• Cardiovascular Health – implementation of the Million Hearts Campaign
  • Ensure clinical practices use evidence-based strategies to improve management of heart disease
  • Provide once-a-day medications when appropriate
  • Develop and implement evidence-based clinical treatment protocols for heart disease (high blood pressure, cholesterol, etc.)


Care coordination / patient navigation / population health

  • Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management
  • Follow up with referrals to community based programs to document participation and behavioral and health status changes
  • Facilitate referrals to NYS Smoker’s Quitline

Clinical protocols / standard of care

  • Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting
  • Use the EHR to prompt providers to complete the 5 As of tobacco control (Ask, Assess, Advise, Assist, and Arrange)
  • Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol
  • Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment
  • Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit
  • Prescribe once-daily regimens or fixed-dose combination pills when appropriate
  • Document patient driven self-management goals in the medical record and review with patients at each visit
  • Develop and implement protocols for home blood pressure monitoring with follow-up support
  • Generate lists of patients with hypertension who have not had a recent visit and schedule a follow-up visit
  • Adopt strategies from the Million Lives Campaign

Integration of care / IDS

  • Use EHRs and other technical platforms to track all patients engaged in the project
  • 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 directed exchange, alerts and patient record look-up, by the end of Demonstration Year (DY) 3
  • Ensure that EHR systems used by participating safety net providers meet MU and PCMH Level 3 standards by the end of Demonstration Year 3
  • Perform additional actions including “hot spotting” strategies in high-risk neighborhoods, linkages to Health Homes for the highest risk population, group visits, and implementation of the Stanford Model for chronic diseases
  • Engage a majority (at least 80%) of primary care providers in this project

Other / misc.

  • Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment

Payment reform

  • Form agreements with the Medicaid Managed Care organizations serving the affected population to coordinate services under this project

PMO Project Representatives:

Tara Foster- fostert1@mail.amc.edu


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