Central New York Accountable, Integrated Medicine (CNY AIM) was established in 2015 to allow the physician and provider community to work together in an integrated, cohesive, and coordinated way. 

A CIN is a physician-led entity where participants organize into a single network focused on performance improvement and achieving healthcare’s Triple AIM. A CIN can collectively engage payers to contract and reward the network based on Triple Aim performance for attributed populations. 

The Triple Aim refers to the simultaneous pursuit of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. CNY AIM paraphrases that powerful academic statement to “Better Care, Better Health, and Lower Costs”.  The IHI Triple Aim framework was developed by the Institute for Healthcare Improvement in Cambridge, Massachusetts (www.ihi.org).

 An ACO is a group of physicians, hospitals and other health care providers who come together to give coordinated high quality care to their Medicare patients.  The purpose of an ACO is to enable care coordination that allows a patient to receive the right care at the right time while reducing cost.  CNY AIM members are eligible to become participants of Trinity Health Integrated Care (THIC) ACO, which is considered an Advanced Alternative Payment Model (AAPM) by CMS.  Trinity Health is a national leader in value-based care delivery. 

We know that payment and associated care models will be dramatically different within the next five to ten years.  We will be a leader in our markets by mobilizing a people-centered, evidence-based approach to managing health, consistently producing excellent triple aim outcomes.

The payer community, governmental and commercial payers have demonstrated their commitment to shift to new reimbursement models that reward value and quality.  We are already accountable for the cost and quality of care for many of the patients covered by Excellus Blue Cross Blue Shield products Medicare, and Medicaid Managed Care plans.

One of the key components of CNY AIM is to serve a venue where physicians can collaborate.  Physicians across specialties and practice locations should come together to identify opportunities to:

  • Identify ways to better coordinate and integrate care across the network.
  • Develop improved models of care delivery.

You can expect to collaborate with other providers in terms of transitions of care, timely access and shared best practices.  Providers in CNY AIM are open to sharing practice improvement opportunities and have agreed to data transparency as it related to practice performance.  The role of the physician is central to achieving Better Health, Better Care, and Lower Costs.  

To support your commitment to clinical integration, CNY AIM will commit to the following support activities

  • Negotiate and execute both APM and FFS contracts that are beneficial to physicians and that recognize and promote value based healthcare.
  • Develop and support the infrastructure for successful care coordination with physician input
  • Support and respect the physician in providing services and managing his or her patients based on evidence based best practices.
  • Incorporate physician input into establishing clinical collaboration structures, developing clinical performance standards and protocols, quality initiatives and other activities affecting the provision of care.
  • Encourage physician leadership through participation in governance.
  • Provide support to help physicians understand and interpret patient data, implement and comply clinical guidelines, disease management, and other quality improvement effort.

Together we will develop and support a patient-centered infrastructure for successful care coordination.

Patient Navigators main role is to become advocates for quality standards of care and the promotion of healthy lifestyles throughout patient engagement and care coordination.  

  • Patient Engagement: assist patients in navigating the health care system and encourage preventive and chronic care management to ensure the highest level of care. Patient navigators will facilitate necessary follow-up appointments, preventive screenings, lab work, and medical imaging procedures.
  • Care Team coordination: support preventive and chronic care to foster strong patient-provider relationships. Works towards increasing patient adherence to their medical plan. And appropriately refers patients to health coach, social work, and community-based resources to facilitated health maintenance and self-management.  

The Population Health Pharmacist serves as a resource for the entire CIN/ACO clinical healthcare team, working toward the overall goal of effectively managing the health and wellbeing of our population of attributed patients, with an emphasis on patients with chronic or complex diseases and/or high utilization patterns.

The Population Health Pharmacist is responsible for providing expert advice on the use of medications and on the provision of pharmacy services to medical providers and the clinical healthcare staff, including the Health Coaches.

Working at the programmatic level, the Population Health Pharmacist makes recommendations to the formulary of the CIN; works closely with the Medical Director of the CIN/ACO to advise on protocols and standards of practice related to medications and pharmacy services; and serves as a consultant to the clinical team to review medication schedules and assess for: appropriate use of medications to treat condition(s) based on clinical finding; polypharmacy; cost; and the potential for a simplified regimen.

The PHM Pharmacist serves as a liaison to other clinical services along the continuum of care, including support services.  In order to provide the best and safest pharmaceutical service and care to all patients in the CIN/ACO network, the Population Health Pharmacist provides care using the most current drug concepts and technologies available.

These Services May Include but are Not Limited to:

  • Dispensing medications
  • Participation in inter-professional care coordination rounds
  • Ensuring appropriate dosing of medications
  • Interpreting cultures
  • Therapeutic drug monitoring
  • Review of medication profiles
  • Conducting educational programs for providers/ patients
  • Providing drug information
  • Medication reconciliation
  • Training of new pharmacists
  • Active support of pharmacy residency and student programs

The LPN Care Coordinator role was developed to support the organization's increasing commitment to value-based and patient centered health care.  The LPN Care Coordinator will work with patients identified as at risk for avoidable ER and inpatient admissions within a 30-day cycle.  The LPN Care Coordinator will utilize predetermined patient lists and targeted interventions that may include education, coordination and consultation to help prevent ER and inpatient utilizations.

The LPN Care Coordinator also serves as liaison to other services along the continuum of care and community support services.

A Risk Adjustment Coding Auditor is an expert on current Medicare coding and billing requirements , ICD-10 and CMS regulations.  The coder conducts retrospective and prospective audits of HCC coding by means of pre-visit planning and post visit reviews in addition to:

1. Performing coding quality audits and evaluating clinical documentation of provider charts to support CCD, HCC, Risk Adjustment and ensures the proper level of payment.

2. Uses claims data provided by Edifecs/Health Fidelity reports, performs suspect condition identification and validation.

3. Collects and analyzes data to formulate recommendations and solutions based on audit trends and results.

4. Provides regular feedback to leadership on performance improvement opportunities as a result of performance gaps.

5. Develops and participates in orientation and continuing education of providers, clinical staff and ambulatory coders.

The Mobile Integrated Services Team provides multidisciplinary primary care/oversights to patients in the home/community setting, including coordination with other healthcare providers and community services. 

MIST provides multidisciplinary primary care/oversight to patients in the home/community setting, including coordination with other healthcare providers and community services.

The team optimizes care by offering interdisciplinary coordination, behavioral care, and social supports as part of primary care within the home; rapid response to urgent and acute care needs; palliative care; and support for family members and caregivers.

The MIST team consists of a : Manager ,Nurse Practitioner, RN Care Manager, Licensed Master Social Worker ( LMSW) and a Care Coordination Assistant.

Patient Criteria for Consideration:

  • Resides in Onondaga County
  • Homebound/unable to access ambulatory care office for visits
  • Is attributed to St. Joseph's Health BPCI/ACO/ACQA
  • Must have a PCP or provider in the community who will collaborate with the MIST on an ongoing basis.