Goals

The overall goal of DSRIP is to reduce avoidable hospital use by 25% through transforming the New York State health care system into a financially viable, high performing system. To transform the system, DSRIP will focus on the provision of high quality, integrated primary, specialty and behavioral health care in the community setting with hospitals used primarily for emergent and tertiary level of services.

Through its specific DSRIP initiatives, CCB will focus on development of a primary care practice support infrastructure, training and engaging more providers, deployment of a broader range of clinical programs and development of a shared governance infrastructure to support integrated delivery.

Our strategy includes: specific changes to strengthen the ambulatory health care system by development of comprehensive protocols shared across all providers and social service organizations to improve care outcomes and transitions and divert patients from hospital care to community-based care; bolstering primary care practices through implementation of PCMH Level 3 standards and embedding care managers/ navigators within practices who can engage patients and coordinate care.

CCB will use DSRIP funding to further leverage clinical and technological infrastructure developed collaboratively over the last five years to establish an integrated system of care across a broad range of medical, behavioral and social sectors. This will improve care coordination and communication among providers throughout the borough and enhance population health management for the most complex patients

Supporting Care Coordination Through Technology

Providers in CCB’s network will utilize a web-based application to support collaborative care management. This platform allows providers in different locations and sectors to securely coordinate patient care, whether in the emergency room, prison, primary care office or transitional housing.   The technology supports analysis of performance and outcomes to drive continuous improvement.

CCB’s care coordination platform will enable health care providers to manage care, prevent hospital readmissions, and improve population health.