Michele Mercer


By Michele Mercer, RN, MSHSA

First, a great big thank you to our partners for your contributions to the Delivery System Reform Incentive Payment (DSRIP) Program Year 2 deliverables! (We are in the process of closing out Quarter 4 deliverable reporting requirements and may reach out to some of you for missing information or for clarification.)

The Clinical Integration team is now looking ahead to DSRIP years 3-5 with a focus on three key areas that expand beyond the concept of Patient Centered Medical Home (PCMH) to include the “Medical Neighborhood” targeting:

  • Effective patient-centered care transition and care coordination processes.
  • Active use of tools to support interconnectivity, such as HealtheIntent.
  • Expansion of patient-centered care teams including, demonstration of bi-directional communication processes with other care team and community-based partners.

To be successful in this evolving and complex healthcare environment, Millennium will continue to work with partners to support extending traditional clinically-focused care teams to include non-clinical factors that affect health to ensure these factors are integrated into providing the best patient care.

Efforts in the first two years of DSRIP focused on ensuring that our primary care partners established the foundation of patient-centered care through PCMH accreditation and our behavioral health, acute and post-acute care partners established a foundation for clinical integration.
Focus will continue to expand beyond the internal functions of the PCMH certified primary care practice to our community partners, social service and other organizations which contribute to holistic care for patients.

This expanded focus requires the workforce outside of primary care to understand population health and care coordination and the importance of their role for patients to obtain appropriate, cost-effective care in the right setting.

This structure, also known as the “Medical Neighborhood”, establishes high-functioning primary care practices, as well as ambulatory, behavioral health, acute, post-acute, and community-based health care providers, and non-clinical community-based partners such as community-based organizations (CBOs), schools, and public health agencies, to name a few.

Stay tuned! The Millennium Clinical Integration team will be scheduling appointments with our partners and future workgroup meetings will focus on expanding the care teams and building upon the “Medical Neighborhood” concepts.


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