Cayuga Health Partners, Formerly CAP, Partnerships in 2015

Addressing HbA1c and Controlling Diabetes in Our Community

In response to the growing need for enhanced diabetes management, Cayuga Area Preferred (CAP) has partnered with the Cayuga Center for Healthy Living (CCHL), Cayuga Medical Center, and Cayuga Medical Associates (Hospitalists) to improve care coordination of diabetes services – both inpatient and outpatient within the network. CAP is work proactively identify diabetic patients and establish real-time care follow-up for patients.

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CAP to Partner with Organizations in May 2014 and Begin Accepting Referrals for Discharge Patients in Sept 2014

In 2014, the New York State Department of Health issued a Request for Applications for the Balancing Incentive Program (BIP).  The BIP Innovation Fund was designed to engage New York’s broad network of providers, advocates, and community leaders in developing system improvements that address barriers encountered when providing community-based long term supports and services (LTSS) across all populations of Medicaid beneficiaries in the State.

In May, the Tompkins County Office for the Aging submitted a BIP application in partnership with CAPCONNECT and Visiting Nurse Service of Ithaca and Tompkins County (VNS) and in August received notice of grant awardship.

TRANSITIONS is an adaptation of the Eric Coleman model of Care Transitions and was developed utilizing lessons learned from previous Community-based Care Transitions Program (CCTP) initiatives in Tompkins County geared towards Medicare patients.  TRANSITIONS is free to all Medicaid patients.

In September 2014, TRANSITIONS began accepting referrals (for patients being discharged) from CMC medical and surgical units and expanded services to include patients being discharged from the behavioral health unit in October.  TRANSITIONS is now accepting referrals from additional community partners including Beachtree, Seneca View, Cayuga Ridge and the Health Homes of Upstate New York (HHUNY).

The goal of TRANSITIONS is to prevent avoidable ED visits and subsequent admissions by setting the patients up with the appropriate tools to live safely, and have optimal health outcomes, at home.  TRANSITIONS involves a combination of RN home visits and follow-up phone calls focusing on:

• Medication reconciliation, management and teaching;
• Specific disease/diagnosis teaching;
• Recognition of signs/symptoms of worsening disease and how to respond;
• Timely follow-up with primary and specialty care physicians;
• In-home safety evaluation;
• Appropriateness for telehealth/remote patient monitoring*; and
• Referral to additional community resources (and assistance filling out required applications/forms).

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The TRANSITIONS program

The TRANSITIONS program has enabled the network to begin providing population-driven care coordination within the greater Tompkins County community and beyond.  To date CAP has seen marked reduction in both inpatient and ED utilization patterns for those patients enrolled.  With the onboarding of 2 RN Care Coordinators in 2015, CAP Care Management can continue this relevant work and begin to expand services into the commercial and employer-based populations.