Better Health for Northeast New York


  • BHNNY Cares is also available in Portable Document Format (PDF)

Kallanna Manjunath, MD, FAAP, CPE
Charlene Schlude, BSN, MPA, CCM


  • Program overview
  • Components of BHNNY Cares Program
  • Why partner with a MCO?
  • Additional partner engagement
  • Critical success factors


A care management program sponsored by

Better Health

for Northeast New York

BHNNY Cares – Objectives

  • Identify, engage, address identified needs
    • Clinical, medication adherence, self–management support
  • Facilitate access
    • Primary care, BH services, Health Homes,
  • Enhance communication and data sharing
    • Care plans, access to Hixny (RHIO)
  • Collaborate to address relevant Social Determinants of Health (SDH)
    • Housing, Transportation, Health Literacy/Health Coaching
    • Community–based support for members with Asthma & Hypertension

BHNNY Cares – Component of a developing IDS

PCMH – Patient Centered Medical Homes
BH – Behavioral Health Providers
CMAs – Care Management Agencies
ED/Hosp – Emergency Departments/Hospitals
CBOs – Community–Based Organizations
(Pharmacy, Transportation, Housing, CHW/Peer Coaching)

BHNNY Cares Central – Why Partner with a MCO?

  • CDPHP – Prominent physician–led regional MCO with an effective community–based care management program
  • BHNNY´s need to align with HHARI project objectives & meet milestone timelines
  • BHNNY´s desire to develop a potentially sustainable program to minimize negative impact on patients and providers
  • CDPHP´s extensive primary care and behavioral health provider networks

BHNNY Cares – Additional Partner Engagement

  • Community Care Management Agencies
    • Alliance for Positive Health
    • Catholic Charities Care Coordination Program
    • Mental Health Association of Columbia and Greene
    • Rehabilitation Support Services
  • Non–clinical care coordination needs
  • Linkages to community–based providers to address

BHNNY Cares – Additional CBO Engagement

  • Working on establishing agreements with CBOs to address SDH
    • Transportation – Circulation Platform – Collaboration with other PPSs
    • Housing – Collaboration with Alliance for Better Health & AHI PPS
    • Health literacy & Health coaching – Collaboration with ABH PPS & AHI PPS
    • CVD self–management support –Albany County DOH CHW program

BHNNY Cares – Target Population

  • Priority Groups for Initial CM Interventions
    • Patients identified by partnering providers
    • Patients with frequent ED visits/Hospitalizations
    • Patients identified by data analytics – patients without PCP assignment, high risk, high users, P4P gap list, etc.
    • Additional groups – Hospital CM feedback

BHNNY Cares – Referrals are easy!

  • Identified patients can be referred with a simple fax or a call
  • Fax (518) 810–0021
  • Call (518) 810–0002

BHNNY Cares – Critical Success Factors

  • Shared vision
  • Active leadership support
  • Active practitioner / organizational participation
  • Effective member / consumer engagement
  • Availability and utilization of health information systems – risk stratification, real–time exchange of care plans, data analytics
  • Ability to demonstrate value – reduce cost and improve care

Centralized Care Management in Partnership with CDPHP

Charlene Schlude BSN, MPA, CCM
Director Centralized Care Management

Innovative Partnership: MCO and PPS collaborate on a unique centralized care management model

How did we come together?

  • Strong hospital partnership between CDPHP and PPS affiliated hospitals
  • CDPHP´s mission aligns well with BHNNY Cares population health strategy
  • Solid relationships with community partners
  • Alignment in our roles for supporting primary care practices
  • Demonstrated success of CDPHP´s Medicaid case management program

Centralized Care Management Model

  • Dedicated Multidisciplinary Care Team
    • ✓ Care Coordinators
    • ✓ RN Case Manager
    • ✓ SW case managers (behavioral health background)
    • ✓ Pharmacist
  • Comprehensive Assessment
  • Patient Activation Measure (PAM)
  • Person Centered Care Plan
  • A hybrid model : triage and refer /triage and management for defined subsets of the population
  • Monthly reporting in support of DSRIP requirements

Key Program Deliverables

  • Perform care transitions after an ER encounter
  • Address all social determinants of health
  • Facilitate engagement with NCQA Level 3 PCMH practices
  • Maintain relationships with community–based resources and refer as appropriate
  • Maintain relationships with payers and evaluate benefits and services offered
  • Use health information technology to link services
  • Maintain accurate data and provide timely, meaningful data to PPS
  • Perform regular monitoring of all referrals to assess for care plan modifications
  • Facilitate health home referrals as appropriate

Challenges along the way...

  • Limited options for case management system on go live date
  • Restricted access to alternate PPS data
  • Difficulty identifying health home eligibility

Expected Outcomes...

  • Strong focus on DSRIP milestones
  • Follow guiding principles of the Triple Aim
    • ✓ Reduce avoidable IP/ ER admissions
    • ✓ Demonstrate improved access to Level 3 PCMH practices
    • ✓ Engage with rising risk populations that are not health home eligible

Program status...

7/14/17 through 8/30/2017

  • 25 enrolled
  • 95% engagement rate
  • Referral source : primary care practices