NORTH

COUNTRY
HEALTH
SYSTEMS
REDESIGN
COMMISSION
Toward an Integrated Rural Health System:
Building Capacity
and Promoting Value
in the North Country
April 2014
1





1oward an lnLegraLed 8ural PealLh SysLem: 8ulldlng CapaclLy and
romoLlng value ln Lhe norLh CounLry




















2

!"#$% '( )'*+%*+,

norLh CounLry PealLh SysLems 8edeslgn Commlsslon 3
AcknowledgemenL 4
LxecuLlve Summary 3
lnLroducLlon Lo Lhe norLh CounLry 8
1he Commlsslon 10
1he Charge 11
Worklng rlnclples 11
1he norLh CounLry and lLs 8esldenLs 13
PealLh Care ln Lhe norLh CounLry 14
SLrengLhs of Lhe norLh CounLry 19
lmperaLlves and lmpllcaLlons of PealLh 8eform 22
8eforms aL Lhe lederal Level 22
8eforms aL Lhe SLaLe Level 23
1he AblllLy Lo MeeL opulaLlon needs 30
1elehealLh 33
Long 1erm Servlces and SupporLs 36
8ecommendaLlons 38
Concluslon 43
Appendlces 46









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-'.+/ )'0*+1 2%"$+/ 31,+%4, 5%6%,78* )'447,,7'*

Chalr: uanlel SlsLo, pasL presldenL, PosplLal AssoclaLlon of new ?ork SLaLe (PAn?S)
Co-vlce-Chalr: ArLhur Webb, prlnclpal, ArLhur Webb Croup
Co-vlce-Chalr: !ohn 8ugge, M.u., presldenL and CLC, Pudson PeadwaLers PealLh neLwork, Chalr of Lhe CommlLLee
on PealLh lannlng of Lhe n?S ubllc PealLh and PealLh lannlng Councll
Call 8rooks, execuLlve dlrecLor, Adlrondack CommunlLy 1rusL
uan 8urke, reglonal presldenL, SaraLoga-Clens lalls 8eglon-n81 8ank
1edra Cobb, presldenL, 1edra L. Cobb and AssoclaLes
1om Curley, pasL execuLlve dlrecLor, 1he AssoclaLed ress
Susan uelehanLy, chlef execuLlve offlcer, ClLlzens AdvocaLes lnc.
Carry uouglas, presldenL and CLC, norLh CounLry Chamber of Commerce
Ponorable !aneL uuprey, new ?ork SLaLe Assembly Member
Sherrle CllleLLe, ulrecLor, CllnLon CounLy CommunlLy MenLal PealLh Servlces
Ponorable 8eLLy LlLLle, new ?ork SLaLe SenaLor
lred Monroe, supervlsor, 1own of ChesLer
Ponorable aLLy 8lLchle, new ?ork SLaLe SenaLor
nell 8oberLs, 8oard member, lorL Pudson PealLh SysLem
Ponorable Addle 8ussell, new ?ork SLaLe Assembly Member
Ponorable uan SLec, new ?ork Assembly Member
uenlse ?oung, execuLlve dlrecLor, lorL urum 8eglonal lannlng CrganlzaLlon

Congressman 8lll Cwens, speclal advlsor








4

9:;*'<$%68%4%*+

1he Commlsslon would llke Lo exLend lLs graLlLude Lo Lhe numerous sLaff members aL Lhe new ?ork SLaLe
ueparLmenL of PealLh SLaff who conLrlbuLed Lo Lhe pro[ecL's plannlng and lmplemenLaLlon. A small group qulckly
became a large one, and we wlsh Lo Lhank (ln no parLlcular order) Lhose who conLrlbuLed: Llsa 8rown, Carlos
Cuevas, Laura uellehunL, 1lmoLhy uonovan, 8oberL uurlak, karen Madden, norman Marshall, Colleen McLaughlln,
Shaymaa Mousa, Llnda nelson, Pope lavln, Lduardo SanLana, kelLh Servls, !ennlfer 1reacy, Llsa ullman, karen
WesLervelL, Angela Whyland and Wlnnle ?u.
We'd also llke Lo Lhank uCP sLaff who Look Lhe Llme Lo glve presenLaLlons: Charles Abel, Creg Allen, Cus 8lrkhead,
Lee 8urns, !ohn Cahan, losLer CesLen, 8arry Cray, !ason Pelgerson, Llnda kelly, and 8aeAnn vlLall.
We also wlsh Lo acknowledge Lhe CenLer for PealLh Workforce SLudles, Lhe n?S PealLh loundaLlon, kMC,
Mcklnsey and uave Chokshl.


















