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Key Initiatives

Care Coordination

Care Coordination

One problem with health care today is that care is often disconnected and difficult for patients to navigate across providers and care settings—especially for patients with complex health care needs. New health delivery models incorporate improved care coordination as a foundational element, connecting care delivery to the community as well as clinical and financial resources.


THINC is pursuing improved care coordination through a project that requires participating providers to meet a specified set of care coordination activities. Incentive payments from six health plans--Aetna, CDPHP, Hudson Health Plan, MVP Healthcare, United, and WellPoint—and  a local employer, IBM, will be paid to providers in 2011 upon achievement of certain quality goals and a review of utilization data.


Beginning in July 2011, THINC and Taconic IPA (TIPA) launched an 24-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. The 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.


The advanced primary care pilot fouces 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 manager will work with patients and will be using standardized protocols and processes designed by TIPA.  A reserach and evaluation component of the project, managed by THINC, will measure outcomes consistent with the Triple Aim, in collaboration with researchers from Weill-Cornell Medical College and RAND Public Policy Research.