THE 2023 INNOVATOR AWARDS PROGRAM
cohort management approach, we enrolled people who are shared between Tri-County Family Medicine and CASA-Trinity. The cohort of patients is comprised of individu- als who have had at least one visit with CASA-Trinity in the last two years. And we manage that cohort with care coordina- tion activities. So we put a care coordina- tor from Tri-County together with care coordinators from CASA-Trinity. We keep patients enrolled and monitor them until they’re stabilized, and then when they’re stabilized, they return to sole primary care management from Tri-County.”
Raising awareness of a successful model Briannon O’Connor, Ph.D., chief clinical officer at FLIPA, says that all the members of the team are aware that what they’ve achieved is a model that they believe could be helpful to other provider organizations around the country. “Part of the reason we keep trying to get the word out is to raise awareness that this is a really criti- cal piece about how to support people,” she explains. “These are currently non- billable activities that are expected in a value-based payment contract. They’re expected, but not paid for. So these orga- nizations have to figure out how to make this happen and work.” And, per that, those involved in this model in the FLIPA- affiliated organizations have figured out precisely how to do that. And, along this journey, what have the
major learnings been so far? “One of the major learnings,” CASA-Trinity’s Applin says, “is that one of the best approaches is to keep it simple yet efficient. If you start adding too much or create too many forms or have too many people involved, it can get messy. We’ve always had our core members from each agency heading up this project. But the stability and making it as simple as possible, have made it effective. We’ve kept it simple, and people keep the lead involved in care coordination. That has made it simple and made it easier for the clients [and patients] of the organizations.” “We try to keep it simple here as well,”
says Stephanie Buchinger, R.N., B.S.N., CM, care management supervisor at Tri- County Family Medicine. “There are a lot of people who work with all these patients, but one specific person reports to CASA, so they know how to reach me, I know how to reach them.” What’s more, O’Connor says, “The fact
that team members across our organiza- tions have been able to break down the
“We applied an integrative care model; and the source of that was that the Univer- sity of Rochester developed the bio-psychosocial model about 100 years ago; they had concluded that one had to pay attention to all those factors to help a patient recover. And that developed into an integrative care model.”
— Robert Grolling, CASAC
barriers and silos, is not rocket science, but no one’s been doing it, because of the structural and systemic barriers in place” across the U.S. healthcare system. “But the challenge is to sustain it. It absolutely is sustainable, and we’re planning to repli- cate it throughout the network.”
Looking at data and analytics Applin notes that there are ongoing chal- lenges: “We still have to keep our agency and medical records separate, because of legal regulations. But as long as there’s consent on file, we can share information back and forth. At CASA, we have a god- send of a team that has been able to take our medical record, and they can extract all sorts of information from it and build t into a dashboard that makes it so easy for everyone to see what’s being worked on. And our medical record allows us to create our own forms, so we’ve been able to make SDOH assessments, acuity assessments, and so forth. Scores on different question- naires, surveys, and be able to compile it in one place and therefore share it with FLIPA and everyone else involved. NY is going through a push for value-based payments. And when we first saw that it would be a huge push, we decided we needed to get on this. And in a sense, COVID helped us, because we had to figure things out quickly. And our data team can pull what- ever you ask them; it’s incredible.” O’Connor adds that “FLIPA is in progress
on how effectively we share data, but [robust data-sharing] is a significant goal. And we have a shared population health manage- ment platform. We’re working towards sharing that information more readily and
timely. Per 42CFR, we’re working towards improving consent processes. Scaling it up at a network level within the structural barriers, takes time, energy and resources, but we’re working on having shared data. Grolling notes that “The data analyt-
ics has progressed light years in the last two years. The ability to get informa- tion from claims data to see the gaps in care” is advancing rapidly, he reports. “Historically, the only information we had is what patients gave us. And often they’re impaired and don’t have a good way to tell their story. But claims data tells us the exact story. So we’ve been able to mine that data and know exactly what’s going on with that patient.” Given the marrying of claims and
clinical data, Grolling reports, “We can bring a patient up on a screen and see their utilization, and we can make deci- sions based on that. And let’s say we’re dealing with 100 patients between the two of us, we get that data and analyze it and use it to help them. And we’re trying to expand this integrated care model of behavioral health and primary care will be the model that will be used throughout the state. We’re aware it’s leading-edge, and we’re very excited about it,” he adds. “Data and clinical care have to walk hand in hand in a marriage. Without one or the other, and without that communication between the two, we don’t get that coordination. The data is showing we’re closing gaps, address- ing measures, reducing costs, reducing preventable utilization, and improving the quality of patients’ lives.” And ultimately, Buchinger notes, “Our
communication” among individuals in all the collaborating entities “makes it work very well. When patients see us and we make referrals, we can call CASA and say, ‘Can you help get them there?’ The same thing is true on the other end, especially, per ER visits and inpatient. It’s more com- munication than anything else.” All those involved in this initiative
are certain that it will thrive and expand over time, because it speaks to mission and vision. As O’Connor notes, “Someone recently asked me, ‘How do you incen- tivize the organizations in your network to do their best work?’ But I don’t need to; we’re mission-aligned. No one says, I don’t want to do an integrated model; some say I lack the resources. And we don’t need to incentivize folks around these best practices, because they know the value of it.” HI
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