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=>%:0+7?% 3044".1

new ?orkers ln Lhe norLh CounLry llve ln one of Lhe mosL beauLlful reglons of Lhe u.S., one populaLed by hlgh
peaks, vasL landscapes and scenlc vlsLas. 8uL resldenLs of Lhls far-flung reglon also confronL Lhe harsh reallLy LhaL
access Lo healLh care has become lncreaslngly dlfflculL.
1he norLh CounLry's healLh care dellvery sysLem ls under growlng sLress. aymenL reform, aglng of Lhe populaLlon
and workforce shorLages all pose speclal challenges. nomlnal coordlnaLlon among provlders and lack of a
reglonally lnLegraLed healLh care dellvery sysLem LhreaLen Lhe conLlnued exlsLence of many healLh care faclllLles.
Addlng Lo Lhe burden are rlslng raLes of chronlc dlsease, whlch [eopardlze Lhe reglon's economy, workforce, and
quallLy of llfe. 8ural communlLles always have dlsLlncL healLh care needs due Lo geographlc lsolaLlon and large
numbers of un- and under-lnsured resldenLs, buL Lhese challenges are especlally sLrlklng ln Lhe norLh CounLry
where Lhe confluence of Lrends ls magnlfylng Lhe problems.
Across Lhe norLh CounLry, Lhe need Lo bulld capaclLy and promoLe value ls crlLlcal and fasL becomlng a crlsls.
SLakeholders ln Lhe reglon and governmenL offlclals allke need Lo glve Lhelr urgenL aLLenLlon Lo necessary
LransformaLlons ln care dellvery, paymenL, and populaLlon healLh whlle also respondlng wlLh a more flexlble
regulaLory sysLem. Change wlll requlre Llmely acLlon on all fronLs.
1he reglon's healLh ls sub-par. 8y example, compared Lo sLaLe-wlde norms, Lhe norLh CounLry counLs a hlgher
percenLage of adulLs wlLhouL healLh lnsurance, and more dlagnosed wlLh dlabeLes, asLhma , and obeslLy-as well
as more smokers.
1he reglon's healLh care dellvery sysLem ls hlghly fragmenLed and remalns cenLered around lnpaLlenL beds. As a
resulL, Lhe norLh CounLry has a hlgher raLe of prevenLable hosplLallzaLlons, Lmergency ueparLmenL vlslLs, and
chronlc lower resplraLory dlsease (CL8u) hosplLallzaLlons compared Lo sLaLewlde raLes. WlLhln Lhls reglon Lhere are
16 hosplLals, 21 dlagnosLlc and LreaLmenL cenLers, and 29 nurslng homes. 1here are 601 hosplLal beds, 1,203
nurslng home beds, 279 adulL home beds and 38 asslsLed llvlng beds per 100,000 people. Cverall, Lhe reglon has
Loo many hosplLal beds and an excess of nurslng home beds, buL prevenLlve and prlmary care capaclLy ls
lnadequaLe, and Lhe uneven dlsLrlbuLlon of hosplLals causes serlous access lssues.
WlLhouL quesLlon, healLh care employmenL plays a ma[or role ln Lhese local economles. 8ural hosplLals are ofLen
Lhe healLh care and economlc foundaLlons of Lhelr communlLles buL face an lncreaslng sLruggle as relmbursemenL
raLes decllne, and care shlfLs from Lhe lnpaLlenL Lo an ambulaLory seLLlng. ln many cases, norLh CounLry hosplLals
and provlders have yeL Lo adapL Lo Lhls change and are noL prepared Lo deal wlLh addlLlonal relmbursemenL and
sysLem ad[usLmenLs LhaL are sure Lo come wlLh healLh care reform.
MosL people ln Lhe reglon have longer LransporL Llmes for Lmergency Medlcal Servlces (LMS) Lhan ls Lhe case
elsewhere. SLaLewlde, Lhe average LransporL Llme for an LMS ambulance ls 13 mlnuLes, whlle ln Lhe norLh CounLy,
40 of munlclpallLles have LransporL Llmes longer Lhan 23 mlnuLes.
1he reglon's dlfflculLy ln recrulLlng all Lypes of pracLlLloners, parLlcularly physlclans, adds Lo Lhe sLruggle. 1he
norLh CounLry has 40 fewer acLlve prlmary care physlclans (86 per 100,000 populaLlon) Lhan sLaLewlde (120 per
100,000) and 73 fewer acLlve physlclan speclallsLs. lL also has correspondlngly fewer denLlsLs (43 per 100,000)
Lhan Lhe resL of Lhe sLaLe or upsLaLe new ?ork (78 and 62, respecLlvely).
An aglng populaLlon and hlgh raLes of poverLy force provlders ln Lhe norLh CounLry Lo rely heavlly on Medlcare and
Medlcald wlLh Lhelr relaLlvely low relmbursemenL levels. Care ls ofLen fragmenLed as many provlders have reslsLed
mergers ln an aLLempL Lo reLaln lndependence. ?eL, llke Lhe resL of Lhe sLaLe, norLh CounLry communlLles need
lnLegraLed dellvery sysLems Lo enable care coordlnaLlon across Lhe conLlnuum of care, lncludlng prevenLlve,
6

