Millennium's DSRIP Projects and Workstreams

11 Projects

The mission of Millennium is to work in partnership with physicians, healthcare providers, and community-based organizations (CBOs) on the implementation of 11 DSRIP programs designed to positively impact Medicaid patients across the eight counties of Western New York (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming).

The projects were chosen based on the data collected during the 2014 WNY Community Needs Assessment (CNA), which prioritizes regional health needs.

2.a.i Create Integrated Delivery System Focused on Evidence-Based Medicine/Population Health Management
2.b.iii ED Care Triage
2.b.vii Implementing the INTERACT Project
2.b.viii Hospital/Home Care Collaboration Solutions
2.d.i Patient Activation Activities to Engage, Educate and Integrate Uninsured/Non-utilizer Populations (PAM)
3.a.i Integration of Primary Care and Behavioral Health (Models 1&2)
3.a.ii Behavioral Health Crisis Stabilization Services
3.b.i Evidence-Based Strategies for Disease Management (CVD)
3.f.i Increase Support for Maternal and Child Health (Model 3)
4.a.i Promote Mental, Emotional, and Behavioral (MEB) Well-Being
4.d.i Reduce Premature Births


In addition to the 11 projects, several “workstreams” have been identified which span across all projects.

Cultural Competency and Health Literacy: The objective of this workstream is to assist in the integration of knowledge, attitudes and skills reflective of a culturally competent organization in order to help ensure that everyone receives equitable and effective health services. In addition, the cultural competency and health literacy team is developing and implementing a training strategy focused on addressing the drivers of health disparities.

Workforce Development: System transformation will create significant new and exciting employment opportunities for appropriately prepared workers. Millennium’s workforce team is tasked with identifying impacts and working towards minimizing negative impacts.

Clinical Integration: One of the central goals of the DSRIP program, clinical integration is intended to foster collaboration among hospitals, healthcare providers, and CBOs in ways that increase quality and efficiency of patient care resulting in better care, lower costs, and improved health of our population.

Financial Sustainability: One of the primary goals of the DSRIP program is to transition from the current system of fee-for-service to value-based payments (VBP). Today, many organizations that provide services which address the social determinants of health cannot or do not receive adequate reimbursement. One component of the conversion to VBP will be enabling CBOs to bill Medicaid (or other payers as appropriate) for these important services that directly affect the health of the target populations.

Population Health: The aims of this workstream are to improve access to care, care coordination, and health outcomes by shifting the healthcare focus from acute to ambulatory, utilizing technology to provide care remotely, and providing ambulatory services within the community—a shift which is enabled by the transition to VBP.

Practitioner Engagement: The practitioner engagement workstream at Millennium seeks to ensure that practitioners understand their role in contributing to the success of DSRIP projects. This team regularly engages practitioners through a variety of modalities to provide education, motivation, and training to support the implementation of our projects.

DSRIP Project Highlights

  • Creating Integrated Delivery Medicine and Population Health Management
  • ED Care Triage: +8,000 connected to Primary Care, lowering ER readmissions.
  • INTERACT Project: 51 Skilled Nursing Facilities throughout the 8 counties of WNY have implemented the Interventions to Reduce Acute Care Transfers program.
  • Hospital/Home Care Collaboration: Certified Home Healthcare Agencies (CHHA) have adopted similar “INTERACT-like” evidence-based care protocols and tools, performed hospitalization tracking and root cause analysis, trained staff on new communication forms and techniques, and rolled out use of enhanced patient and family education materials.
  • Patient Activation Activities to Engage, Educate and Integrate Uninsured/Non-utilizer Populations:
  • Over 91,400 individuals have received a Patient Activation Measure® (PAM®) assessment to identify the motivations to seek health care. Five community-based organizations are collaborating with Primary Care providers and the Medicaid managed care organizations to connect low- and non-utilizers of health care services back to Primary Care.
  • Integration of Primary Care and Behavioral Health
  • The Chautauqua Center in Dunkirk, NY has added staff Behavioral Health professionals.
  • ECMC has launched a rebranded “Primary Care Access Center.”
  • BestSelf has partnered with ECMC to create the “ECMC Behavioral Health Bridger Program” whereby a BestSelf team member serves as the “Bridger.”
  • Niagara Falls Memorial Medical Center has implemented an ED-Based Screening of Behavioral Health Patients and has begun Behavioral Health Home Visits.
  • Behavioral Health Crisis Stabilization Services
  • Achievements include:
  • prevention initiative
  • Development and implementation of new Mental Health Triage Tool
  • Supported additional Crisis Intervention Training (CIT) for officers serving “hotspot” zip codes in Erie County
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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

Millennium Collaborative Care

1461 Kensington Ave
Buffalo, NY, 14215

t:  716-898-5389

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