Patient Activation for Uninsured, Under-insured and Low Utilizers of Health Care

DSRIP Project Title: Implementation of Patient Activation Activities to Engage, Educate and Integrate the Uninsured and Low/Non-Utilizing Medicaid Populations into Community-Based Care (Project 2.d.i.)

Alliance staff contact: Nicole Suissa | 518.318.3110


Engage and educate patients who do not generally seek preventive care services. Connect patients with available primary care to promote overall health and wellness and reduce illness and hospital visits. Empower community based organizations to engage and mobilize their community toward better health outcomes.

Why does the community need this project?

It is important for people in our community to take control of their healthcare. In order to do so, they have to be given the right tools, connections, and encouragement. Patients who are not properly connected to primary care and services are more likely to seek costly and inefficient care at the Emergency Department (ED). Our patients need a coaching community where they can receive education, resources, referrals, and proper connections to services like food pantries, transportation, shelter, prescription payment assistance, and childcare to achieve and maintain better health outcomes.

Project Goal

To connect uninsured and non/low utilizing Medicaid patients to primary care and resources through meaningful and lasting coaching relationships, in order to decrease and prevent the number of times patients visit the emergency department unnecessarily.

Our Plan

  • Partner with community based organizations and healthcare providers to engage patients in the Patient Activation Measure (PAM), a survey tool that assesses self-healthcare awareness and management.
  • Identify areas with large populations of uninsured or low-utilizing individuals and train providers on how to engage patients in preventive care and health management.
  • Coach individuals on why and how to become engaged in their own health, and empower individuals by providing necessary resources and coaching them to manage their health and care.