danielle m. macfee, mph new york state department of health healthy heart program 1 state of new...
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Danielle M. MacFee, MPHNew York State Department of HealthHealthy Heart Program
1
State of New YorkDepartment of Health
▪ Year 01: 2 models of CDSMP dissemination▪ Year 02: development of regional approach (AID + CDC HDSP funding)▪ Role of health plans▪ Role of collaborative
It’s a start, and a process …
State of New York Department of Health 2
State of New York Department of Health 3
Community Health Care Delivery
Total Population CVD risk factors CVD Complications
Informed Population
Strong Community Organizations
Community/Health Care
Interface
Information Systems/ EMRs
Decision Support
Clinical Team
Screening forRisk Factors
Controlling Risk Factors
Structured Lifestyle Programs Regular
Monitoring
Insurers
Employers
Reimbursement
}
Healthy Public Policy
Supportive Environments
Informed, Empowered
Patients
Pharmacies
Clinical Guidelines
Surveillance Transitions in Care
Community Preventive Services
Personal Health
Records
Quit lines
CHWs
State of New York Department of Health 4
Community Health Care Delivery
Total Population CVD risk factors CVD Complications
Informed Population
Strong Community Organizations
Community/Health Care
Interface
Information Systems/ EMRs
Decision Support
Clinical Team
Screening forRisk Factors
Controlling Risk Factors
Structured Lifestyle Programs Regular
Monitoring
Insurers
Employers
Reimbursement
}
Healthy Public Policy
Supportive Environments
Informed, Empowered
Patients
Pharmacies
Clinical Guidelines
Surveillance Transitions in Care
Community Preventive Services
Personal Health
Records
Quit lines
CHWs
State of New York Department of Health 5
From: The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health Promotion and the Chronic Care Model Victoria J. Barr, Sylvia Robinson, Brenda Marin-Link, Lisa Underhill, Anita Dotts, Darlene Ravensdale and Sandy Salivaras
Leading Health Care Organizations
MedicaidMedicare Insurance Providers Community-based
Organizations *State Chronic Disease
Prevention Programs
State of New York Department of Health 6
Health plans▪ Independent Health▪ HealthNow NY, Inc. ▪ Univera
P2 (Pursuing Perfection) Collaborative of Western New York ▪ Non-profit health
collaborative
American Red Cross
▪ Community-based organization
State of New York Department of Health 7
Incorporated in 2002, non-profit health collaborative 200 partners representing health care consumers,
providers, payers and purchasers, and business, government, education, religious and other community leaders (including the participating health plans and CBO)
March 2003 Target the Heart conference in Buffalo supported by the Healthy Heart Program
Focus on improving care for patients with chronic diseases
Goal to expand access to care, improve efficiency, empower individuals to take responsibility for and act on their own wellness, develop community-wide standards for promotion of wellness, and engage government leaders to promote policy changes
State of New York Department of Health 8
Health Plans: ID staffer to coordinate, develop plan to sustain staff after
the pilot Market, promote, and recruit plan members to workshops Follow up with targeted members to encourage participation Develop utilization matrices
P2: Convenes stakeholders Aligns resources in the community Identifies individuals/organizations to carry out work
American Red Cross: Program coordination (registration, scheduling, training, fidelity etc.)
State of New York Department of Health 9
Scale Up & Sustainability
Add health plans, sustain buy-in Increase community accessibility,
increase reach Replication & expansion Incorporate community resources into
EHR, expansion to ‘menu’ of options Explore PCMH recognition
opportunities
State of New York Department of Health 10
Health plan members in WNY Independent Health: 365,000 Univera: 130,000 HealthNow: 470,000
Community members at large
Influence of funding source on target and reach
State of New York Department of Health 11
Assess and reevaluate
Expand community partners (including Independent Living Centers and Vision Rehabilitation Centers) and engage healthcare at the provider level
Foster growth of additional networks in other regions
ARRA: Partnership with NYSOFA
State of New York Department of Health 12
Businesses
Boards
Be proactive
Be opportunistic
State of New York Department of Health 13
State of New York Department of Health 14
Disability and Health Program: Independent Living Centers (ILCs) and other disability service and advocacy organizations
Diabetes Prevention & Control Program: Vision Rehabilitation Centers (VRCs)
Healthy Heart Program: Community Health Centers
State of New York Department of Health 15
