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Population Health
Improvement Program
Kick-Off Meeting
February 26, 2015
HealtheConnections
Cayuga Community Health Network
Seven Valleys Health Coalition
Madison County Rural Health Council
Central New York Health Home Network
Onondaga County Health Department
Oswego County Opportunities 1
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“Connecting You to Better Care”
In collaboration with our Central New York stakeholders and participants, HealtheConnections' trusted and valued
services support healthcare transformation and efficiency initiatives focused on achieving the triple aim of better care,
better population health and lower healthcare costs.
HealtheConnections provides unbiased, neutral health information exchange (HIE) services*, population health
improvement support services, data analytics, and electronic health record adoption and meaningful use advisement
services for the eleven counties of the Central New York region.
The name HealtheConnections represents our commitment to connect and engage Central New York healthcare
physicians, hospitals, public health, mental and behavior health, human services and other health care providing
entities, insurers, business and consumers to implement services and initiatives that support New York State’s health
information exchange and population health improvement agendas.
In the pursuit of this mission, the actions of leadership, staff and our business partners will be guided by the following
values:
Integrity & Trust, Excellence, Teamwork & Collaboration, Respect, Commitment, Accountability, Responsibility, &
Diversity
HealtheConnections takes a business oriented approach to our non profit work; emphasizing value, efficiency, results
and sustainability.
*HealtheConnections is a Qualified Entity of the State Health Information Network of New York (SHIN-NY)
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Introduction of the PHIP Team
HealtheConnections
Rob Hack
Rachel Kramer
Bruce Hathaway
Mary Carney
Megan Lee
John Snow, Inc.
Craig Stevens
Alec McKinney
Apter & O’Connor
Nancy Smith
County Agents
Cayuga: Cayuga County
Community Health Network
Cortland: Seven Valleys Health
Coalition
Madison: Madison County
Rural Health Council
Oneida: Central New York
Home Network
Onondaga: Onondaga County
Health Department
Oswego: Oswego County
Opportunities
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Meeting Goal
By the end of the meeting, participants will understand:
• Activities necessary to meet NYS contractual obligations
• Objectives and priorities
• Framework and recommended approaches
• PHIP resources that can be leveraged
• County priorities across 6-county region
• Expectations for stakeholder involvement
• Contract parameters and payments from HeC
• Activities to be accomplished within first 6 months
Build an engaged and informed Central New York Population Health Improvement Program (PHIP) team.
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• PHIP Overview
• Central New York PHIP Framework and Approach
• Example of PHIP Approach
• Working Lunch – Discussion of County Priorities
• Stakeholder Mapping
• Next Steps and Closing
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Agenda
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Better population
health
Better care
Fewer health
disparities
Lower health
care costs6
NYS DOH Population Health Improvement
Program (PHIP) will promote the Triple Aim
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Promote population healthReduce health care disparities
Best Practices
Innovative Strategies
Identifying
Sharing
Disseminating
Helping to implement
PHIP contractors will provide a neutral forum for:
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PHIP contractors will engage stakeholders, including but not limited to:
Health, behavioral health, & disabilities
service providers
Rural health networks
Insurers, and other payers Consumer & patient advocacy organizations
Behavioral health advocacy organizations Disability rights organizations
Local public health officials, other elected
officials
Local human service agencies
Business community Unions
Schools Higher education institutions
Local housing authorities Local transportation authorities
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Stakeholder Engagement
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• Support and advance the Prevention Agenda by
serving as a resource and assisting in the
implementation of evidence based initiatives to
address priorities
• Support and participate in the development,
implementation, measurement and evaluation of
innovative health system strategies that support the
goals and objectives of the SHIP
• Serve as a resource to DSRIP Performing Provider
Systems (PPS)
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PHIP contractors will, within their regions:
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PHIP Regions
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PHIP Contractors by Region
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Central New York PHIP Objectives
