Beginning in 2010, Taconic worked with more than 350 Primary Care Providers (PCPs) at 64 sites facilitating the adoption of the Patient Centered Medical Home (PCMH) model of practice transformation. All of these practices achieved NCQA PCMH Level 3 Recognition within approximately 2 years from their project start. To realize this project, Taconic functioned as the transformation agent and THINC (Taconic Health Information Network and Community) fostered project engagement throughout the region through their leadership of the Multi-Stakeholder Committee.
Embedded Care Manager (ECM) Program
Recognizing the importance of care managing a practices’ highest risk patients to decrease unnecessary healthcare utilization and the associated costs, in 2010 Taconic launched an embedded care manager program that involved hiring, training, and “embedding” care managers in PCP practices. Generally 1% - 5% of a practices’ active patient population will be risk stratified as highest risk. A full time ECM can generally manage 100-150 of these highest risk patients. Small practices, therefore, do not require a full time ECM. The Taconic program allows for a practice to engage an ECM for only the percent of time required to manage that practices’ highest risk patient population. Certified ECMs are “leased” to practice sites and can be embedded in a practice from a half day per week to full time depending on the practice’s needs, thereby allowing smaller practices to utilize these services without the necessity of hiring a full time care manager. This program was discontinued in 2015 with the hiring of these ECMs into the practices where they worked.
The New York Capital District – Hudson Valley Region is one of seven national regions selected to participate in the Center for Medicare & Medicaid Services’ Comprehensive Primary Care initiative (CPC).
This four-year effort was designed to strengthen primary care and has partnered providers with commercial and State health insurance plans in seven U.S. regions to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of five “Comprehensive” primary care functions. These five functions are: (1) Risk-stratified Care Management; (2) Access and Continuity; (3) Planned Care for Chronic Conditions and Preventive Care; (4) Patient and Caregiver Engagement; (5) Coordination of Care across the Medical Neighborhood.
In the NY region CMS selected 75 primary care practice sites – 286 providers – reaching over 40,000 beneficiaries. Participating practices are located in the Capital District, Hudson Valley and lower Westchester areas of New York and must meet 9 milestones based on the three part aim of improving healthcare quality, patient engagement and decreasing costs. To meet program requirements, practices have had to demonstrate practice redesign and annually achieve key milestones.
Taconic serves as the Regional Learning Faculty for the NY CPC Region working with these primary care practices to achieve CPC’s milestones and goals. The milestones are designed to challenge practices to achieve a new level of performance, consistent with advanced primary care. Our team has engaged practices in onsite and remote assessment and coaching, establishing and running a CPC Leadership Group composed of clinician and administrative practice leaders, learning activities and information sharing through CMS specific collaboration websites, regional and national calls and webinars, and full day face to face learning collaboration meetings.
Community Based Integrated Delivery System (CBIDS)
Recognizing the need to engage the continuum of healthcare organizations across the community to truly influence enhanced healthcare quality and decreased costs, Taconic launched our unique community based Integrated Delivery System Transformation Program. This project receives funding from THINC’s Population Health Improvement Program (PHIP) grant. Our program engages a cluster of organizations including acute care, SNFs, Home Health agencies, and ambulatory care practices across a regional care community.
Starting with a commitment for participation from the acute care facility, the acute facility then defines the SNFs they most frequently transfer patients to; the home health, behavioral health, palliative care, and hospice service agencies that their patients are referred to; and the community PCPs and specialists most frequently admitting patients to their facility. Taconic then engages the other constituents’ participation and works with all organizations to implement enhanced care strategies and evaluate organizational performance at multiple intervals throughout the first year and beyond to maintain and enhance the transformation.