Bassett/LCHP covers Herkimer, Madison, Otsego and Schoharie counties which are largely deemed HPSA–primary care and MUA/P. Capacity issues are challenged by health workforce recruitment, burnout and large rural geography. Majority of practitioners are hospital employed. Patient transportation to appointments is a barrier and leads to calls for ambulance use to the ER. There are large vacancy rates within the primary care workforce. Funds flow reporting is mostly to hospital as majority of PCPs are hospital employees.

Overall Assessment: Plan is written more as a "challenge and mitigation" document instead of an overall approach or strategic plan for primary care. PPS descriptions are of incremental efforts which are positive however also reflect an environment where primary care is challenged and not well supported. PCMH is cited as initially a huge lift with hopes that it will ultimately provide satisfaction and other resources through team–based model of care. Plan is often generalized and difficult to discern whether implementation is limited or widespread and among what providers. Areas cited as challenges for PPS such as compensation model and incentives for providers raise questions regarding how PPS Governance is addressing overall primary care strategy as it relates to VBP.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Of the 264 Primary Care practices in region, most are hospital–employed.
  • Workload pressures to see more patients within the current fee for service payment model, engage in transformational projects, increased EMR use, care management and population health analysis are frustrating for workforce. Survey of burnout and fatigue continue.
  • Large rural nature of region favors centralized staff sites and disadvantage patients with transportation challenges.
  • 44% vacancy rate for PC physicians and 30% primary care RN/LPNs which are easier to recruit and also need for front line admin staff.
  • Developing partnerships with universities, retention bonus, housing stipend, salary increases for nursing and hiring patient navigators for referrals and transportation coordination.
  • PCMH 2011 and 2014 analysis and strategy for PCMH/APC timeline expectations are missing.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Overcome resistance and encourage PCPs commitment to PCMH and hiring case managers
  • PCMH consultant engaged with 65 practices toward on PCMH 2014 level 3 /APC.
  • Educated concept of warm handoff via PC/BH and use of Phytel for chronic conditions.
  • Introducing care management for patient follow up and social determinants of health
  • Use of scribes in working with EMR to redistribute physician workload.
  • Pending job title analysis and strategy to close gaps by AHEC
  • In October, co–coordinated Rural HC and Transportation Conference with neighboring PPS developing innovative solutions for no–shows, care planning and medication adherence.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Bassett Health network and the AO Fox Hospital entities use same EMR as of 4/1/17.
  • Connections to HIXNY RHIO for Community Memorial hospital & other providers.
  • Epic CareLink at long term care facilities and Bassett Medical Center expanding providers– access outside of its network for chart reviews, alerts and messaging.
  • Embedding patient navigators in EDs and clinics
  • Sharing care management software licensing, expenses and utility discussions are ongoing.
  • MAX series on Super–utilizers linked previously siloed Little Falls Hospital & Herkimer HC to reduce ER visits. MAX series with another hospital and Train the Trainer are pending.
  • Executive Governance and other workgroups co–chaired and staffed by PCPs.
  • Launched Disparities of care events for LGBTQ, Substance Use Disorder and elderly.
  • Clinical psychologist is lead mentor on psychosocial issues for newly trained clinicians.
  • Hospital–employed practitioners placed in more rural communities welcome integration of behavioral health, palliative care, and Medication Adherence Treatment.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Educating partners about core concepts, VBP QIP program with Excellus and AO Fox Hospital and integrated Primary Care model with Excellus
  • Pursuing Total Care of General Population or Integrated Primary Care VBP bundles.
  • Some partners have set up performance dashboards and compensation committees.
  • VBP payment model requires hospital based staff compensation model change.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • 75% of the available funds distributed but actual dollars not provided in this report.
  • Majority of PCPs are hospital–employed, yet located out in the community, thus largest funds flow show as payments to the hospital category.
  • 85% funds to actively engaged targets and 15% for "citizenship."
  • Bassett Hospital, largest partner, has cost center set aside for hiring, training and education while LCHP reports less understanding how partner spends downstream.
  • Innovative project areas, tobacco and MH/SU prevention programs.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • MAX series at Community Memorial Hospital integrated PC/BH concept and increased satisfaction between previously disparate practitioners.
  • May model an integrated behavioral health clinic pilot in one large PC site
  • Training behavioral health specialists to refer eligible patients to Health Homes.
  • Agreement to share minimal required behavioral health notes piloting at one primary care site using the same EMR platform.
  • Developing SBIRT training with assistance from CBO.
  • Pursuing ECHO project partnership with Univ. of Rochester Medical Center designed to bring behavioral health and other services to patients via telemedicine.