1. Convene stakeholders and demonstrate
transparency
2. Incorporate health disparities strategies
3. Data-driven priorities and decision making
4. Advance state and county goals
5. Promote consumer engagement and coordinate
regional activities
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HealtheConnections Roles & Responsibilities
• Ensure meaningful engagement of stakeholders
• Develop and implement governance structure
• Develop strategic plan and business plan
• Identify and disseminate best practices and innovative
strategies
• Identify and implement capacity-building trainings for region
• Support awareness and coordination of existing regional
initiatives
• Facilitate and support plans for regional health improvement
initiatives
• Develop website • Compile, analyze, interpret and present population health data
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County Agent Roles & Responsibilities
• Convene local stakeholders to inform PHIP activities and
share best practices
• Collect, analyze and utilize county-specific data
• Support and advance county activities addressing Prevention
Agenda priorities
• Serve on Operating Committee and Leadership Advisory
Committee
• Support and participate in regional health improvement
initiatives
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John Snow, Inc. Roles & Responsibilities
• Provide recommendations regarding:• PHIP governance structure
• PHIP strategic plan
• Best practices for community engagement and addressing health disparities
• Assist with county inventories
• Provide trainings to build capacity in community engagement
• Compile population health data with focus on health disparities
• Support the development of a public use data dashboard and portal
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• Develop performance management plan • Incorporate evaluation outcomes and measures reflective
of strategic plan
• Prepare report on best practices for regional health improvement initiatives
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Apter & O’Connor Roles & Responsibilities
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• Hire HealtheConnections staff
• Establish contracts with County Agents, John Snow, Apter &
O’Connor
• Identify governance structure
• Put in place Leadership Advisory and Operating Committees
• Identify stakeholders and partners at county and regional level
• Identify county level prevention agenda priorities and existing
initiatives
• Review and compile regional data
• Review and compile best practices
• Complete business plan and strategic plan
• Launch PHIP website
First Six Months of PHIP
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• Convene local stakeholders to inform PHIP activities and share best practices, with a focus on improving health and health equity
• Collect, analyze and utilize county-specific data
• Support and advance county activities addressing
Prevention Agenda priorities
Wo
rk W
ith
in t
he
Co
un
ty
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Working Together Across the Region
• Serve as a nexus for data management and analytics
• Establish regional PHIP objectives that support Prevention Agenda priorities
• Participate in CNY regional population health improvement strategies
• Promote local participation in the PHIP Leadership Advisory Council (LAC) and other operating committees
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Working Together Across the Region
Wo
rk W
ithin
th
e C
ou
nty
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PHIP Vertical
and Horizontal
Alignment
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Madison
Oswego
Cortland
Oneida
Cayuga
HeC
Onondaga 24
Working As A
Team
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LEVERAGE and
CONNECT
PREP PLAN ACT SHARE
P1: Identify
County and
Hospital Priorities
P2: Identify
Stakeholders
P3: Examine Data
P4: Explore
Evidence-Based
Approaches
P5: Identify
Existing
Interventions
P6: Identify Gaps
and Opportunities
P7a: Implement
County-Level
Work and
Evaluation
(Vertical)
P7b: Implement
Regional Work
and Evaluation
(Horizontal)
P8: Report Back
P9: Illustrate
Impact
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Introduction
to Lincoln
County
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Prevent Chronic Diseases
• Reduce obesity
• Increase access to high-quality chronic disease preventive care and management
Promote Healthy Women, Infants, and Children
• Reduce premature births
• Increase the rate of babies who are breast fed
Lincoln County ExamplePhase 1: Identify county and hospital priorities
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Lincoln County ExamplePhase 2: Identify stakeholders
Lincoln County Health Department National Alliance for the Mentally Ill (NAMI)
Excellus BlueCross BlueShield, Lincoln Valley Lincoln Valley Midwifery Services
Big Lincoln Hospital YMCA of Lincoln Valley
Four Trees Walk-In Community Clinic Lincoln Transit Authority
Lincoln City School District University of Lincoln Student Health Center
United Builders of Lincoln County, No. 56 American Cancer Society
Lincoln City Landscape Architecture Firm Little Lincoln Hospital
