Albany Medical
Center
The Center for Health
Systems Transformation
DSRIP 101
• Medicaid program
• Redesign care delivery through the use of
health information technology
• Patient focused, evidence based and
project driven
• Reduce avoidable hospital and
Emergency Department admissions
• Transition to value based care
Projects
• Domain 2
– System wide transformational Projects
• Domain 3
– Clinical improvement focused
• Domain 4
– Population Health focused
System Transformation Projects
(Domain 2)
• Integrated Delivery System
– To create integrated delivery systems that are
focused on evidence based medicine &
population health management
• 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
System Transformation Projects
(Domain 2)
• Health Home at Risk Intervention Program
– Expand access to integrated primary care
teams to meet the needs of higher risk
patients that do not currently qualify for Health
Home Care Management services
• Using EHR registries the PPS will identify patients
who do not have access to appropriate care
management services
System Transformation Projects
(Domain 2)
• Create a medical village (or other
healthcare use) using existing nursing
home infrastructure
– Transform current nursing home infrastructure
into a service infrastructure consistent with
the long term care needs of the community
System Transformation Projects
(Domain 2)
• ED care triage for at-risk populations
– Develop and evidence based care
coordination and transitional care program to
assist patients and link them with primary care
• Establish linkages with Patient Centered Medical
Homes through improved information technology
• Provide required screening and immediate
appointments with primary care
• Utilize community based organizations to provide
patient education about how and where to receive
care
System Transformation Projects
(Domain 2)
• Implementation of Patient Activation
Activities to Engage, Educate and
Integrate the uninsured and other
Medicaid populations into primary care
– Increase patient activation related to health
care while increasing resources to help gain
access to primary and preventative services
– Focus on patients who are not interacting with
the healthcare system for various reasons
Clinical Improvement Projects
(Domain 3)
• Integration of primary care and behavioral
health services
– Integrate mental health and substance abuse
services including care coordination
• Provide behavioral health services at PCMH sites
• Provide primary care services at behavioral health
sites
• Provide collaborative care with behavioral health
including depression case managers and stepped
care
Clinical Improvement Projects
(Domain 3)
• Behavioral health community crisis
stabilization services
– Provide appropriate access to behavioral
health crisis services that allow access to
services and providers to support rapid deescalation
• Crisis intervention services that include outreach,
mobile crisis and intensive crisis services
• Crisis residence for up to 48 hours of monitoring to
attempt stabilization
Clinical Improvement Projects
(Domain 3)
• Cardiovascular Health – implementation of
the Million Hearts Campaign
– Ensure clinical practices use evidence based
strategies to improve management of heart
disease
• Implement the Million Hearts Campaign
• Provide once a day medications when appropriate
• Develop and implement evidence based clinical
treatment protocols for heart disease (high blood
pressure, cholesterol, etc.)
Clinical Improvement Projects
(Domain 3)
• Implementation of evidence-based medicine
guidelines for asthma management
– Ensure patients with asthma have access to care
consistent with evidence-based guidelines
• Establish collaboration with Regional Asthma Coalitions
to support population based approaches to asthma
management
• Reach agreement on adherence to national guidelines
and protocols for asthma care
• Include electronic health records, health information
exchange and tele-medicine
Population-wide Projects
(Domain 4)
• In line with the NYS Prevention Agenda
– Intended to influence population-wide health
• Promote Tobacco Use Cessation
– Especially among disadvantaged populations
• Increase Access to High Quality Chronic
Disease Preventive Care and
Management
– Improve incentives for prevention services
such as screening
Great questions!
• How will the system changes under the
DSRIP model impact patient care?
• What about local health care providers?
• What about aging services?
The Center for Health Systems Transformation
at Albany Medical Center
Contact:
George Clifford, PhD.
[email protected]
Evan Brooksby
[email protected]