prlmary, acuLe, behavloral, and long Lerm care servlces. ueveloplng such sysLems should lmprove cllnlcal
ouLcomes and populaLlon healLh whlle also assurlng flnanclal vlablllLy for provlders of needed servlces.
1hlrLeen of Lhe 16 hosplLals ln Lhe nlne-counLy area had a negaLlve operaLlng margln ln 2012 wlLh slx of Lhese
faclllLles experlenclng losses for Lhree or more years. ln aggregaLe, Lhe 16 hosplLals have an operaLlng deflclL of
abouL $20 mllllon dollars annually. AbouL Lwo-Lhlrds of Lhe faclllLles have hlgher long Lerm debL Lo caplLallzaLlon
compared Lo slmllar faclllLles ln Lhe resL of Lhe sLaLe. Lack of access Lo caplLal ls a serlous lmpedlmenL LhaL lnhlblLs
LransformaLlon.
1he ouLlook ls even worse for Lhe area's nurslng homes. SlxLeen ouL of Lhe 29 nurslng homes
1
ln Lhe nlne-counLy
area had negaLlve operaLlng marglns, wlLh a comblned loss of over $27 mllllon dollars ln 2012. 1he flscal sLrengLh
of nurslng homes ln Lhe norLh CounLy ls sLrongly affecLed by Lhe facL LhaL mosL nurslng home resldenLs ln Lhe area
are healLhler Lhan oLhers ln Lhe resL of Lhe sLaLe. 8uL Lhe lack of alLernaLlves such as home care and asslsLed llvlng
forces people who would oLherwlse noL need nurslng homes Lo use Lhese servlces. 1he Medlcald program ad[usLs
paymenLs Lo nurslng homes based on case mlx," whlch ls a measure of how much care Lhe paLlenLs ln Lhe nurslng
home need. 1he case mlx lndex for Lhe Medlcald paLlenLs ln norLh CounLy nurslng homes ls 10 lower Lhan lL ls
elsewhere ln new ?ork. WlLh 76 of nurslng home paLlenLs quallfylng for Medlcald, Lhe low case mlx has a
subsLanLlal lmpacL on Lhe faclllLles' boLLom llnes.
1o ensure LhaL new ?orkers ln Lhe norLh CounLry achleve hlgh quallLy care, beLLer healLh ouLcomes, and lower
cosLs, boLh now and lnLo Lhe fuLure, an lnLegraLed approach Lo care musL be developed. We need a sysLem LhaL
emphaslzes prevenLlon, lncreases prlmary care, bullds more communlLy-based opLlons, sLrengLhens coordlnaLlon
and communlcaLlon, supporLs crlLlcal safeLy neL provlders, monlLors and rewards quallLy, and bullds afflllaLlons and
parLnershlps LhaL achleve Lhese goals ln a cosL-efflclenL and flscally sound way.
1he Commlsslon recognlzes Lhe value and Lhe lmporLance of Lhe SLaLe PealLh lnnovaLlon lan (SPl) LhaL has been
developed by Lhe ueparLmenL of PealLh as a sLaLewlde blueprlnL for lmprovlng Lhe healLh care sysLem and
appreclaLes Lhls opporLunlLy Lo suggesL a deslgn for Lhe norLh CounLry as new ?ork's mosL rural and one of lLs
mosL hard-pressed reglons. We also appreclaLe Lhe Llmlng of Lhls reporL Lo recommend prlorlLles and fundlng LhaL
ls anLlclpaLed ln Lhe sLaLe budgeL for Lhe comlng year and Lhe $8 bllllon award pledged by Lhe federal CenLer for
Medlcare and Medlcald Servlces Lo lnvesL ln healLh sysLem LransformaLlon.
ln concerL wlLh Lhe SPl, Lhe Commlsslon recommends as a LopmosL prlorlLy Lhe promoLlon and supporL of Lhe
Advanced rlmary Care model across Lhe norLh CounLry. 1o achleve full poLenLlal, Lhls model wlll need Lo lnclude
lnLegraLlon of behavloral healLh servlces lnLo prlmary care seLLlngs, developmenL of LelehealLh servlces, and Lhe
creaLlon and expanslon of prlmary care Lralnlng programs, lncludlng graduaLe medlcal educaLlon for famlly
medlclne physlclans along boLh Lhe wesLern and easLern slopes of Lhls mounLaln reglon.
We also recommend enfoldlng cerLaln skllled nurslng homes lnLo a new deslgn as Skllled Care Campuses (SCCs).
An SCC would lnclude, Lhrough corporaLe or vlrLual lnLegraLlon, a conLlnuum of communlLy-based long Lerm care
servlces wlLh flnanclal lncenLlves Lo place resldenLs ln Lhe leasL resLrlcLlve approprlaLe seLLlng whlle aL Lhe same
Llme enabllng down-slzed faclllLles Lo malnLaln Lhelr vlablllLy by recommlLLlng exlsLlng space Lo new uses and
provldlng sufflclenL relmbursemenL Lo keep Lhe mosL vulnerable members of our communlLles reasonably close Lo
home and famlly.
1he Commlsslon has Laken care noL Lo recommend Lhe closure or merger of any speclflc faclllLles, lncludlng
hosplLals, whlle recognlzlng LhaL downslzlng of Lhe acuLe care secLor ls already Laklng place and can be expecLed Lo
acceleraLe. WhaL we do recommend ls Lhe sLaLe recognlze Lhe perlls and merlLs of lndlvldual hosplLals
parLlclpaLlng ln lnlLlaLlves Lo Lransform and lmprove Lhe sysLem LhaL wlll lnevlLably also serve Lo undermlne Lhelr

1
1here are addlLlonal nurslng homes ln Lhe nlne counLy area LhaL are afflllaLed wlLh hosplLals and do noL submlL
Lhelr lndlvldual flscal daLa on Lhelr lnsLlLuLlonal cosL reporLs.

7

own flnanclal prospecLs. 1o Lhls end, we recommend LhaL Lhe sLaLe deslgnaLe Lhose organlzaLlons-be Lhey
hosplLals, nurslng homes, or oLher esLabllshed enLlLles-LhaL are successfully pursulng Lhe 1rlple Alm of beLLer
care, beLLer healLh and lower cosLs Lhrough lnLegraLlon as LssenLlal CommunlLy PealLh neLworks (LCPns). 8y
vlrLue of Lhls deslgnaLlon, LranslLlon fundlng should be exLended Lo Lhese dlsLressed faclllLles Lo assure effecLlve
LransformaLlon lnsLead of dlsappearance.
llnally, all Lhe members of Lhe Commlsslon would llke Lo noLe LhaL our work represenLs an efforL aL reglonal
plannlng aL a very fasL pace. We are proud of Lhls reporL and Lhe many recommendaLlons lL conLalns, we commend
lL Lo Commlssloner Shah, Lo oLher pollcymakers, and Lo all Lhe sLakeholders ln Lhe norLh CounLry. AL Lhe same
Llme, we recognlze LhaL Lhls work ls only a sLarL, hopefully a head sLarL. 1o reallze Lhe frulLs of Lhls endeavor wlll,
we belleve, requlre on-golng, sysLemaLlc, lncluslve, and susLalned plannlng acLlvlLy such 8eglonal PealLh
lmprovemenL CollaboraLlves (8PlCs).

