By Janet Stoeckl RN, CCM, Clinical Director

Millennium Collaborative Care is actively working with Health Homes, Primary Care Practice (PCP) offices, and Managed Care Organizations in an effort to streamline a process for Health Home Integration with Primary Care Practices.

With our partners from the “Community Alignment in the Health Home Environment,” we’ve identified the need to develop and standardize communication about Health Home services and the need to strategize best ways to integrate Health Home service providers with primary care partners. Regular meetings are occurring to address these initiatives.

We have also developed standard communications and materials to assist practices with understanding the value of Health Homes Services to PCP practices and their patients. A standard Health Home referral document will be distributed to partners and community referral sources.

Health Home goals are to improve the value of care that is being provided for at risk Medicaid beneficiaries. Aligning Health Home providers with primary care practices will support the patient in coordinating their care across the continuum of services, including preventive, outpatient, inpatient and acute hospital care.

WNY has four Health Home Leads: The Greater Buffalo United Accountable Healthcare Network (GBUAHN); Health Home Partners of WNY; Niagara Falls Memorial Medical Center and Health Home of Upstate New York (HHUNY), including Lake Shore Behavioral Health Home Services, and Chautauqua County Department of Mental Hygiene). A Children’s Health Home will be available in December 2016.

Next Steps:
The Health Home Alignment team will be identifying a few Primary Care pilot sites offices to test out the integration needs in order to meet our deliverables. By March 2016 we plan on having Health Homes integrated at Primary Care Sites that currently are not connected.


Al Hammonds joins Janet Stoeckl, Clinical Director and LaTonya Diggs, MSW, DSRIP Project Specialist at the Second Annual DSRIP Statewide Learning Symposium held in September in Syracuse, NY. The Millennium team presented the “MAX Series” project which seeks to reduce avoidable hospital use by linking high utilizers to primary care.

The Symposium was hosted by the New York State Department of Health and attended by Performing Provider System (PPS) organizations across the state. In keeping with DSRIP’s stated goal of restructuring the health care delivery system, the conference focused on system transformation, clinical management and population health. The symposium also offered opportunities for peer-to-peer information sharing, provided guidance from subject matter experts, and highlighted best practices across program participants.


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

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