North Country Initiative History
2014
North Country Initiative is Formed
NCI formed as a clinically integrated network of primary care, specialty care, emergency medical services, behavioral health, substance use, and social care providers in and around Jefferson, Lewis, and St. Lawrence counties. Its vision is to develop a high-quality, value-driven regional healthcare system that will enhance the healthcare of the entire population and serve the unique needs of the local community.
2015
DSRIP Begins
The regional ACO is formed as a partnership between hospital-based, independent, and federally-qualified health center primary care providers and enters its inaugural contract with the Centers for Medicare & Medicaid Services (CMS) in the Medicare Shared Savings Program.
2020
North Country Independent Practice Association (IPA) Begins its First
Value-Based Contract
Following success with the ACO’s Transitional Care Management (TCM) services, NCI launched a regional “mTCM” project to bring TCM to the area’s Medicaid-insured populations. In lieu of Medicaid reimbursement, NCI utilizes internal funds to support partners to conduct this service, in which primary care and/or behavioral care partners follow up with Medicaid-insured patients in the days following a hospital or emergency department (ED) discharge with a goal to safely transition the patient back to their home setting and avoid future hospital/ED events. mTCM also includes health-related social needs screenings, documentation, and referrals to appropriate services.
June 2021 - March 2022
First “Promising Practices Fund”
Projects are Implemented
Three projects were implemented in the second round, including Bolton’s Pharmacy’s “Vaccines and Vitamins for Children,” Complete Family Care & Laser Center’s “Bridging the Care Management Gap for Medicaid Patients”, and the third project was Watertown Family YMCA’s “Blood Pressure Self-Monitoring Innovation: A Partnership to Empower Low-Income High-Risk Individuals through Self-Monitoring for Successful Hypertension Control.” CLICK HERE for more information on each individual project.
2023
Behavioral Health & Substance Use Organizations Gain Patient Attribution
In North Country IPA
Seven projects were implemented in the third round of funding, including ARC Jefferson-St. Lawrence - Reducing Fall Risk of Intellectually/Developmentally Disabled Residents, Bolton's Pharmacy - Diabetes Self-Management Education (DSME) & Support Program, Credo Community Center (now known as “THRIVE Wellness and Recovery Inc.”) - Targeted Case Management for High-Risk Individuals, Pediatric Associates of Watertown - Improving Quality of Care in the Pediatric Population, Pediatric Wellness of NNY (formerly “Watertown Pediatrics”) - New Home for Pediatric Wellness of NNY, South Jefferson Rescue Squad - Fall Prevention Program, and the Watertown Urban Mission - Addressing Social Determinants of Health through the CARE Center. CLICK HERE for more information on each individual project.
2023
Regional “mCCM” Project Launches
2015 started New York State’s five-year Delivery System Reform Incentive Payment (DSRIP) program aimed at fundamentally changing healthcare delivery. DSRIP brought together partners from across the health & wellness landscape to increase access to preventive care while reducing avoidable emergency department and inpatient services, with a focus on the state’s Medicaid-insured and uninsured populations. DSRIP concluded in 2020. CLICK HERE for "Five Years of High 5's"
2015
Healthcare Partners of the North
Country Accountable Care Organization (ACO) is Formed
The regional IPA is established to engage in value-based contracts with payors other than Traditional Medicare. It began its first value-based contract in 2020 with a Managed Medicaid payor, with its second contract launching in 2021.
2021
Regional “mTCM” Project Launches
NCI utilized internal funding to issue a request for proposals from its clinically integrated network members for projects that impact the health & wellness of patients located in Jefferson, Lewis, and/or St. Lawrence counties (with an emphasis on those insured by Medicaid and/or Medicare, and uninsured populations). Five partners were awarded. CLICK HERE for more information on each individual project.
April 2022 - March 2023
Second “Promising Practices Fund”
Projects are Implemented
The IPA incorporated additional Medicaid members with behavioral health and/or substance use needs into one of its value-based contracts. It also included the behavioral health & substance use providers who serve these patients in the IPA contract, thereby meaningfully engaging them in value-based care alongside primary care providers.
April 2023 - March 2024
Third Round of “Promising Practices Fund”
Projects are Implemented
With demonstrated positive impacts of Chronic Care Management (CCM) services among its Medicare populations – and following a successful “Promising Practices Fund” pilot of CCM among Medicaid patients in the region – NCI expanded CCM to additional Medicaid patients in 2023. In “mCCM,” regional primary care and/or behavioral care partners establish a holistic care plan for patients with multiple chronic conditions, conduct health-related social needs screening/documentation/referrals, and contact the patient each month to monitor their symptoms, progress, and needs.
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2024
HRSA Northern Border Regional Commission: Community Health Workers in Primary Care
NCI’s work is bolstered by a 3-year HRSA NBRC grant received by FDRHPO to deploy Community Health Workers in 6 rural hospital-based primary care sites to improve clinical and social outcomes of rural high-needs individuals. The project is a collaboration with Carthage Area Hospital, Claxton-Hepburn Medical Center, Clifton-Fine Hospital, Northern Regional Center for Independent Living, River Hospital, and Samaritan Medical Center. The project is anticipated to impact the health outcomes of high needs patients in NCI’s ACO and IPA.