The AMCH PPS serves 5 counties (Albany, Columbia, Greene, Saratoga, Warren) and the various counts cited in the report appear to be over 400 PCPs. Medicaid PC visits are lower than the NYS average in 4 out of the 5 PPS counties. The third next available appointment for new adult patients in safety–net practices ranges from 4 to 38 days. There are almost 600,000 potentially preventable ED visits within the PPS, and over 70% of patients using AMCH's ED did not have an identified PCP. Fewer than 50% of the PPS's 90 practices have current NCQA recognition, but several practices are in the process of pursuing certification.

Overall Assessment: Plan is not clear on what has been implemented and what might be implemented, but it appears many activities are still in the planning phase. Detailed description of PCP participation in different committees and subcommittees. Funds flow for Phase 1 described, though unclear if funds distributed (Plan states funds have been allocated). Funds flow for the next phases are not described.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Target Workforce State Report indicates that the demand for PCPs will increase as much as 50 FTEs by 2020.
  • Application submitted to procure funds through the Statewide Health Care Facility Transformation Program to expand PC capacity by creating 2 new clinical sites in hot spots.
  • New providers have been hired or planning to be hired.
  • Open access scheduling and walk–in blood pressure checks in some sites.
  • Evaluating feasibility of financial incentives for PCPs and other partnering organizations.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Clinical and operations manager hired in DY1 to support PCPs on their transformation endeavors.
  • Primary Care Advisory Group formed to promote active PC participation in DSRIP projects, facilitate PCMH recognition, promote PC/behavioral health (BH) integration, and facilitate participation in the development of VBP models.
  • Effort launched to engage a vendor to support true practice transformation – plan to select vendor by beginning of December, 2016.
  • HIXNY, SHIN–NY, Salient Interactive Miner (SIM), and MAPP all being leveraged to support transformation.
  • Advanced Primary Care (APC) model will be used to support practices in transition.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Strategies to ensure that PCPs are key players who orchestrate other members of the IDS:
    • Provide technical assistance to PCPs to acquire PCMH recognition and strengthen their relationships with secondary and tertiary services
    • ensure linkages to partners including health homes (HHs) and BH providers,
    • developed and now implementing a Clinical Integration/Care Coordination Model which includes establishment of a centralized care management entity, improvements in HIXNY connectivity, and placement of care coordinators in various clinical settings
  • Committees and subcommittees (SC) include representation from institution– and community–based PCPs including the Project Advisory Committee, Clinical & Quality Affairs Committee, ED Care triage SC, HH At–Risk Intervention SC, Asthma SC, Cardiovascular SC, PC/BH Integration SC, and Community–Based Crisis Stabilization SC. PCP participation also in the PC Advisory Group.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • VBP Workgroup formed to provide education and guidance to partner organizations and to collaboratively create a VBP roadmap. Workgroup has met monthly since April, 2016 and includes four MCOs and 12 partner organizations.
  • Planning a PPS–wide learning collaborative for organizations to present real–life examples of VBP arrangements and provide feedback on their transition.
  • Contracted COPE Health Solutions to assist in funds flow and partner contracting process.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • In collaboration with COPE Health Solutions, the PPS has created a funds flow methodology that supports the PPS network, specifically PC.
  • $9.7 million allocated to partner organizations during first phase of contracting (PCPs represent 77% of this allocation). Allocation based on project participation, safety–net designation, and attributed lives.
  • Incentives for PCPs include: participation in a PCMH learning collaborative, completion of project–specific registries and patient engagement data, collaboration with HHs and EDs, policies/procedures on various topics, and adoption of best practice guidelines.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Two workgroups established under Project 3.a.i subcommittee: one focused on PC–based models of integration, the other on the BH–based models of integration. A number of participating providers are well–along integrating BH into PC sites and vice versa.
  • Currently conducting assessment of PC and BH organizations to obtain detailed information about their current capacity and processes. Responses will guide PPS on tailoring DSRIP support and assistance to the needs of each organization.
  • Established an internal BH team that works with PPS Committees and in PC work streams.
  • Providing PCPs with education and assessing interest in integrating for substance abuse treatment.