Maryam Mallory, Mayor of Lincoln City Big Brother Big Sisters
Planned Parenthood Associates for Cardiac & Vascular Surgery
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Lincoln County ExamplePhase 3: Examine data
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LincolnNYS
PA 2017
Percentage of infants exclusively
breastfed in the hospital (33)
From Vital Statistics data, February 2014
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Lincoln County ExamplePhase 3: Examine data
Infants
breastfed
Average number
of live birthsPercentage
Black Non-Hispanics 33 101 32.6%
White Non-Hispanics 324 667 48.6%
Medicaid patients 140 401 34.9%
Non-Medicaid patients 254 487 52.2%
Total 389 888 43.8%
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From Vital Statistics data, February 2014
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Prevent Chronic Diseases
• Reduce obesity
• Increase access to high-quality chronic disease preventive care and management
Promote Healthy Women, Infants, and Children
• Reduce premature births
• Increase the rate of babies who are breast fed
Lincoln County ExampleRevisitation of Phase 1: Identify county and hospital priorities
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Lincoln County ExampleRevisitation of Phase 2: Identify your stakeholders
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Tabernacle Church of God in Christ Women’s Educational Opportunity Center
Obstetrics & Gynecology Care Network Dr. Kenneth Raymond & Rajeena Tiwari, NP
Lincoln County Health Department National Alliance for the Mentally Ill (NAMI)
Excellus BlueCross BlueShield, Lincoln Valley Lincoln Valley Midwifery Services
Big Lincoln Hospital YMCA of Lincoln Valley
Four Trees Walk-In Community Clinic Lincoln Transit Authority
Lincoln City School District University of Lincoln Student Health Center
United Builders of Lincoln County, No. 56 American Cancer Society
Lincoln City Landscape Architecture Firm Little Lincoln Hospital
Maryam Mallory, Mayor of Lincoln City Big Brother Big Sisters
Planned Parenthood Associates for Cardiac & Vascular Surgery
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Lincoln County ExamplePhase 4: Explore evidence-based approaches
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Lincoln County ExamplePhase 4: Explore evidence-based approaches
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From the Lincoln County CHIP, 2013:
• Implement well-tested social marketing campaigns to change attitudes, social
norms and behaviors related to breastfeeding initiation, exclusivity and/or duration
• Train physicians, nurses, and other health care providers on the importance of
breastfeeding and lactation support, and reduce distribution of infant formula
• Ensure that businesses/organizations create an environment to support
breastfeeding, pumping and provide lactation support
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Lincoln County ExamplePhase 5: Identify existing, current, local interventions
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Lincoln County ExamplePhase 5: Identify existing, current, local interventions
Organization(s) Interventions
Lincoln City School District Improved workplace breastfeeding & pumping
policies; Converted designated areas.
Big Lincoln Hospital Training for new hires in clinical roles;
discouraging distribution of free formula at birth
Little Lincoln Hospital Pinpointed their low-wage shift workers as at-risk
population; Planning to improve policies
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Lincoln County ExamplePhase 6: Identify gaps and opportunities
DataCurrent
Interventions
Evidence Base
Stake-holders
CHA, CHIP, and
CSPs
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Lincoln County ExamplePhase 5: Identify existing, current, local interventions
Organization(s) Interventions
Lincoln City School District Improved workplace breastfeeding & pumping
policies; Converted designated areas.
Big Lincoln Hospital Training for new hires in clinical roles
Little Lincoln Hospital Pinpointed their low-wage shift workers as at-
risk population; Planning to improve policies
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• Supply Little Lincoln Hospital with evidence based tools
• Participate in ongoing dialogue and engagement
• Convene Lincoln City School District administrators and
Little Lincoln Hospital project manager
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Lincoln County ExamplePhase 7a: Implement county-level work and evaluation
ACT
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• Engage Leadership Advisory Committee
• LAC engages 3 neighboring County Agents
• County Agents assist in formation of large work group
• Big Lincoln Hospital leverages their expertise &
resources to bring the region’s providers on board
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Lincoln County ExamplePhase 7b: Implement regional-level work and evaluation
ACT
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• Agencies contribute to a large-scale TV and radio media
campaign to highlight the importance of breastfeeding.
