2.a.ii PCMH Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan)
3.a.i Primary Care: Behavior Health - Integration of mental health and substance abuse with primary care services to ensure coordination for care for both services
2.b.v & 2.b.vii Skilled Nursing Facility- This Project will provide a supported transition period after hospitalization to ensure discharge information are understood and implemented for SNF patients at high risk readmissions. The SNF will implement evidence based INTERACT program with the support of the CMS.
2.b.viii Home Care Committee - Implementation of INTERACT like programs in the homecare settings to reduce risk of rehospitilization for high risk patients
3.b.i Cardiovascular To ensure clinical practices in the community and ambulatory care setting use evidence based strategies to improve management of cardiovascular disease.
3.d.ii Pediatrics Asthma - To ensure implementation of asthma self-management skills including in home environmental trigger reduction, self- monitoring, medication use and medical follow up to reduce avoidable ED and hospital care. Special focus will be on children where asthma is a major driver of avoidable hospital use.
3.g.ii: Integration of Palliative Care into Nursing Homes
4.c.ii HIV -Increase early access to, and retention to, HIV Focus