NYAPRS Note: Innovative integration models targeting high-needs clients will pave the way for more reform in DSRIP. But with the relatively high rates of unnecessary hospitalizations for people with Medicaid, we remain concerned that hospital systems will attempt to reach outcomes without incorporating community based behavioral health providers in their project plans. The model mentioned below could provide the necessary integration if it fully regarded community needs assessments, community providers with historical and cultural knowledge of clients, and natural supports.
Presby’s Community Health Program Gets Results
Crain’s Health Pulse; 11/5/2014
Four years ago, New York-Presbyterian and Columbia University Medical Center launched an ambitious program to broadly improve the health of their patient base in upper Manhattan. The New York-Presbyterian Regional Health Collaborative, which took two years to launch, brought together technology and team-based care for some 34,000 patients who were deemed high-risk.
The results are encouraging. Emergency department visits in 2013 dropped 29.7%. Hospitalizations fell 28.5%, compared with the year before the launch. Thirty-day readmissions declined by 36.7%. A full study of nearly 6,000 of the project’s patients will be presented at a National Press Club briefing today by Dr. J. Emilio Carrillo, vice president of community health at New York-Presbyterian.
“We took successful models and created one that met the needs of Washington Heights-Inwood,” said Dr. Carrillo. “It’s important to note this is a collaborative model. It’s not an integrated delivery system like Geisinger or the Mayo Clinic.”
In addition to working with Columbia, New York-Presbyterian made use of faculty practices, visiting nurse services, the New York State Psychiatric Institute and the Isabella Geriatric Center, Dr. Carrillo said.
New York-Presbyterian earned a short-term return on investment of 11% thanks to state incentives for medical homes, he added.
The model centered on six care teams, each led by a doctor and nurse care manager, who met weekly for about an hour. Each team of about 12 included medical assistants, community health workers, social workers and registrars. They focused on patients at risk for conditions such as diabetes, heart failure, asthma or depression. Using robust information technology, in particular a Microsoft product called Amalga, the team was able to identify, for example, all diabetic patients who have been to the ED in the past six months. A community member or social worker could then contact patients individually to urge them to see their primary care doctor and take their prescribed medication.
The model’s success means the system is likely to replicate it elsewhere. “We’re building the same medical homes in our east campus [on East 68th Street] with other population groups, and we’re building this technology into our DSRIP project,” said Dr. Carrillo.