Monthly Archives: October 2012

CGA Amendment Working Group Organized

At The July 2012 Common Ground Alliance meeting in Long Lake, one of the work groups discussed two possible constitutional amendments, concepts that bubbled up from the ADK Futures Project. We are just beginning to organize work on this topic.

One idea is to come up with a systemic solution to utilitarian problems like burying fiber optic cable or sewer lines under roads that cross Forest Preserve.  With asphalt on the surface it seems obvious this should be ok, but this was declared unconstitutional by the NYS Attorney General in 1996.  We think this issue is one that can be resolved and we have until the 2014 legislative session to figure out specifics with all the bells and whistles.

The second (more difficult) idea is to facilitate improvements to the Forest Preserve and its interface with private lands.  Everyone knows of some land that should be in the Forest Preserve and other unremarkable land that causes undue problems because it is Forest Preserve.  Most people think a system allowing additions and deletions with the goal of a net improvement to the whole Park makes sense, so long as they were the decision maker.  Of course, it isn’t that simple.  So what would a real proposal look like and how might it actually work?  That is worthy of discussion even if it seems more difficult to enact than that first idea.

Both ideas will be explored at the same time in a series of upcoming interviews.

The CGA Amendment Working Group is:
Neil Woodworth, Exec Director, Adk Mountain Club
Ross Whaley, Adk Landowners Association, former APA Chair
Sherm Craig, APA Commissioner
Karyn Richards, Forest Preserve Coordinator, DEC
Bill Farber, Chair, Hamilton County
Ed Franz, Adk Park and Forest Preserve Manager, DOT
Ken Hamm, Associate Attorney, Office of the General Council, DEC

Jim Herman, ADK Futures Project and consultant to the working group
Dave Mason, ADK Futures Project and consultant to the working group

In the same sense that the Common Ground Alliance is not an official group, this is not an official committee appointed by anyone.  It is simply a working group.  We do hope to do enough work, reach out to enough people, gather diverse points of view, hold sufficient forums, and so on…. to be able to propose solutions with credible support to be taken forward officially by others.

Adirondack Medical Home Summit

Yesterday Jim attended the Adirondack Medical Home summit meeting in Lake Placid.  Since health care is so critical to the future prosperity of the region, this effort deserves a closer look.  Revolutionizing primary care can lead to much better care in our region.

The Adirondack Medical Home project is one of many efforts around the country to restructure the management and delivery of health care with the aim of strengthening the Primary Care Provider (PCP) role.  This regional effort, which is managed by the Adirondack Health Institute (see recent post) involves CVPH, Adirondack Health (formerly AMC) and Hudson Headwaters Health Network.  It provides incentives (i.e., more money) to primary care providers to take on the role of coordinating care for their patients.  By involving multiple provider networks and multiple insurance companies, it is one of the most ambitious in the nation.

At the conference, excellent presentations explained the data analysis that shows why this shift to putting the PCP in charge can achieve a threefold win:  better health outcomes, lower costs and a better experience for the patient.  The key data show that it is patients with more than one serious chronic condition or with a serious condition combined with a mental health or substance abuse problem who incur costs way out of line with other patients and for whom the health care system often becomes confusing and hard to navigate at best.  The problem is lack of coordination of care across multiple specialists, between physical and mental health services, and with social services.

The “Medical Home” approach puts the PCP in charge on the theory that your PCP is best able to make the correct decisions about your overall care and to see, for example, when drugs for one condition are interacting badly with those being taken for a different condition.  The PCP can also short circuit unnecessary and redundant testing that an individual specialist wouldn’t see or care about.  The goal is to optimize the entire process of care delivery for a patient not just a piece of it.

The other thing that the PCP can do is to work hard on keeping the patient engaged in their own care.  All kinds of studies show that costs go way up when patients get confused or indifferent about what they are supposed to do for their own care (e.g., fulfill prescriptions, go to rehab, etc.).  The idea of health coaches was put forth, who represent a new kind of role in the health care system, but one that can have a huge impact on outcomes and costs.

Using insurance claim data, practices can identify their patients with the greatest risk of problems in coordination and reach out to them proactively with the goal of preventing unnecessary visits to the emergency department or inpatient hospitalizations, which are the primary drivers of the high cost of health care in the US.

The next step in the evolution of this restructuring is to bring mental health, substance abuse and social programs into the coordination role at the Primary Care Provider, advancing us from a Medical Home for each patient to a Health Home that worries about a person’s complete health needs.  Medicaid is moving first to this model in New York but the Adirondack Health Institute is also moving in this direction.