8

@*+.'60:+7'* +' +/% -'.+/ )'0*+.1
Much of Lhe brlcks and morLar of modern" healLh care ln norLhern new ?ork was developed ln a dlfferenL era.
1he acuLe care sysLem evolved durlng Lhose relaLlvely opLlmlsLlc days afLer Lhe Second World War, when healLh
care happened aL a slower pace, 14-day sLays for maLernlLy were Lyplcal, and caLaracL exLracLlons enLalled days ln
Lhe hosplLal wlLh your head packed ln sand bags. Lconomlcally, Lhe Seaway was belng developed, lLs elecLrlclLy
servlng companles such as Alcoa. 1he paper lndusLry was local and supporLed several Lowns, Lhere were people
and [obs ln remoLe areas. CommunlLles had relaLlve prosperlLy. Conslderable dlsLances, noL Lo be covered easlly or
qulckly, separaLed Lhe clLlzens from each oLher, cars were slower, roads narrower, and l-87 and l-81 were, aL besL,
englneers' dreams. PealLh care dellvery as lL sLood was a raLlonal developmenL for Lhe Llmes.
LvenLually all Lhls changed. Many companles closed or lefL Lhe area and [obs evaporaLed. 1he Adlrondack ark
became a more popular desLlnaLlon, and a servlce and LourlsL-based economy became domlnanL. 1he sysLem" of
healLh care dellvery sLruggled Lo adapL, lacklng flnanclal resources, sLruggllng wlLh ouLdaLed lnfrasLrucLure, absenL
slzable populaLlon cenLers, and faced wlLh lnconslsLenL publlc pollcy.
Long Lerm care developed lLs lnfrasLrucLure slmllarly Lo Lhe resL of new ?ork ln response Lo Lhe esLabllshmenL of
Medlcare and Medlcald. ln Lhe early 70's Lhese faclllLles were fllled wlLh senlors, many of who would noL be, nor
would wanL Lo be, admlLLed Loday. 1he proflle of Lhe earllesL admlsslons Lo Lhe long Lerm care seLLlng would
beLLer maLch Loday Lhose consldered approprlaLe for supporLlve houslng, or care ln Lhe home. Chronlc and acuLe
condlLlons LhaL demanded hosplLal admlsslons four decades ago are managed dlfferenLly Loday, wlLh dramaLlc
shlfLs ln whaL we now conslder Lhe proper use of Lhe long Lerm care sysLem.
As for prlmary care-a Lerm yeL Lo be lnvenLed-medlcal pracLlce was deflned as a solo general pracLlLloner
worklng ln hls offlce.
lf we look aL Lhe norLh CounLry Loday, lL has experlenced slgnlflcanL loss of [obs, wealLh and populaLlon. 1he norLh
CounLry has had Lhe added dlfflculLy of adapLlng an ouLdaLed lnfrasLrucLure Lo conform Lo a seLLlng LhaL may work
well ln areas of sLable or expandlng populaLlons, and where dlsLance ls measured ln lncremenLs far less Lhan hours
of Lravel. CpLlng for servlces ln a nelghborlng communlLy LhaL's Len mlnuLes down Lhe road has a far dlfferenL
lmpacL when LhaL nelghbor" ls 30 mlles away. 1hls lmmuLable facL challenges Loday's noLlon of access, cholce and
consumer expecLaLlons.
Lven wlLh able managemenL and commlLLed leadershlp, norLh CounLry healLh care provlders have noL Lhrlved nor
adapLed easlly Lo changlng condlLlons, yeL Lhey musL fulflll a fundamenLal need of Lhe populaLlon. 1he relaLlve
weakness Lhey exhlblL, and llkely Lhe condlLlon Lhey presenL Loday, ls Lo some exLenL a naLural evoluLlon of an
economlc cycle LhaL has plagued Lhls reglon.
new ?orkers ln Lhe norLh CounLry sLlll llve ln one of Lhe mosL beauLlful reglons of Lhe u.S., surrounded by hlgh
peaks, vasL landscapes and scenlc vlsLas. 8uL resldenLs of Lhls far-reachlng reglon musL also confronL Lhe harsh
reallLy LhaL access Lo healLh care has become lncreaslngly dlfflculL. 1he norLh CounLry's healLh care dellvery sysLem
ls under growlng sLress amld rapld changes ln organlzaLlon, dellvery models, and publlc fundlng. aymenL reform,
an aglng populaLlon, and workforce shorLages pose addlLlonal challenges. nomlnal coordlnaLlon among provlders
and Lhe absence of a reglonally lnLegraLed healLh care dellvery sysLem LhreaLen Lhe conLlnued exlsLence of many
healLh care faclllLles. Addlng Lo Lhe burden are rlslng raLes of chronlc dlsease, whlch [eopardlze Lhe reglon's quallLy
of llfe, workforce, and Lhe economy. 8ural communlLles have always had unlque healLh care needs due Lo
accesslblllLy lssues and large percenLages of un- and under lnsured resldenLs. 8uL ln Lhe norLh CounLry, Lhe
confluence of Lrends ls magnlfylng Lhe problems.

new ?ork's norLh CounLry has nlne counLles: Warren, WashlngLon, Lssex, CllnLon, lranklln, SL Lawrence, !efferson,
Lewls, and PamllLon. 1he reglon encompasses 13,100 square mlles and ls home Lo 362,116 people. A populaLlon
denslLy of 43 people per square mlle wlLh a lack of publlc LransporLaLlon presenL a dlfflculL challenge for pollcy
9

