2.a.i - Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Medicine

  • Rebalance the health care delivery system to meet the needs of the community
  • Ensure patients needing Care Coordination receive appropriate care – create system linkages
  • Expand access to high-quality primary care


Care coordination / patient navigation / population health

  • Ensure patients receive appropriate health care and community support, including medical and behavioral health, post-acute care, longterm care, and public health services
  • Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers
  • Achieve 2014 Level 3 PCMH primary care certification for all participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standards by the end of Demonstration Year (DY) 3

Integration of care / IDS

  • All PPS providers must be included in the Integrated Delivery System; the IDS should include all medical, behavioral, post-acute, long-term care, and community-based service providers within the PPS network; additionally, the IDS structure must include payers and social service organizations, as necessary, to support its strategy
  • Utilize partnering HH and ACO population health management systems and capabilities to implement the strategy towards evolving into an IDS
  • Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of Demonstration Year (DY) 3
  • Ensure that EHR systems used by participating safety net providers must meet Meaningful Use and PCMH Level 3 standards by the end of Demonstration Year (DY) 3

Patient and family engagement

  • Engage patients in the integrated delivery system through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations, as appropriate

Payment reform

  • Contract with Medicaid Managed Care Organizations and other payers, as appropriate, as an integrated system and establish value-based payment arrangements
  • Establish monthly meetings with Medicaid MCOs to discuss utilization trends, performance issues, and payment reform
  • Re-enforce the transition towards value-based payment reform by aligning provider compensation to patient outcomes

PMO Project Representatives:

Susan Kopp - Kopps@mail.amc.edu

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