Westchester Medical Center Health Network Partnerships and Community Investments Promote Healthier Communities

Westchester Medical Center Health Network's Performing Provider System (PPS) and its Center for Regional Healthcare Innovation (CRHI) have made significant progress to date with partnerships and investments in community initiatives that close gaps in access to healthcare resources and create sustainable, healthier communities at the grassroots level. 

The WMCHealth PPS was established to participate in New York State's Delivery System Reform Incentive Payment (DSRIP) program, a statewide program launched in response to a federal government initiative that aims to restructure the state's health care delivery system by reinvesting in the Medicaid program and reducing avoidable hospitalizations over five years.

Now entering its fifth year, the WMCHealth PPS' efforts have resulted in decreased avoidable hospital use and dozens of community-level collaborations. Although the program is supported by Medicaid funding, the changes in health delivery services benefit all who access these same services.

"Healthcare is continuing to transform, and our goal is to transform with it to meet the needs of our communities," said Joshua Ratner, Senior Vice President of Network Strategy and Executive Director of the Center for Regional Healthcare Innovation at WMCHealth. "Our efforts to connect residents with the community-based services they need is vital to the long-term health and well-being of residents across the Hudson Valley."

New York State has reported a statewide 17.6 percent reduction in preventable Medicaid readmission; The WMCHealth PPS has shown a reduction of 25.2 percent between July 2014 and June 2017.

WMCHealth's PPS works collaboratively with community partners on initiatives that include an integrated healthcare delivery system; an effort to reduce repeat hospitalizations; disease management and illness-prevention programs; improved access to health and wellness services and efforts to engage and empower communities to foster healthier lifestyles for their residents.

Programs created by WMCHealth's PPS include:

• Project ECHO, which provides primary care providers located in medically undeserved communities with training and support to treat patients with common and chronic mental health and substance use issues. Since the launch in May 2018 of the WMCHealth PPS' ECHO clinic, Behavioral Health in Primary and Family Practice, there have been 21 sessions involving 50 clinicians (physicians, physician assistants, nurse practitioners, social workers, case/care managers, and community health workers) from 25 practice sites
  

• Two diabetes programs were piloted. One program pairs patients with trained peers/mentors to assist with education, referral resources, and medication access via remote methods including phone calls, text messaging, and smartphone courses. Approximately 85% of program participants saw an improvement in their blood testing results after enrolling in the program. A second, community-based diabetes self-management program is led by trained mentors in a 6-week group program to help participants learn skills to better manage their diabetes.
  
  

• The WMCHealth PPS' asthma care management program has trained more than 150 people on asthma action plans, implementing asthma management guidelines and increasing access to pulmonary and allergy specialists in New York State.
  

• Other programs focus on topics including nutrition education, initiatives to expose high school students to healthcare careers, cancer screening and prevention and more.

Among the WMCHealth PPS' successes in the first four years of the program are:

• WMCHealth hospitals enhanced and expanded community relations by serving and engaging with community organizations, such as clinics, other hospitals and nursing homes that provide vital services for residents who use Medicaid.
  

• The WMCHealth PPS has provided more than 545 educational and training opportunities, engaging more than 9,200 people from 350 organizations in eight counties.

• The WMCHealth PPS has formed connections with primary-care providers to help them become "patient-centered medical homes" focusing on overall wellness, case management, and helping patients cope with issues such as access to specialized medical care and educational resources.

• Partnerships have been formed with New York Medical College, the academic affiliate of Westchester Medical Center, to provide training to manage community care; Marist College to provide care-management education; Westchester Community College to train "community navigators" to serve as peers who can steer those with substance use disorders and mental health issues toward successful treatment; and Pace University on executive and leadership training.

The five-year NYS DSRIP program is scheduled to expire in 2020, though the relationships and programs underway are expected to be sustainable and deliver long-term benefits long after the program ends.

To learn more about program and initiatives made possible through WMCHealth's PPS and the Center for Regional Healthcare Innovation, please visit www.crhi-ny.org.

Participants engage in a workshop during a WMCHealth PPS Summit and Quality meeting.

Participants in the WMCHealth PPS' Community Based Diabetes Self-Management program.