Working Together

Established in 2015, CNY Care Collaborative works to improve delivery of healthcare services to Medicaid patients in CNY, cutting avoidable hospital use by 25 percent

By Mary Beth Roach

You may have seen the ads on local media promoting an initiative called CNY Care Collaborative and its message of “Working Together.”

But what is the CNY Care Collaborative all about?

The CNYCC is one of the lead agencies in this region helping to lead the state’s efforts to transform healthcare to better serve the Medicaid patient population and prepare the region for a different payment system — one that is value-based as opposed to fee-based, according Virginia Opipare, executive director.

In 2014, New York state announced its Medicaid redesign team reforms, a five-year plan aimed at improving the delivery of healthcare services as well as cutting avoidable hospital use by 25 percent.

In an all-too-common scenario, individuals in need of medical treatment go to an emergency room because they don’t have a primary healthcare provider, and they don’t know where else to turn. They are treated and released. But because they are not connected to any care provider, where they might receive ongoing or preventive care, their chances of repeated visits to the ER are high. And it’s a major factor in rising Medicaid costs.

The main means for implementing the reforms has been the delivery system reform incentive payment program (or DSRIP), with 25 different performance provider systems (PPS) to cover each region in the state. The CNY Care Collaborative, established in 2015, is the PPS for the six-county area of Cayuga, Lewis, Madison, Oneida, Onondaga, and Oswego.

To achieve its goals CNYCC has been taking a multi-pronged approach.

“Ultimately, we wanted to establish a network that better coordinates care across this region and develop programs that enhance access,” Opipare said.

She discussed some of their initiatives, among them improved connections across health-care agencies; development of a navigator system in local emergency rooms; and creation of a population health management system.

CNYCC has established a network with 125 organizations across the region that provide a wide range of services. These organizations include hospitals, senior care facilities, mental healthcare providers and community-based organizations, which often are more familiar with the most vulnerable populations in an area.   

CNYCC recently began running ads on local media to increase awareness across the region.

“Anybody involved in healthcare or social service has the opportunity to be part of our partnership. That’s why our advertisement focuses on working together across the region to improve the overall health of our community,” Opipare said.

CNYCC, she added, helped establish the navigator program in local emergency departments to assist patients that frequently use the ER.

The navigator program, funded by CNYCC, allows local hospitals to employ ER Navigators that can identify patients using the emergency department for non-emergency situations.

The navigators can determine if there are underlying reasons for the repeated visits to the ER, according to Bj Adigun, director of communications.

“The patient may not have their own primary care doctor. Or they may be homeless, which is one reason they’re showing up in the ED. Or they may not have had a decent meal in a few days. Being able to connect that individual with resources in the community that can help address some of those social needs” will hopefully prevent them from having to chronically use the ED, Adigun said

“The key is making sure we connect the patient to the type of service that they need.” Opipare said.

Population Health Management System

CNYCC is also working with IBM Watson Health to develop a population health management system that integrates data from a variety of electronic medical record systems across the region and can offer advanced analytic capabilities. The technology will offer a community-wide view of the many factors that can impact care and help improve delivery of services.

“With this technology, care providers will be able to identify the high-risk patients and address areas where they can make the biggest difference,” according to Adigun.

Measuring Success

To determine the ongoing effectiveness of the program, the state has quality measurements for each PPS, including the overall project progress; system transformation, clinical improvement and the impact population-wide.

In addition to the quality measures, the relationships forged by different partners is also a sign of success, according to Adigun.

Attending a recent meeting with partners in one particular county, Adigun said that one of the things he kept hearing was that it used to be rare that these organizations would be all together in the same room.

“For us, that was pretty significant,” he said. “It shows the power of those partnerships and how they can lead ultimately to helping the community.”

And yet another sign of success is the support CNYCC can provide to expand services across the community.

With a $250,000 grant CNYCC provided to AccessCNY, which serves people with disabilities, the agency was able to open a respite home at the beginning of 2018, for adults experiencing mental health and drug abuse issues. It is known as Berkana Crisis Respite.

After the opening, representatives from AccessCNY told the story at one of the CNYCC’s board meetings of one of their patients and how the respite center had changed his life.

 If you can do that for one, that means something. If you can help one life make a big difference, that’s important. And our goal is to help as many as possible,” Opipare said.