1. Danielle M. MacFee, MPH New York State Department of Health Healthy Heart Program 1 State of New York Department of Health

2. ▪ Year 01: 2 models of CDSMP dissemination ▪ Year 02: development of regional approach (AID + CDC HDSP funding) ▪ Role of health plans ▪ Role of collaborative It’s a start, and a process … State of New York Department of Health2

3. 3 CommunityHealth Care Delivery Total Population CVD risk factorsCVD Complications Informed Population Strong Community Organizations Community/Health Care Interface Information Systems/ EMRs Decision Support Clinical Team Screening for Risk Factors Controlling Risk Factors Structured Lifestyle Programs Regular Monitoring Insurers Employers Reimbursement } Healthy Public Policy Supportive Environments Informed, Empowered Patients Pharmacies Clinical Guidelines Surveillance Transitions in Care Community Preventive Services Personal Health Records Quit lines CHWs

4. State of New York Department of Health4 CommunityHealth Care Delivery Total Population CVD risk factorsCVD Complications Informed Population Strong Community Organizations Community/Health Care Interface Information Systems/ EMRs Decision Support Clinical Team Screening for Risk Factors Controlling Risk Factors Structured Lifestyle Programs Regular Monitoring Insurers Employers Reimbursement } Healthy Public Policy Supportive Environments Informed, Empowered Patients Pharmacies Clinical Guidelines Surveillance Transitions in Care Community Preventive Services Personal Health Records Quit lines CHWs

5. State of New York Department of Health5 From: The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health Promotion and the Chronic Care Model Victoria J. Barr, Sylvia Robinson, Brenda Marin-Link, Lisa Underhill, Anita Dotts, Darlene Ravensdale and Sandy Salivaras

6.  Leading Health Care Organizations  Medicaid  Medicare  Insurance Providers  Community-based Organizations  *State Chronic Disease Prevention Programs State of New York Department of Health6

7.  Health plans ▪ Independent Health ▪ HealthNow NY, Inc. ▪ Univera  P 2 (Pursuing Perfection) Collaborative of Western New York ▪ Non-profit health collaborative  American Red Cross ▪ Community-based organization State of New York Department of Health7

8.  Incorporated in 2002, non-profit health collaborative  200 partners representing health care consumers, providers, payers and purchasers, and business, government, education, religious and other community leaders (including the participating health plans and CBO)  March 2003 Target the Heart conference in Buffalo supported by the Healthy Heart Program  Focus on improving care for patients with chronic diseases  Goal to expand access to care, improve efficiency, empower individuals to take responsibility for and act on their own wellness, develop community-wide standards for promotion of wellness, and engage government leaders to promote policy changes State of New York Department of Health8

9. Health Plans:  ID staffer to coordinate, develop plan to sustain staff after the pilot  Market, promote, and recruit plan members to workshops  Follow up with targeted members to encourage participation  Develop utilization matrices P 2 :  Convenes stakeholders  Aligns resources in the community  Identifies individuals/organizations to carry out work American Red Cross:  Program coordination (registration, scheduling, training, fidelity etc.) State of New York Department of Health9

10.  Scale Up & Sustainability  Add health plans, sustain buy-in  Increase community accessibility, increase reach  Replication & expansion  Incorporate community resources into EHR, expansion to ‘menu’ of options  Explore PCMH recognition opportunities State of New York Department of Health10

11.  Health plan members in WNY  Independent Health: 365,000  Univera: 130,000  HealthNow: 470,000  Community members at large  Influence of funding source on target and reach State of New York Department of Health11

12.  Assess and reevaluate  Expand community partners (including Independent Living Centers and Vision Rehabilitation Centers) and engage healthcare at the provider level  Foster growth of additional networks in other regions  ARRA: Partnership with NYSOFA State of New York Department of Health12

13.  Businesses  Boards  Be proactive  Be opportunistic State of New York Department of Health13

14.  Q: How do we move from the health plan level of engagement to the practice/provider level  A: That’s the million dollar question…we’re not going to put all our eggs in one basket  Patient Centered Medical Home  Physician Champions  Community Health Centers  Community Health Workers  Others?? State of New York Department of Health14

15.  Disability and Health Program: Independent Living Centers (ILCs) and other disability service and advocacy organizations  Diabetes Prevention & Control Program: Vision Rehabilitation Centers (VRCs)  Healthy Heart Program: Community Health Centers State of New York Department of Health15

16. Contact Info: Danielle M. MacFee dmr17@health.state.ny.us 518.408.5142 State of New York Department of Health16