Sarah Dawson, Population Health Director
NYS PCMH IBM Watson VBP
Recognition Program through NCQA that began April 1, 2018 Innovative advanced primary care approach to improving the health of our patients by a systematic focus on high quality primary care, population health, and integrated behavioral health NYS is paying for technical assistance provided to practices for 12-18 months, we will be working with Common Ground Health Utilize IBM Watson Engagement Manager as a vehicle to close care gaps
Population health platform that will be utilized as our analytics tool for identifying and closing care gaps Comprehensive view of our patients by pulling patient information from Medent, Paragon, billing codes, and claims data Identifying and closing documentation gaps; efficiency and effectiveness of the EMR
Perfor orman ance M e Manag ager er ◦ Measure and manage quality performance ◦ Identify care opportunities ◦ Create and view reports
Engag agem ement M t Manager er ◦ Identifies patient care opportunities and notifies then about recommended visits, test, procedures, or follow-up ◦ Evidence-based protocols that reflect the most up-to- date standards of care, including published guidelines from organizations such as NCQA, HEDIS, AAFP, and NQF ◦ Strengthens both preventive care and chronic disease management, and encourages patients to be more actively engaged in their health care Ca Care M e Manager er
Potential Revenue Condition Measure / Protocol All Fidelis UHC Empire Plan Excellus RPE3 Medicare MIPS Medicaid PCMH Preventive Breast Cancer Screening X Cervical Cancer Screening X Colorectal Cancer Screening X Influenza X X X Pneumococcal Immunization X X HPV Immunization X X X Medicare Wellness X Wellness Annual X Bone Mineral Density Scan (DXA) Peds Attention Deficit Hyperactive Disorder X Pediatric Asthma X X Well Child Exam X X X X OB/GYN Annual Visit OB-GYN Annual Visit OB-GYN - Established Patient Diabetes Diabetes (Enhanced) X Obesity Obesity Management (Enhanced) X X X Heart Failure Heart Failure Coronary Artery Disease (CAD) Hypertension Hypertension (Enhanced) X X X COPD Chronic Obstructive Pulmonary Disease (COPD) Behavioral Depression X X Asthma Asthma Thyroid Disorders Thyroid Disorder Severe Thyroid Disorder Hypercholesterolemia High Cholesterol Hypercholesterolemia Management
Executive Team - for approval and support with NYS PCMH and IBM Watson Engagement Manager (5/15) Reviewed IBM Watson Engagement Manager Protocols with AMMS FM (5/17) – Pilot Met with leadership & Bill Brien from Common Ground Health (5/18) Primary Care Provider Meeting w/ leadership and Bill Brien (5/21) IBM Watson Protocol Review and Workshop (6/20-6/21) Office visits w/ leadership and IT to learn workflow & EMR use Primary Care office meetings (7/17, 7/23, 8/1) AMMS Practice Manager Meeting
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