This expansion is intended to divert patients from unnecessary hospitalization and keep them safe in the community. The expanded service hours will increase the number of crisis evaluations performed in the community and reduce avoidable ED-based crisis evaluations, with a positive impact on the overall DSRIP metric of reducing preventable ED visits. Parsons has well-established working relationships and agreements with the Local Government Units (LGUs) in the service counties as well as the hospital EDs and the state psychiatric hospital, emergency services (police, fire, EMTs), and other community-based organizations that will ensure smooth transitions for patients and provide linkage to services and facilitate cross-system collaboration. $343,000
Community Health Center (CHC) CHC will educate primary care physicians about the new CHC Interact-like Zone Triage Phone call program. Community Health Center (CHC) has implemented the Interact-Like Zone Triage Phone call program for Home Care Staff to PCPs. CHC works efficiently with Hospital Based Primary Care offices, but Fulton and Montgomery counties have a lot of private practice PCPs that need to be engaged in this program. $10,000
Center for Disability Services CDS will install a Welch Allyn CardioPerfect Software based ECG/Spirometry system. With this device the Center can do Pulmonary function testing in house to treat asthma and COPD patients and no longer have to refer outside the practice, thereby helping patients to be more compliant and to have better outcomes. Also the ECG that work with our EMR GE Centricity. This is the same hardware/software and EMR that is used by Saratoga Cardiology. This will support the Center's patients in the long term. $7,252
St. Mary's Healthcare Purchase 3 spirometers and associated supplies and install and use in accordance with guidelines. $10,000
St. Mary's Healthcare Hire two full time employees (example, LPNs) to support two primary care practices with management of patients being treated with suboxone. $100,000
Schenectady County Chapter, NYSARC, Inc. Hire a full-time nurse practitioner at Ridge Health Services, Inc. to provide individuals with intellectual and other developmental disabilities regular access to primary care services that are adapted to their unique and complex needs. $100,000
US Committee for Refugees and Immigrants (USCRI) Create a new Health Literacy program to introduce refugees and immigrants to the U.S. healthcare system and provide them with health literacy education and added support needed to further their health self-sufficiency skills to navigate the complex American healthcare system and be able to better care for their families' healthcare needs. The program will include the skills necessary to decrease avoidable hospital admissions and ER visits, increase use of preventive health care when appropriate and seek behavioral health care when needed. $51,148
SPHP Fund salary of Project Manager to coordinate the SPHP data management and reporting for DSRIP. This role will be trained on the use of SpectraMedix dashboards, as well as how to operationalize DSRIP data in order to develop new interventions. The intent is for this position to be a permanent SPHP employee, with the first year (12 months) funding and focus being exclusively on DSRIP. This role will report to Karen Leblanc, Sr Director for IT at SPHP, with a dotted line reporting to Brianna Brennan at Alliance for Better Health. $120,000
St. Peter's Health Partners Medical Associates Cover the costs of Virtual Visits for the initial trial period of May – July 2018 for Medicaid patients who have been identified as high utilizers. $7,200
Capital Care Pediatrics, Troy Office (Community Care Physicians Group) To implement an ACES pilot and create a model that can be transferred to other practices and gather data to show the effectiveness of the program . This is a pilot to screen for ACEs, address high ACE scores in families and develop community-based response mechanisms. The goal is to see what works and create a model for screening and intervention that can be implemented in other Alliance partner practices. $18,100