The AHI PPS serves nine counties (all of Clinton, Essex, Franklin, Hamilton, Warren and Washington counties, and portions of Fulton, Saratoga and St. Lawrence). With the exception of Saratoga County, the region served has been identified as MUA/P and/or HPSAs. There are 144,000 attributed Medicaid lives. The AHI PPS has partnered with more than 100 organizations. AHI has a total of 332 primary care providers (PCPs) at present: 70% are family practice, 19% are internal medicine and 11% are pediatrics. The network is almost evenly split between community-based PCPs (52%) and hospital-based providers (48%). Of the 332 PCPs, 15% are practicing at sites having PCMH 2011, Level 2; 53% are practicing at sites having PCMH 2011, Level 3; and 7% are practicing at sites having PCMH 2014, Level 3 recognition.

Overall Assessment: Detailed and thorough PC plan, with many activities already in motion. PCPs are involved in leadership committees. Detailed funds flow summary (highlights below but Plan contains more details).

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Workforce analysis has identified the need for nearly 130 additional PCPs through 2020
  • Workforce efforts towards increasing the number of PCPs include: the Workforce Recruitment and Retention Fund, trainings on successful recruitment and retention, and advocating for increased Family Medicine residency programs within the region
  • PC expansion includes: Construction of an FQHC in Plattsburgh (to be completed DY4); replacement of North Country FH Center with a new, expanded FQHC in Clinton County (open by DY2Q4 or DY3Q1); transformation of two Planned Parenthoods into PCMHs (completion DY3); and construction of PC Center in Fonda (begin construction DY2)
  • Funding has been provided for the recruitment of 12 physicians, 7 NPs, 6 Pas
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Practice Transformation team provides expert services including: practice transformation, PCMH recognition assistance, and quality improvement (QI) initiatives. Transformation Coaches are available to assist practitioners in transformation efforts including, but not limited to: training and coaching in transformation and QI, training in patient self– management and behavior change, support in obtaining NCQA PMCH or PCSP recognition and meeting MU Stage 2 requirements, and developing patient–centered care teams
  • Trainings will be offered in–person and on–line
  • PPS workforce funds support care coordination (CC) training.
  • PPS has been selected as a practice transformation technical assistance vendor for OQPS´s SHIP/SIM Initiative
  • Conducted two HIT surveys to guide implementation of PPS HIT infrastructure
  • To date (DY1 to year–to–date DY2): $431,338 has been provided for recruitment of PCPs; $7,000 for retention of PCPs; and $71,195 has supported PMCH and CC training
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Primary care has been identified as one of three priority areas in the AHI PPS, which also includes behavioral health (BH) and post–acute care.
  • PPS recognizes that PC is the foremost strategic component of any sustainable IDS
  • PPS´s IDS Model assumes that PCMHs function as the core of the medical neighborhood, defined as a clinical–community partnership that includes the medical and social supports necessary to enhance health, with the PMCH serving as the patient´s primary "hub" and coordinator of health care delivery
  • Anticipated outcomes of the IDS Model include: improved CC, patient safety, patient experience, clinical outcomes, population health management, and reduced costs
  • Community– and hospital–based PCPs participate in the Steering Committee, Clinical Governance & Quality Committee, and the Network Committee. PCPs also serve on work groups as Physician Champions.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Formed a VBP workgroup to create a plan towards achieving 90% VBP by DY5
  • Distributed VBP survey, which will be used to identify roles AHI should fill in assisting PPS partners with transition to VBP
  • PPS will select a vendor to provide advanced data analytics and decision support
  • To encourage cooperation between PCPs and hospitals, three criteria will be incorporated: data management and sharing that provides real time data feeds to providers; innovation and care redesign; and quality improvement and PCP engagement in achieving the overarching goals of the PPS
  • Training will be developed and offered on–line. PCPs can also apply for Workforce Training Funds to offset costs (e.g. registration and travel) related to off–site trainings.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • A per–project value for partner–level distribution has been determined. Within each project, there are funded project activities; PCPs receive payment as each activity is completed.
  • For PCPs, the PPS felt it was also important to provide funding throughout the transformation process, rather than base payment solely on project completion. There have been two rounds of engagement funds; both included over $1 million.
  • On an ongoing basis, direct payment to PCPs will encompass project milestone requirements and partner performance. Payment to providers has been budgeted with a focus on P4P measures. Budgeted amounts for P4R and P4P are listed in Plan.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • BH Toolkit created to educate PCPs about BH screening beyond depression screening
  • AHI Health Home has subcontracted with nearly all OMH TCM providers in the region. A number of physician practices are subcontractors as well. Linkages facilitate collaboration with BH organizations on a large scale within PPS.