Urban Family Practice Urban Family Practice P.C.P.C.

Health Home PresentationHealth Home Presentation Coordinated By

Greater Buffalo United IPA

Right now I take in a patient, and I have 15 minutes. And although I can do a lot in 15 minutes, after he/she leaves my office, I lose control.

Combine this with a mental health or substance abuse issue, they may go to the ER who will take them in without my knowing.

After presentation, then I get the notice.

I need to be the point person in their life.

But right now I am limited by the current systems in place.

But … imagine an alternative

Coordination of Care Team

I take the patient in. Again, I do a lot in 15 min and she leaves the office;

But now we add in alternatives for supportive structures,

Now we have a behavioral stop gap to fill in the weaknesses,

Now we improve the system so that we do not just dump patients in hospitals

Care Coordination Zone (CCZ)

Medical Home 1.0

Medical Home 2.0

Medical Home 3.0

Urban Family Practice, P.C

Greater Buffalo United IPA (GBUIPA)

Greater Buffalo United iACO Ecosystem

Financial Relationships .

Service delivery providers (SDP) will be used to indicate the role of delivering hospital and/or medical/behavioral care to patients in the fee-for service or managed care programs

Care coordination participants (CCP or participant) will be used to indicate the care coordination role envisioned as part of the HH efforts pursuant.

Health Home Care Coordination Participant Range of Service

.

Beneficiary recruitment and outreach Comprehensive care management Health promotion Transitional care including appropriate follow-up

from inpatient to other settings Beneficiary and family support Referral to community and social support services Use of health information technology to link services

and data reporting and analysis.

Greater Buffalo United IPAStructure

Greater Buffalo United IPAStructure

Greater Buffalo United IPAStructure

Urban Family Practice, P.C. Interfacing with Healthelink.

Western New York Beacon Community. Reduce emergency department visits, hospitalizations, and readmissions for influenza, pneumonia, and congestive heart failure in patients with diabetes. Reduce health disparities, especially in both urban and rural underserved areas, using HIT (including clinical decision support systems, patient portals, and tele-monitoring) to facilitate patient monitoring and treatment

Phase 17 of the Health Care Efficiency and Affordability Law of New York (HEAL NY). The HEAL grant will be used to support a collaborative effort focusing on those with affective disorders, including major depression. HEALTHeLINK is working with various primary care and mental health providers to improve the delivery and coordination of mental health, long-term care and home care for approximately 20,000 patients in Western New York with complex mental health problems.

Greater Buffalo United IPAiConnect

GBUIPA iConnect

IPA export modules are created by EMRUsed to send all procedures and diagnosis of any patient

seen by the practice to the IPA for analytical purposes, such as timely services alerts when a patient is overdue for services.

GBUIPA Connect Portal will include a broader range of patient data, and more comprehensive clinical decision support. The RHIO would be pleased to support GBUIPA’s efforts to provide high quality, integrated care delivery.

Urban Family Practice Location

Prevention Quality Indicators

Urban Family Practice P.C.Urban Family Practice P.C.Health Home PresentationHealth Home Presentation

Coordinated By Greater Buffalo United IPA