Population Health Services Update

Population Health Transformation = ‘Medical Neighborhood’ Implementation

By Al Hammonds, CSSBB, Executive Director

Millennium and our extended team of Partners across Western New York’s eight counties are off to a focused start on 2018/DSRIP Year 3/Q4 priorities.

In the critical area of organizational leadership, we’re extremely excited to have Pastor Kinzer M. Pointer assume a new role as Chair of Millennium’s Board of Managers. Pastor Pointer succeeds Anne Constantino, President & CEO, Horizon Health, who provided outstanding Chair leadership, and whom we’re also thrilled will continue to serve in a committee leadership capacity.

Millennium has also continued to advance our organizational development by refining our mission, vision and key DY4 strategic priorities — as follows — to guide and drive us through the coming calendar year and beyond.

Our Mission/Purpose: We are a Population Health Services Organization for our Partners within the MCC network. Beyond the services we provide, our true purpose and passion is improving health care quality, access and outcomes through a best-in-class Physician-driven and analytics enabled transformation.

Our Vision: We will be a diverse, Community-based collaboration that enables healthier people through Value-Based Population Health.

Our DY4 Strategic Priorities: Payment System Reform; Delivery System Integration; Physician Stewardship; Healthier Patient Behaviors.

Specific to the continued advancement of delivery system integration; Millennium is concentrating a majority of our resources on driving Population Health transformation through “Medical Neighborhood” implementation.At a grass roots level, the “Medical Neighborhood” construct is key to healthcare transformation because it requires collaboration by a spectrum of providers including hospitals, primary care, behavioral health, home health, skilled nursing, community based organizations, etc.

The “Medical Neighborhood” also thrives on bi-directional communication and relies on the active use of the public data tool HEALTHeLINK. As a result of these capabilities and more, the “Medical Neighborhood” ultimately ensures Medicaid clients, who may be challenged by social determinants of health (transportation, nutrition, housing, etc.) receive the integrated/coordinated care that they need. As we begun what I hope will be a most successful 2018 for all, I look forward to connecting with our Partners across WNY on how you are continuing to lead healthcare transformation by collaborating on the development and implementation of new “Medical Neighborhoods.”

Pastor Pointer was recently interviewed by Avery Schneider, Lead Reporter for the WBFO Health & Wellness News Desk, on the expansion of the “Beauty & Barber Shops Blood Pressure Self-Screening Initiative” to six Erie County/Buffalo locations.


Advancing COPD Population Health/Medical Neighborhood Pilot

By Anthony J. Billittier IV, MD, Chief Medical Officer

Last quarter, I reported plans to launch a Chronic Obstructive Pulmonary Disease (COPD) Medical Neighborhood Pilot.

To briefly re-cap, a COPD-focused “Medical Neighborhood” is led by the Primary Care Physician/provider and takes into consideration all the attributes a COPD patient needs to maintain stability; both medically and socially. For example, the COPD Medical Neighborhood may need to include several specialists in key areas such as Pulmonology; Respiratory, and Behavioral Health. And depending on the social determinant of health challenges the patient may be experiencing; important linkages may also need to be established with Home Care and Community-Based Organizations.

Bringing all key elements efficiently together requires the development of a care plan involving all Medical Neighborhood participants; and then coordinating that agreed upon plan through Primary Care with an abundance of bi-directional communication so all caregivers know what is happening with the patient as close to real time as possible. Ultimately, it’s all about the Primary Care lead knowing who the referral sources are within the Neighborhood so when an incident arises and a phone call comes in about the patient, Primary Care can activate systems of care more readily.


The framework for the COPD Medical Neighborhood Pilot initiative continues to evolve on several fronts. We have engaged Millennium’s new Care Coordination Support Team to assist with COPD projects taking root at three Primary Care organizations — The Chautauqua Center, ECMC Grider Family Health Center, and ECMC Internal Medicine. Initial work at these practices involve defining and implementing diagnostic standards, environmental controls and new workflows; solidifying relationships with practice-specific Medical Neighborhood partners; and establishing bi-directional communication processes with them.