makers and provlders aLLempLlng Lo ensure access Lo hlgh quallLy servlces for all norLh CounLry resldenLs. 1he
area ls comprlsed of varlous sub-reglons, clusLerlng around populaLlon areas wlLh healLh servlce caLchmenL areas
noL bounded by counLy llnes, and lL ls becomlng more apparenL LhaL any plannlng musL be done reglonally.
1he norLh CounLry also has a hlgher number of older adulLs Lhan Lhe resL of Lhe sLaLe. More Lhan 13 of Lhe
populaLlon ln Lhe norLh CounLry ls over age 63 compared Lo 13 of Lhe populaLlon sLaLewlde and 14 ln upsLaLe
new ?ork.
As a reglon, norLh CounLry communlLles face slgnlflcanL sLruggles LhaL affecL populaLlon healLh and sLress Lhe
healLh care sysLem. 1he need Lo boLh bulld capaclLy and promoLe value ls crlLlcal and fasL becomlng a crlsls. 1he
sLakeholders ln Lhe reglon need Lo brlng a sense of urgency Lo Lhe LransformaLlons requlred ln care dellvery,
paymenL and populaLlon healLh as well as overslghL of a more flexlble, Llmely and responslve regulaLory sysLem.
Changes Lo address Lhe growlng crlsls wlll be posslble only lf Lhe ad[usLmenLs are made on all fronLs and from
governmenL, and wlll requlre greaLer flexlblllLy ln lnLerpreLlng regulaLlons.
1he reglon's demographlcs are an lnherenL challenge. overLy ls a concern across Lhe norLh CounLy. Cverall, Lhe
percenLage of famllles wlLh lncome levels aL or below Lhe federal poverLy level ls 32 hlgher Lhan Lhe resL of Lhe
SLaLe excludlng new ?ork ClLy
2
. ln addlLlon, poverLy among chlldren ls 37 hlgher Lhan Lhe resL of Lhe sLaLe.
1he reglon's healLh ls a slgnlflcanL concern. 1hls area has a hlgher percenLage of adulLs (ages 18-64) wlLhouL healLh
lnsurance (12), and more adulLs dlagnosed wlLh dlabeLes (10), asLhma (12.6) and obeslLy (30). 1he reglon
also has more smokers (23) Lhan Lhe resL of Lhe sLaLe.
ln addlLlon, Lhe reglon's healLh care dellvery sysLem ls hlghly fragmenLed and acuLe care-cenLrlc. As a resulL, Lhe
norLh CounLry has a hlgher raLe of prevenLable hosplLallzaLlons, Lmergency ueparLmenL vlslLs, and chronlc lower
resplraLory dlsease (CL8u) hosplLallzaLlons compared Lo sLaLewlde raLes. WlLhln Lhls reglon Lhere are 16 hosplLals,
21 dlagnosLlc and LreaLmenL cenLers, and 29 nurslng homes. 1here are 601 hosplLal beds, 1,203 nurslng home
beds, 279 adulL home beds and 38 asslsLed llvlng beds per 100,000 people. 1here are 601 hosplLal beds, 1,203
nurslng home beds, 279 adulL home beds and 38 asslsLed llvlng beds. 1he shorLage of adulL home beds ls evldenL.
1he norLh CounLry reglon has only 49 adulL home beds per 100,000 populaLlon, whlle Lhe resL of Lhe SLaLe has 228
adulL home beds per 100,000 populaLlon. Cverall, Lhe reglon has Loo many lnpaLlenL hosplLal beds and an excess
of nurslng home beds, buL prevenLlve and prlmary care capaclLy ls lnadequaLe, and Lhe uneven dlsLrlbuLlon of
hosplLals causes serlous access lssues.
1he reglon's dlfflculLy ln recrulLlng all Lypes of pracLlLloners, parLlcularly physlclans, adds Lo Lhe sLruggle. 1he
norLh CounLry has 40 fewer acLlve prlmary care physlclans (86 per 100,000 populaLlon) Lhan sLaLewlde (120 per
100,000) and 73 fewer acLlve physlclan speclallsLs Lhan sLaLewlde or upsLaLe new ?ork. lL also has 38 fewer
denLlsLs (43 per 100,000) Lhan Lhe resL of Lhe sLaLe or upsLaLe new ?ork (78 and 62, respecLlvely).
1he reglon's aglng populaLlon, and hlgh raLe of poverLy forces provlders ln Lhe norLh CounLry Lo rely heavlly on
publlcly funded lnsurance programs. As a resulL, changes Lo relmbursemenL can have caLasLrophlc resulLs. Care ls
also fragmenLed because many provlders have reslsLed mergers ln an aLLempL Lo reLaln lndependence. 8uL llke Lhe
resL of Lhe sLaLe, norLh CounLry provlders need Lo develop lnLegraLed dellvery sysLems LhaL wlll allow for care
coordlnaLlon across Lhe conLlnuum of care, lncludlng prevenLlve, prlmary, acuLe, behavloral, and long Lerm care.
ueveloplng such a sysLem wlll lmprove paLlenL ouLcomes, provlder flnanclal sLablllLy and populaLlon healLh.




2
lederal poverLy level ls abouL $22,800 per year for a famlly of four wlLh Lwo chlldren
10

