Care Transitions of Western New York
In the spring of 2012, P² Collaborative was awarded a contract with the Centers for Medicare and Medicaid Services to carry out a Community-based Care Transitions Program (CCTP) in partnership with ten hospitals and eight community-based organizations (CBO) in Western New York. Through this initiative, coaches staffed by the CBOs provide the nationally recognized Care Transitions Intervention (CTI) model developed by Dr. Eric Coleman to support a reduction in avoidable hospital readmissions. To learn more about the program, click here.
Integrated Care Coordination Pilot
The Integrated Care Coordination Pilot – which launched in the summer of 2013 – is testing the efficacy of a care coordination model in primary care settings, specifically for young adults (age 18-26) with depression and a history of substance abuse. The goal of this initiative is to improve the overall well-being of those who participate in the program and further incorporate screening techniques for depression and substance abuse into the primary care practice setting, laying the groundwork for integrated care into the future. This program is supported by the Peter & Elizabeth C. Tower Foundation.
Pediatric Asthma Coalition
Recently, the American Lung Association Northeast was designated as the coordinating entity for the Erie County Regional Asthma Coalition by New York State for three years. As a result, establishing and defining a relationship between the previously established Pediatric Asthma Consortium and the revitalized Erie County Regional Asthma Coalition has emerged as a priority. Through these conversations, the Pediatric Asthma Consortium has been designated as the umbrella group for all local efforts, including that of Erie County. The groups are well aligned for partnership given their similar composition in membership (representing diverse sectors including: education, health, foundation community, local and state government, etc) and the similarity of measures collected to track progress (ER utilization and re-hospitalizations).
Physician Advisory Council
The overall aim of the WNY Physician Council is to serve as a collective voice for the physician community across Western New York on regional improvement efforts. The work of the PAC helps to inform the strategic direction of the P² Collaborative.
Prostate Cancer Initiative
With the support of several regional health plans, a consortium came together to create local guidelines for prostate cancer screenings based off of national evidence-based guidelines and support the reduction of unnecessary screening and services. Composition of this consortium included urologists, primary care providers, and radiologists. P² Collaborative was approached as a neutral regional convener and to support the process of spreading the guidelines throughout Western New York and helping to educate practices and providers about how to utilize them effectively. To view the full guidance statement, click here.
Quality Assurance Reporting Requirements (QARR)
Quality Assurance Reporting Requirements (QARR) are the New York State Department of Health’s (NYSDOH) version of HEDIS (the National Health Plan Employer Data and Information Set), a method by which state-run insurance programs are scored. These annual performance measures rate health plans on their participating providers’ use of preventive and cost-sensitive services. P²
Collaborative works to facilitate the diverse partnerships in the process and align their efforts with concurrent reforms at the local and state level to improve care at lower costs.
Safety Net Care Coordination Initiative
The Safety Net Care Coordination Initiative is a pilot project to demonstrate the value of care coordination for patients with diabetes in high-Medicaid primary care practices. It is an evolution of the Community Medicaid Collaborative (CMC) demonstration project, expanding t to test a person-centered intervention to improve the quality and cost of care at a larger scale. With funding support from the Robert Wood Johnson Foundation's Aligning Forces for Quality initiatve, safety net primary care practices are working to strengthen care for individuals with diabetes across Western New York.
Breastfeeding Friendly Initiative
In 2012, the P² Collaborative, in partnership with the Healthy Start, Healthy Future for All Coalition, received funding support from the New York State Department of Health (NYSDOH) to increase exclusivity and duration of breastfeeding in Erie County. The primary focus of the P2 Collaborative through this initiative has focused on assisting OB/GYN and pediatric practices in achieving ‘Breastfeeding Friendly,’ designation through the NYSDOH.
In 2011, with seed funding support from the regional health plans and local and national foundations, P² Collaborative engaged six primary care practices that serve a high number of Medicaid recipients to pilot a care coordination model to improve health outcomes for patients with complex medical and behavioral health care needs. Through the “Community Medicaid Collaborative” (CMC) initiative, three of these practices located in the City of Buffalo focused on working with patients with diabetes, and three located in the City of Niagara Falls focused their efforts on patients with depression.
P² Collaborative worked on the federal Beacon program in partnership with the local Regional Health Information Organization (RHIO) HEALTHeLINK, and the federal Regional Extension Center (REC) program in partnership with New York eHealth Collaborative (NYeC) enabling the spread of electronic health records, broader use of quality improvement methods in ambulatory settings and local hospitals, implementation of a care coordination programs, targeted programs (such as National Committee for Quality Assurance Diabetes Recognition for primary care physicians), and Electronic Medical Record adoption for Behavioral Health providers.
Transforming Care at the Bedside
In hospitals, P² Collaborative conducted two cohorts of Transforming Care at the Bedside, helping local hospitals empower front line clinical staff to brainstorm solutions to common problems and use quick turnaround cycles to prove the efficacy of those solutions, leading to significant success in the reduction of pressure ulcers and hospital falls.