Click below to find links to community-based organizations, guides to experts and community resources and tools to help patients get engaged in their health.
Resource Library
Resources that pertain to mental health, mental illness, and substance abuse. Resources include providers and mobile crisis information. Tools include safety assessments.
Examples: PHQ9, county mobile crisis contact information, mental health, mental illness, addictions, New York state
- Community Resources for Rochester and Finger Lakes Region - includes multiple resources, such as mental health, domestic violence, early intervention, and food and nutrition.
- Livingston County Mobile Crisis
- Mental Health Counselors of Greater Rochester
- Wayne County Free Mobile Crisis information
- Psychiatric and Counseling Providers in the Rochester and Finger Lakes Region - Includes providers for youth and adults, substance abuse, and counseling programs for various issues and needs.
- Yates County emergency contact list
Resources and information that pertain to chronic medical conditions. Sub folders include resources and tools. Tools subfolders are separated by specific conditions. Resources for chronic conditions will include patient teaching tools, support services, and health literacy appropriate literature. For information on depression, see behavioral health.
Examples: chronic disease red flag teaching tools, insulin administration education, self management literature for patients, clinician focused literature
- Greater Rochester Pre-Diabetes and Diabetes Education and Support Services Guide
- Diabetes Education and Support Services for Rochester and Finger Lakes Region
- Rochester Health Healthcare Resource Guide - Local health resources all in one website.
- Healthy Living Center - University of Rochester's resources for healthy living
- Asthma
- Blood Thinners
- Chronic Conditions
- COPD
- Diabetes
- Fibromyalgia
- Pain
- Pneumonia
- Pneumonia self-care management
- Partnering in self-management support: A toolkit for clinicians (Login may be required)
- High Blood Pressure
- Video: How to measure blood pressure accurately (American Medical Association)
- Video: Blood Pressure Measurement (New England Journal of Medicine)
- Video: Monitoring your blood pressure at home (American Heart Association)
- Presentation: Improving High Blood Pressure in Your Practice (Common Ground Health)
- Blood Pressure and Diet/Spanish:Presión arterial alta y su dieta
- Blood pressure control without medication/Spanish: Diez maneras para ayudar a controlar la presión arterial alta sin medicinas
- Blood pressure medication/Spanish: Control de la presión arterial alta con medicinas
- Exercise and blood pressure/Spanish: Ejercicio y presión arterial alta
- Blood Pressure Wallet Cards/Spanish: Mi rastreador de presión arterial
- Pneumonia
Information and resources that pertain to end of life planning and care. Sub folders include resources and tools.
Examples: Hospice homes, MOLST forms
- Hospice Homes (PDF) - Hospice homes providers for the Rochester and Finger Lakes region
Resources that benefit various patient populations and do not fit into any other categories listed. Sub folders include resources and tools. Resources for the general folder will include health ministries, support services for children, developmental disability services (non-waiver programs), and resources for blind/deaf populations.
Example: Interdenominational Health Ministry Coalition, Rochester-area Healthcare Service Agencies and Support Groups
- Statewide
- Eating healthy on a budget
- United Way - A non-profit organization that partners with charities across the country to help local communities.
- Pathstone - A non-profit community development and human service organization providing services to low-income families and economically depressed communities.
- Regional
- Interdenominational Health Ministry Coalition
- Rochester Health Resource Guide - A broad list of various resources for the Rochester region, ranging from healthcare to advocacy services.
Resources that pertain to insurance programs, including private insurance, Medicare, and Medicaid, as well as managed care and managed long term care plans. Resources are included for programs that offer government funded assistance to income eligible persons. Subfolders will include Resources and Tools.
Examples: multiple pharmacy programs, EPIC, neighborworks information.
- Statewide
- Benefits Checklist - then click "Click Here to download free copy of latest benefits checklist"
- Prescription Assistance Programs - Patient assistance resources for members who need help with prescription costs.
- PillPack - Service that offers medications to be sorted and delivered to patients.
- New York State myBenefits - website for patients to manage their benefits as well as determine benefit eligibility.
- List of $4 medications at WalMart - then click "Download list of $4 medications in the US"
- Extra help with Medicare prescription drug plan costs
- Insurance in-person assistors/navigators - List of IPA's that provide in-person enrollment assistance to individuals and families applying for health insurance through the Marketplace
- EPIC Deductible Plan Schedule - EPIC is a NYS program for seniors 65+ to supplement their out-of-pocket Medicare Part D drug plan costs.
- New York State Managed Long-Term Care Plan Directory
- New York Medicaid Choice - Information on New York State's Managed Care Enrollment program.
- Consumer Directed Personal Assistance Association of New York State - CDPAANYS contacts by county througout the state.
- Regional
- Neighborworks Rochester flyer - Resource that collaborates with people and partners to strengthen, sustain, and promote city neighborhoods
- Independent pharmacies in Western New York
- iCircle NY: A nonprofit central New York managed long-term care plan
- Honor Flight Rochester - Rochester program that flies veterans to Washington D.C. to attend memorials. Veterans from Buffalo and Syracuse welcome to apply.
- Saratoga Rx – Simplify My Meds to get all prescriptions on the same day every month, all prescriptions refilled and ready for patients. Offers free medication packaging and free delivery.
