The Center for Health Systems Transformation Albany Medical Center The Center for Health Systems Transformation

DSRIP 101 Medicaid program Redesign care delivery through the use of health information technology Patient focused, evidence based and project driven Reduce avoidable hospital and Emergency Department admissions Transition to value based care

Projects Domain 2 Domain 3 Domain 4 System wide transformational Projects Domain 3 Clinical improvement focused Domain 4 Population Health focused

System Transformation Projects (Domain 2) Integrated Delivery System To create integrated delivery systems that are focused on evidence based medicine & population health management Rebalance the health care delivery system to meet the needs of the community Ensure patients needing Care Coordination receive appropriate care – create system linkages Expand access to high quality primary care

System Transformation Projects (Domain 2) Health Home at Risk 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 Using EHR registries the PPS will identify patients who do not have access to appropriate care management services

System Transformation Projects (Domain 2) Create a medical village (or other healthcare use) using existing nursing home infrastructure Transform current nursing home infrastructure into a service infrastructure consistent with the long term care needs of the community

System Transformation Projects (Domain 2) ED care triage for at-risk populations Develop and evidence based care coordination and transitional care program to assist patients and link them with primary care Establish linkages with Patient Centered Medical Homes through improved information technology Provide required screening and immediate appointments with primary care Utilize community based organizations to provide patient education about how and where to receive care

System Transformation Projects (Domain 2) Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and other Medicaid populations into primary care Increase patient activation related to health care while increasing resources to help gain access to primary and preventative services Focus on patients who are not interacting with the healthcare system for various reasons

Clinical Improvement Projects (Domain 3) Integration of primary care and behavioral health services Integrate mental health and substance abuse services including care coordination Provide behavioral health services at PCMH sites Provide primary care services at behavioral health sites Provide collaborative care with behavioral health including depression case managers and stepped care

Clinical Improvement Projects (Domain 3) Behavioral health community crisis stabilization services Provide appropriate access to behavioral health crisis services that allow access to services and providers to support rapid de-escalation Crisis intervention services that include outreach, mobile crisis and intensive crisis services Crisis residence for up to 48 hours of monitoring to attempt stabilization

Clinical Improvement Projects (Domain 3) Cardiovascular Health – implementation of the Million Hearts Campaign Ensure clinical practices use evidence based strategies to improve management of heart disease Implement the Million Hearts Campaign Provide once a day medications when appropriate Develop and implement evidence based clinical treatment protocols for heart disease (high blood pressure, cholesterol, etc.)

Clinical Improvement Projects (Domain 3) Implementation of evidence-based medicine guidelines for asthma management Ensure patients with asthma have access to care consistent with evidence-based guidelines Establish collaboration with Regional Asthma Coalitions to support population based approaches to asthma management Reach agreement on adherence to national guidelines and protocols for asthma care Include electronic health records, health information exchange and tele-medicine

Population-wide Projects (Domain 4) In line with the NYS Prevention Agenda Intended to influence population-wide health Promote Tobacco Use Cessation Especially among disadvantaged populations Increase Access to High Quality Chronic Disease Preventive Care and Management Improve incentives for prevention services such as screening

Great questions! How will the system changes under the DSRIP model impact patient care? What about local health care providers? What about aging services?

The Center for Health Systems Transformation at Albany Medical Center Contact: George Clifford, PhD. cliffog@mail.amc.edu Evan Brooksby brookse1@mail.amc.edu