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 member s 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.

2.            Use patient registries to identify and address gaps in care.  By collecting all available information on recent patient encounters into a comprehensive patient record, we can use patient registries to help our care providers identify gaps in care that, when addressed, will help reduce risk of conditions getting worse.  There are evidence based protocols that, when followed, will better manage identified conditions or diseases.   This could involve keeping blood sugar levels or blood pressure within a certain range.  When they are out of range corrective actions can take place, such as prescribing medications or life style changes that can restore better health.

3.            Improve coordination of care within and across care settings.  It is important that patient information and care plans are communicated and coordinated when patients are discharged from a hospital back to their physician, skilled nursing facility or home health agency to reduce preventable hospital readmissions or emergency room visit.  Better care coordination and communication is also needed between medical care providers and behavioral health organizations that are working with the same patients to better manage their care.

4.            Encourage consistent use of evidence based protocols and performance data to manage chronic diseases starting with COPD.  COPD is a chronic inflammatory disease that makes it hard for patients to breath. We are using our data and analytics paired with evidence based protocols to improve the effectiveness of our management of this disease as first step toward improved chronic disease management.

5.              Create the most comprehensive patient record in Western New York.  The more information we can provide physicians and their care teams about healthcare services that have been provided for their patients, the better they will be able to create care plans that address their health needs while reducing unnecessary tests or services.  Our data strategy is to combine Medicaid claims data with electronic medical record data from our hospitals, clinics and physician offices to provide a comprehensive longitudinal patient record that is available at the fingertips of physicians and care teams in the form of over 40 chronic disease and wellness registries and ability to generate reports and analysis from the enterprise data warehouse that measure/monitor performance as well as actionable insights to improve health outcomes.

6.            Support the transition to Value Based reimbursement models.   The federal government and health plans are aggressively transitioning care providers to value based reimbursement models that focus on improving the quality of care for chronic diseases, strengthening prevention and wellness programs while driving down unnecessary and costly utilization such as preventable hospital admissions, readmissions and ER visits.  Our work with our partners in pay for performance arrangements is an important step toward this goal.


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

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