As the state’s Medicaid reform plan known as DSRIP picks up steam in its second year, health systems (PPS) are contracting with community based nonprofits as “partners” to help them in providing follow up coordinated care after discharge. Many of the nonprofits are also involved in other projects that are priorities for Medicaid reform under DSRIP such as chronic disease management, asthma treatment or smoking cessations. Some community organizations have been assisting by administering patient activation surveys and patient coaching of Medicaid beneficiaries to urge them to get more involved in their own care.
The New York State Department of Health is actively urging health care systems to work closely with community based agencies that provide the kind of non-medical, social services that will be essential to successfully transitioning patients back into the community and preventing re-admissions. The New York State Health Foundation, in analyzing DSRIP, noted “Community-based organizations (CBOs) are an untapped resource crucial to meeting DSRIP’s goals of reducing avoidable hospital use by 25% over 5 years. They are well positioned to address population health issues; have long-standing, trusted community relationships; and provide critical services to New York’s most vulnerable populations.”
Albany Medical Center which is running its DSRIP project in a five county area around the Capital District has decided to provide a base contract of about $7000 to a number of community organizations to have them as partners in their plan even though some of the organizations don’t have Medicaid clients but can assist in providing other support. The nonprofits are involved in the various projects by sitting on committees and working on some of the projects which could include providing care coordination services.
Since DSRIP is a five year program running through early 2020, community based organizations will have opportunities to renew contracts or negotiate new, larger ones as DSRIP projects get underway. Some organizations, for example, may be interested in developing community patient navigators, in the coming years since this one-on-one patient assistance is something many community organizations which already serve a client base may be able to successfully undertake.