ECMC True Care Healthcast


ECMC True Care Healthcast
Millennium Collaborative Care, the Performing Provider System for Western New York

Featuring: Al Hammonds, CSSBB


True Care Healthcast is the official podcast from Erie County Medical Center. Each short podcast features ECMC physicians, nurses, and support staff and covers health and wellness topics from ECMC’s community-based approach to healthcare, as ECMC serves the needs of patients and their families from across Western New York.

True Care Healthcast is heard on:

The following is a feature article compiled from the recent interview with MCC Executive Director Al Hammonds.

ECMC True Care Healthcast:
Millennium Collaborative Care: Performing Provider System for Western New York

Across New York State, innovative organizations called Performing Providers Systems (PPS) have been working to improve the delivery of healthcare to Medicaid clients. In Western New York, Erie County Medical Center (ECMC) is the parent of Millennium Collaborative Care, a PPS that serves over 270,000 clients across eight counties.

“New York State alone has a Medicaid population of about six million folks, at a cost of about 60 billion dollars a year,” says Al Hammonds, Executive Director of Millennium Collaborative Care. “State-of-the-art hospitals like ECMC need to reinvest in the system to drive improvements, and in the process, lower costs. We are looking at restructuring the healthcare delivery system, reducing avoidable hospitalizations by 25% over a five-year period.”

Millennium is comprised of a highly diverse group of approximately 40 employees. The organization partners with providers such as primary care physicians, hospitals, community health centers, and community-based organizations to collaborate on projects aimed at specific improvement metrics.
Collaborative Success

One example of successful collaboration has been ECMC’s relationship with Niagara Falls Memorial Medical Center, which serves a high need population.

“Sheila Key, who is the Chief Operations Officer there, is truly a visionary and healthcare leader. She coined this phrase called the ‘Loneliness Factor’ which identified one of the root causes of why people come to the ER. It’s not always an ailment, sometimes they are just lonely,” shares Hammonds. “Through this, Niagara Falls established several goals, including how to enhance the system to achieve improvements in patient outcomes and overall performance.”

Effective solutions have involved incorporating a new emergency room information desk, a sandwich program to provide nourishment, after-hours primary care at the Golisano Center, and screening for behavioral health patients, including behavioral health home visits.

“We also implemented a ‘hot spotter’ program. After nine emergency room visits, a patient is assigned to this program so they get special attention,” explains Hammonds. “The results have been outstanding. After a four month period, Niagara Falls Memorial Medical Center identified 763 high utilizers. Of these, 52% received face-to-face contact with a social worker, resulting in a reduction in the overall emergency room high utilizer visits by 16.5%. The data is doing the talking and we are actually helping people get better.”

Other areas of collaboration include an asthma and chronic obstructive pulmonary disease program at Chautauqua Center, community-based beauty and barbershop program for engaging clients in a high blood pressure self-screening initiative, and the Million Hearts Program, which was a partnership between Millennium Collaborative Care, the University of Buffalo School of Nursing, and the Greater Buffalo United Churches to put together cardiovascular health screening fairs. “This was really a great win-win for the nursing students out of UB. They received really good practical hands-on experience,” adds Hammonds.

Three Areas of Continued Focus
As Millennium Collaborative Care continues its efforts, Hammonds identifies three critical areas in which the organization remains focused. One is population health services, which is coaching primary care practitioners to become care team leaders. Second is value-based payment performance services. “Our role is conducting organizational and contractual assessments with providers and organizations to make sure they are ready for this transition, from a fee-for-service to a value-based payment world,” notes Hammonds.

The third area involves data analytics, data warehousing, and analytics capabilities. “A significant investment has been made in Cerner’s population health platform and health management platform to look at data analytics, predictive risk identification, and stratification, as well as making sure the key partners are in the loop in developing data sharing agreements so we can share data across all of western New York,” states Hammonds. “We have the region’s largest Medicaid data analytics platform and most powerful platform to be able to perform these analytics and help the population.”

**To listen to an interview with Al Hammonds, Executive Director of Millennium Collaborative Care, follow this link:


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The Erie County Medical Center (ECMC) is the lead entity in the Millennium Collaborative Care Performing Provider System.

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