1. Paul Kaye, MD VP for Practice Transformation Hudson River HealthCare October 1, 2010

2.  Improve the health of the population  Improve the experience of care  Reduce the cost

3.  Population management  Care management of the chronically ill  Referral management (urgent and routine)  Transitions coordination  Reducing readmissions  Coordinating care for special populations

4.  Hudson River HealthCare  Institute for Family Health  Open Door Family Medical Centers  CHCANYS  Hudson Health Plan  Taconic Health Information Network and Community (THINC)

5.  All 3 CHCs collaborated in achieving PCMH Level 3 recognition  Participants in THINC Medical Home project through Taconic IPA Medical Council  All 3 CHCs will participate in Johns Hopkins Guided Care curriculum  Joint commitment to useful information exchange with THINC RHIO

6.  Aim: Provide 5000 diabetics with coordinated, continual, evidence-based care ◦ Isn’t this the Triple Aim?  Measures in 3 domains: ◦ Clinical Status (BP, A1C, LDL, screenings) ◦ Care Coordination (SM goals, hospital follow-up, admission and ER utilization rates) ◦ Patient Experience (CAHPS or similar data)

7.  Monthly Clinical Committee meeting drives technology requests  Multidisciplinary team includes MDs, CDEs, nursing, operations directors  Subcommittee of CDEs examining best practices and developing standard curriculum for all 3 CHC organizations

8.  Population management  Care management of the chronically ill  Referral management (urgent and routine)  Transitions coordination  Reducing readmissions  Coordinating care for special populations

9.  Agreement on diabetes clinical guidelines  Embedded decision support  Tracking of self management goals  Tracking of regular screening (eye, foot, urine)  Monitoring population to find new high risk pts  Systematic assessment of barriers to self management and care  Referral to community-based programs (weight control, exercise, smoking)

10.  Use EHRs to identify pts with A1C >9 for intensive management ◦ Monthly visit to PCP ◦ Intensive monitoring with onsite testing ◦ Individualized care plans recorded in EHR ◦ Referral to standardized Diabetes Education Program ◦ Individual counseling as necessary ◦ Referral to behavioral health as necessary ◦ Multidisciplinary case conferencing

11.  CHW/patient navigators/Care Partners managing referrals from inception to reception of reports  Electronic communication between hospitals, specialists, and PCP  Referral to public benefit programs to cever costs of specialty care  Reinforce self management goals

12.  Focus on follow up of diabetic admissions  Notification of admission and discharge  Hospital discharge planners and CHC coordinators communicate early  Nursing phone call from CHC to discharged pt within 24 hrs; daily phone followup as needed  Office visit with 2-5 days depending on status