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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 de-escalation• 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.
Evan Brooksby
