Deborah Kozick, MPH, Center for Health Care Strategies and Katherine Heflin, MSc

November 10, 2016


Last month, CHCS’ blog explored the broad take-up of Delivery System Reform Incentive Payment (DSRIP) opportunities in Medicaid programs across the nation; this latest blog post looks at selected DSRIP innovations in New York. 


Innovations from New York DSRIPA number of innovative health care improvements initiated by states across the country in recent years warrant our attention. In the arena of delivery system and payment reform, key transformational shifts toward greater provider accountability have emerged. One driver of innovation unique to Medicaid is the 1115 Waiver and its derivative, the Delivery System Reform Incentive Payment (DSRIP) program.

This blog post focuses on perhaps the most advanced DSRIP waiver implemented to date: New York State’s Medicaid Redesign Team Waiver Amendment, which takes a groundbreaking approach to reducing avoidable emergency department (ED) visits and inpatient admissions. NY DSRIP encourages the establishment of broad provider networks — called Performing Provider Systems (PPS) — that bring together multidisciplinary providers with community-based partners to work together in improving care delivery and reducing unnecessary hospital visits.

The insights generated by NY DSRIP’s 25 regionally based PPSs are already helping to inform other, newer delivery system reform efforts around the country. Following is just a sampling of some of the innovations taking place across the state, each addressing key areas to improve health delivery:

Social Determinants of Health

  • Bronx Partners for Healthy Communities, led by St. Barnabas Health System, refers high-risk asthma patients to a.i.r. bronx, a subsidiary of a.i.r. nyc. The community-based organization uses community health workers to provide in-home asthma education and environmental assessments — including checking for and helping remediate risk factors in patients’ homes — to help avoid asthma flare-ups and frequent ED visits.
  • Montefiore Hudson Valley Collaborative PPS (MHVC) is collaborating with community-based organizations to implement a Housing-at-Risk Program, which has already demonstrated reductions in avoidable ED admissions (for example, a 2014 pilot reduced overall ED admissions by 39 percent). The MHVC developed a process for: (1) identifying homeless (or nearly homeless) patients in the health system who present at the ED; and (2) sending automated alerts to a dedicated social worker at the ED and clinical director. The provider and social worker then join forces to integrate responses to social and clinical needs through internal hand-offs across primary care, behavioral health, and other social service/housing providers — as well as external hand-offs to coordinate care beyond the hospital into the community.

Data Exchange and Health Data Analytics

  • Community Care of Brooklyn PPS, led by Maimonides Medical Center, is working to connect provider organizations electronically and has successfully connected more than 800 participant organizations and more than 3,000 clinical providers to date. To encourage meaningful data exchange, the PPS supports a combined care plan and web-based platform that includes secure messaging and dynamic consent — where patients electronically control consent and can access their data via a user-friendly interface. Providing real-time data exchange can help providers identify and address “near-crisis” issues and avoid unnecessary hospital utilization.
  • Staten Island PPS uses health analytics and heat maps to target populations with high rates of diabetes, opioid use, obesity, and/or asthma with at least three calls to 911 in the past two years. As part of a dedicated multidisciplinary care team, care coordinators partner with emergency medical service, crisis stabilization center, and substance use disorder treatment providers, to connect these high-risk patients with services such as crisis beds, alcohol and opioid detoxing, behavioral health management, and ambulatory medical services. After patients are stabilized, continuous patient engagement and monitoring is implemented to avoid unnecessary hospitalizations.

Behavioral Health Integration

  • Staten Island PPS, in cases of substance use disorders, has a behavioral health pilot that dovetails with the analytics-based care coordination referenced above. The Pre-Arraignment Diversion Program, through the Richmond County District Attorney’s Office, is a partnership that reduces overdose-related health outcomes, hospitalizations, and deaths by diverting individuals to treatment post-arrest and pre-arraignment.
  • Care Compass Network PPS, spanning a nine-county rural region in central New York, recognized that patients with depression often show up in the ED due to physical health issues, but their underlying behavioral health needs are not addressed. In response, Care Compass now proactively identifies patients needing behavioral health services using electronic medical record referrals as well as a new Patient Health Questionnaire screening process for mild or acute depression that is implemented in the primary care waiting room. These patients are then offered care from a full-time social worker and support in developing and tracking care goals through an integrated care plan.

This is just a subset of the DSRIP innovations being tested across the 25 regional provider networks in New York State — with each PPS carefully selecting its projects based on community needs assessments. Through these PPS delivery system and payment reforms, New York is moving toward its statewide DSRIP goal of reducing avoidable hospital use by 25 percent over the five years of its waiver demonstration.

Delivery system, payment, and care coordination improvements — such as those emerging over the past few years through DSRIP — provide models for how state-driven Medicaid reforms can continue to advance transformational change in our nation’s health system.

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