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Millennium Collaborative Care, the Performing Provider System for Western New York

Performing Provider Systems have been working to provide better care to Medicaid clients in New York. Al Hammonds, Executive Director of Millennium Collaborative Care, discusses how they help improve healthcare delivery for Medicaid clients.
Millennium Collaborative Care, the Performing Provider System for Western New York
Al Hammonds, CSSBB
In his leadership role as Executive Director of Millennium Collaborative Care, Al Hammonds oversees a staff of 35 working to collaborate and partner with physicians, healthcare providers and community-based organizations on the implementation of 11 DSRIP programs designed by Millennium to positively impact Medicaid patients across Western New York’s eight counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming).

Bill Klaproth (Host): Across New York State, innovative organizations called Performing Providers Systems have been working to improve the delivery of healthcare to over six million Medicaid clients. In western New York, ECMC is the parent of Millennium Collaborative Care, the PPS that serves over 270,000 clients over eight counties. But unlike ECMC, Millennium does not provide healthcare services. Here to tell us what Millennium is focused on is Al Hammonds, Executive Director of Millennium Collaborative Care. Al, thank you so much for your time today. So, let’s start with this. Can you tell us more about why Millennium was created and what a Performing Providers System like Millennium is focused on.

Al Hammonds, CSSBB (Guest): Great question Bill. Let me take a shot at that. Really a very brief history of Medicaid. In 1965, Medicaid became law under President Johnson, Lyndon B. Johnson. Fast forward about 50 years to now, 2019, New York State alone has a Medicaid population of about six million folks at a cost of about 60 billion dollars a year. The state of the – while Medicaid is prominent, there’s also Medicare and commercial as well. But state-of-the-art hospitals like ECMC need to reinvest in the system to drive improvements and in the process, to lower costs.

So, Governor Cuomo in 2015, initiated and announced the delivery system reform and payment program which is called DSRIP which enables New York to invest about 7.3 billion dollars and to establish 25 different entities, what we call Performing Provider Networks across New York State. We Millennium are one of those 25 here in Western New York and we fundamentally are looking at restructuring the healthcare delivery system, reducing avoidable hospitalizations by 25% over a five year period. So, hopefully that helps.

Host: Wow, that’s really interesting. So, improving healthcare delivery for Medicaid clients is Millennium’s focus. So, can you tell us how your organization does this?

Al: So, one of the DSRIP programs, the delivery system reform is in the payment program, it’s designed to stabilize the state’s safety net healthcare provider system and realign the state’s delivery system following what is known as on a national basis the Triple Aim. The Triple Aim which is the goal of DSRIP is to A, improve population health and to drive population health mentality. B, improve the quality of care for the Medicaid population and then C, to control costs.

So, Millennium is a highly diverse group of about 40 employees. We partner with providers such as primary care physicians, hospitals, community health centers, community based organizations, just to name a few, to collaborate on specific projects aimed at specific improvement metrics. So, that’s what we’re doing.

Host: Well that is a great goal. Improve population health, improve quality care and control costs. So, Al, can you give us a few examples of Medicaid improvement initiatives Millennium and your partners have worked on?

Al: It’s really hard to single out one, but a few come to mind. We have got about ten months left in the initiative here. Two great examples of collaboration and improvement and success revolve our partner ECMC who is the parent, the DSRIP partner and parent for this program here in western New York and another one is with the Niagara Falls Memorial Medical Center. One of the most important insights that we’ve learned and gained over this time is how critical the social determinants of health are to help improve this population.

So, at ECMC, Erie County Medical Center, they launched in December of 2017, a primary care access center which has been really successful. Choosing this name was important to change the culture of ECMC and wanted to help patients understand that there are services that the primary care doctor can provide not just the emergency room or the hospital itself. So, that was a really great program the Primary Care Access Center. And the results were really good. I mean overall, approximately 35 Medicaid patients per month were redirected to primary care. ECMC’s Primary Care Access Center also gets about 75% of the patients’ physicals over the course of a year and they also help transition patients to other community based primary care physicians as well. Also it’s very instrumental in engaging community based organizations to help with the social determinants of health like patient transportation, food and those kinds of things.

Host: So, it sounds like there should be a cost savings as well. This might be a tough question to answer, but besides getting the patient to the right care, what kind of savings is there between a visit to the ER and to a primary care doctor?

Al: Yeah, the dollars and cents of it, kind of under the DSRIP Program, we’re driven by process and transformation and really driving the metrics. We really aren’t driven by the cost itself, but from what we understand and what we see with the data that we see; if an emergency room visit costs call it approximately $1000, a primary care visit at the doctor’s office is more in the neighborhood of $100. So, you can see that kind of order of magnitude, that scale there in terms of the difference between an ER visit and a primary care visit. So, it’s a huge cost savings to do that and it’s better for the patient.

Host: Absolutely. That really puts it in perspective. So, this is a really big initiative. Can you tell us maybe a challenge that you had at Niagara Falls Memorial Medical Center?

