Our ED High Utilizer initiative
Here is just one example of a patient impacted by our ED High Utilizer initiative:
Maria, a 43-year-old unemployed single mother, struggles with managing her diabetes and hypertension while juggling her 3 school-aged children. Maria had become a frequent visitor to an NYC-based ED as the hours were seen as “more convenient”. The management of her conditions was challenging due to factors like inadequate transportation and limited financial resources. As a result, Maria found herself relying on the ED for immediate care whenever her health deteriorated or when she needed and could afford refills for medications.
CHIPA’s has an RN on staff who is dedicated to transitions of care for ED high utilizers. She reached out to Maria and offered her access to care management and virtual visit options. Because the CHIPA RN has remote access to the FQHC’s EMR, she was able to schedule Maria promptly for a virtual visit and communicate with the care team at the health center in advance about Maria’s health needs.
Five months after the intervention of CHIPA’s RN, Maria has established regular care with her PCP, completed overdue labs, she is receiving her medications in three-month intervals at $0 copays to reduce the burden of obtaining refills, and she is monitoring her blood pressure at home. She has not used the ED for care that could be delivered through her virtual visits.
Our Best Practice guides
While Best Practices has been a concept for many decades, Community Health IPA was committed to helping our partners eliminate wasted time and money that comes with trial and error, in the quest to find the right approach to performance improvement. Guided by input from key staff at Community Health IPA health centers, our Population Health Team created a searchable online library where partners may access dozens of successful projects implemented by the top performing CHIPA health centers. This framework helps our members expedite their transformation efforts and allows for the most efficient and fruitful route to solving the unique problems facing FQHCs.
The Best Practice Library houses information on improvement projects that have been successfully implemented by an IPA member and is organized by clinical class. These are:
- Preventive Screening for Malignancy
- Immunizations, Well Visits, and Post-Partum Care
- Chronic Conditions, Including HIV
- Behavioral Health and Substance Use Disorders
Information available for each project includes quantitative data and relevant resources such as workflow diagrams, screenshots, training and support materials, and policies relevant to the project. Community Health IPA’s next phase of this initiative is to replicate and scale best practices across the network to collectively elevate performance for all partners.
Developing this tool has fostered an environment of collaboration among partners and had led to increased trust and stronger working relationships across the network. Moreover, partners are now cross collaborating on projects beyond improving clinical measures, an unintended but positive benefit for our entire network. Lastly, seeing the early success of this project, other workgroups within CHIPA will replicate this framework as they seek to enhance their collaboration efforts, turning the concept of sharing best practices into a product.
Our Social Care partnerships
Community Health IPA partners with God’s Love We Deliver and United Health Care to provide medically tailored home-delivered meals and nutritional counseling support to members. All meals are approved by a Registered Dietitian Nutritionist (RDN) and reflect appropriate dietary therapy based on evidence-based practice guidelines. Diet and meals are recommended by an RDN based on a session of nutrition diagnostic and therapy for disease management (medical nutrition therapy) and a referral from primary care to address a medical diagnosis, symptoms, allergies, medication management and side effects to ensure the best possible nutrition-related health outcomes.
Community Health IPA, Fidelis, and AIRnyc are collaborating to address social determinants of health in the Medicaid population. By leveraging relevant health data, the partners identify and support members with chronic conditions and social needs. The primary care provider refers eligible members to AIRnyc for outreach, where community health workers conduct telephonic or in-person visits, providing health education and conducting assessments. The project focuses on priority populations within the five boroughs of New York City.