!/% )'447,,7'*
Cn uecember 2, 2013, new ?ork SLaLe PealLh Commlssloner nlrav 8. Shah, M.u., M..P., announced Lhe creaLlon
of Lhe norLh CounLry PealLh SysLem 8edeslgn Commlsslon (nCPS8C). 1he goal of Lhe nCPS8C was Lo provlde
recommendaLlons LhaL would lead Lo an effecLlve, lnLegraLed healLh care dellvery sysLem for prevenLlve, medlcal,
behavloral, and long- Lerm care servlces for all communlLles ln new ?ork's norLh CounLry.
1he nCPS8C was led by Lhree healLh care experLs and lncluded represenLaLlves of buslness, paLlenLs, provlders,
and oLher communlLy sLakeholders LhaL reslde ln Lhe norLh CounLry. 1he Commlsslon was deslgned Lo be a
neuLral, LransparenL and LrusLed enLlLy (noL conLrolled by any slngle sLakeholder or Lype of sLakeholder) Lo engage
healLh care sysLem sLakeholders ln a reglonal plannlng process. 1he Commlsslon members are hlghly respecLed
lndlvlduals ln Lhelr communlLles wlLh exLenslve knowledge of Lhe reglon's needs. 1he Commlsslon was supporLed
by sLaff from Lhree sLaLe agencles: Lhe ueparLmenL of PealLh (uCP), Cfflce of MenLal PealLh (CMP), and Cfflce of
Alcohol and SubsLance Abuse Servlces (CASAS).
ur. Shah charged Lhe Commlsslon wlLh provldlng recommendaLlons deslgned Lo creaLe a vlable sysLem of care LhaL
emphaslzes prevenLlon, lncreases prlmary care, esLabllshes more communlLy-based opLlons, provldes flscal
sLablllLy Lo crlLlcal safeLy-neL provlders, monlLors and rewards quallLy and coordlnaLlon of care, and forges
lnnovaLlve afflllaLlons and parLnershlps. 1he Commlsslon was asked Lo provlde lLs reporL Lo Commlssloner Shah by
March 31, 2014.
1he Commlsslon seL reallsLlc goals for accompllshlng Lhls amblLlous asslgnmenL ln a LlghL Llmeframe. lL held
monLhly meeLlngs from uecember 2013 Lhrough March 2014, each ln a dlfferenL communlLy wlLhln Lhe reglon.
1he meeLlngs provlded a LransparenL publlc forum for provlders, Lhe publlc, and oLher sLakeholders Lo presenL
analyses and perspecLlves Lo Lhe Commlsslon. resenLaLlons focused on Lhe crlLlcal lssues and dynamlcs drlvlng
Lhe healLh servlces ln Lhls vasL reglon.
1he Commlsslon approached lLs work Lhrough Lhe prlsm of Lhe SLaLe PealLh lnnovaLlon lan (SPl) wlLh Lhe
overarchlng goal of achlevlng Lhe 1rlple Alm" for Lhe clLlzens ln Lhe norLh CounLry -- beLLer paLlenL care, lmproved
populaLlon healLh, and lower healLh care cosLs. AL Lhe hearL of Lhe SPl ls Lhe Advanced rlmary Care model, a
model of care LhaL provldes Llmely, well-organlzed and lnLegraLed care and allgns paymenL wlLh Lhls care model.
1he work of Lhe nCPS8C ls lnLended Lo serve as a blueprlnL for how Lhe SLaLe may parLner wlLh reglonal and local
communlLles Lo Lransform healLh care dellvery ln Lhe norLh CounLry and meeL Lhe 1rlple Alm goals. We anLlclpaLe
LhaL Lhe lessons learned by Lhe nCPS8C wlll be able Lo asslsL oLher reglons ln Lhe sLaLe faclng slmllar challenges.







11

1he Charge
1he nCPS8C ls charged wlLh:
Assesslng Lhe LoLal scope of care ln Lhe norLh CounLry: communlLy and prevenLlve care, secondary and
LerLlary care and long Lerm care.
Assesslng Lhe reglonal populaLlon's healLh care needs and Lhe sysLem's ablllLy Lo meeL Lhem.
8ecommendlng ways ln whlch Lo ensure LhaL essenLlal provlders survlve or LhaL approprlaLe capaclLy ls
developed Lo replace falllng provlders, a resLrucLurlng and re-caplLallzaLlon agenda.
ldenLlfylng opporLunlLles for merger, afflllaLlon and/or parLnershlp among provlders LhaL wlll malnLaln or
lmprove access and quallLy, and flnanclal vlablllLy and promoLe lnLegraLed care.
Maklng speclflc recommendaLlons LhaL provlders and communlLles can lmplemenL Lo lmprove access,
coordlnaLlon, ouLcomes and quallLy of care, and populaLlon healLh.
ueveloplng recommendaLlons for Lhe dlsLrlbuLlon of re-lnvesLmenL granLs.

Worklng rlnclples
1he Commlsslon recommended LhaL Lhe followlng prlnclples drlve Lhe creaLlon of recommendaLlons Lo ur. Shah:
1he norLh CounLry PealLh SysLem needs Lo be resLrucLured on a base of prlmary care and populaLlon
healLh Lo yleld more efflclenL and effecLlve healLh ouLcomes.
Many norLh CounLry provlders are noL poslLloned Lo adequaLely respond Lo changes ln Lhe sysLem ln parL
because Lhey face a unlque seL of clrcumsLances due Lo a large geographlc area, sLrong rellance on publlc
Medlcare and Medlcald, low populaLlon denslLy and seasonal changes ln populaLlon.
1he SLaLe PealLh lnnovaLlon lan (SPl) seLs Lhe sLage for Lhls effecLlve LransformaLlon Lhrough Lhe
Advanced rlmary Care model. 1he uellvery SysLem 8eform lncenLlve aymenL lan (uS8l) provldes an
opporLunlLy Lo develop lncenLlves and programs LhaL wlll conLrol cosLs and keep people healLhler. 1he
revenLlon Agenda provldes Lhe framework for communlLles Lo lmprove populaLlon healLh.
lL ls lmperaLlve for healLh care provlders Lo resLrucLure, collaboraLe, lnLegraLe, and consolldaLe Lo develop
new organlzaLlonal models LhaL respond Lo a rapldly changlng paymenL sysLem. We need Lo bulld,
leverage and sLrengLhen parLnershlps ln order Lo achleve a smooLh conLlnuum of care LhaL wlll save
money, wlLh flexlblllLy Lo lower Lhe cosLs of LhaL care.
1o be effecLlve, Lhls LransformaLlon should noL be solely governmenL drlven and needs Lo be achleved on
an lnLegraLed reglonal plaLform.
SysLems ln rural areas wlll need Lo connecL Lo hub-based provlders. 8ural sysLems should provlde hlgh
quallLy non-LerLlary servlces ln Lhe communlLy Lo ensure servlce sLablllLy and access. 1hese sysLems have
afflllaLlons wlLh larger provlders buL are deslgned Lo manage care ln Lhelr communlLles.
1he Commlsslon calls for lnLegraLlon and coordlnaLlon of behavloral healLh, lncludlng menLal healLh and
subsLance use dlsorders, wlLh prlmary medlcal care, whlle malnLalnlng speclalLy servlces. 8ehavloral
PealLh lnLegraLlon (8Pl) research and demonsLraLlons lndlcaLe poslLlve ouLcomes ln Lerms of menLal
healLh and beLLer LreaLmenL of medlcal condlLlons.
PealLh sysLem redeslgn Lakes years of dedlcaLed hard work and ongolng flnanclal supporL. A susLalnable
flnanclng and lnvesLmenL model and approprlaLely Lralned workforce of sufflclenL slze are necessary lf
efflclenL provlders are Lo susLaln conLlnuous lmprovemenL and adapLaLlon Lo change.
12

