NCI covers Jefferson, Lewis and St. Lawrence counties, also known as the Tug Hill Seaway Region and the area is a Low-Income Medicaid HPSA. The Samaritan PPS Community Needs Assessment finds that residents are living without a primary care (PC) physician, with a Medicaid beneficiary PC visit rate 20% below the state rate. Of Medicaid residents surveyed, 47.5% noted visiting an ER within the last year. The PPS region has an ER visit rate 32% higher than the NYS rate, and exceeds the NYS rate on every single adult prevention quality indicator composite for avoidable hospitalizations. There are conflicting numbers in the Plan on how many PC sites are participating in the PPS (33 vs. 42), and how many have achieved PCMH 2014 (0 vs. 2). Per Plan, all practices are on track to receive PCMH 2014 Level 3 recognition by March 31, 2018.

Overall Assessment: Well-organized, detailed and thorough PC Plan. Many initiatives already established and in progress. Detailed funds flow information.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Physician champions and care coordinators have been identified for each practice.
  • All primary care providers (PCPs) will be required to actively share information through connection to the HIE.
  • PPS developed a Provider Incentive Program for the recruitment of professionals to the region. To date, approximately $3 million has been distributed for the successful recruitment of 11 PC physicians, 2 NPs, 3 PAs, 2 dentists, 2 psychologists, and 2 psychiatrists. A LCSW and CDE incentive program currently under development.
  • PPS working with community–based PCPs in the same manner as institution–based PCPs.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • PPS is resourcing all PCPs within the PPS with PCMH coaches and CCEs to meet MU and PCMH 2014.Level 3 by end of DY3. PPS also leveraging the support of for practices that are located more remotely. Practices are incentivized to achieve PCMH recognition.
  • Staff training on PCMH will be conducted. Other training support includes: SBIRT trainers, tobacco dependence treatment specialists and customized videos.
  • With assistance from IT, systematic record transitions and patient engagement activities are being developed and implemented by PC and behavioral health (BH) providers.
  • All PCs are either already or in process to actively share information by HIE.
  • PPS is resourcing funds to PCPs for care management services. Care managers are resourced with care connectivity internally and externally.
  • Collaboration with workforce strategy vendors, e.g. Iroquois Health Alliance, Northern Area Heath Education Center, and the Fort Drum Regional Health Planning Organization.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Strategy for how PC would play a central role in IDS was identified and developed before DSRIP. Primary community–based care is the center of all PPS strategies and plays a leadership role across all decision–making processes of the IDS.
  • Emphasis on care coordination being established between PC and others through the placement of care managers at all PC settings.
  • North Country Health Home has a key role in IDS and is included throughout planning
  • EHR systems support discrete data fields for chronic disease and BH needs. Referral processes are being developed to BH providers and chronic disease programs.
  • Participation of multiple PCPs in Board of Directors and medical management governance committee. There are three DSRIP Medical Directors.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Baseline assessment conducted to demonstrate the current state of VBP among partners.
  • PPS created and sent out multiple educational opportunities on VBP.
  • Implementing specific resources/tools: care coordination platform, population health management tool, QI/tracking.
  • Other initiatives: technical assistance (TA) on contracting and data analysis, ensuring PCPs receive necessary data from hospitals/EDs, creating transition plans, addressing workforce needs, and BH integration.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • $700,000 per year has been allocated to PCPs in DSRIP Years 2–4.
  • PCMH 2014 Level 3 recognition: non–safety net PCPs will be awarded $25,000. Safety net sites: $50,000 for the primary site, additional $25,000 per site within the same entity.
  • Provider recruitment funding has been distributed. By DY3 will total $2.8M with $2M already approved for distribution to PCPs.
  • Phase 2 incentive dollars will primarily be driven by the achievement of patient engagement targets as well as performance measures.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Expansion of providers: Provider Incentive Program to assist with recruitment of BH providers, new consulting psychiatrist was hired to resource the PPS
  • Access: Sites integrating PC and BH, telemedicine units deployed to several PC sites
  • Training and education: SBIRT training, Depression Care Manager training, community forums, plan to create public service announcement for community at large
  • Analyzing and planning: draft metric database has been developed