• Regional Agents bring in medical anthropology fellows
from the University of Lincoln to consult on the content
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Lincoln County ExamplePhase 7b: Implement regional-level work and evaluation
ACT
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SHARELincoln County ExamplePhase 8: Report back
Communicate with County & Regional Agents
Com
mun
icate
with
Sta
keh
old
ers
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Lincoln County ExamplePhase 9: Illustrate impact
SHARE
• Showed preliminary data from local hospitals
• Reported improvements to NYSDOH as part of
Prevention Agenda communications
• Presented approach & progress at NYSPHA conference
• Featured in media interviews and articles as part of
Central New York’s “Kids Health Week”
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Subcontracts
Master services agreement with HealtheConnections
Exhibit will include statement of work (aligned with MOU)
Budgets and Payment
$70,000 annually for two years
12 monthly payments ($5,833)
Monthly invoice submitted by 10th of following month
Reimbursement contingent upon receipt of HeC vouchers
Reporting
Will align with HealtheConections’ reporting to NYSDOH
Monthly report to submit with invoice
Reporting format, content and schedule TBD
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Subcontracts, Budgeting, and Reporting
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• Provide feedback on meeting via Survey Monkey
• Meeting minutes
• Governance structure discussion – Friday, March 6th
• Nominations for Leadership Advisory Committee
• County assessment/inventory
• Monthly meetings of Operating Committee
• Weekly check-in with PHIP staff assigned to each county
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Next Steps
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Thank you!
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Central New York Population Health Improvement Program (PHIP)
Regional Advisory Committee MeetingMay 27, 2015
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Agenda
• Welcome/Introductions
• Population Health Improvement Program (PHIP) Overview
• Healthy Communities Institute (HCI) Website Presentation
• Regional Advisory Committee Roles and Responsibilities
• Next Steps
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New York State’s PHIPwill promote the Triple Aim
Better population
health
Better care
Fewer health
disparities
Lower health
care costs
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PHIP contractors will provide a neutral forum for:
Promote population healthReduce health disparities
Best PracticesInnovative Strategies
Add value Fill gaps
Build capacity
Identifying
Sharing
Disseminating
Helping to implement
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PHIP contractors will provide a neutral forum for:
Health, behavioral health, & disabilities service providers
Rural health networks
Insurers, and other payers Consumer & patient advocacy organizations
Behavioral health advocacy organizations
Disability rights organizations
Local public health officials, other elected officials
Local human service agencies
Business community Unions
Schools Higher education institutions
Local housing authorities Local transportation authorities
Convening a broad set of stakeholders
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PHIP Regions
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NYS Health Improvement Initiatives
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Central New York PHIP Team
Oneida
Onondaga
Oswego
Cayuga
Cortland
HeC
Madison
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PHIP’s CNY Region
County Percentage
Onondaga 45%
Oneida 23%
Oswego 12%
Cayuga 8%
Madison 7%
Cortland 5%
6 Counties1,026,817 People
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PHIP’s CNY Region
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CNY PHIP Initial Activities
• Stakeholder engagement
• Governance structure established
o Steering Committee – met 2/26, 3/23, 4/13, and 5/11
o Regional Advisory Committee
• Generating reports on best practices:
• Models for population health improvement work
• Addressing health disparities
• Community engagement
• Identification of Central NY priorities
• Prevention Agenda Priorities Grid
• Identification of regional projects
• Development of website with health data, best practices and resources
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CNY Prevention Agenda Priorities
Reduce obesity among children & adults
Reduce illness, disability and death related to tobacco use and secondhand
smoke exposure
Increase access to high quality chronic disease preventive care and management in both clinical and community settings
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Supporting the Chronic Disease Self-Management Program (CDSMP) in CNY
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Convening Function
Health Equity Dialogues• Partnering with several stakeholders• How to better address health equity and health
disparities• Dialogue designed to inform collective action for
stakeholders
Listening Forum• Sponsored by the YMCA, PHIP and other stakeholders• How to better connect healthcare and community
based organizations and services• Informs DSRIP, PHIP and NYS Prevention Agenda
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Central New York Website
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HCI Website Examples
