Alliance for Better Health Care LLC 1 Alliance

Alliance for Better Health Care, LLC 1

Alliance for Better Healthcare Alliance for Better Health Care Who we are: • 1, 400 providers and community based organizations • Serving o 116, 000 Medicaid members o 94, 000 uninsured, low utilizers • Supported by 7 key partners: o 3 health systems with group practices o 2 FQHCs o 2 Independent group practices Experience d Results Oriented Inclusive Collaborative 2

Alliance for Better Health Care Our Vision In 5 years, it is expected that the population of the PPS’ service area, particularly those served by the Medicaid program, will experience an integrated system of care across the continuum that is significantly different than the current fragmented one. These new partnerships among health care providers and social service agencies will ensure that Medicaid members receive high quality care that is specific to individual needs both medically and socially. A greater involvement of case managers and care navigators will ensure that high-need individuals receive coordinated care at an earlier stage resulting in healthier individuals and lower health care costs. 3

Alliance for Better Health Care Our Collective Goals 1, 400 Providers Supported by: Ellis Medicine St. Peter’s Health Partners St. Mary’s Healthcare Hometown Health Center Whitney Young Health Ctr. Capital. Care Medical Group Community Care Physicians 4

Alliance for Better Health Care Our Strategic Plan Care Coordination Increases Access IT Integration Supported by local PHIP Grantee and RHIO IHANY Clinically Integrated Network AFBHC DSRIP Value Based Payment System Health Homes Improves Quality Decreases Costs Improves Satisfaction Comprehensive Provider and Community Services Network Population Health Management Clinical Integration Future State: Incorporate SHIP Decreases Avoidable Hospital Use 5

Alliance for Better Health Care AFBHC Projects System Transformation • Create an Integrated Delivery System focused on evidence-based medicine and population health management: – Clinical integration across partners – All primary care level 3 PCMH by end of year 3 – Transportation solutions – PPS governance, funds flow – IT connectivity with RHIO (HIXNY) – Contract with MCO for value based contracts by end of project 6

Alliance for Better Health Care AFBHC Projects System Transformation • ED Care Triage for at risk populations • Embed patient navigators in all hospital EDs to help patients get primary care appts and needed community supports • Care transitions intervention model to reduce 30 day readmissions for chronic health conditions • Standardized protocols for a care transitions intervention model in all hospitals; partner with home care and social service agencies; transition case manager to visit patient in hospital • Hospital-home care collaboration solutions • Use Interact-like tool and advanced care planning tools to assure that patients being discharged receive all necessary care to prevent readmission; identify risks of non-compliance with discharge orders and put services in place to mollify risks; increase number of patients receiving home care - may require additional home care nurse skills i. e. , behavioral health 7

Alliance for Better Health Care AFBHC Projects System Transformation • Implementation of patient activation activities to engage, educate and integrate the uninsured and low/non-utilizing Medicaid populations into community based care (Project 11) • Partner with community-based organizations (CBOs) to engage target populations using PAM®(patient activation measures). 8

Alliance for Better Health Care AFBHC Projects Clinical Improvement • Integration of primary care and behavioral health services • Provide primary care services in select BH sites; BH services in select primary care sites • Development of withdrawal management capabilities and appropriate enhanced abstinence services within community based addiction treatment programs • Establish several ambulatory detox programs • Expansion of asthma home-based self-management programs • Develop training and home-based asthma self-management education services (trigger reduction, self-monitoring and medication use; collaborate with medical and social service partners • Integration of palliative care into the patient centered medical home model • Educate providers on the benefits of palliative care and deploy palliative care coaches in PC practices to increase provider comfort and willingness to offer palliative care interventions; partner with community based organizations including hospice providers to incorporate CBO services and supports 9

Alliance for Better Health Care AFBHC Projects Population Wide • Strengthen mental health and substance abuse infrastructure across systems • MEB taskforce to train PCPs and other professionals in MEB health promotion and MEB disorder prevention based on the development of a trauma informed culture using NYS Prevention Agenda strategies. • Promote tobacco use cessation, especially among low SES populations and those with poor mental health • Collaborate with CBO’s and MH/SUD treatment providers to advance the adoption of tobacco-free outdoor policies , coordinating evidence based strategies to build public, political and organizational support for tobacco cessation. 10

Alliance for Better Healthcare Alliance for Better Health Care AFBHC PPS Patient Experience Current State Mrs. Jones is a 61 year old Medicaid member who lives alone • History of diabetes, COPD, poor diet, untreated clinical depression • Uses catheters for urinary incontinence • Visited multiple EDs 12 times during past year for urinary tract infections resulting in 5 admissions at different hospitals • Does not have primary care physician. Future State • • • Place in Patient Centered Medical Home (PCMH) Assign Care Coordinator (CC) Receive multidisciplinary person-focused team- care including: – – – • • diabetic educator nutritionist mental health screening assessment and services social services via community based organizations home environment assessment Patient calls Care Coordinator when issues develop Evidence based alternatives to using urinary catheter implemented Community health worker visits to monitor engagement and compliance Monitor health services delivered through integrated EMRs and RHIO. 11