N-CHIP Accomplishments

1. N-CHIP Accomplishments Project and Community List of Successes

2. Governance • Provider Executive Committee(PEC) • N-CHIP’s Success Has Been Due To The Clinical Leadership Provided by the PEC. • 16 Voting Members (14 Providers & 2 Others) • 13 Non-voting Members • This committee consists of primary care providers, specialists, and public health representatives who continue to volunteer their time and expertise to advise and govern projects and programs aimed at increasing quality, reducing cost and improving the patient experience (CMS Triple-Aim)

3. Governance (Cont.) • Steering Committee • The Technical Implementation of the PEC’s Directives Were Overseen by the Steering Committee • 14 Voting Members • 13 Non-voting Members • This committee consists of technical, administrative and operational representatives who continue to volunteer their time and expertise to ensure a reliable, secure and compliant system is in place to support projects and programs aimed at increasing quality, reducing cost and improving the patient experience (CMS Triple-Aim)

4. Electronic Health Record (EHR) Adoption • 37 Practices/Clinics Fully Adopted EHR Technology • 12 Primary Care Practices (95% of the Primary Care Providers in the Care Coordination Zone or CCZ*) • 20 Hospital-based Clinics • 2 Urgent Care Clinics • 3 Specialty Practices • 1 Radiology • 1 Allergy & Immunology • 1 Pulmonology *Defined as a 40 mile radius around FT Drum and includes Jefferson, Lewis and Southern St. Lawrence Counties

5. Patient Centered Medical Home(PCMH) • A PCMH practice is a team-based model of care -led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. • 2012, American College of Physicians • All 32 primary care practices (103 Providers) have achieved Level 2 or 3 PCMH recognition from the National Committee for Quality Assurance (NCQA) • 12 Practices • 20 Clinics

6. PCMH (Cont.) • The Fort Drum region CCZ which consists of Jefferson, Lewis, and Southern St. Lawrence counties – now has 19% of PCMH Level III, and 71% of Level II recognized providers that are certified nationally and located in designated rural Health Provider Shortage Areas (HPSA)!

7. Meaningful Use (MU) • 2 of the 5 Hospitals Have Attested for MU • 30 of the 75 Participating Eligible Providers (EP) Have Attested for MU • 2 of 7 Medicaid • 28 of 68 Medicare

8. Increased Community Healthcare Dollars • Meaningful Use • Currently $594,000 (33 providers) • Projected $3,234,000 • Grand total of $3,828,000 • Patient-Centered Medical Home • $725,000 Annually based on estimated Medicaid visits* *Estimated based on volume data provided and interpolated where actual data was absent

9. Connecting Regional Health Care Services to a Health Information Exchange (HIE) • 5 Hospitals Connected to the HIE and Delivering: • Laboratory Results • Radiology Reports & Images • Transcribed Reports (Discharge Summary, H&P, Etc.) • Admission, Discharge & Transfer (ADT) (Demographics, Allergies, Medications)

10. HIE Integration (Cont.) • 27 Practices/Clinics Will Be Fully Integrated With the HIE (Others Will Use the Portal – Virtual Health Record or VHR) • 12 Primary Care Practices • 10 Hospital-based Clinics • 2 Urgent Care Clinics • 3 Specialty Practices • 1 Radiology • 1 Allergy & Immunology • 1 Pulmonology

11. Clinical Measurement • The COPD Clinical Process Measures • % of patients with diagnosed COPD have spirometry results evaluated (not refused or contraindicated) • % of patients with symptoms and spirometry FEV/FVC less than 70% were prescribed an inhaled bronchodilator • % of COPD identified smokers provided with recommendation and treatment for smoking cessation based on HHS evidence based guideline “treating tobacco use and dependence” • % of COPD patients annual flu vaccine unless contraindicated

12. Clinical Measurement (Cont.) • The COPD Clinical Process Measures Have Completed 1 of 3 Stages • Stage 1 – Baseline Through Manual Chart Review • Stage 2 – Full Population Measurement Through EHR Data Extraction (50% Complete) • Stage 3 – Sustainable Clinical Quality Reporting Through a Community Disease Registry

13. Chronic Disease Management Model • Created a Chronic Disease Intervention Model for the community to build on the success of our COPD use case towards other chronic diseases

14. Current & Future Projects • Health Resources and Services Administration (HRSA) Grant (3 Years – Oct 2011 – Sep 2014) • Get All Existing N-CHIP Providers and 6 Additional Practices to MU • North Country Children’s Clinic • NY Heart Center • Cardiology Associates • Med-Ready Urgent Care Clinic • North Country Orthopedic Group • Dr. Nancy Girard

15. Current & Future Projects (Cont.) • NY Health Foundation’s NCQA Diabetes Recognition • 49 Primary Care Providers are Participating • Will Assist Them in Qualifying for Physician Quality Reporting System (PQRS) [Formerly PQRI]

16. Current & Future Projects (Cont.) • HEAL-NY 21 – Reduce Potentially Preventable Admissions (PPA) and Readmissions (PPR) Through a Regional Collaborative. • Telemedicine • Case Management • EHR & HIE