Integrated Delivery System (Project 2.a.i)

The PPS will collaborate with the New York State Department of Health Medicaid Program to develop a sustainable DSRIP Integrated Delivery System, which will include:

  • Integration of New York State Health Homes to provide community-based care coordination
  • Warm handoffs between care settings
  • Connections across local health information exchanges and use of other Health Information Technology tools to facilitate sharing of information
  • Use of a culturally competent workforce
  • Collaboration with safety net community-based organizations
  • Adoption of a PPS-wide Patient Centered Medical Home model to address the health needs of our patient population
  • Identification of a path to financial sustainability using Value-Based Payment Method

NY State Requirements

  1. All PPS providers must be included in the Integrated Delivery System. The IDS should include all medical, behavioral, post-acute, long-term care, and community-based service providers within the PPS network; additionally, the IDS structure must include payers and social service organizations, as necessary, to support its strategy.
  2. Utilize partnering HH and ACO population health management systems and capabilities to implement the strategy towards evolving into an IDS.
  3. Ensure patients receive appropriate health care and community support, including medical and behavioral health, post-acute care, long term care and public health services.
  4. Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of Demonstration Year (DY) 3.
  5. Ensure that EHR systems used by participating safety net providers must meet Meaningful Use and PCMH Level 3 standards by the end of Demonstration Year (DY) 3.
  6. Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers.
  7. Achieve 2014 Level 3 PCMH primary care certification for all participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standards by the end of Demonstration Year (DY) 3.
  8. Contract with Medicaid Managed Care Organizations and other payers, as appropriate, as an integrated system and establish value-based payment arrangements.
  9. Establish monthly meetings with Medicaid MCOs to discuss utilization trends, performance issues, and payment reform.
  10. Re-enforce the transition towards value-based payment reform by aligning provider compensation to patient outcomes.
  11. Engage patients in the integrated delivery system through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations, as appropriate.