Addressing Social Needs and Partnerships with CBOs

Cohort Management Program
 CAP expands Care Management Team in Preparation for Program Launch

In 2018, Care Compass Network (CCN) announced their Cohort Management Program – a population health strategy designed to support the active management of what are viewed as priority Medicaid populations, or cohorts. CCN’s Cohort programs were designed with the intention of creating partner “networks” consisting of Safety Net Organizations and Community-Based Organizations (CBOs) in efforts to support Medicaid patients in their own self-management through a deeper view into the social determinants of health (SDH) that may be impacting their health. In response, CAP is working on behalf of Cayuga Medical Center to support 3 different Cohort programs within Tompkins County – and providing additional support to two others in Schuyler and Cortland counties.

Working with patients, their care teams, and relevant community partners to address social determinants of health is no new concept for CAP’s Care Coordination team which is why it made perfect sense to participate in this CCN-funded program. Participation in CCN’s Cohort Management Program has allowed CAP to expand its Care Programs to include the care coordination of additional Medicaid populations. CAP has already hired one additional care coordinator, and is in the interview process for a second to work with a host of CBOs to address the SDH for the following Medicaid populations:

• Patients experiencing their 3^rd (or more) emergency department visit in a 6-month time frame,
• Patients being discharged from CMC’s Behavioral Health unit with intended follow-up at Tompkins County Mental Health Services, and
• Patients in CMC’s emergency department in active overdose, or who have a history of opioid use        disorder and are without current primary care physician.

Additional partners in CAP’s Cohort Management Programs include:

• Reach Medical
• Tompkins Community Action
• Alcohol & Drug Council of Tompkins County
• Cayuga Medical Associates – Care Connections Clinic
• The Human Services Coalition
• Suicide Prevention and Crisis Services
• Cayuga Medical Center – Behavioral Health Unit
• Tompkins County Mental Health Services

In preparation for an “active management” 12-month time frame beginning April 1^st, 2019, CAP has been working closely with the above-mentioned agencies to develop workflows and program design intended to boost primary care engagement and post-acute follow-up across the care continuum while identifying barriers to self-management, inclusive of SDH – in support of improved (and sustainable) health outcomes. The ability to partner with community agencies to support patients to self-manage in the outpatient setting has been a core function of the CAP care coordination team to date and CAP is excited to have the opportunity to expand its efforts while driving some financial support to a host of community partners.

*Shorter summary of Cohort Management Program:

In 2018, Care Compass Network (CCN) announced their Cohort Management Program – a population health strategy designed to support the management of what are viewed as priority Medicaid populations. CCN’s Cohort programs were designed with the intention of creating partner “networks” consisting of Safety Net Organizations and Community-Based Organizations (CBOs) in efforts to support Medicaid patients in their own self-management. Participation in CCN’s Cohort Management Program has allowed CAP to expand its Care Programs to include the care coordination of additional Medicaid populations. The CAP care coordination staff is continuously expanding in response and additional partners in CAP’s Cohort Management Programs now include Reach Medical, Tompkins Community Action, Alcohol & Drug Council of Tompkins County, Cayuga Medical Associates – Care Connections Clinic, The Human Services Coalition, Suicide Prevention and Crisis Services, Cayuga Medical Center – Behavioral Health Unit and Tompkins County Mental Health Services.