To transform all safety net providers in primary care practices into NCQA 2014 Level 3 Patient Centered Medical Homes (PCMHs) or Advanced Primary Care (APC) Models.
A key component of health care transformation is the provision of high-quality primary care for all Medicaid recipients, and uninsured, including children and high-needs patients. This project will address those providers who are not otherwise eligible for the necessary support or resources for practice advancement as well as those providers with multiple sites that wish to undergo a rapid transformation by achieving NCQA 2014 Level 3 Patient Centered Medical Homes (PCMHs) or Advanced Primary Care Models by the end of Demonstration Year 3 (DY 3). Performing Provider Systems undertaking this project, while focused on the full range of attributed Medicaid recipients and uninsured, should place special focus on ensuring children and parenting adults, and other high-needs populations have access to high-quality care, including integration of primary, specialty, behavioral and social care services.
- Project Requirements Milestones and Metrics
- 2016 Requirements for EHR Incentive Programs: Eligible Professionals
- Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings, reference guide from the NYS DOH and OMH.
- The Evidence-Based Practices (EBP) Web Guide features research findings and details about EBPs used to prevent and treat mental and substance use disorders. EBPs integrate clinical expertise; expert opinion; external scientific evidence; and client, patient, and caregiver perspectives so that providers can offer high-quality services that reflect the interests, values, needs, and choices of the individuals served.
- The PCDC PCMH Financial Sustainability Toolkit is intended to give primary care practices and health centers that have been recognized as NCQA Patient Centered Medical Homes (PCMH) for at least six months, information on how well they are sustaining their PCMH activities. Sustainability is looked at across three different areas: process, performance, and outcomes.
- Prevention Agenda 2013-2018: New York State’s Health Improvement Plan – The blueprint for state and local action to improve the health of New Yorkers in five priority areas and to reduce health disparities for racial, ethnic, disability, and low socioeconomic groups, as well as other populations who experience them.
New York State’s Advanced Primary Care Model
- APC Capabilities
- APC Overview
- New York State’s Advanced Primary Care Model Frequently Asked Questions
- NYS DOH APC Webinar, April 4, 2016 (PDF) – Provides a basic understanding of New York State’s Advanced Primary Care (APC) model. APC is an integrated care delivery and payment model that ties together service delivery and reimbursement to promote improved health and health care outcomes that are financially stable.
- Physician Champion – Health System Transformation Overview and Benefits
- Adolescent Immunization Rates
- Top 10 Ways to Improve Adolescent Immunization Rates offers suggestions to encourage adolescents to have regular health assessments that include immunization, setting the expectation for well-adolescent care.
- AHRQ Health Literacy Universal Precautions Toolkit
- The Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
- Alternative Payment Models in the Rural Setting
- As part of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services’ Innovation Center was established to develop and test payment and service delivery models, focused on moving from volume-based payment (such as fee-for-service) to value-based payment. This webinar, Alternative Payment Models: Are You Ready?, sponsored by the American Academy of Pediatrics, offers strategies to assist smaller/rural practices in adapting to the change to value-based methods.
- American College of Preventive Medicine Adolescent Wellness Exam
- The American College of Preventive Medicine’s Adolescent Wellness Exam Time Tool: Overcoming Reluctance on Both Sides by Building Rapport Using Every Opportunity to Promote Healthy Choices.
- Behavioral Health Integration
- AHRQ Behavioral Health Integration Playbook – Integrated primary care (or integrated ambulatory care) is an emerging approach for improving health care delivery in order to achieve better patient health outcomes. This Playbook aims to address the growing need for guidance as greater numbers of primary care practices and health systems begin to design and implement integrated behavioral health services.
- Behavioral Health Screening
- Behavioral health screenings, primary care and other health care settings enables earlier identification of mental health and substance use disorders, which translates into earlier care. The SAMSHA-HRSA Center for Integrated Health website offers resources and tools for behavioral health screening.
- CDC Health Literacy Training
- The CDC Health Literacy for Public Health Professionals training course is designed to introduce participants to the fundamentals of health literacy and demonstrate the importance of health literacy within public health practice.
- LGBT-Friendly Practices
- The goal of Creating an LGBT-Friendly Practice activity is to help providers and staff gain knowledge and competency in delivering LGBT-friendly care, which may result in improved access and reduced health disparities in the LGBT community.
- Patient-Centered Medical Home-Advanced Primary Care
- The Urban Institute’s research report on Patient-Centered Medical Home-Advanced Primary Care “Payment Methods and Benefits Designs: How They Work and How They Work Together to Improve Care.” (April 2016)
- SBIRT (Screening, Brief Intervention, Referral to Treatment)
- SBIRT is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related health consequences, disease, accidents and injuries. The Office of Alcoholism and Substance Abuse Services (OASAS) website includes comprehensive information about the use of SBIRT, links to training materials, including an SBIRT online Core Training Program, screening instruments, educational videos, and other resource materials.
- Strategies for Success as a Patient-Centered Medical Home
- NCQA offers complimentary online CME/CE learning activities to help lead to more effective communication and better patient outcomes. These 30-minute learning activities focus on a team-based approach to the most recent evidence-based approaches to screening, treatment and referral in primary care for disease states: depression, diabetes, dyslipidemia, hepatitis C virus and obesity.To access the learning activities, visit the complimentary online portal. Log in or create your own account using your email address. Go to “My Apps” in the “Strategies for Success as a PCMH” panel and click “Begin.” Enter the invitation code – PursuePCMH – when prompted. Follow the on-screen instructions.
- The SHARE Approach
- AHRQ’s SHARE Approach is a five-step process for shared decision making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient.
- TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety
- TeamSTEPPS® is an evidence-based teamwork system aimed at optimizing patient care by improving communication and teamwork skills among health care professionals, including frontline staff. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into a variety of settings.
- Adolescent Immunization Rates