Posted on: February 16, 2023

Groundbreaking teamwork ensures that at-risk North Country patients have transition support.

Two years ago, the University of Vermont Health Network—Champlain Valley Physicians Hospital (CVPH) applied for a federal Health Resources & Services Administration (HRSA) grant for rural health care coordination. The goal of the project was to ensure that patients with diabetes, chronic obstructive pulmonary disease (COPD), heart disease and mental health conditions who were discharged from five North Country hospitals would receive prompt and effective post-acute care—in turn, improving health while reducing avoidable admissions and emergency department visits.

The North Country Care Coordination Collaborative (NCCCC) took shape, bringing together several organizations to advance the project, including:

  • CVPH and the other North Country hospitals and their provider networks, representing the majority of primary care practices in the region
  • Adirondack Health Institute, a convening nonprofit community-based organization committed to supporting population health improvement in the region
  • Adirondacks ACO, an accountable care organization contracted with Medicare and seven commercial health insurance plans, including Medicaid managed care organizations
  • Northwinds IPA, an association of 14 mental health and addiction providers
  • ADK Wellness Connections through UniteUs, which contracts with more than 100 community-based organizations
  • Hudson Headwaters Health Network, a multi-site federally qualified health center
  • Several community-based, managed care and care management organizations and agencies
  • Hixny

NCCCC represents an evolution in care coordination and value-based payment. It serves the medically underserved North Country region, where collaboration among providers is critical to patient care. The organization strives to ensure that high-risk residents of the region, when transitioning from hospital to community-based care, are offered the support of a care coordinator to promote their health and well-being, improving the rate of positive outcomes.

Their decision to call on Hixny as the information partner for all of their collaborators, and the source of a technology-based solution to a major barrier to care, created a first-of-its-kind relationship in New York. As such, it’s a model for other organizations to follow in the state and well beyond its borders.

“When we started the grant two years ago, we thought our 30 partner health organizations were using NCQA-required risk stratification scores that they could just add to Hixny. Then we realized they were all using different systems for risk stratification,” explains NCCCC Director Mary McLaughlin. “We worked through several options with Hixny to land on a customized way of standardizing risk stratification.”

Using Health Homes as a Model

Ultimately, Hixny worked with AHI, which serves as the project director for NCCCC, to mimic the system used to identify Medicaid patients in New York State health homes—but for patients with all kinds of insurance. Chronic conditions, complex care, hospital use, social determinants of health (SDoH) and more all weighed into the high, low and no risk strata.

The risk criteria then helps providers know at a glance whether care coordination is necessary or may be beneficial for individual patients. By publishing the criteria itself, not just the score, Hixny also helped NCCCC cut down on contact from providers seeking the rationale behind specific risk levels.

“For some organizations where just a couple people had access to Hixny before, it’s really driven a change—now all care managers have access to all of the information,” McLaughlin says. “The way that’s increased client engagement has been really powerful.”

Planning for Better Resource Use

NCCCC is working to ensure that anyone who has a “high” flag has a care manager when they are discharged from a hospital. The next step, McLaughlin says, is to identify whether a patient already has a care manager. “The efficiency of knowing that information saves time and increases coverage. Right now, [the industry is] not being a good manager of care management resources—one patient could have five care managers through multiple programs while another has none. In this time of slim resources, we need to be using the ones we have appropriately.”

McLaughlin also looks at Hixny’s patient record snapshot as a critical evolution in the industry, and she’s been excited to join our product development focus groups. “Hixny’s team is so good about making sure there’s a use case for something they’re considering. They want to make it something people wouldn’t think about not using. It’s now a tool that gives you clinical, billing and insights information in one place—that you can’t get anywhere else—to support patient care and improve population health.”

Read Hixny’s full 2022 Annual Report.

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will be impacted and unavailable—including access to the provider portal.