Partnership with CBOs
Second in a 3-part series aimed to showcase CAP-lead population health efforts
in Tompkins County:
On May 17th, CAP hosted its second in a series of three community forums geared towards business
leaders, community-based organizations, and consumers of health care services in Tompkins County. The forum series has an overarching goal to provide information to community members about CAP, but more specifically what it means to be a part of a clinically integrated network.
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Data Capabilities
CAP’s IT & Data Warehousing team, in collaboration with Practice Support staff, has worked diligently
to create a central data warehouse capable of providing program-specific reports on a timely basis.
These reports assist the Care Management team in their efforts to close gaps in care for primary care
patients across the network; contribute to the evaluation of performance in the CI program; and assist
in the completion of quality program audits for our contracted payers. For example, the IT & Data
Warehousing team is able to use both claims and clinical EMR data to verify patient gap lists, ensuring
that outreach resources are appropriately allocated to engaging patients who are not up to date on
key health maintenance services, for both the CAP Care Management team and for practice personnel.
In addition, the CI program primarily utilizes claims-based quality coding to evaluate performance,
wherein providers drop CPT-II quality codes on encounter bills to attest to completing appropriate
activities related to their assigned measures.
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Equity in care, Care Coordination
CAP just completed the second of our community healthcare forums in mid-May.
The forum was centered on our robust Care Management program that is making
outstanding headway into helping some of our most disadvantaged patients. The
event was highlighted by a video featuring two of our nurse care coordinators,
Bernice Hayward and Danielle Jones, along with a patient whose involvement with
the nurse care coordinators has drastically reduced his need to visit the ER on a
regular basis. Please join me in congratulating our Director of Care Management,
Emily Mallar, and her entire team on a job very well done!