We have also continued to communicate/distribute the Gold Standards of Care, and due to continued demand, are pleased to continue to make the handbook on “Global Initiative for Chronic Obstructive Lung Disease” available. Please click HERE for a copy.

Lastly, we are developing further education in the form of a comprehensive webinar program that will be focused on the implementation of a “COPD-Focused Medical Neighborhood.” The target audience includes our COPD Work Group in addition to Behavioral Health, Community Based Organizations, Primary Care, Hospitals, and Post-Acute/Home Care. The ultimate objective of this MPA deliverable is to communicate critical information needed to successfully manage a COPD patient outside hospital walls. Please watch for an invitation to our COPD Medical Neighborhood webinar in the coming weeks.


Value Based Payment Update

MCC, CPWNY Collaborating on Value-Based Payment Education

By Christine Blidy, Chief Network Officer, DSRIP

The Medical Neighborhoods of today… and tomorrow… will be built on a foundation of Value Based Payment arrangements.

To continue to assist Partners in VBP development and implementation, Millennium is working in partnership with fellow Performing Provider System Community Partners of Western New York to pursue a regional approach to VBP support and education. By collaborating, our joint objectives are to consolidate best-in-class current offerings, and in the process, develop and deliver VBP educational opportunities and materials applicable to all, as opposed to being specific to any one PPS.

To this end, Millennium Collaborative Care and Community Partners of Western New York (CPWNY) are pleased to collaborate on offering webinars in February and March specific to Community Based and Behavioral Health organizations. The webinars are intended to be of interest to organizations and staff at various levels of familiarity with value-based payment.

Kristin M. Woodlock RN, MPA, CEO, Woodlock & Associates  will serve as the Presenter for each webinar. Kristin has over 30 years of public service in County and State Government.  She served in various executive roles in the New York State Office of Mental Health, including Commissioner.  Kristin currently consults with CBOs, Behavioral Health and Health Care Providers across the Country on operational strategies for value-based payment.

For further information on our Feb. and March VBP webinars, including registration, please see the following.


CBO Webinar 1: “Creating Your CBO Strategy for Value-Based Payment”
Date: Thurs., Feb. 8, 2018
Time: 2:30 PM to 4 PM

BHO Webinar 1:   Introduction to Value-Based Payment for BH Organizations
Date: Fri., February 9, 2018
Time: 1 PM to 2:30 PM

BHO Webinar 2: Personalizing Your Organizational VBP Strategy for your BH Organization
Date: Fri., February 23, 2018
Time: 1 PM to 2:30 PM

CBO Webinar 2:  Operationalizing Value-Based Payment for your CBO
Date: March 1, 2018
Time 2:30 PM to 4 PM



Introducing Care Coordination Support Team

Introducing Millennium’s Care Coordination Support Team: (from left) Esra Mustafa, Care Manager Pharmacist; LaTonya Diggs, LMSW, Behavioral Health Project Manager; Tera McIlwain, Care Manager Pharmacist; Dr. Kenyania Davis, Millennium Assistant Medical Director; Michele Mercer, Chief Clinical Integration Officer; Sandy McDougal, Project Manager, Nicole Aloisio, Care Coordinator Assistant; Ebony Patterson-White. Community Health Worker Coordinator 

Millennium Launches Care Coordination Support Team

By Michele Mercer, RN, MSHA, Chief Clinical Integration Officer

As a follow-up to the “Care Coordination and Transitions of Care Survey” reported on last quarter; I’m extremely pleased to update that the new Millennium Care Coordination Support Team is up and running, and ready to continue support our Partners.

