Too often, a patient’s health care is uncoordinated and fragmented, leading to higher costs, poor outcomes and negative patient experiences.  

To turn the tide on uncoordinated care, Taconic IPA is partnering in an 18-month pilot project to demonstrate that advanced medical homes featuring embedded case managers can increase quality and deliver care that achieves the Triple Aim. Advanced primary care is a new model for care delivery that successfully leverages the use of health information technology to support a practice’s transformation to the patient-centered medical home, with a heightened emphasis on care coordination. TIPA’s advanced primary care pilot  will take place within primary care settings across the Hudson Valley, ranging from solo practices to large multi-specialty group practices in multiple locations. We selected the pilot sites based on their commitment to continuing to advance the effectiveness of the primary care transformation that started with achieving NCQA Level 3 PPC-PCMH medical home recognition in 2009. 

The advanced primary care pilot focuses on adults with chronic, complex medical conditions who are likely to benefit from care coordination by an experienced RN case manager working as part of a collaborative team in primary care practices. The case managers will work with patients and will be using standardized protocols and processes designed by TIPA.  A research and evaluation component of the project,  managed by the Taconic Health Information Network and Community (THINC), will measure outcomes consistent with the Triple Aim, in collaboration with researchers from Weill-Cornell Medical College and RAND Public Policy Research.

The goal of the pilot is to demonstrate that patient-centered care coordination services as part of an advanced primary care model in an open community of care can deliver safe, effective and efficient care to achieve the Triple Aim. We intend to also show scalability and the ability to replicate the pilot in other communities that desire to follow in our footsteps and transform care in their own communities.

Click below to learn more about:

The Embedded Care Manager

Centralized Infrastructure

Community-Related Practices