Al: Yeah, certainly, I mean Niagara Falls Memorial Medical Center serves a high need population. A very needy area of – Sheila Key who is the Chief Operating Officer there, she’s truly a visionary and a healthcare leader. She coined this phrase called “The Loneliness Factor” and what they’ve been able to do is really get their arms around that. It was a really big challenge. What is the root cause of why people come to the emergency room? And not all the time, it’s not an ailment but they are just lonely. And so through this, Niagara Falls established several goals including how to enhance the system to achieve improvements in patient outcomes and overall performance. How do they overcome the loneliness factor, they tried to get their arms around that. How to implement behavioral health screening in the emergency room. How to better engage the most frequent users of the ED, we call them high utilizers.

So, some of the solutions ended up being they established a new emergency room information desk, kind of a better more friendlier intake process, implemented this new emergency room sandwich program to provide food which has really been effective. The sandwich program, we joke about it. implemented after hours primary care at the Golisano Center which was really good and then also implemented some emergency room based screening for behavioral health patients including behavioral health home visits, which has really been effective.

And then lastly, really looking at like an ED hot spotter program after nine emergency room visits a patient is assigned to a Niagara Falls Memorial Medical Center ED hot spotter program so they get special attention. The results have been outstanding. The desk has proved to be a very convenient, no issues, no nonsense type of program and after a four month period, Niagara Falls Memorial Medical Center identified 763 high utilizers; of these 52% received face to face contact with a social worker resulting in a reduction in the overall emergency room high utilizer visits by 16.5%. So, the data is doing the talking and we are actually helping people get better.

Host: So, great results and creative solutions to “the loneliness factor”. Very interesting. So, Al you mentioned other areas of healthcare Millennium is working in. Can you share a few of those examples?

Al: Yeah, I’d be happy to. So, one example is our physician engagement that we do, engaging physicians specifically in the southern tier at the Chautauqua Center, we looked at the asthma and chronic obstructive pulmonary disease program, which is a COPD program, kind of like a medical neighborhood pilot program that was extremely effective. The Chautauqua Center is a federally qualified healthcare center down in Jamestown with offices in Jamestown and Dunkirk. So, that was really effective engaging physicians.

Some of the strategies they looked at was the patient experience with care, the health of the population being cared for around asthma and COPD, reduction in the inpatient admissions. All those things were approved.

We also have another area Millennium is working in and doing with the community based organizations that was really effective. We have a community based organization task force which none of the other PPS’s have in the state which is part of our governance process which helps us run and make decisions with the unit with PPS here. We really got a lot of high praise and a lot of notoriety around our local beauty and barbershop program engaging clients in a high blood pressure self-screening initiative. So, people that don’t feel comfortable going to the doctor’s office and have that stigma, the local beauty and barbershop program helps the county get a handle on and get in touch with what their blood pressure is in a very comfortable setting. Twelve shops in Buffalo and in Niagara Falls were equipped with self-monitoring blood pressure cuffs and we go some pretty good press on that.

And then lastly with the community based organizations, we had this cardiovascular disease arena initiative that we focused on here in western New York called the Million Hearts Program. And that was extremely effective. It was a collaborative in partnership between us, Millennium Collaborative care, the University of Buffalo School of Nursing, the Greater Buffalo United Churches to put together health screening fairs. These were really a great win-win for the nursing students out of UB. They received really good practical hands-on experience. And Millennium and UB received a spotlight on population health kind of award regionally here in western New York a couple of years ago. So, that was a really high profile program.

So, hopefully, those help you understand kind of the depth and the breadth of other projects that we worked on that have been really effective.

Host: Wow, so much accomplished. That’s amazing. So, what’s on the horizon for Millennium? Where do you go next with this?

Al: We are in year five of a five year demonstration project with only like ten months to go at this point. We’re hoping to continue collaboration with partners, continue to drive Medicaid population improve it’s metrics. We are in alignment with ECMC’s vision of population health. ECMC is a leader in this area here in western New York and this is a key part of ECMC’s mission and vision is to drive population health with its population in particular. So, there’s three critical areas that we are looking at remaining focused in. One is population health services which is coaching primary care practitioners to become care team leaders. So, that’s a big thing.

Number two is the value based payment performance services. So, value based payments is coming hot and heavy over the next couple of years and ramping up so, what our role is conducting organizational and contractual assessments with providers and organizations to make sure they are ready for this from a fee for service to a value based payment world.

And then the third piece is our data analytics, data warehouse and analytics capabilities which is huge. Significant investment has been made in Cerner’s population health platform and health management platform to look at data analytics, predictive risk identification and stratification as well as making sure the key partners are in the loop in developing data sharing agreements so that we can share data across all of western New York. We have the region’s largest Medicaid data analytics platform and most powerful platform to be able to perform these analytics and help the population.

Host: Al this is great. Thank you so much for your time and congrats on all of the accomplishments of Millennium Collaborative Care. And if you want to learn more please visit, that’s And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This is the True Care Healthcast from Erie County Medical Center. I’m Bill Klaproth. Thanks for listening.