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Upcoming Important Dates:
October 31st, 2018: PPS Year 4 Second Quarterly report due from PPS
November 6th, 2018:
Confronting Disparities in Care: Discussing Social Determinants of Health,
An Evening of Practitioner Cultural Competency- The Farmers' Museum, Rt. 80, Cooperstown, NY **By registration only**
December 12th, 2018: Q4 2018 PAC Meeting, LCHP HQ
December 19th, 2018: Q4 Executive Governance Body Meeting, LCHP HQ
December 20th, 2018: All Partner Meeting, The Otesaga Hotel, 12-4 pm
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Impressive Patient Outcomes Shared at Hub Assembly Meeting
On September 12th , an array of organizations who work with LCHP gathered at the Otesaga in Cooperstown for the second Hub Assembly meeting. The day commenced with a screening of the critically acclaimed film "SMACKED!", which highlights the opioid abuse epidemic facing our area and the success of the LCHP-funded medication assisted treatment program. It was followed by a panel discussion by three clinicians involved with the program who fielded questions from the audience.
Brett Wilhelm, LCHP Director of Operations and Data Analytics shared the latest data concerning lead partner Bassett Health Network's ED usage. A comparison of second quarter data from 2017 and second quarter data from 2018 showed that the daily mean of network-wide avoidable* ED use was reduced by 4.1 visits per day. The total quarter reduction was 374 avoidable visits, or a decline of 13.4 %. Wilhelm noted that while many efforts impacted these figures, there is a correlation between the data and Performance Hub interventions which began on 1/1/2018.
*Avoidable is defined as acuity level of "4/less urgent" or "5/non-urgent" for this analysis.
Following a Performance Hub update by the Hub Champions, Dr. Amy Gildemeister, Director of Public Health for the Schoharie County Department of Health, shared her perspective on the issues facing counties in the realm of population health.
With the advent of Value Based Payments and the expanding role of Community Based Organizations in tackling the social determinants of health, LCHP invited Martine Ahadzi (right) and Jill McMullin, Project Managers from the NY Department of Health, to speak to the ways in which CBOs can become involved in contracting with MCOs and other safety-net providers in the future. This was followed by a discussion and "table-top" activity about creating a CBO Value
Proposition.
The meeting concluded with Project Coordinator, Halley Chiodo, outlining the Funds Request process and the tracking system she has developed.
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"Living Well" Receives Federal Recognition
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Martha Sunkenberg, Nisha Patel (FORHP) and Lynae Wyckoff
at FORHP annual meeting and award ceremony.
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An LCHP-funded program program designed to help patients with chronic conditions live an improved quality of life by teaching them how to better self-manage their health issues has been recognized at the federal level for its success. The Federal Office of Rural Health Policy (FORHP) recently presented Bassett Medical Center with its Evidence-Based Model Award for the strategic evaluation and implementation of solutions that help improve health outcomes for patients struggling with chronic conditions.
Bassett initiated the chronic disease self-management program through its network of primary care health centers last year. Called "Living Well", the program consists of a series of educational workshops designed to enhance patients' ability to self-manage chronic conditions like diabetes, high blood pressure, breathing problems, depression, anxiety, heart conditions and arthritis.
David Strogatz
, PhD, a research scientist and director of the Bassett Research Institute's Center for Rural Community Health, explains, "Chronic conditions such as cardiovascular disease, diabetes and chronic lower respiratory disease have become more prevalent in rural regions of the United States. To promote population health, it is essential to develop and implement strategies not only for primary prevention but also for improving patients' abilities to manage these conditions in order to prevent complications and maintain a better quality of life."
Since its inception, the Living Well program has helped nearly 300 patients. Now, thanks to a $600,000 Health Resources and Services Administration grant to Bassett last month, the program is being expanded to include workshops for patients suffering from chronic pain.
Martha Sunkenberg
, Senior Director of Strategic Initiatives for the Bassett Medical Group, says, "It is a significant accomplishment to be selected for this award from our peers across the country who are working in similar rural settings on quality improvement initiatives. Since the program was initiated, the data we've compiled shows patients feel less stress about living with their chronic conditions, less isolated in their challenges to manage their chronic conditions, and patients with diabetes have lower blood sugar levels as a result of participating in the Living Well peer group workshops.
