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Direct Care Management Team

Meet the Direct Care Management Team

Helping those most in need is what we do. 

The GRHHN Direct Care Management (DCM) team play a vital role in our effort to improve care among the most vulnerable population in our community. A DCM team member:

  • Manages the needs of clients with high risk or complex medical and behavioral health needs through community and home-based visits as well as telephone support.
  • Links clients to appropriate community resources and refers them to appropriate care services.
  • Supports client self-management and communicates with providers to reduce barriers and improve health care outcomes.

Our DCM Team can assist agencies with outreach, enrollment or care management in ways that best suit the needs of each agency. We have the flexibility to embed a DCM or Outreach Worker at a facility to assist with outreach. 

What Sets Us Apart?

As a lead health home, GRHHN is responsible for managing and supporting a network of 22 Care Management Agencies in Monroe County. By supporting our own DCM Team, GRHHN offers a wide range of flexible services to both community organizations and primary care offices.
GRHHN was established in 2012 and has close connections and support from community-based providers throughout Monroe County. In 2018 Finger Lakes Performing Provider System (FLPPS) acquired GRHHN. FLPPS is a partnership comprised of 19 hospitals, 6,700 healthcare providers and more than 600 healthcare and community-based organizations in a 13-county region.

GRHHN was established in 2012 and has close connections and support from community-based providers throughout Monroe County.

In 2018 Finger Lakes Performing Provider System (FLPPS) acquired GRHHN. FLPPS is a partnership comprised of 19 hospitals, 6,700 healthcare providers and more than 600 healthcare and community-based organizations in a 13-county region.

Analytics and claims data from FLPPS enables GRHHN to offer detailed lists of patients to primary care and community organizations. They can use this data to identify those most at risk and GRHHN can assist with outreach and care. 

This results in increased continuity of care, reduced system costs, improved outcomes, and reduced burdens in Emergency Departments. 

Success Stories Are Coming Soon!

Direct Care Management Team Contacts

NameTitlePhoneEmail
Hani AliHealth Home Care Manager585-239-9366hani_ali@flpps.org
Scott AnnechinoHealth Home Care Manager585-239-9360scott_annechino@flpps.org
Naima HassanHealth Home Care Manager585-239-9385Nassan_Hassan@flpps.org
Christine LaBargeHealth Home Care Manager585-239-9386christine_labarge@flpps.org
Tomicka MadisonSenior Manager, Direct Care Management585-239-9356Tomicka_Madison@flpps.org
Erika SaltersOutreach Specialist585- 239-9383Erika_Salters@flpps.org
Kelsey SoloHealth Home Care Manager585-239-9346Kelsey_Solo@flpps.org
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