Al Hammonds, Millennium Executive Director, welcomes “Summit” participants.

Overcoming the “Loneliness Factor”.… Learning and implementing new Social Determinant of Health and Diabetes screening skills…. Re-branding patient communications to change culture.

These are just a very few of the ways Western New York’s largest hospital, behavioral health, primary care and managed care organizations are working to prevent and reduce avoidable emergency department visits and hospital admissions.

Recently, Millennium hosted a Summit meeting under the leadership of Christine Blidy, Chief Network Officer, and developed by Saralin Tiedeman, Post-Acute Care Manager, with support from Tammy Fox, Director, Project Management Office. The objective of the “Summit” was to bring together representatives from the four major regional hospital groups (Erie County Medical Center, Kaleida Health, Niagara Falls Memorial Medical Center, Olean General Hospital), in addition to leaders from several of the region’s largest Primary Care, Behavioral Health and Managed Care organizations.

“By joining together to share best practices, success stories, and ideas for the immediate future, we will maximize this Summit by strengthening mission-critical linkages,” said Al Hammonds, Executive Director, in his kick off remarks. “Most importantly, we will come away with renewed and reinvigorated trust – which from my perspective after almost four years of DSRIP – is really the key to the most important work we all want to achieve.”

“Clinical integration is where our heart and passion lies,” added Christine Blidy, Chief Network Officer. “By working collaboratively and across provider types we can make the greatest impact on our most important goals.”

The following is a summary of Summit “success sharing” highlights including:
• Organization
• Presenter
• Challenge
• Solution(s) Shared
• Results

Organization: Erie County Medical Center

Presenter: Lucia Rossi, Director of Outpatient Operations, Primary Care

Challenge: How to increase Emergency Department (ED) diversion through primary care promotion?

Solutions Shared: In December of 2017, ECMC launched a re-branded “Primary Care Access Center”

“Choosing this name was important to changing the culture,” explained Lucia Rossi. “We wanted to help patients understand that there are services you can get from your Primary Care doctor.
“We began with a greeter who in a friendly manner engaged patients to determine if the need was for Primary Care or the Emergency Department,” Lucia continued. “The greeter explained to the patient that he or she could see the Primary care doctor today.”

• Overall, approximately 35 Medicaid patients per month were re-directed to Primary Care.
• ECMC’s Primary Care Access Center was able to get 75 percent of their patients in for their physicals this year due to ED diversion/ Primary Care Access Center program.
• Community Based Organizations were engaged to assist with patient transportation.
• Opportunities are being evaluated to extend Primary Care Access Center hours to 8 PM; and to possibly open Primary Care to patients outside of ECMC as an option for ED diversion.

Organization: BestSelf Behavioral Health

Presenter: Liz Woike Ganga, Chief Operating Officer

Challenge: How to immediately connect clients who come to the ECMC ER to behavioral health services?

Solution Shared: BestSelf partnered with ECMC to create the “ECMC Behavioral Health Bridger Program” whereby a BestSelf team serves as the “Bridger”.
“The most important part is the ability to develop a relationship with the client, to build trust,” explained Liz Woike.

• Since beginning in May 2018, 60 clients have been seen by the Bridger and connected directly to BestSelf services following hospital discharge. Compliance to subsequent outpatient Behavioral Health appointments following home visit by the Bridger appears to be increasing.

Organization: Horizon Health

Presenters: Michelle Curto, Vice President of Administration and Brenda John Banach, Vice President of Quality Operations/Chief Compliance Officer

Challenges: How to implement community behavioral health strategies to improve quality and outcomes?
How to improve patient medication adherence?

Solutions Shared:
Horizon Health partnered with Kaleida to train staff to perform blood draws to enable A1C screening for Diabetes.
Horizon is partnering with Pharmacists to provide home delivery for patients.

“We never did blood draws in our clinic before,” explained Michelle Curto. “We partnered with Kaleida to train our team and also created multiple levels of education sheets for both our clinical staff and patients.”
“One of the Pharmacists we work with will sync all medications for the patient,” Michelle added.

Organization: Kaleida

Presenter: Barbara Surace, Director, Regional Perinatal Care Outcomes

Challenge: Develop initiatives to reduce ambulatory ED visits.

Solution Shared: Kaleida launched the “Oishei Asthma Pathways Program” primarily focused on children ages 6 to 17. The program is managed by Catherine Phillips who serves as Project Manager for Utilization Management.

“Children with asthma should be able to be healthy with asthma,” said Barbara. “We wanted to be as proactive as possible. We looked at what a day in the life looks like for a patient with asthma…and worked very actively with our Visiting Nursing Association (VNA) support, in addition to weekly calls with Patient Coordination and Social Work.”

According to Barbara, the “Oishei Asthma Pathways Program” employs the “Asthma Action Plan”, which was developed by Kaleida Primary Care Physicians and is used statewide.

