Frequently Asked Questions

What is the Mobile Integrated Services Team (MIST) ?

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.

What is a Risk Adjustment Coding Auditor ?

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.

What is a LPN Care Coordinator ?

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.

What is a Population Health Pharmacist ?

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

What is a Patient Navigator? Patient Engagement? Care Team 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.

What type of support will CNY AIM provide?

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.

As a physician, what is my role?

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.

What does the future hold for CNY AIM?

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, THIC ACO, Medicare, and Medicaid Managed Care plans.

What is an Accountable Care Organization (ACO)?

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.

What is a Clinically Integrated Network (CIN)?

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).

What does CNY AIM stand for and when was it established?

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.

Since the contract for chronic care management services is exclusive, can my practice still refer eligible patients to Health Homes for Medicaid care coordination?

Yes. The contract for CCM services applies only to those patients that have not already been assigned to an existing Medicaid Health Home. For example, Medicare beneficiaries with both Medicare and Medicaid coverage (dual eligible enrollees) may be assigned to a Medicaid Health Home that is not affiliated with the Trinity Health Integrated Care ACO. Incidentally, your practice may refer patients to any eligible participating Medicare provider regardless of their participation with the Trinity Health Integrated Care ACO.

How will patients be assigned to receive care management services?

Historical claims data and current clinical information for all ACO assigned beneficiaries will be reviewed and stratified using the ACO’s risk stratification tools and applications. Patients will be ranked according to several different criteria and assigned to a RN Health Coach. Health Coaches will build a panel of patients from the practices that they serve.

Is the practice required to pay the defined percentage of collections for all CCM Services/AWV Services billed by the practice or only for patients who have received care management services from the CIN Care Management Team?

The practice is only required to remit collection for the CCM or AWM Services performed by CIN Health Coaches on behalf of the practice. The practice is not required to remit a percentage of collections for those CCM and AWM services rendered by the practice’s employed staff.

If my practice contracts with the CIN to provide chronic care management services, what portion of my practice’s collections for CCM Services and AWV Services must be paid to the CIN as a fee for care management services?

Your practice will be required to remit a percentage of the practice’s collections for CCM services and AWV services. The exact percentage is determined through the use of a Fair Market Value (FMV) assessment. Specifically, it was calculated using the ratio of Work RVU’s to Total RVU’s. This methodology was reviewed by the CIN’s Quality Improvement and Population Health Committee and approved by the CIN’s Management Board.

Why can’t I send names of patients to the Health Coach for management?

We know that not all patients need the same intervention. A unique feature of the Health Coach care management program is the strategic identification of patients who will benefit. Rather than a traditional referral program, we will be Case Finding based on Reports and Registries, which combine clinical and claims based data and utilize predictive analytics. Each Health Coach regularly receives updated, current lists of patients that have been risk stratified and identified as high risk, attributed patients to reach out to and manage.  The Health Coaches are responsible for monitoring and interacting with these patients only.  In order to meet expectations of care team volumes and be successful in our collaborative care management efforts, our focus must remain on these patients.

How often do the Health Coaches contact their patients?

The frequency of the contacts depends on the needs of the patients. Some may need multiple contacts in one week while others may not need a contact for a few weeks. The minimum expected interaction is at least once, every other week.

How are patients attributed to the CIN/ACO?

Patients are attributed to the ACQA based on their claims for services through their Primary Care Provider and having Excellus coverage; Patients are attributed to our ACO by CMS based on their claims for services, sometimes through their PCP and sometimes via a specialist, and all have Fee for Service Medicare, also called Traditional Medicare. We are not currently working with patients who have Medicare Advantage or other forms of managed Medicare.

What do Health Coaching efforts focus on?

Our CIN/ACO Health Coaching efforts focus on high cost, high risk, attributed patients, a small percentage of your overall patient population. Each Health Coach, RN receives a list of risk stratified patients to reach out to and to add to their care team. Therefore, not all CIN/ACO patients will fall under the care of a Health Coach. The expected care team of each Health Coach, RN is approximately 80-100 patients.  

• The Health Coach engages with high risk, attributed patients telephonically for care management.
• The Health Coach initiates the collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.
• The Health Coach helps patients gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals.
• The Health Coach ensures that the patients are aware of Red Flag Symptoms specific to their disease process, reviews medications and ensures that the patients are knowledgeable about the medications that they take, and supports the patient in identifying and reaching their personal goals.
• The Health Coach will notify you or your office with any identified change in condition or if they identify that the patient is not following your prescribed plan.
• The Health Coach will also notify you of a positive Depression, Anxiety, or Fall Screen.
• If the Health Coach identifies a resource need that requires a Physician order (such as home health care) you will receive a flag/alert containing the details.

The Health Coach does not interfere with your patient care, practice clinical medicine, direct patient care, or provide treatments or medications.

Are there any costs to my practice for the data analytics?

As a participant of CNY AIM, there is no cost to the practice for data analytics. These costs are carried by Trinity Health, the Hospital, or the CIN/ACO.

Are there any consents/privacy notifications that I’m required to provide to my patients as a result of my practice’s participation in the ACO or CIN?

As an ACO Participant, you will be required to passively notify beneficiaries that your practice participates in a Medicare Shared Savings Accountable Care Organization. This notification provided through the use of posters and flyers – in the office. No other beneficiary consent/privacy notification requirements apply.

What is the frequency of the reporting requirements?

Most practices submit clinical information through the IT interface on a weekly basis although it is not uncommon to submit on a nightly basis.

Will my practice be required to invest in IT interfaces to participate in the clinical integration and quality measures programs?

No. The cost to set up IT interfaces to participate in clinical integration and the quality measures will be absorbed by the CIN or ACO.

As a participant of CNY AIM, there is no cost to the practice for data analytics. These costs are carried by Trinity Health, the Hospital, or the CIN/ACO.

Does my practice need to have an EMR to participate in the ACO or CNY AIM?

Yes, there is an expectation that all groups will invest in and support the infrastructure for care coordination and follow a path towards eventual EMR implementation. Effective January 2025, all EMR's will be required, and have the ability to submit a QRDA1 file.