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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.)

12. 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

13. 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

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

15. The Center for Health Systems Transformation at Albany Medical Center
Contact: George Clifford, PhD. Evan Brooksby