Ambulatory ICU – Pediatric and Adult (Project 2.b.i)

What do we hope to accomplish?

  • Improve care and health outcomes for high-risk and high-cost adult and pediatric populations with complex care needs

Who is our target population?

  • Adult: Patients seen in the last 12 months who have at least two or more chronic conditions with 4 or more emergency room visits or inpatient visits or a combination of both
  • Pediatric: Patients under the age of 21 who are high risk and cost with specialized needs. (e.g. children with uncontrolled seizures, depression, autism)

How will we do it?

  • Establish nine Ambulatory ICUs in existing Patient Centered Medical Homes that will:
    • Deliver comprehensive, coordinated team-based care for complex patients using a patient-centered approach
    • Deploy a population health strategy that identifies high-risk patients and provides services based on medical complexity, stability and level of need
    • Embed culturally competent and family-centered Nurse Care Managers, Social Workers, Psychiatric Nurse Practitioners and Community Healthcare Workers to coordinate care
    • Ensure the Ambulatory ICU collaborates with a network of providers and community based organizations, including medical, behavioral health, nutritional, rehabilitation, care management and other necessary provider specialties to meet the needs of the population
    • Extend weekday hours and offer weekend hours to improve access
    • Provide specialized education to providers and patients to promote chronic disease management
    • Utilize technical platforms to support provider, patient and care team communication

NY State Requirements

  1. Ensure Ambulatory ICU is staffed by or has access to a network of providers including medical, behavioral health, nutritional, rehabilitation and other necessary provider specialties that is sufficient to meet the needs of the target population.
  2. Ensure Ambulatory ICU is integrated with all relevant Health Homes in the community.
  3. Use EHRs and other technical platforms to track all patients engaged in the project, including collecting community data and Health Home referrals.
  4. Establish care managers co-located at each Ambulatory ICU site.
  5. Ensure that all safety net project participants are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including secure notifications/messaging.
  6. Ensure that EHR systems used by participating providers meet Meaningful Use and PCMH Level 3 standards.
  7. Implement a secure patient portal that supports patient communication and engagement and provides assistance for self-management.
  8. Establish a multi-disciplinary, team-based care review and planning process to ensure that all Ambulatory ICU patients benefit from the input of multiple providers.
  9. Deploy a provider notification/secure messaging system to alert care managers and Health Homes of important developments in patient care and utilization.
  10. Use EHRs and other technical platforms to track all patients engaged in the project.

Scale and Speed

Metric: The number of participating patients who had two or more distinct services at an Ambulatory ICU in a year.

Commitment: The Adult Ambulatory ICU will provide services to 8,496 patients by the end of DY4. The Pediatric Ambulatory ICU project will provide 2+ services to 12,674 distinct pediatric patients annually by the end of DY4. This is roughly 9,000 patients at Columbia and 3,674 patients at Weill Cornell.