www.ochealthiertogether.orgwww.ncnyhealthcompass.org
www.dchealthmatters.org
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Improving Population Health in Central New York
Scott DahlDirector of Business Development, East RegionHealthy Communities Institute
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• Mission‒ Improve the health, vitality and environmental
sustainability of communities, counties and states
• Problem/Solution‒ Health data is too decentralized, quickly out of date, doesn’t identify health problems‒ Need to move beyond a traditional medical/disease model towards an active and systemic
philosophy that seeks to better prevent and manage disease‒ Built upon WHO/Healthy Cities Initiative – a catalyst to community health improvement,
widespread through the ubiquity of the internet, dynamic
• Our Unique ApproachProactive and dynamic integrated technology and services for monitoring disparities, synthesizing data, evaluating results, and creating action plans for health improvement and health equity
• National Relationships / Awards / Coverage:‒ Department of Health and Human Services Healthy People 2020 Award‒ Health Data Initiative Forum III Best Community App Award‒ VHA and CHA National Agreements‒ >130 million lives in the United States, 485 counties, 7 states, 425 hospitals
Healthy Communities Institute: focused on health informatics for community health since 2002
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mm
Benefit from an experienced team of epidemiologists, biostatisticians, informatics experts
• Ambassador Kevin Moley, U.S. Ambassador to United Nations 2001-06, Assistant Secretary, Health and Human Services
• Kevin Patrick, MD, Professor UCSD, Editor In Chief American Journal of Preventive Medicine
• Len Duhl, MD, Professor UC Berkeley, Co-Founder Healthy Cities Movement
• Linda Neuhauser, PhD, Clinical Professor, School of Public Health, Co-PI Health Research for Action, UC Berkeley
• David Holbrooke, MD, Founder PerSe Techs, Board Advisor McGill University Medical School
• Larry Leisure, Global Healthcare Practice Leader Accenture, CRO Kaiser Permanente
• Hans Ploos Van Amstel, CFO Levi Strauss
• David Warthen, Founder Ask Jeeves
HCI Advisors• Deryk Van Brunt, DrPH, President/CEO‒ Associate Clinical Professor, UC Berkeley;
CEO, eMedicine; COO HealthCentral• Marcos Athanasoulis, DrPH, CTO
‒ Director IT, Harvard Medical School; VP Engineering RelayHealth; CTO HealthCentral.com
• Florence Reinisch, MPH, VP Content/Research/ClientSvcs ‒ Research Director, CA Health Department
• Robert Murphy, Marketing Director‒ SVP Marketing iMetrikus
• Jan Barker, RN, FNP, MS, Business Development Advisor ‒ MedVenture
• Kathi deFremery, MBA, Director of Finance ‒ Finance Director, Center for Volunteer & Non-profit
Leadership• Sheila Baxter, MPH, Business Development
‒ WHO, UCSF, Kaiser Permanente
• Scott Dahl, MBA, Business Development, ‒ VHA, Kimberly-Clark, Texas Health Resources
HCI Management
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• 100 – 200 indicators• Constantly updated• Analytic tools
Community Knowledge
• >2000 in database• Programs & policies• Evaluation-based
Promising Practices
• Form working groups • Set local goals• Manage achievement
of objectives
Collaboration Centers• HP 2020 tracker
• Local Priorities tracker
• Comparative and longitudinal evaluation
Evaluation &Tracking
Continuous health improvement: Effectively moving from data to action
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Stakeholder Engagement
Management and Legal
Entity
Operations
HealtheConnections Steering Committee Regional Advisory Committee
6 County Advisory Groups
Standing Committees
Short-term Committees
Individual Outreach
Strategic Input StakeholderEngagement
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Thank you!
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Central New York Population Health Improvement Program (PHIP)
Regional Advisory Committee MeetingAugust 18, 2015
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Agenda
• Welcome/Introductions
• PHIP Funding Changes
• PHIP Scope of Work – Past and Future
• HealtheCNY Website – Launch and Promotion
• Next Steps
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PHIP Funding Changes
• Reduction in PHIP funding
• 50% cut - retroactive to January 2015
• Consultant work taken on by HeC staff
• Overhead and business costs absorbed by HeC
• County Agent contracts significantly reduced
• Explore new funding opportunities
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PHIP Scope of Work
Convening Stakeholders___________
• PHIP regional and local stakeholders
• Clinic to community linkages
• Health equity
Data and Best Practices
_____________• HealtheCNY
• Promoting best practices
• CDSMP
• NYS Prevention Agenda
Building Capacity
___________• Website TA and
Training
• Training
• Connecting to resources
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HealtheCNY Website – Launch and Promotion
• Pre-launch feedback
• Regional Advisory Committee, topic area experts, key stakeholders, beta testers
• Planned promotion efforts:
• Targeted announcements to intended audience/press release
• County based introduction events - in coordination with County Agents
• Ongoing activities
• Website work group
• Ongoing additions and improvements
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Next MeetingWednesday, November 18, 2015
Thank you!