Accomplishments

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Fiscal Year 2016

  • Expanded population management care coordination across our clinically integrated network of community providers, to assist practitioners in coordinating patient care
  • Improved collaboration across the Hartford HealthCare System, for improved patient care experience
  • Implemented weekly LEAN huddles for the Care Management team focused on improving patient outcomes
  • Implemented Clinical Audit tools to ensure adherence to standard care management workflows
  • Participated and contributed to HHC CHF Kaizen project to address standard work and reducing readmissions
  • Implemented the PatientPING platform which identifies ICP patients for collaboration and coordinated care transitions to HHC sites, from non HHC hospitals, nursing facilities and home health agencies
  • Implemented Crimson Medical Referrals (CMR) platform across 90+ practice sites which improves the bi-directional communication of patient care among primary and specialty care practitioners
  • Expanded the HHC ACO participation and kicked off MIPS/MACRA education for calendar year 2017, which impacts payments in calendar year 2019
  • In collaboration with the Orthopedic council and key partners at Backus and MidState hospitals, kicked off the comprehensive care for joint replacement bundled payment program and defined governance structure
  • Kicked-off the EPIC Healthy Planet Care Management platform training, for implementation in 2017
  • Over 500 Practitioners credentialed through ICP to meet the NCQA regulations
  • In collaboration with the Hartford Healthcare Behavioral Health Network, embedded behavioral health clinicians in over a dozen HHC MG and ICP affiliated primary care practices; Through increased access to behavioral healthcare, demonstrated improvement in patient health conditions, reduced Emergency Department utilization and inpatient admissions for this patient cohort

Fiscal Year 2015

  • MSSP performance was in the top 20th percentile of participating MSSP accountable care organizations in the nation. ICP was 66th out of 334 ACO participants. In 2014, the total cost of care was reduced by $5.58 million.
  • In commercial value-based agreements, ICP is distributing $1 million in shared savings, with 77 percent of primary care physicians and 74 percent of ICP specialists expected to receive full shares.
  • Brought a new chief medical officer on board, Dr. Michael Pinnolis, who is focused on population health management and moving our system into the top decile in quality and outcomes.
  • Implemented a partnership with the University of Connecticut School of Pharmacy to bring Dr. Sean Jeffery onto the staff a director of ICP Clinical Pharmacy Services. The goal is to help providers and patients more effectively manage medications to reduce readmissions and cost and improve quality of life.
  • Increased the ICP care management team to more than 30 members, including nurses, social workers and health coaches. All team members are nationally certified in managing chronic diseases.
  • Led the implementation of RightCare, a software platform, at all Hartford HealthCare hospitals (Backus, Hartford, the Hospital of Central Connecticut, MidState Medical Center and Windham) to reduce readmissions by identifying high-risk patients at admission and quickly begin planning those patients’ transitions to skilled-nursing facilities and home.
  • Led the development of a pilot preferred provider network of 38 skilled-nursing facilities that have met high quality standards. These facilities are connected to RightCare and quickly communicate with hospital care coordinators.
  • Led development of Congestive Heart Failure Bridge Clinics at HHC hospitals to reduce readmissions and help CHF patients and their families become more engaged in care. Clinics at Hartford Hospital, MidState Medical Center and Windham are modeled after the Hospital of Central Connecticut clinic, which has been successful in reducing readmissions of CHF patients.
  • Began work to expand palliative medicine into outpatient settings, including physician offices.
  • Continued work integrating behavioral health services into primary care.
  • Implemented an Employee Population Health Management Program for 25,000 Hartford HealthCare employees and their family members, with ICP providers as Tier One providers.
  • ICP primary care providers with Hartford HealthCare Medical Group successfully implemented the Epic electronic health record. Implementation of Epic through Community Connect is available to ICP providers.
  • Came to an agreement with Aetna for the development of a cobranded insurance plan with Hartford HealthCare and the Value Care Alliance (Aetna Whole HealthSM – Hartford HealthCare & Value Care Alliance). ICP members will work with Aetna to coordinate healthcare services and demonstrate high-quality care.

Integrated Care Partners