Integrated Care for Kids Project Abstract Summary
The New York State Department of Health’s (NYS DOH) Office of Health Insurance Programs, the State’s Medicaid agency, acting as the Applicant, and Montefiore Medical Center, acting as the Lead Organization, propose to plan and implement the Integrated Care for Kids (InCK) Model in the Bronx. Bronx County is the nation’s poorest urban county and ranks last of NY’s 62 counties in health outcomes in 2019 (Robert Wood Johnson Foundation County Health Rankings & Roadmaps).
NYS Medicaid and Montefiore have a long history of collaboration and are deeply committed to this seven-year partnership to integrate care for children with varied levels of service integration needs. While both NYS Medicaid and Montefiore have been leaders in care coordination, behavioral health integration, and value-base payment, there is a critical need to apply these approaches to children. Working with a Partnership Council of providers of core services and family representatives, our goals are to drive quality improvement, reduce avoidable emergency department and inpatient hospital utilization, reduce out-of-home placements, improve the care experience for children and their families, and link payment to measures of quality and efficiency. We propose to include pregnant women in our model to promote 2-Generational care. The model service area will include 143,000 Medicaid-covered children and pregnant women in eight zip codes in north-central Bronx, with a propensity score-matched comparison population in select zip codes in Kings County (Brooklyn), for evaluation purposes.
New York State is a leader in health care transformation and payment reform through its 1115 waiver Delivery System Reform Inventive Payment program and children and adult Health Home programs. Montefiore is an early adopter of provider-led transformation efforts and value-based payment, participating and succeeding in CMS’ Pioneer Accountable Care Organization (ACO) and now in the successor Next Generation ACO. We will develop an Alternative Payment Model (APM) with at least one managed care organization and will include a developmental screening measure as part the APM’s quality metrics. We will use a gap-to-goal methodology to improve performance by at least 10% from baseline for the 2018 Medicaid Child Core Domain 1 Measure Set measures over the 7 years of the model.
We are requesting a budget of $16 million to develop an eligibility and enrollment process that results in comprehensive identification and appropriate stratification of 143,000 attributed beneficiaries. We will hire Service Integration Coordinators to provide integrated care coordination for attributed beneficiaries with the greatest service needs and ensure that each child’s primary caregivers have one main point of contact for integrated care coordination and/or case management. We will also use our resources to provide a patient-facing portal to encourage data sharing and deploy a mobile application that has demonstrated success in increasing family and patient engagement in care planning. We will leverage previous investments in data capture and sharing by using the Bronx RHIO, as well as the Information Technology infrastructure and protocols developed under the NYS DOH Health Home Program.