July 2024

While lack of coordination leads to negative outcomes, communication and coordination lead to better chances for improved outcomes.

Independent Health has long recognized that when doctors and other health care providers work together and share patient information, the patients’ needs and preferences are made known and communicated at the right time to the right people, and the information is used to provide safe, appropriate, and effective care. This can help to keep patients healthier longer, better manage chronic conditions and experience care that is consistent with their goals.

When doctors and other health care providers don’t communicate effectively with each other, treatments prescribed by different doctors for a patient’s different health issues might conflict or become unmanageable for the patient. Lack of coordination can lead to negative health outcomes for patients, such as:

• Increased use of emergency care
• Medication errors
• Poor transitions of care from hospital to home, or other setting
• Medical errors
• Readmissions

These effects can have a larger negative impact on chronically ill patients or patients with multiple complex health conditions.

Discharge from a hospital is a critical transition point in a patient’s care. Poor care coordination at discharge can lead to adverse events for patients and avoidable rehospitalization. Health risks associated with hospitalization include infection, adverse drug events, loss of function, isolation and negative quality of life, and readmission.

Medication reconciliation also plays an integral role. This process is important to improve patient safety, for identifying and resolving discrepancies, such as duplicates, omissions, or incorrect dosages. By helping to reduce medication errors and adverse drug outcomes, patient safety is preserved.

Ideas for providers to help improve care coordination

• Use Care Coordinators or assign designated staff to improve care coordination efforts.
• Use a universal EHR care coordination screening tool.
• Build digital tools that allow care coordinators, social workers, and providers to identify community partners that address social determinants of health and make direct referrals.

Independent Health’s efforts to improve care coordination

At Independent Health, we have led or participated with several initiatives to advance care coordination. In 2021, Independent Health and ECMC collaborated on an opportunity to create and implement a solution to address the challenge of costly patient readmissions. ECMC implemented a care transition pilot program focused on our members in need of this high-touch and closely coordinated care. The care team of ECMC clinicians and support professionals proactively worked with the most acute/high-risk members on a care plan for discharge and 30-day follow up. The pilot with Independent Health proved to be so successful, ECMC was recently awarded $8.3 million in funding from New York State to expand its care transitions program to reduce avoidable readmissions for all its patients.

Independent Health’s Care for You program helps our members with chronic health conditions get the medical care and assistance they need without having to navigate the health care system alone. To address the specific and extensive care required by individuals with multiple chronic conditions, Care for You involves a dedicated care team of physicians, physician assistants, nurse practitioners, registered nurses, social workers, dietitians, and community health workers who work with the patients to develop individualized, proactive care plans in concert with their primary care physician.  Care for You enhances access to the most appropriate care for individuals in order to reduce hospitalizations, readmissions and emergency room visits by wrapping around the delivery system to help enhance coordination and communication.

Independent Health offers a variety of case management programs that can assist providers to coordinate appropriate care for their patients. Programs are coordinated by licensed health professionals who include Registered Nurses, a Certified Diabetic Educator/Registered Dietitian, Exercise Physiologist and Behavioral Health Specialists.

For additional information and resources, please visit: 

Care Coordination | CMS

Introduction | Agency for Healthcare Research and Quality (ahrq.gov)

The Erie County Department of Health is monitoring an increase in Tuberculosis (TB) cases. Rapid identification of cases is essential in controlling the spread of TB.

The Erie County Department of Health (ECDOH) is experiencing an increase in Tuberculosis (TB) cases. Rapid identification of cases is essential in controlling the spread of TB. With the increase in TB cases, early detection, treatment, reporting and the management of cases and contacts are essential in preventing serious medical problems and the further spread of the disease.

Providers must report suspected and confirmed cases of TB immediately to the county where the patient resides.

Download and distribute the full advisory from the ECDOH about who should be considered for testing, types of screening tests and how to report cases to the ECDOH.

Follow all NYSDOH and ECDOH bulletins here. 

As a supporter of the NYS Start at 9 campaign, Independent Health encourages parents and guardians to discuss the importance of starting the HPV series at age 9. 

In the United States, Human Papillomavirus (HPV) infects about 13 million people each year, and about 36,500 people will develop cancer as a result. Several barriers to HPV vaccination exist at the patient, provider, and systems levels. However, providers can overcome or address many of these barriers.

Independent Health is pleased to be part of the New York State "Start at 9" Campaign to Prevent HPV cancers.  As a supporter of this campaign, we encourage providers to talk with parents or guardians about the importance of the vaccine to reduce the risk of HPV-related cancers. The latest research also suggests that starting the HPV vaccination series at age 9 can increase the percentage of your patients that are up to date by age 13.

We have developed an HPV Toolkit that includes practical ways to address barriers by communicating clearly with patients and adopting interventions such as provider prompts and standing orders along with Independent Health’s commitment to improve HPV vaccination gap closure.

Please share this with all clinicians in your practice.  

View and Download the Toolkit. 

As mental health needs grow, primary care practices are sometimes the first entry point for connecting patients to care.

In 2021, in the United States, 22.8% (57.8 million) of adults aged 18 or older were diagnosed with a mental illness. Yet, less than half (47.2%) of adults with mental illness receives mental health services.

Primary care settings are increasingly the first place where behavioral health conditions are identified. Patients present to primary care for both behavioral and physical health conditions. As their patients’ trusted provider, PCPs can identify a concern early and refer to treatment.

Behavioral health screenings in the primary care setting allow for early identification and intervention. Addressing behavioral health services in primary care reduces stigma. Treating common behavioral health disorders in primary care is cost effective.Patients linked with both primary care and behavioral health specialists have better outcomes.

Detailed Web Resources Available Online

Independent Health's behavioral health team has compiled helpful resources for primary care practices. 

We encourage you to view this page in the provider portal under Resources/Behavioral Health where you can easily access: 

• Screening Tools to consider
• The NYSDOH Authorization for Release Form
• Link to and information about the Matters Network
  
• HEDIS Measures Definitions 

Our Behavioral Health Case Management Team is available at (716) 529-3945, Monday through Friday 8 a.m. to 4 p.m. to answer any questions you may have about your patients’ access to BH treatment and resources.

Updated guidelines for Hepatitis and STI screening recommendations; kidney disease; obesity treatment.

The Clinical Practice Guidelines (CPG’s) have been reviewed and approved by IH Quality Performance Committee and updated, where necessary. Changes include adoption of the following guidelines:

Testing Recommendations for Hepatitis C Virus Infection (CDC 2023)

2024 Kidney Disease, Improving Global Outcomes (Kdigo)

Obesity: American College of Cardiology (ACC)/American Heart Association (AHA)/The Obesity Society (TOS), and the other by the American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) A Review of Current Guidelines for the Treatment of Obesity (ajmc.com) 2022

STI Screening Recommendations (cdc.gov) (CDC 2022)

To view the updated clinical practice guidelines, please log in to the provider portal. Go to Policies & Guidelines>Clinical Practice Guidelines.

Guidelines for safe prescribing

As health care providers continue to face challenges with claims submissions, Independent Health has once again extended timely filing deadlines.

Throughout the year, the Health Care Services and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.

Stay up-to-date on Independent Health's pharmacy policies and formulary updates.