ResProg Webinar | 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.


  • José Pagán, PhD, Professor, College of Global Public Health, and Chair, Department of Public Health Policy and Management
    New York University
  • Lisa Fisher, MPH, MSW, Deputy Director, Population Health and Health Reform
    Center for Health Policy and Programs, New York Academy of Medicine

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Pagan J, Fisher E