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
- 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.
- Ensure Ambulatory ICU is integrated with all relevant Health Homes in the community.
- Use EHRs and other technical platforms to track all patients engaged in the project, including collecting community data and Health Home referrals.
- Establish care managers co-located at each Ambulatory ICU site.
- 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.
- Ensure that EHR systems used by participating providers meet Meaningful Use and PCMH Level 3 standards.
- Implement a secure patient portal that supports patient communication and engagement and provides assistance for self-management.
- 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.
- Deploy a provider notification/secure messaging system to alert care managers and Health Homes of important developments in patient care and utilization.
- 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.