2.a.iii- Health Home At-Risk Intervention Program: Proactive Management of Higher Risk Patients Not Currently Eligible for Health Homes through Access to High Quality Primary Care and Support Services

  • Expand access to integrated primary care teams to meet the needs of higher risk patients that do not currently qualify for Health Home Care Management services
  • Using EHR registries, the PPS will identify patients who do not have access to appropriate care management services


Care coordination / patient navigation / population health

  • Develop a Health Home At-Risk Intervention Program, utilizing participating HHs as well as PCMH PCPs in care coordination within the program
  • Ensure all participating primary care providers participating in the project meet NCQA (2011) accredited Patient Centered Medical Home, Level 3 standards and will achieve NCQA 2014 Level 3 PCMH or Advanced Primary Care accreditation by Demonstration Year (DY) 3
  • Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers

Clinical protocols / standard of care

  • Implement evidence-based practice guidelines to address risk factor reduction as well as to ensure appropriate management of chronic diseases; develop educational materials consistent with cultural and linguistic needs of the population

Integration of care / IDS

  • Ensure that all participating 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
  • Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards
  • Establish partnerships between primary care providers and the local Health Home for care management services - this plan should clearly delineate roles and responsibilities for both parties
  • Establish partnerships between the primary care providers, in concert with the Health Home, with network resources for needed services - where necessary, the provider will work with local government units (such as SPOAs and public health departments)

Patient and family engagement

  • Develop a comprehensive care management plan for each patient to engage him/her in care and to reduce patient risk factors

PMO Project Representatives:

Elizabeth Stockwell-Wheeler - stockwe1@amc.mail.edu 

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