Testing an Integrated Delivery and Financing System for Older Adults with Health and Social Needs

Addressing the social determinants of health is vital to improving individual and population health and advancing health equity. Research indicates that integrating health and social services is both necessary and cost-effective. This is especially true for the growing number of older adults who face increasing risk of multiple chronic health conditions, cognitive decline, and disability. The Community Care Connections program developed by Lifespan of Greater Rochester integrates care navigators and health care coordinators into the workflow and referral systems in health care delivery settings. These coordinators connect patients to resources, guide them across healthcare settings, and serve as their patient care advocates. The study utilizes a mixed-methods approach to assess the health, social, and economic impact of this program and examines these novel inter-organizational partnerships between social services and healthcare sectors. Project partners include New York University, The New York Academy of Medicine, Lifespan of Greater Rochester, the Rochester Regional Health Information Organization, and the University of Rochester Medical Center. The findings will help strengthen existing programs and provide important information about components critical for successful implementation.









Principal Investigators:
José Pagán, PhD
Professor, New York University School of Global Public Health
Chair, Department of Public Health Policy and Management

Lisa Fisher, MPH, MSW
Deputy Director, Population Health and Health Reform, Center for Health Policy and Programs, New York Academy of Medicine

Project Details:
Year: 2017
Funding Amount: $249,785
Status: Inactive

Results and Resources