The Team and overall care coordination support initiative is led by Sandy McDougal, Project Manager; with key strategic guidance from Dr. Kenyania Davis, Millennium Assistant Medical Director, who is working to define care coordination priorities as relates to Primary Care organizations. LaTonya Diggs, LMSW who serves as Behavioral Health Project Manager, has also accepted the task of leading development of the Team’s social determinants of health services support. Ebony Patterson-White is the team’s Community Health Worker Coordinator and Nicole Aloisio serves as Care Coordinator Assistant.

In addition, based on key survey feedback identifying medication reconciliation and adherence as complications leading to avoidable admissions and readmissions, Millennium is very pleased to welcome Tera McIlwain and Esra Mustafa to the Care Coordination Support Team as Care Manager Pharmacists.  

Tera holds a Doctor of Pharmacy degree (PharmD) from D’Youville College, and most recently worked as a Pharmacy Resident at Union Medical Pharmacy in West Seneca, NY.  She is a member of the Pharmacists Society of the State of New York, Inc. (PSSNY); the American Society of Health-System Pharmacists (ASHP); and the American Pharmacists Association (APhA).

Esra graduated Magna Cum Laude from the University at Buffalo School of Pharmacy with a Doctor of Pharmacy Degree (PharmD).  She most recently worked for Mobile Pharmacy Solutions as a Clinical Pharmacist.  Esra also served as an Adjunct Instructor at the University at Buffalo.

As key members of our new Care Coordination Support Team, Tera and Esra will support our Partners with medication adherence and reconciliation challenges that Medicaid patients may face.

With the launch of our new Care Coordination Support Team, Millennium is committed to zeroing in on the key social determinant barriers that our Medicaid clients experience (transportation, housing, nutrition, childcare, employment). We are on a mission to help our Partners break down these barriers, and in the process, help our Partners provide patients the care they need.

Please contact Michele Mercer at 716-898-4293; mmercer@millenniumcc.org if interested in learning more and/or to begin working with our new Care Coordination Support Team.


Data Analytics Update 

What’s the Big Deal Using Data Analytics to Improve Care?

By Jon Phillips, Chief Analytics Officer 

Our healthcare delivery systems are under-going significant change. The pressure is on to deliver better and more cost-efficient care. A significant driver of this change is driven by shifting reimbursement models from traditional fee-for-service to Value Based Payments. The rise of population health management models that identify and stratify patient health risk to appropriately manage chronic diseases and a stronger focus on promoting wellness and prevention is needed to meet today’s challenges. To support this change, data and analytics is needed to successfully support our care providers in meeting today’s challenges to do more with less.

Millennium’s population health management program is targeting six critical success factors that are important to achieving our transformation goals for our Medicaid members in Western New York.

1.            Link members to a primary care provider   We will use our data to identify and engage our Medicaid members who are not presently working with a primary care physician and help them choose one that is meets their needs.  Understanding and addressing any barriers to healthcare such as transportation, food and housing needs to be part of this engagement.  Engaging our members in preventative and wellness care promotes early identification of health issues before they become chronic is vitally important.  When chronic conditions such as diabetes, asthma or hypertension are found they can be managed to improve quality of life and reduce the risk of preventable hospital admissions and ER visits.
(Click here to continue reading.)

Behavioral Health Update 

Importance of Screening, Brief Intervention, and Referral to Treatment (SBIRT)

‘Depression Screening & SBIRT’ Webinar Set for Noon, Thurs., Feb. 1

By Andrea J. Wanat, MA, CPP, Director of Behavioral Health 

Substance use and abuse can be costly to individuals and society.

It can lead to multiple interpersonal problems, physical health concerns, and emotional effects. Cardiovascular disease, stroke, cancer, HIV/AIDS, anxiety, depression, sleep problems, as well as financial difficulties, legal, work, and family problems, can all also result from and/or be exacerbated by substance abuse.

To further support ongoing Primary Care efforts to more effectively assist patients who may be in the beginning stages of developing a substance or alcohol use disorder; Millennium has launched a Behavioral Health education initiative focused on delivering “Screening, Brief Intervention, and Referral to Treatment” (SBIRT) training.