The conference was very encouraging.  We are at the forefront of improving the healthcare system.  We are already seeing a drop in emergency department visits.  Others talked about the beneficial effect this can have on our ability to recruit primary care providers to the region.  One doctor highlighted studies that showed that medical students shy away from primary care, especially in a rural setting, because it appears to be too stressful a lifestyle.  The brain surgeons have more control over their schedule and have plenty of time for golf.  But if we are transforming primary care here and modernizing it, then it can be more rational and less stressful, especially if the compensation is there to support the additional staff needed in care management roles.

On a national level, this shift to the PCP requires that a lot more medical students decide to go into primary care (the most recent statistic cited was that only 2.5% of medical students go into primary care).  The most innovative idea put forth was being tried by a medical school in Texas:  students going into family practice or other primary care roles can graduate a year earlier than specialists.  This would be huge.

Others pointed out that almost all increases over the past 5 years in reimbursement rates have gone to primary care duties not to specialist procedures and that will continue, somewhat closing the disparity between primary care and specialists, who a few years ago earned as much four times that of a family practice doctor.

The big takeaway from the conference, however, was that in the future we will need fewer hospitals and more full service clinics or community health centers.  Many of the small hospitals in the north country will have to close or mutate into something focused more on outpatient services and primary care.  Hudson Headwaters is leading the way, building new clinics in Champlain and greatly expanding the one in Warrensburg.  The other takeaway was that we need to start training new kinds of community health workers to perform roles like health coach, care management and patient outreach.  As our population ages, there will be more service jobs in the local economy devoted to these and other services for the aging.  But we need to develop the training and certification programs for these new roles.

Working with Adirondack Schools

We spent Friday October 19th visiting Long Lake Central School and Indian Lake Central School.

We took the teachers at these schools through a sample of the ADK Futures materials and process with the idea of working them into the curriculum of middle school and high school students this year or next.  We discussed various ways we might work with the schools to bring ADK Futures to students.

The new common core standards for schools emphasize learning through real-world problems that are relevant to the students’ lives rather than abstract or fictional problems or topics.   Our work provides some great content that can be integrated across a number of subjects: science, math, civics, history, social studies, arts, physical education, etc.  Going through a process like scenario planning would teach students to work in teams and allow them to become more engaged in the efforts to improve their communities and the region. But the greatest benefits, we feel, would come from students feeling more empowered to participate in the creation of their own future.

Students would need background information on many aspects of the Adirondack Park region prior to participating in some form of the process.  We were pointed to the Adirondack Curriculum Project which already provides a great deal of relevant material, already organized into the lesson plans.  As we work with a school, what we develop with them can be reused by other schools.  Over time, we could have a pretty complete set of modules that any school in the region can use.  Ultimately, we might have a youth planning summit in which students from multiple schools come to debate the best future for them as they grow up and the ways in which they can work to make that future happen.

We look forward to continuing these discussions with these two schools and others.

Regional Health Care Update

Today we went to Queensbury to meet with the Adirondack Health Institute (AHI), which is a joint venture of Hudson Headwaters Health Network (HHHN), CVPH and Adirondack Health (the former Adirondack Medical Center).  This is the go-to group for regional health care in our area.  Their main claim to fame is the Adirondack Medical Home pilot, which is one of first underway in the nation.   It provides incentives to primary care providers to strengthen their role in prevention and care coordination to improve quality and contain costs.

We had many take-aways from our discussions this morning.  The direction is toward more regional planning, assessment and implementation of new programs. Our area is ahead in implementing innovative approaches to rural health care delivery.   AHI is working to integrate other social and mental health services into the Medical Home approach. But the Medical Home pilot ends in 2014. What happens then? AHI invited us to attend the Adirondack Medical Home Summit in Lake Placid next week and Jim will go.

Some potential good news on the horizon is New York State’s request to the Federal Government for many billions of dollars to invest in health care innovations and make the State a model of health care reform.  If even a small piece of that money can come our way, we need to have some really good new ideas to put on the table.

Another piece of good news was HHHN’s planned major expansion of their Warrensburg Health Center, which is the hub of their Adirondack Network.  Work is scheduled to begin next spring.

One service that could benefit from a more regional approach is the Home Health Agencies that are currently at the county level.  We also discussed the ACTION broadband network being built now across the Park. This network is just becoming operational and reimbursement policies that include payment for remote consultations are just now being ironed out.  The co-leaders of the project are SUNY Plattsburgh and the Fort Drum Regional Health Planning Organization.  It is being built and run by DANC.