New digital tool can improve patient care

Sep 8, 2016, 6:06pm EDT

Health providers in the region have partnered to introduce a digital tool to help identify patients at risk of chronic conditions.

HealtheIntent, a population health product by Cerner, combines medical records information from hundreds of providers, including six hospitals, with claims data to identify and reach out to patients before problems worsen.

The local utilization of the effort is spearheaded by Millennium Care, a nonprofit group in Buffalo funded by the state Health Department through its Medicaid delivery system reform incentive program.

Cerner, a $4.4 billion health information technology company based in Kansas City, describes HealtheIntent as a cloud-based platform that enables health care systems to aggregate, transform and reconcile data across the continuum of care. The system is designed to help providers improve outcomes and lower costs for health and care.

Dr. Anthony Billitier, medical director for Millennium, gave an update on the program to hundreds of providers, calling it an important tool to improve outcomes and lower costs.

“We can have that 360-degree view of patients,” he said. “I’m telling you, once we build that, that doesn’t exist anywhere else that I know of. It will be extremely useful.”

Millennium will get much of the data for the effort through HealtheLink, the regional health information organization. Initially, the system will be fed data from six hospitals, with additional data coming from the thousands of providers and over 800,000 consenting patients whose health information data is shared through HealtheLink.

Daniel Porreca, executive director of HealtheLink, said although it won’t be using the system capabilities directly, it should help doctors get the information they need to provide better and more efficient care.

“Using population health tools such as HealtheIntent to analyze and better understand patient populations and individual patient health risks is very beneficial to patient care,” he said.

The partners also are working to add claims data, as well as information on the social determinants of health, such as whether a patient is homeless or doesn’t have access to transportation to pick up medication.

Once aggregated, the system will allow for more deep dives of data and analytics to identify who needs the most help. Millennium is one of the performing provider system groups working to improve the health care delivery system for more than 330,000 Medicaid recipients. The goal of the state’s DSRIP program is to reduce costs related to Medicaid, including unnecessary hospital readmissions and emergency department visits.

Billitier said HealtheIntent will allow providers to focus their efforts on the sickest of patients who take up the most resources.

“The good news is the 80/20 rule is alive and well,” he said, pointing to the statistic that 80 percent of health care costs are expended on just 20 percent of individuals.

“We don’t need to throw all of our resources at many of our patients,” Billitier said. “But the ones who are high needs, we better find out who they are and we better target our limited resources at them. HealtheIntent will allow us to do that.”


Tracey Drury


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Health Organizations Partnering Up With Churches to Improve Community Well-Being

By Katie Gibas Friday, August 26, 2016 at 05:00 AM EDT



For many, Sunday service is more than just prayer. It’s about building a community. For many pastors, it’s about building a healthier congregation, which is why Pastor Dennis Lee has a nurse practitioner at his services.

“Part of our program each and every Sunday is she gives us a health tip. She takes anywhere from five to 10 minutes and gives us health tips on different situations that are going on, and the congregation is really starting to appreciate it,” said Lee.

Now, many health organizations are realizing the benefit of partnerships with local churches as a way to improve community health.

“Their connections to other people, particularly in their faith communities, because being engaged with other people really does help to improve health,” said Dianne Lumis, with UB School of Nursing.

Millennium Collaborative Care is partnering with several faith organizations across New York state to offer health clinics.

“This gives the opportunity to have discussions, longer acting discussions and be able to have more questions that are answered. We have healthy recipes. We have ways to exercise, and part of it is really just breaking down barriers, that we are a partnership and we are not telling you what to do,” said Lumis.

“One of the great things about having these health events is that people have the opportunity to get health information about their medical needs and how to take care of themselves,” said Lee.

The training is helpful for students entering medical professions to understand the underlying social determinants of health.

“Often clinical training is at the hospital, and they really don’t know what people are going home to. They don’t understand the barriers to getting medications, to engaging in care, trying to get to providers. This event helps them to, number one, talk one on one and have a conversation with individuals in the communities that they may not be familiar with to understand some of the barriers,” said Loomis.

The goal is build health partnerships with as many churches across the state as possible.



NYS far behind national heart health benchmark

Jul 18, 2016

Uncontrolled blood pressure is the number one killer locally, according to Millennium Collaborative Care, a five-year, state-funded effort to prevent and treat the major health problems confronting our region. The effort was made necessary because Western New York has a number of problem areas, including heart health.

Listen – 1:25

WBFO’s Marian Hetherly reports

In 2012, the national Million Hearts campaign established a goal of preventing 1 million heart attacks and strokes in five years by controlling blood pressure.

“But what the goal really is to control blood pressure, because blood pressure is one of the key drivers of heart attacks and strokes,” said Priti Bangia, Millennium population health manager. “So bring those with high blood pressure under control and have 70 percent of those with blood pressure controlled across the U.S.”

However, Bangia said, we are far from meeting that 70 percent goal locally. She said only 50 percent of New York’s Medicaid population have their blood pressure under control, so there is a lot of work still to do – even if the goal is eventually met.

“It’s not something that we can say, ‘Oh, we’ve reached our five-year goal. That’s the end, then stop,’” she said. “The goal really is to continue to push for improving our heart health, to continue to recognize that blood pressure is the number one killer, to continue to screen people, so they’re not having heart attacks and strokes in their 40s to 60s.”


Priti Bangia is population health manager for Millennium Collaborative Care, a five-year effort to reduce the region’s major health problems.

Credit Peter Ciotta / Millennium Collaborative Care

Bangia said heart attacks and strokes are largely preventable, by watching what we eat, whether we smoke, whether we exercise and how regularly we see a physician. To help with that, Millennium and the University at Buffalo School of Nursing are holding a health fair that will feature free blood pressure checks on Wednesday from 5 p.m.-7 p.m. on the lawn of Hayes Hall on the South Campus.

WBTA Batavia


Meredith Rutherford, Communications Director, Finger Lakes Performing Provider System, Inc. (FLPPS), far left, joins Catherine J. Lewis, Director of Community Based Initiatives, Millennium Collaborative Care, PPS and Rita Hubbard-Robinson, JD, Project Director, Patient Activation Measures and Engagement, Millennium Collaborative Care in the WBTA radio studios.

On Monday, July 11, 2016, Millennium Collaborative Care teamed up with the Finger Lakes Performing Provider System, Inc. (FLPPS) and Lake Plains Community Care Network to co-host a “Voice of the Consumer” meeting at Lake Plains offices located at 575 East Main Street, Batavia, NY.

A community engagement priority, the meeting strived to ensure the interests of Medicaid consumers are included and understood, while also enabling Genesee county-based Medicaid consumers to:

  • Help identify gaps in services.
  • Make recommendations to improve patient communications.
  • Review patient education materials.
  • Provide suggestions to enhance patient understanding of written materials.

Prior to the meeting, representatives from FLPPS and Millennium spoke to WBTA radio Morning Show Host Jerry Warner about ongoing collaboration between FLPPS and MCC; and ongoing Delivery System Reform Incentive Payment (DSRIP) program improvement efforts.

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Dr. Anthony Billittier, Emergency Physician, UBMD/ECMC and CMO Millennium Collaborative Care, discusses the important of having access to HEALTHeLINK in a hospital Emergency Department.


HEALTHeLINK’s YouTube channel:


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