This SBIRT initiative originated with our Behavioral Health Best Practices Workgroup (which is a subcommittee of the Millennium Physician’s Steering Committee). This expert panel of Physicians who volunteered their time to address the issue of substance abuse lead the charge to create and recommend the necessary policies, algorithms and educational sessions that make up our SBIRT training. (To further underscore the importance of SBIRT training, it is also included as a requirement in our Primary Care Master Participation Agreements.)

The first SBIRT learning opportunity is being offered on Thurs., Feb. 1 at Noon in conjunction with an overview of Millennium’s Depression screening policies. Local expert, and former ECMC Medical Director for Substance Abuse Units, Dr. Robert Whitney will serve as featured speaker for the Feb. 1 webinar entitled “Depression Screening & SBIRT”. Millennium’s Assistant Medical Director, Dr. Kenyani Davis will lead the discussion on depression protocols and screening. Providers have requested assistance in this topic area, so Millennium developed a useful package of information and this webinar to aid primary care practices. The webinar will serve as a great base for training, and all Millennium PCP practices will receive additional resources to help them to assist patients in their PCP offices. (To join the Feb. 1 webinar, please see access instruction below.)

Overall, SBIRT is an important process that we want all Physicians partners to feel comfortable with as we transition to integrated services and an increased Population Health approach to treating individuals.  For a copy of the Feb. 1 webinar presentation, please email awanat@millenniumcc.org

Additional SBIRT resources are also available via the OASAS web site at www.oasas.ny.gov  or contact Communications@oasas.ny.gov to order publications.


Webinar Start Time: Noon
Please join our Feb. 1 webinar “Depression Screening & SBIRT” from your computer, tablet or smartphone.

You can also dial in using your phone.
United States: +1 (872) 240-3412
Access Code: 555-657-757

Joining from a video-conferencing room or system?
Cisco devices: 555657757@
First GoToMeeting? Let’s do a quick system check: https://link.gotomeeting.com/system-check


Quick Read: MCC Headlines

Donna Brown, Associate Hospital Administrator, ECMC, far left, joins Andrea Hammonds; Michele Mercer, MCC Chief Clinical Integration Officer; Kimberly Backey, MCC Manager of Cultural Competency & Diversity Initiatives; and Kelly Showard, Director of Community Relations, ECMC, in congratulating Al Hammonds on being honored as an NFJC Healthcare Community Leader.

NFJC Honors MCC Executive Director Al Hammonds as 2018 Community Healthcare Leader

Millennium, Erie Niagara AHEC Develop, Distribute New ‘Health Literacy Toolkits’ to Primary Care, Hospital, Community Partners

Pastor Kinzer M. Pointer Appointed Chair, Board of Managers, Millennium Collaborative Care

Beauty & Barber Shops Blood Pressure Screenings Initiative Expands to Six Erie County/Buffalo Locations

MCC’s Ebony Patterson-White Graduates from WNY Trauma Informed Community Initiative 

MCC Team News

Welcome to Millennium!
Beatrix Balogh, Population Health Analyst
Joseph (Joe) Eberle, Director – Data & Analytics
Tera McIlwain and Esra Mustafa, Care Manager Pharmacists

Jeannette Wallace, Administrative Assistant 

In the Press
Click on Photo to Listen to/Read Coverage!

Carla Foster, co-owner of Black Butterfly salon shares with WGRZ TV2 Reporter Claudine Ewing how offering blood pressure self screening helps her clients.

WGRZ: Checking your pressure at the salon and barber shop

WBFO: Blood pressure checks at barber shops and beauty salons expands into Buffalo

Buffalo News: Just Communities federation announces honorees for 2018

Association of Health Care Journalists: For radio reporter, a Health Journalism 2017 panel comes to life


MCC on Radio

Guest: Kenyani Davis, MD, MPH, Assistant Medical Director
Millennium Collaborative Care

Topic: The Importance of Annual Doctor Visit



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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

Millennium Collaborative Care

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t:  716-898-5389

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