We supporL sLaLe and reglonal programs LhaL promoLe Lhe Lransparency of quallLy, uLlllzaLlon and cosL
measuremenL across Lhe healLh care sysLem.
We endorse and expecL LhaL person-cenLered plannlng wlll be a core enabler ln supporL of collaboraLlon.
We supporL consumer engagemenL across Lhe plannlng process and collaboraLlons Laklng place
LhroughouL Lhe norLh CounLry.
1o ensure success of healLh sysLems reform and Lhe lmplemenLaLlon of Lhe SPl, Lhe workforce ls
paramounL Lo achlevlng success. A quallLy workforce wlLh adequaLe supply of key sLaff ls a hlgh prlorlLy
for Lhe Commlsslon.
1he SPl ls dependenL on lnvolvlng a broad cross-secLlon of Lhe communlLy.





















13

!/% -'.+/ )'0*+.1 "*6 7+, 5%,76%*+,
1he norLh CounLry ls new ?ork's mosL sparsely populaLed reglon, caLegorlzed as a rural area wlLh lnLense wlnLer
weaLher
3
. 1oLal populaLlon ln Lhe norLh CounLry ls around 600,000, whlch accounLs for 3 of Lhe sLaLe's
populaLlon (19.4 mllllon). SL. Lawrence (109,624) and !efferson (121,712) are Lhe mosL populaLed counLles,
accounLlng for abouL 40 of Lhe LoLal norLh CounLry populaLlon. PamllLon ls Lhe smallesL (4,068). ln Lerms of
eLhnlclLy, Lhe populaLlon of Lhe norLh CounLry ls less dlverslfled Lhan Lhe resL of Lhe sLaLe, Loo: 90.3 of norLh
CounLry are WhlLe non-Plspanlc.
ln Lhe norLh CounLry, 14.2 of Lhe resldenLs, or 83,302 people, are 63 years or older. 1hls ls hlgher Lhan Lhe LoLal
sLaLe average of 13.3 buL lower Lhan Lhe sLaLe average (excludlng new ?ork ClLy)
4
of 14.3
3
. MosL people aged
63 and above llve ln Lhe mosL sparsely populaLed reglon of Lhe norLh CounLry: Lhe Adlrondack ark. ln Lhe fuLure,
Lhe populaLlon ls expecLed Lo lncrease sllghLly beLween 2013 and 2018 (0.7), buL aL lower raLes Lhan Lhe resL of
Lhe sLaLe. opulaLlon shrlnkage ls expecLed ln CllnLon, Lssex, PamllLon and SL. Lawrence counLles.
AL Lhe same Llme, Lhe medlan famlly lncome of $33,244 ln Lhe norLh CounLry ls lower Lhan lL ls ln Lhe resL of Lhe
sLaLe, where medlan famlly lncome ls 30 hlgher aL $46,796.
1he reglon ls also challenged by poor healLh. Many of Lhe norLh CounLry counLles rank among Lhe lowesL ln new
?ork SLaLe. SL. Lawrence counLy healLh ranklngs are conslsLenLly ln Lhe boLLom 10 for a varleLy of facLors such as
ouLcomes, morbldlLy and healLh behavlor. Chlld obeslLy, smoklng raLes and blnge drlnklng raLes are all above Lhe
sLaLe average lndlcaLlng general poor healLh behavloral paLLerns.
AL Lhe same Llme, Medlcald enrollmenL ln Lhe norLh CounLry ls slgnlflcanLly hlgher Lhan Lhe resL of new ?ork SLaLe.
ln addlLlon Lo hlgher levels of enrollmenL, Lhe average annual Medlcald expendlLure per enrollee ls hlgher ln Lhe
norLh CounLry Lhan ln Lhe resL of Lhe sLaLe Powever, Lhe norLh CounLry seems Lo follow new ?ork SLaLe ln lLs
downward Lrend ln Medlcald expendlLure seL ln moLlon by Lhe Medlcald 8edeslgn 1eam (M81) lnlLlaLlves. 1he
amounL of annual Medlcald expendlLure per enrollee may dlffer by as much as $3,000 beLween Lhe lndlvldual
counLles. Cn Lhe oLher hand, annual Medlcare spend per enrollee ls lower ln Lhe norLh CounLry Lhan ln Lhe resL of
Lhe sLaLe.
1he populaLlon of Lhe norLh CounLry ls expecLed Lo remaln vlrLually sLagnanL over Lhe nexL few years. As Lhe
populaLlon becomes older, Lhe need for servlces LhaL speclflcally address chronlc condlLlons and Lhe needs of
paLlenLs wlLh mulLlple age-relaLed condlLlons wlll rlse. 1he norLh CounLry's relaLlvely poor healLh ouLcomes and
poor healLh behavlors wlll creaLe challenges ln Lhe reglon LhaL are furLher sLralned by Lhe reglon's lower
socloeconomlc sLaLus.







