Connecting Organizations Across the Region

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Funding through Care Compass Network’s IT grant allowed Rural Health Network of South Central New York (RHNSCNY), over the past year, implement the GSI Care Management platform to support the work their Community Health Workers (CHWs) are doing in the community. These CHWs assist people with navigating complex healthcare and social service systems, using a wide variety of evidence-based tools to assess and identify barriers to accessing need resources such as transportation, food, and housing that will help improve their own health and wellbeing, or in a caregiver role, for their family members.

The Care Management platform, a HIPPA compliant web-based system, has the ability to house the evidenced-based assessments being used by the CHWs. RHNSCNY has reconfigured what is referred to as their ‘environment’ by choosing the assessments that fit the needs of their direct service programs, including Community Health Services, Community Health Education, Getthere, and the Fruit and Vegetable Prescription Program.

The Care Management platform “really gives us a good framework to wrap all of our work, collectively, around each person as well as cohorts of patients” shares Pam Guth, Director of Community Health Services at RHNSCNY. “We’ve actually set up different programs based on our funders and we can monitor the populations of the people that fall within those programs. GSI allows us to slice and dice the data.

Intake assessments help identify needs that the client may have and assists in establishing goals and interventions. These assessments will be almost exclusively housed on the Care Management platform specifically created for RHNSCNY. Care Compass Network set up a team of consultants to support Guth and her team during the implementation process. “It’s a lot of building, testing, learning, refining, and reconfiguring. It’s been a huge learning curve,” she says, but in the end is looking forward to how well this will support her team of CHWs. While the Care Management environment was launched at the end of February 2019, it was fall 2018 when RHNSCNY started the build out.

To build the environment, Guth and her team had to sift through the various behavioral health assessments that were available and decide which were the right fit for their work. In doing this, the team took into consideration the approved behavioral health screening tools listed under Care Compass Network’s Project 4aiii, Strengthen Infrastructure Across Mental Health/ Substance Use Programs (Preventions). In the end, the team chose both clinical and nonclinical assessments, including screening tools for mental health, substance use, and physical health, that support the work of the CHWs and enable them to further expand their ability to help their clients.

One of the assessments Guth and her team choose was the Patient Activation Measure (PAM) Pre-Screen. Developed by Insignia Health, this tool can be used to screen uninsured or Medicaid, the individual member themselves, their caregiver (professional or personal), and parents of minors. This evidence-based tool uses 10 questions to provide a baseline level and score on their knowledge, skill, and confidence to be their own health advocate or to have that capacity for someone else. Six months after the first assessment CHWs administer a post-screening with the same set of questions. Guth reports that “even a 1-2 point score increase in the PAM survey equates to all these positive, wonderful outcomes. Less stress, more physical activity, increased consumption of healthier foods, better medication adherence, better communication with their provider and, the ultimate goal, less ER visits and less hospital admissions.”

The PAM screening empowers the individual to give them some ownership over their care but also becomes a conversation starter. RHNSCNY uses the PAM survey to do outreach and engagement, namely reengaging folks who have not been going to their primary care physician. “Our job is to figure out what some of the barriers are,” says Guth. “We use the PAM survey as our conversation starter but it still wasn’t asking other critical questions like food, transportation, housing, and dependent care so we used a variety of resources and our quantitative and qualitative data out of our old database and programs to build those questions in [to the Care Management Platform].

In total, the needs assessment is 47 questions that collectively takes 7-10 minutes to complete. “The beauty is my team can do the assessment, even on paper, and once they enter it into the system, the system scores it for them. And then it auto populates some of the client’s needs, whether its social determinants or clinical needs which then would help them write some standard language for the goals and interventions,” states Guth. The CHW starts by introducing goals until the client is engaged and creating goals for themselves.

RHNSCNY is now working to build a stronger workforce that are trained in these tools. The CHW training has been based around this evidence-based toolkit. Guth utilizes the free trainings that Care Compass Network offer, including SBIRT, Motivational Interviewing, and Mental Health First Aid trainings. “When we can use tools like this my team can focus on the person and then get the questions answered to meet the guidelines of the evidence-based tool. Our philosophy is that these are just tools, your job is to engage in conversation, try to build that rapport and trust and give them a safe place and space to talk about what their concerns are,” Guth reports.

Overall the use of the Care Management platform and Patient Care Plan helps the language and workflow become standardized, allowing other partners, such as hospital systems and safety net providers, to input data so there can be a bigger picture of health for both the individual person and specific populations of patients/ clients. As Guth relates, “this standardizes the care plan but puts the person at the center of the plan, putting the person first.”

If you are interested in learning more about Care Compass Network’s Care Management Platform and how you can become involved, please contact the CCN IT Department at (607) 240-2545 or email at