“This help allowed me to get my head above water and stay there.” —Finger Lakes Medicaid member receiving waiver-supported services
For many Medicaid members, the factors with the biggest impact on a person's health are having a safe place to sleep, enough food, and a reliable way to get to care. That’s why housing, nutrition, transportation, and other health-related social needs are the focus of New York State’s 1115 Medicaid Waiver, also known as NY Health Equity Reform—a statewide effort to pilot innovative approaches to Medicaid that address root causes of poor health.
And the impact is already real. In recent outreach with community organizations delivering waiver-funded services, people described rental assistance and relocation support as the difference between stability and homelessness: “I would have been homeless.” Others described the relief of prompt, compassionate help: “It’s life or death for some of us. These services carry some of the load so we can breathe.”
On March 18 in Geneva, Finger Lakes partners gathered for the second regional convening on the 1115 Medicaid waiver—a working session designed to improve how people move from screening to real support and to identify feasible actions partners can implement over the next two to four months.
The waiver: what it is and how it works in the Finger Lakes
New York’s 1115 Medicaid Waiver supports a regional approach to identifying and addressing health-related social needs, helping Medicaid members get connected to services that support stability and health.
In this effort:
- The New York State Department of Health named United Hospital Fund (UHF) as the statewide Health Equity Regional Organization (HERO) in 2024.
- In the Finger Lakes, UHF works alongside Forward Leading Independent Provider Association (FLIPA), the region’s Social Care Network lead, and Finger Lakes Performing Provider System (FLPPS), the region’s workforce investment organization.
- Health systems and community-based organizations are building pathways so Medicaid members can be screened for needs, connected to navigation and eligibility supports, and receive services that can prevent crises and improve health and well-being.
Our role: connecting partners, centering data, and learning as the system builds.
From community health workers to regional health system leaders, Common Ground Health-Finger Lakes Performing Provider System (FLPPS)-Rochester Regional Health Organization (RHIO) brings partners together around data and shared priorities, helping establish trust, align workflows, and focus on what’s working (and what needs to improve).
As part of this waiver work, Common Ground Health-FLPPS-Rochester RHIO has supported UHF to:
- Identify local needs and inequities by population and service gaps,
- Establish regional priorities rooted in local needs and specific populations,
- Develop strategies to address barriers that limit access to care,
- Support conversations that centralize data collection and exchange, and
- Identify local social services programs to screen and connect people to support.
To prepare for the convening and understand early implementation, Common Ground Health-FLPPS-Rochester RHIO also reached out to community-based organizations contracted through the Social Care Network. While partners surfaced challenges still being worked out, they also shared clear evidence that waiver-funded services are already changing lives.
The convening focus: Getting people in the door.
The convening was structured around a key question: How do Medicaid members enter the pathway from screening to services—and how do we make that path easier, more trusted, and more effective?
“Screening is the moment when needs that may have gone unseen finally come into view,” said Tiffany Sturdivant, director of regional assessment and planning for United Hospital Fund, in opening remarks. “But the real impact is in what follows—engagement, trust building, and sustained connections to services.”
By the end of the day, each table aimed to leave with one possible action to test over the next 2–4 months.
Early momentum—and the growing need
Since launch, the region has seen significant growth in screening. At last check, about 4% of waiver-eligible Finger Lakes Medicare members were screened, up from ~0.6% from September 2025.
Even more striking: ~60% of screened members in the region reported more than one social need (compared to ~46% statewide). Among enhanced populations, postpartum and pregnant women reported extremely high housing needs (~93%), and high-risk children showed the highest food needs (~76%).
This tells us that the system is beginning to find people who need support—often with multiple needs at once—and the work now is ensuring screening reliably leads to meaningful help.
Key takeaways from the day—and what partners are doing next
Trust is the difference between a “screen” and real help
Throughout the convening, frontline partners emphasized that trust determines whether help actually lands. One participant named the challenge plainly: “It’s the opposite of trust—it’s suspicion,” describing how repeated broken promises can make people reluctant to share their needs again.
