Category: Thought Leadership
July 25 2016
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Many of us can share a health care experience, either personally or professionally, that was disjointed and lacked communication between the care team and various venues across the continuum. The frustration, confusion and helplessness we’ve felt is unforgettable. As we continue to drive toward a value-based health care system, it’s more important than ever to connect health and care across the continuum and ensure care is provided at the right time, in the most appropriate venue. In an effort to support this transformation, the Centers for Medicare and Medicaid Services has expanded the Section 1115 waiver to include a program to incentivize organizations to improve how care is provided to Medicaid and uninsured patients. Delivery System Reform Incentive Payment (DSRIP) programs focus on four main areas of improvement: infrastructure development, system redesign, clinical outcome improvements and population-focused improvements:

  1. Create and adopt a governance structure: Create and support an integrated delivery network by moving beyond the traditional continuum of care partners to engage new provider types, such as behavioral health, skilled nursing facilities and community-based organizations.
  2. Connect the continuum: Aggregate and normalize data in near real-time, bringing data together across disparate systems and do so in a meaningful way. This process facilitates access to information that encompasses traditional venues, the care continuum and advanced information about an individual’s lifestyle.
  3. Identify opportunities for improvement: Analyze the normalized data, risk-stratify populations, and develop strategies and targeted campaigns. This process enables decreased costs and improved quality across communities, delivery network and the populations we serve.
  4. Empower care teams: Deliver actionable capabilities, through configurable solutions, that are aligned with the identified strategies. It’s essential these solutions scale across any size population at the local, state and government level, while empowering care teams across the continuum.

Across the U.S., states are evaluating or preparing how to best utilize this program and drive the changes necessary to support a population health management strategy. In Stony Brook, NY, the Stony Brook Clinical Network (SBCN) is leading the charge in utilizing a DSRIP program to improve outcomes.

Their program is a joint Center for Medicaid and Medicare Services and New York State (NYS) Department of Health effort that puts $8 billion back into NYS health care over five years to help reduce Medicaid costs by improving outcomes across the state.

“Stony Brook is one of roughly 25 lead entities in the state that will help drive this program by forming a county-wide clinically integrated system of primary care providers (PCP), nursing homes, specialists, behavior health facilities and community outreach programs,” said Jim Murry, chief information officer at Stony Brook Medicine/Suffolk Care Collaborative (SCC). “It requires good care management outside the hospital, the tracking of common quality measures, strong clinical data integration and registries of focused areas.”

Jim shares that technology plays a very large role in supporting Stony Brook’s population health vision. SCC is connecting its providers through powerful data acquisition tools, standards and Medicaid provider inventories built in HealtheIntent, Cerner’s population health management platform.

“With disparate electronic health records and clinical systems across our county, we need a common set of registries and dashboards for our providers,” said Jim. “We need to have a powerful and scalable tool for our care managers to manage large cohorts of patients and map those patients to specific chronic diseases. With a population of more than 470,000, that platform must be easily accessible and connected to all of their providers best address their health and care needs.”

Suffolk Care Collaborative has initiated several target campaigns to drive the change it’s working for. Patients that have not been connected to a health care system in the county are now being identified and helped or assigned a PCP.  Patients in nursing facilities that were headed for a re-admit are now more easily identified.  Patients with chronic diseases are being placed in registries and assigned care managers. And high-potential re-admit patients are starting to be screened before leaving the hospital with a special focus on tracking and engagement to cut down the potential for another visit.

Transforming the Medicaid payment and delivery system requires a strategic approach to ensure projects result in measurable improvements that impact the quality of care and overall health of a defined population. Cerner serves as a catalyst for change in this respect. We believe health and care is at its best when the entire care team is informed, connected and engaged.

Katie Chaffee,SVP, Population Health

Katie Chaffee SVP, Population Health Cerner


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