• A Care Navigator is based in the Oishei ED from 7 AM to 11 PM.
• “Proactive education efforts are underway to capture the population and educate them so they don’t even come to the ED,” said Catherine Phillips.

Organization: Niagara Falls Memorial Medical Center (NFMMC)

NFMMC Team: Front row from left: Chuck Petko, Vicki Landes, Cate Velzy, Sheila Kee, Jonathan Rossi, Timothy Shaughnessy, Patty LeGasse. Back row from left: Kevin Burgess, Vicky Wideman, Christopher Herndon, Peggy Grandinetti

Presenter: Sheila Kee, Vice President and Chief Operating Officer and members of the NFMMC Team.


• How to enhance systems to achieve improvements in patient outcomes and enable measurement of performance.
• How to overcome the “Loneliness Factor”?
• How to implement Behavioral health screening in the ED?
• How to better engage the most frequent users of the ED? (High utilizers of the Emergency Department represent one half of one percent in NYS; but cost 11 times more than normal Medicaid visits.)

Solutions Shared:

NFMMC established a new “ED Information Desk”.
“The first thing the patient must now do is stop and register,” explained Sheila Kee. “Our ED Care Manager is then able to talk to the patient about the attributes of Primary care. Slowly but surely, it’s working.”

“We have a system when high utilizers are discharged, we escort them on the same day to Primary Care provider. Continuity of care is key,” Sheila added.
“Under the guidance of Vicki Landes, (RN/BSN, MBA), Vice President, Community Care Coordination and Services, and our Health Home team, we do outreach to Primary Care Providers. When providers work in a true connected circle of care it has a positive impact.”

NFMMC established a new “ED Sandwich Program”
“We have many people who come to the ED for a cup of coffee, to see a friendly face, for a little sense of security, or because they are hungry,” explained Sheila Kee.

“We strive to cater to the individual to devise solutions for each patient,” said Chuck Petko , ED Social Worker . “If someone has been to the ED several days in a row, we work with them to connect them to shelters, soup kitchens and other community-based services.”

NFMMC implemented After Hours Primary Care at the Golisano Center
(The Center is connected to the NFMMC ED by an adjoining hallway.)

NFMMC Implemented ED-Based Screening of Behavioral Health Patients and has begun Behavioral Health Home Visits

NFMMC Engaged in a MAX Series Project Approach and is Achieving Transformation By Focusing on High Utilizer Needs

In addition to implementing an email alert system that contacts the members of the NFMMC High Utilizer Care Team when a patient comes to the ED; NFMMC has also implemented Social Determinant of Health screening and has launched the “Connect 4 U” program which links patients to over 160 community based organizations’ services.

“We work very hard to try to understand why the person is coming to the ED vs. pointing the finger at the person,” said Chuck Petko “It really is more of a systemic and even generational issue, and important factors such as homelessness; loneliness; and issues with medication management play major roles.”

“What I call the ‘Loneliness Factor’ drives so much,” explained Sheila Kee.

“Our approach to care is to meet them where they are at,” added Chuck. “I go out into the streets to look for and meet with patients who are homeless.”

“The MAX program produces results,” concluded Sheila Kee. “It builds team work like crazy. I think it’s one of the best projects in my career.”

NFMMC implemented an ‘ED Hot Spotter’ Program
After nine ED visits, a patient is assigned to the NFMMC “Hot Spotter Program”.

“We use a social determinants of health screening tool,” said Chuck Petko.
“We also have a ‘Pop Up Alert’ system which gives everyone involved in our ED Hot Spotter Program a picture of the patient.”

• Patients are finding the new NFMMC ED Information desk is very convenient with no issues.
• Behavioral Health clients were thrilled the NFMMC team was coming to their home and especially appreciated receiving breakfast from the team.
• NFMMC reduced repeat visits by high utilizers by 44.9 percent.
• Medical readmission rate for Medicaid clients is down to 4.4 percent.
• From March thru June 16, NFMMC identified 763 high utilizers. Of these patients, 52 percent have had face-to-face contact with a social worker.
• NFMMC reduced ED High Utilizer visits by 16.5 percent

Organization: Olean General Hospital

Presenter: Gail Bagazzoli, Vice President of Quality
Challenge: How to implement strategies to promote medical screenings for patients with Behavioral Health diagnoses?
Solution Shared: OGH Implemented Hgb A1C Screening in the OGH Emergency Department
“If a patient is over 6.5, the Diabetes Educator facilitates immediate communications with Primary Care,” explained Gail Bagazzoli. “Patients are used to coming to the ER,” she added. “They see the ER as their second home.”
• OGH has begun screening and connecting patients back to Primary Care who are found to be at high risk for developing diabetes. To date, OGH has screened over 200 people.
• OGH has developed a new Diabetes education flyer.



To view photos from the Summit, please click here.


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