Patricia McMahon, chief executive officer of FLIPA, underscored why trusted relationships matter: “Can you imagine having someone new coming in and asking you all these questions? A strength of many of the organizations that are here today, is that you have relationships with the people that we're trying to serve.”
Partners shared approaches that reduce retraumatizing retells, including embedding licensed social work support in shelters so screening and diagnosis can happen together.
What’s working? Meeting people where they already gather. Partners are screening in libraries, food pantries, courts, and other trusted spaces; using culturally relevant messaging through known messengers; integrating social needs questions into clinical intakes; and bridging roles across clinical and community settings so referrals don’t stall.
“It was a wonderful experience…rather than broken promises… they were like, ‘I got you.’” —Finger Lakes Medicaid member receiving waiver-supported services
Partners are being candid about barriers—and solving them together
Participants were clear-eyed about obstacles that can slow screening and referrals, including:
- Administrative burden and rigid screener language that requires translation and time during sensitive conversations,
- Navigating multiple platforms, duplicative screening, and variable workflows across agencies, and
- Growing needs that outpace the availability of housing, food, and transportation supports.
At the same time, partners shared meaningful course corrections already underway. UHF/SCN leaders described near-term training upgrades, including cohort-style sessions on billing and eligibility assessment and a “Find Help” mechanism to onboard staff so organizations can bill accurately for the work they’re already doing.
“The conversations were transparent,” said Jackie Dozier, director of community health and well-being at Common Ground Health-FLPPS-Rochester RHIO. “UHF heard barriers and has taken a step back to retrain. They’re working to ensure organizations have the tools to be successful.”
Action ideas are practical—and rooted in real workflows
To close the day, each table developed an achievable idea to test over the next two to four months.
Ideas included:
- Awareness campaigns to increase screening, paired with readiness planning so services can absorb referrals,
- Embedding a screener/care manager with mental health credentials in a women’s shelter to better support women with substance use challenges or mental illness (with potential to help pregnant women and others),
- Integrating 1115 screening questions within standard screens for substance use disorders and medical interventions to reduce duplication,
- Shared toolkits with trusted messengers, stronger jail-to-community handoffs, and even technical work like translating local lab codes into standardized LOINC coding to support more seamless data exchange.
“The gathering in Geneva was an inspiring example of what’s possible when stakeholders come together with a shared purpose,” said Melissa Wendland, director of strategic initiatives at Common Ground Health-FLPPS-Rochester RHIO. “It was a productive session of problem-solving, collaboration, and collective commitment to addressing the systemic barriers that prevent us from helping those most in need.”
Why continued funding matters—especially right now
The 1115 Waiver is reaching a critical point: as screening increases, more needs are being surfaced—and in the Finger Lakes, most people screened report multiple needs. This is exactly what the system is designed to do: find needs early, connect people to services, and prevent escalation into avoidable crises.
Client stories collected through Common Ground Health-FLPPS-Rochester RHIO’s outreach show why these services must continue and what’s at stake if funding stops just as the infrastructure is becoming functional:
- Prevents homelessness: “I would have been homeless.”
- Stabilizes families and protects children: “We were living with black mold; my kids were sick. They helped us move…”
- Reduces crisis-level stress that harms health: “Those services can alleviate the stress…not having to worry about where am I sleeping, what will we eat…”
- Keeps people from falling through the cracks: “Without this support, I’d probably fall through the cracks…”
- Makes the stakes unmistakable: “It’s life or death for some of us.”
Put simply, this work is showing early momentum and real impact—and stopping now risks reversing progress just as partners are improving workflows, strengthening trust, and expanding the pathway from screening to services.
A clear path forward
United Hospital Fund’s role as the HERO is to help regions standardize what makes sense, share what works, and align this work with statewide investments—so impact lasts beyond the waiver timeline. With worksheets and detailed notes collected from the convening, regional leads will synthesize takeaways and connect them to implementation with social care and workforce investment partners.
Carol Tegas, chief executive officer at the new combined entity of Common Ground Health -FLPPS-Rochester RHIO underscores what is at stake: “We’re seeing both the growth of need and the promise of what happens when systems align. Continued investment now protects the progress partners have built—and, more importantly, protects families who are counting on these services to stay stable and healthy.”