D S R I P 6-8pm Free Parking & Light Refreshments Wednesday November 18 th 2015 Albany Medical College ME-100 43 New Scotland Avenue, Albany NY 12208 P U B L I C F O R U M
Albany Medical Center The Center for Health Systems Transformation
Albany Med s Provider System
DSRIP Basics Medicaid program Goal: Reduce un-needed hospital and Emergency Department visits Conducted a community needs assessment Picked from a list of projects Created a community engagement plan Creating a Cultural Competency plan
DSRIP Basics Working together with Ellis & St. Peters (Alliance for Better Health Care) Working together with community based organizations Actively looking to involve members of the community Patient satisfaction impacts our payment
Projects Domain 1 Governance and performance Domain 2 System wide Projects Domain 3 Clinical Projects Domain 4 Population Health Projects
System Transformation Projects (Domain 2) Integrated Delivery System To create integrated delivery systems that are focused on evidence based medicine & population health management High Risk Patient Intervention Program Expand access to integrated primary care teams to meet the needs of higher risk patients that do not currently qualify for Health Home Care Management services and implementing care plans
System Transformation Projects (Domain 2) Provide health care services by using nursing home space better Transform current nursing home infrastructure into a service infrastructure consistent with the long term care needs of the community ED care navigation for the uninsured and Medicaid members who need assistance Develop an evidence based care coordination and transitional care program to assist patients and link them with primary care
System Transformation Projects (Domain 2) Patient Activation: Engage, Educate and Integrate the uninsured and Medicaid populations into primary care Increase patient activation related to health care while increasing access to primary and preventative services Focus on patients who are not using the healthcare system effectively by utilizing the PAM tool
Clinical Improvement Projects (Domain 3) Integrate primary care and behavioral health services Integrate mental health and substance abuse services with primary care services, including care coordination and screenings Community based behavioral health crisis stabilization To provide behavioral health crisis stabilization services with appropriate levels of care to support rapid de-escalation
Clinical Improvement Projects (Domain 3) Cardiovascular Health (High Blood Pressure & Cholesterol) Ensure clinical practices use evidence based strategies to improve management of heart disease including lifestyle goals and plans Implementation of evidence-based medicine guidelines for asthma management Ensure patients with asthma have access to care consistent with evidence-based guidelines including an asthma action plan
Population-wide Projects (Domain 4) Promote Tobacco Use Cessation Especially among disadvantaged populations in the community Increase Access to High Quality Chronic Disease Preventive Care and Management Improve access to prevention services such as cancer screening
The Center for Health Systems Transformation at Albany Medical Center www.albanymedpps.org Contact: George Clifford, PhD. cliffog@mail.amc.edu Evan Brooksby brookse1@mail.amc.edu
Alliance for Better Health Care, LLC Performing Provider System within New York State Department of Health s Delivery System Reform Incentive Payment (DSRIP) Initiative
Alliance: Who we are Our team here tonight: Bethany Gilboard, CEO Carole Boutilier, Clinical Advisor Melissa Russom, Communications & Stakeholder Engagement Erin Simao, Transformation Specialist Patient Activation, Cultural Competency/Health Literacy, Asthma Self-Management, Tobacco Cessation Maria Smirensky, Human Resources/Workforce
Alliance: Who we are 2,000 providers and community based organizations Serving o 123,000 Medicaid members o 94,000 uninsured and low utilizers 7 key partners: o St. Peter s Health Partners o Ellis Medicine o St. Mary s Hospital (Amsterdam) o Whitney Young Health o Hometown Health Centers o Capital Care Medical Group o Community Care Physicians Results Oriented Experienced Collaborative
Alliance Goals Improve the quality of patient care Triple Aim Improve the health and wellness of our communities Reduce healthcare costs
Service Area Alliance serves the following counties: Albany Fulton Montgomery Rensselaer Saratoga Schenectady
Alliance Projects Inpatient Transitions Outpatient Transitions Behavioral Health Population Health Patient Activation Integrated Delivery System
Inpatient Transitions Care Transitions Provide a 30 day supported transition period after a hospitalization to ensure discharge plans are accepted and understood. Hospital to Home Collaboration Provide services in a home care setting following hospital discharge, to reduce re-admissions. Palliative Care Increase access to palliative care programs in patient-centered medical homes (PCMH).
Outpatient Transitions Emergency Department Care Triage Assist patients in linking to a primary care practitioner, providing supportive assistance to transition patients to the least restrictive environment.
Behavioral Health Integration of Primary Care and Behavioral Health Services Integration of behavioral health and substance abuse with primary care services to ensure coordination of care. Ambulatory Detoxification Develop withdrawal management services for substance use disorders within community-based addiction treatment programs and link patient with care management services. Strengthen Mental Health and Substance Abuse Infrastructure Across Systems Support collaboration among leaders, professionals and community members working to promote mental, emotional and behavioral health.
Population Health Asthma Home-Based Self-Management Promote asthma self-management skills including selfmonitoring, medication use and medical follow-up and reducing home environmental triggers. Promote Tobacco Use Cessation Reduce the prevalence of cigarette smoking and increase the use of tobacco cessation services.
Patient Activation & Integrated Delivery System Patient Activation Implementation of Patient Activation Activities Engage, educate and integrate the uninsured and low/nonutilizing Medicaid populations into community-based care and increase access to care. Integrated Delivery System Integrated Delivery System Focused on Evidence- Based Medicine and Population Health Management Create an integrated, collaborative and accountable service delivery structure that incorporates the full continuum of care, eliminates service fragmentation and increases opportunities to align provider incentives.
Questions? www.allianceforbetterhealthcare.com