Redesigning Medicaid Healthcare Delivery in the Finger Lakes Region
Helping those most in need is what we do
Direct Care Management Team (DCM)
The GRHHN DCM team play a vital role in our effort to improve care among the most vulnerable population in our community. A DCM team member:
Naturally Occurring Care Networks (NOCN)
FLPPS is divided into five geographic sub-regions, termed Naturally Occurring Care Networks (NOCN). These Networks represent the full continuum of care and organizational leadership within a shared geographic service area. Each NOCN is led by a participant workgroup that represents the healthcare providers and community-based organizations in their area.
Your Partner in Training
Supporting Your Training & Certification Needs
Throughout the Finger Lakes Region, FLPPS Partners collectively serve:
UNINSURED INDIVIDUALS
Medicaid Beneficiaries
Throughout the Finger Lakes Region, FLPPS Partners collectively serve:
UNINSURED INDIVIDUALS
Medicaid Beneficiaries
Referrals can also be submitted to GRHHN via fax at 585-978-7714 or sent via secure email to grhhnintake@flpps.org
Patient consent is required (verbal consent is acceptable).
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.
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!
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Changing Lives
Offering Hope
Direct Care Management Team Contacts
| Name | Title | Phone | |
|---|---|---|---|
| Hani Ali | Health Home Care Manager | 585-471-1605 | [email protected] |
| Neena Bhala | Health Home Care Manager | 585-315.6679 | [email protected] |
| Sara Constantine | Health Home Care Manager | 585-721-7339 | [email protected] |
| Jakiyyah Jones | Health Home Care Manager | 585-622-1073 | [email protected] |
| Christine LaBarge | Health Home Care Manager | 585-622-2962 | [email protected] |
| Tomicka Madison-Hall | Senior Manager, Direct Care Management | 585-239-9356 | [email protected] |
| Dominique Miller | Health Home Care Manager | 585-330-5655 | [email protected] |
| Makayla Nicometo | Health Home Care Manager | 585-737-7522 | [email protected] |
| Erika Salters | Outreach Specialist | 585- 622-2904 | [email protected] |
| Kelsey Solo | Health Home Care Manager | 585-622-2786 | [email protected] |
| Dan Uhler | Health Home Care Manager | 585-622-6908 | [email protected] |
| Alyssa Zona | Health Home Care Manager | 585-405-4824 | [email protected] |
