Our Work In Action
The North Country Initiative — or “NCI” for short — is a clinically-integrated network with nearly 150 sites among over 80 partners from across the clinical, behavioral, and social care continuum working together in value-based care in northern New York’s Jefferson, Lewis and St. Lawrence counties. NCI works closely with FDRHPO, sharing office space and resources to achieve common goals.
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NCI and its partners continually work to align incentives, standardize clinical protocols, and harness health technology infrastructure in the context of an evolving and dynamic state and national healthcare system. Foundational to these strategies is the overarching goal of improving access to healthcare for all while improving the health of our community, reducing the cost of healthcare, and improving the quality of care for patients.
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Value-Based Care
Previously, NCI served as one of 25 “Performing Provider Systems” (PPS) formed as part of New York’s Delivery System Reform Incentive Payment (DSRIP) Program. This program was a five-year initiative (2015-2020) that transformed and improved healthcare for New York’s Medicaid population. To learn more about the detail and successes of our region’s DSRIP work, visit CLICK HERE.
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Today, NCI continues to build upon the transformational work supported by DSRIP through its efforts to promote value–based care in the region. Value–based care shifts the focus from quantity (volumes of visits or procedures) to quality of care, with success being measured in terms of improved patient health outcomes, patient experience, and well–managed healthcare costs. Value–based care emphasizes prevention and early detection (e.g., annual wellness visits, cancer screenings, lifestyle education and supports); care coordination between clinical, behavioral, and social care teams; care management services (for patients who have chronic conditions or who experience a hospital stay or emergency department visit); and patient–centered approaches (in which care is provided conveniently and accessibly to patients, takes into account patients’ social needs, and considers individuals’ own goals and preferences).
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NCI supports value–based care among regional partners through numerous initiatives. We provide NCQA Patient–Centered Medical Home recognition support services to primary care practices (see FDRHPO’s Health Initiative Technology fact sheet for more details). We convene a Medical Management Committee in which clinical staff across the region track health outcome data and collaboratively identify and implement initiatives to promote value–based care. We work with FDRHPO to leverage and coordinate resources, including grants, to support aligned initiatives (such as to promote chronic care management, transitional care management, breast and colorectal cancer screenings, patient–centered training for staff, and more). We also host a data warehouse to ingest claims and discharge data for the patients included in our value–based contracts, empowering our partners to provide their patients with the right care, at the right place, at the right time. A huge part of our work lies in implementing these value–based contracts – Accountable Care Organization and the North Country IPA.
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