- VA Mobile lab - To provide veterans in rural communities easier access to VA healthcare via Telehealth.
Definition: Resources that pertain to assessing or building knowledge, skills and confidence among patients with the goal of managing their own health and health care. Resources for patient activation include low literacy tools to manage chronic conditions; training materials for motivational interviewing and teach back; and studies of effective self-management.
Examples: management tools for asthma, COPD, diabetes, heart failure, pneumonia, and patients who take Warfarin.
- A1C Thermometer - Instructions for patients to better understand A1c and healthy numbers. Appropriate for most literacy levels.
- Symptoms of high and low blood sugar - Instructions to help patients identify when to check their blood sugar. Appropriate for most literacy levels.
- Eating well with diabetes - Instructions to educate patients on eating when diabetic. Appropriate for most literacy levels.
- Insulin administration - Diagram instructions to educate patients on giving themselves insulin. Appropriate for most literacy levels.
- Medicine log - Tool to educate patients about specific medications and allows them to log medications they've taken. Appropriate for most literacy levels.
- Medical home vs. emergency department - Instructions for patients on when to go to the doctor vs. when to go to the emergency room. Created by a community health center in Rushville, NY.
- Medicines for diabetes - Information on diabetic medications and how they control diabetes. Appropriate for most literacy levels.
- Patient Safety Network - Information on medication reconciliation.
- Partnering in self-management support: A toolkit for clinicians (Login may be required)
- Motivational Interviewing module - Module from Practice Advisor that introduces the concept of Motivational Interviewing (MI), including the theoretical basis of MI; clinical tools of MI; and practical guidance on integrating MI into a medical practice.
- Teach Back FLHSA Collaborative
- Blood sugar log
- Step-by-step blood sugar checks
- My numbers analysis
- Patient self-assessment
- Self management action plan
- Zones for asthma management
- Zones for COPD management
- Zones for diabetes self-care management
- Zones for heart failure self-care management
- Zones for pneumonia self-care management
- Zones for Warfarin (Coumadin) blood thinner self-care management
Definition: Resources that pertain to payment models, billing codes, and government policy related to reimbursement. Tools for reimbursement include presentations, examples of forms, and summary documents.
Examples: presentation on the Medicare Access and Chip Reauthorization Act of 2015; examples of forms used for Chronic Care Management billing codes.
Definition: Resources that pertain to adults 60 years of age and older. Sub folders include resources and tools. Resources help seniors with aging in place, move to higher living, and obtain services that pertain specifically to aging.
Examples: silver sneakers resources, literature on treating persistent pain in older adults, geriatric care management information
- Eldersource - Monroe County resources for older adults and disabled adults.
- Grandma’s Helpers Brochure - Agency that helps older adults with transitioning from aging in place to moving to a higher level of care. Assistance includes helping with moving estimates, movers, packing, and cleaning.
- Silver Sneakers Programs
Resources that pertain to psychosocial factors that impact an individual’s ability to access healthcare or maintain satisfactory health. Sub folder includes Resources. Resources for social determinants of health include cash assistance, benefits information, and food and housing issues.
Examples: HEAP/Project Share Heating Fund information, SNAP, and food cupboards.
- Statewide
- Family Planning Benefit Program - A free public health insurance program for New Yorkers who need family planning services.
- Home Energy Assistance Program (HEAP) - helps low-income people pay the cost of heating their homes. Emergency benefits may be available.
- SNAP for Able Bodied Adults Without Dependents Time Limit Checklist - Includes exemptions to programs and additional SNAP resources.
- Regional
- C.A.S.H. (Creating Assets, Savings & Hope) for tax preparation assistance and other support
- Food cupboards
- Shelters and hot meals
- Legal Assistance of Western New York
- Neighborworks Rochester - Collaborates with people and partners to strengthen, sustain, and promote city neighborhoods.
Definitions: This will provide resources and information that pertain to transitions in care. Sub folders include resources and tools. Resources for transitions in care include transitions tools and processes for practices from AMA, ACP, and AHRQ.
Examples: AMA Transitions in Care – Putting the Pieces Together, AHRQ Transitions Implementation Handbook, and the National Transitions in Care Collaborative Issue Briefs.
- Care transitions from hospital to home: IDEAL discharge planning
- AHRQ Transitions Implementation Handbook
- National Transitions of Care Collaborative issue briefs
- Using the SafeMed model to Improve Transitions of Care
- AHRQ Transitions Tool 1 IDEAL overview
- AHRQ Transitions Tool 2a IDEAL checklist
- AHRQ Transitions Tool 2b IDEAL booklet
- AHRQ Transitions Tool 3 Physician
- AMA Journal of Ethics: Transitions of Care: Putting the Pieces Together
- AHRQ Transitions Learning Tool
Resources that pertain to transportation for patients. Transportation will include transporting for medical appointments, social activities, and personal needs. Transportation for Medicaid recipients as well as private pay will be included.
Examples: Transportation vendors and rates
- Regional
- Local Transportation services
- Rochester Area Transportation, from Rochester Environment.com
- Reconnect Rochester- Public Transportation Resources and Information
- Medical Motor Services for seniors and the disabled
