MCC Poster: “Enhanced Patient Services: A Novel Evidence-Based, Community-Based Program to Coordinate Care and Reduce Hospitalizations”
Millennium Collaborative Care (MCC) joined Performing Provider System (PPS) representatives from across New York state at the NYS Medicaid Population Health Symposium held Nov. 18 – Nov. 19 at the Grand Hyatt New York in New York City.
MCC representatives included Al Hammonds, CSSBB, Executive Director; Christine Blidy, Chief Network Officer; Steve Nelson, Director – VBP and Performance; and Saralin Tiedeman, MS, OTR/L, Director, Population Health Clinical Performance.
They were joined at the Symposium by partners Sheila Kee, Chief Operating Officer, and Kevin Burgess, Clinical Director, Niagara Falls Memorial Medical Center; Andrea J. Wanat, Vice President of Operations, Value Network, Behavioral Health Care Collaborative Independent Practice Association; Michelle Curto, Vice President of Operations, Horizon Health; and Douglas Bisher, Peer Specialist/Certified Recovery Peer Advocate, WNY Independent Living of Niagara County.
According to organizers, “the primary objective of the Annual Learning Symposium for the Delivery Service Reform Incentive Payment (DSRIP) program is to provide a forum to share the perspectives and insight of the DSRIP Performing Providers Systems, Physical and Behavioral Health Providers, Managed Care Organizations, and community organizations addressing the Social Determinants of Health. The goal of the summit is to provide a platform for these perspectives on advancing Value Based Payment (VBP) and gain understanding for further discussion.”
In addition to keynote presentations by Sandro Galea, MD, MPH, DRPH, Dean and Robert A. Knox Professor, Boston University of Public Health; and Rebecca Onie, JD, Founding Partner, The Health Initiative; the Symposium featured “Poster presentations” by selected PPS organizations including the Millennium team who presented “Enhanced Patient Services: A Novel Evidence-Based, Community-Based Program to Coordinate Care and Reduce Hospitalizations”.
The Millennium poster presentation concluded:
We feel that the success of the program was due to care coordination by a highly trained multidisciplinary team approach. Using a multifaceted approach to care coordination, we were able to address a wide range of determinants such as medication adherence, health literacy, disease state education, housing, and transportation. By meeting patients in their own environment, we were able to be the eyes and ears of our partners within the community. One of the key differences between most other care coordination or in-home health organizations was the fact that all our meetings were face-to-face.
We also had clinical pharmacists involved at the start of the program to work directly with the patient for medication adherence and education. Additionally, the pharmacists provided medication reconciliation and offered suggestions to the primary care practice when indicated for medication optimization and evidence-based medication treatment plans for each individual patient. This information was valuable to the treating provider due to the fact that the team had a 360° view of the patient, which is often impossible in a busy primary care practice.
The coordinated effort of the team working together to take care of the total patient in conjunction with the primary care office served as the foundation of the success of the program.
Please click on following to view a PDF of Millennium’s symposium poster: MCC ENHANCED PATIENT SERVICES POSTER
Niagara Falls Memorial Medical Center; Value Network Behavioral Health Care Collaborative Independent Practice Association and Horizon Health Lead Breakout Session Presentations
An additional key component of the Conference were “Breakout Session” presentations including the following delivered by MCC team members and partners Niagara Falls Memorial Medical Center; Value Network Behavioral Health Care Collaborative Independent Practice Association and Horizon Health.
PPS Funded Innovation Programs: Using a Community Approach to Improve Behavioral Health Outcomes
Niagara Falls Memorial Medical Center (NFMMC) plays a vital role serving 40,000 Medicaid beneficiaries in Niagara County, NY. NFMMC has leveraged Innovation funding through Millennium Collaborative Care PPS to rollout programs that have demonstrated success in closing gaps in care. The programs target gaps in medication adherence, diabetes and cardiovascular disease monitoring, and follow-up after behavioral health inpatient discharges. The NFMMC team has also seen benefits beyond the quality metrics as their home visit strategy has touched lives in powerful ways. The hospital team will outline their program models, provide lessons learned, and share a number of moving home visit experiences.
Sheila Kee, Chief Operating Officer, Niagara Falls Memorial Medical Center
Christine Blidy, Chief Network Officer, Millennium Collaborative Care
Presenters: Kevin Burgess, Clinical Director, Niagara Falls Memorial Medical Center
Douglas Bisher, Peer Specialist/Certified Recovery Peer Advocate, WNY Independent Living of Niagara County
System Transformation- Small Steps Towards Big Behavioral Health Outcomes in Western New York
In this presentation, Value Network Behavioral Health Care Collaborative Independent Practice Association will lead the discussion with a diverse panel who will provide an overview of how four lead partner behavioral health entities worked collaboratively with their local PPS towards the achievement of identified outcome measures. An interactive discussion will focus on what has worked and what hasn’t worked in their efforts to change a complicated system, and how to help operationalize changes across a large human services entity from intake, admissions and beyond. Participants will hear how Value Network’s strategies are leading to contracting opportunities with managed care organizations (MCOs) and learn the simple (and not so simple) steps that can help them on the road to developing Value Based Payment contracts with their local MCOs.
Andrea J. Wanat Michelle Curto
Andrea J. Wanat, Vice President of Operations, Value Network, Behavioral Health Care Collaborative Independent Practice Association
Michelle Curto, Vice President of Operations, Horizon Health
For further information on the Annual Learning Symposium, please click the following: http://www.dsriplearning.com/
Christine Blidy, Chief Network Officer listens as a poster session attendee comments on Millennium’s Enhanced Patient Services program.
Saralin Tiedeman, MS, OTR/L, Director, Population Health Clinical Performance responds to a poster session attendee question.
PPS representatives from across New York state attend the symposium poster presentation session.