Adirondack Health Institute

Clinical Integration

Providers in the PPS have engaged in a number of transformational initiatives over the past five years in an effort to address realigning capacity. The Adirondack Region Medical Home Pilot, Health Home, and Adirondacks ACO are improving access to primary and preventive care.

These initiatives have had an impact as evidenced by the trend in declining hospital occupancy rates since 2011. The data shows that there continues to be a need to build on these programs and increase access to primary care. The AHI PPS needs to breakdown the historical separation of these services is due to regulatory restrictions for sharing health information between these types of providers, the siloed nature of funding for these two streams of care, the different facilities in which they exist, and stigma related to behavioral health disorders.

A key strategy to address these issues is a stronger, more coordinated system of primary care integrated with behavioral health services. The PPS has 337 PCMH certified primary care practices so the building blocks for coordinated care already exist.

Clinical Integration Strategy

Our strategy is based on:

  • The AHI PPS operating model: Population Health Networks (PHNs);
  • Clinical and other information sharing;
  • Data sharing system and interoperability;
  • Care transitions strategy.

Clinical and Other Information Sharing

Information is shared with all partners in several venues:

  • PHN triad bi-monthly meetings;
  • Steering Committee monthly meetings;
  • Each region’s All-PHN quarterly meetings;
  • LEAN project-specific, pay-for-performance measurement improvement, gap resolution and Medicaid Accelerated eXchange (MAX) Series workgroups.

Data Sharing and Interoperability

Interoperability is based on optimizing clinical data sharing between partner organizations with the goal of creating an integrated delivery system.

Care Transitions Strategy

The AHI PPS is focused on a care transitions strategy that involves risk stratification, care coordination/transition coaching based on patient need, incorporating self-management in the plan of care through education and support, and plan of care and data exchange to facilitate a warm handoff.

The AHI Health Home Care Management program provides care management services for many high-risk patients in the region.