"It has taken a lot of work on the part of many people across various departments to accomplish what we have to date," continues Sunkenberg. "The FORHP award validates our efforts and shows we are helping our patients improve their lives and keeping our communities healthier."
Projects nominated for the FORHP awards were required to demonstrate tangible results, such as outcomes that were clearly linked to achievement of quality improvement. This information was derived from project reporting and updates shared with FORHP. Among Bassett patients with diabetes who completed the first cycle of the Living Well diabetes self-management program, there has already been a 31 percent reduction in the percentage who have an elevated A1C level. The A1C test measures a person's average blood glucose (sugar), which is particularly important to the management of diabetes and lowering the risk of developing complications such as eye, heart and kidney disease.
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Palliative Care Inititiative Proving Successful
LCHP and Catskill Area Hospice and Palliative Care Foraging Inroads
The palliative care initiative, one of 11 DSRIP clinical projects, is proving successful in LCHP's goal of reducing hospital readmissions and avoidable Emergency Department visits in the Bassett Healthcare Network.
As noted in the preceding article, Brett Wilhelm, Director of Operations & Data Analytics LCHP, reported, "We are seeing statistically significant improvement across all five Bassett network hospitals when it comes to reducing avoidable ED use for Medicaid patients. As a network, we saw a 13.4% reduction from Q2 2017 compared to Q2 2018, resulting in 374 fewer visits."
Prior to the implementation of the initiative, palliative care was not covered for Medicaid recipients. With three major accomplishments, Catskill Area Hospice and Palliative Care (CAHPC) has been the key LCHP partner in advancing palliative care availability throughout the region:
- Palliative Care Medical Director, Dr. Christian Mulik, was put in place and an outpatient palliative care clinic established at FoxCare in Oneonta. Dr. Mulik is working with primary care providers who refer patients from throughout the Bassett network.
- An in-home Care Coordination program is now available to all patients, regardless of insurance payer, who either had been readmitted to the hospital three times or had visited the Emergency Department six times, either within a six-month period. Patients may be referred by a discharge planner or PCMH Care Coordinator.
- Providing all of the same services as Care Coordination, a Palliative Care Pilot program is underway for patients with a serious illness diagnosis.
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"Within a few months of establishing this pilot, we also entered into a managed care contract with Excellus BCBS to provide palliative care treatment," explains CAHPC President and CEO, Dan Ayres. "They saw the benefits that quickly. My expectation is that the data will confirm that we can keep patients cared for in their homes and reduce acute care utilization, and provide a more seamless pathway to end-of-life services.
Medical Director of the Palliative Care Consultation Service at Bassett, Dr. Carol Beechy emphasizes that palliative care is always an important adjunct to serious illness. "Palliative care is not and should not be limited to people for whom you have nothing else to offer," she says. "It is interdisciplinary care aimed at patients with serious, life-threatening illness anytime, including early on when curative treatments are being pursued."
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Please Welcome our NEW PARTNERS!!
LCHP Welcomes:
Cuda Counseling LCSW, PLLC
Andre Cuda, LCSWR, Owner
336 E. State Street
Suite A
Herkimer, NY 13350
Phone: 315-677-4163
Email:
Cuda Counseling
serves a broad range of patients with issues ranging from anxiety, depression, mood disorders and substance abuse, and operates with three licensed therapists out of Herkimer, NY. They are proud to serve the communities of Central New York. Welcome to LCHP!
Sidney EMS
David V. Reynolds
21 Liberty Street
Suite 16
Sidney, NY 13838
Phone: 607-265-3258
LCHP welcomes Sidney EMS! They have been providing emergency medical services to Sidney and surrounding areas since 1957. They recently celebrated their two year anniversary of becoming a 24-hour staffed service.
Southern Tier Connect, LLC
Meghan Andrews-Whitaker, Executive Director
5588 State Highway 7
Oneonta, NY 13820
Phone: (607) 376-7526 Ext. 260
Built on a foundation of successful Medicaid Service Coordination by some of the region's leading service providers, Southern Tier Connect partners with members of the IDD community to provide comprehensive care management. From Otsego to Fulton, Herkimer to Broome, Southern Tier Connect knows the region and works with individuals to make connections that will maximize their health, well-being and potential.
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Check Out Performance Hub Activity
Now the latest work occurring in the LCHP Performance Hubs can be reviewed on our website.
Learn more by clicking this direct link:
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