3
1he norLh CounLry ln SLaLlsLlcal roflle, 2008, Ca8ul 8eporLs
4
All sLaLe flgures from here on exclude new ?ork ClLy.
3
1he nCPS8 Commlsslon presenLaLlon from 17 uecember 2013, p87, daLa source unknown
14

2%"$+/ )".% 7* +/% -'.+/ )'0*+.1


"#$%&'() *(+,
A LoLal of 228 llcensed enLlLles, lncludlng 16 hosplLals, provlde a range of healLh care servlces ln Lhe norLh CounLry.
LxcepL for Lhe mosL sparsely populaLed areas of Lhe Adlrondack ark, mosL resldenLs llve wlLhln 23 mlles of a
hosplLal, wlLh Lhe shorLesL Lravel dlsLances ln SL. Lawrence CounLy. lor resldenLs ln Lhe Adlrondack ark, Lhe
nearesL hosplLal faclllLy ls ofLen more Lhan 30 mlles away. Many norLh CounLry resldenLs musL Lravel 30 mlles or
more Lo obLaln lnpaLlenL care.
Accordlng Lo a sLudy of currenL Lravel paLLerns, many norLh CounLry resldenLs do noL frequenL a norLh CounLry
hosplLal faclllLy for lnpaLlenL and ouLpaLlenL care. AbouL 13 of lnpaLlenL admlsslons and 8 of ouLpaLlenL vlslLs by
norLh CounLry resldenLs ln 2009 Lo 2012 occurred ln hosplLals ouLslde Lhe norLh CounLry buL sLlll wlLhln new ?ork
SLaLe.
8esldenLs ln Warren, CllnLon, !efferson and SL. Lawrence counLles use local counLy hosplLals for Lhe ma[orlLy of
non-LerLlary care servlces. 1ravel ouL of Lhe norLh CounLry and ouL of Lhe sLaLe ls slgnlflcanL, especlally for
subspeclalLy and LerLlary servlces such as cardlac surgery, hlgh rlsk perlnaLal care and burn care, buL also for more
common condlLlons such as acuLe sLroke. ln lranklln CounLy for lnsLance, 33 of all Medlcald beneflclarles LhaL
suffer a sLroke are admlLLed Lo lleLcher Allen PealLh ln vermonL, raLher Lhan a hosplLal ln Lhe norLh CounLry.
ln 2010, Lhe norLh CounLry had 3.4 beds for every 1,000 resldenLs. Llsewhere ln Lhe SLaLe, Lhe supply ls lower aL
3.0 beds per 1,000 resldenLs
6
.
1he above-average supply of beds and generally low occupancy raLe of 43.6
7
on average lndlcaLes excess hosplLal
capaclLy ln Lhe reglon. SL. Lawrence counLy's hosplLals reporL an excess capaclLy of approxlmaLely 30, noL Laklng
lnLo accounL posslble reducLlons ln lengLh of sLay and a reducLlon of avoldable (re)admlsslons. lollowlng naLlonal
Lrends, Lhe numbers of admlsslons ln Lhe norLh CounLry have been gradually buL sLeadlly dropplng over Lhe pasL
four Lo flve years.
1he hosplLal landscape ln Lhe norLh CounLry ls hlghly fragmenLed. 1he wesLern reglon for lnsLance, has several
small hosplLals - one ln every Lown wlLh over 10,000 lnhablLanLs. 1hls leads Lo low paLlenL volumes and slgnlflcanL
lnefflclencles. Mlnlmum paLlenL volumes are necessary for many servlces Lo be flnanclally vlable and Lo reallze
opLlmal quallLy of care. 1ake, for example, pregnancy and dellvery servlces ln SL. Lawrence counLy, where a
mlnlmum of 1,200 dellverles per year are needed Lo be flnanclally vlable Lhe Lhree hosplLals ln Lhe counLy --
CanLon-oLsdam PosplLal, ClaxLon-Pepburn Medlcal CenLer and Massena Memorlal PosplLal -- performed a
comblned LoLal of only 1,030 dellverles ln 2012
8
. ln Lhe easL slde of Lhe norLh CounLry, consolldaLlon and
lnLegraLlon along servlce llnes ls on Lhe agenda. As a parL of an lnLegraLed cardlovascular servlce llne, for example,
cardlovascular surgery ls belng performed ln lleLcher Allen PealLh ln vermonL, LllzabeLhLown CommunlLy PosplLal
and Champlaln valley hyslclans PosplLal wlll refer Lhose servlces Lo lleLcher Allen, and Lhe Lhree faclllLles have
formed Lhe norLhern new ?ork cardlology servlce.

6
Source: n?S uCP PosplLal roflles, nC uemographlc CharL book
7
Source: kMC calculaLlons. 1oLal lnpaLlenL days for 2012 lnpaLlenL sLays ln SA8CS daLa dlvlded by number of
beds ln a glven counLy Llmes 363.

8
nCPS8C 2014-02-18 presenLaLlons, age 10
13

-.,+/,012 *(+, 3,+4&1,$
WlLh lLs low numbers of cerLlfled provlders, Lhe Lmergency Medlcal Servlces (LMS) sysLem ln Lhe norLh CounLry ls
fraglle. Many LMS provlders are near reLlremenL, and Lhe low relmbursemenL raLes and heavy rellance on
volunLeers creaLes concerns regardlng susLalnablllLy. Whlle Lhese concerns are Lo some degree llke Lhose ln oLher
rural reglons requlrlng drlvlng long dlsLances, Lhey are especlally severe wlLhln Lhe Adlrondacks where Lhe
populaLlon ls especlally sparse and ls aglng aL a hlgher raLe Lhan elsewhere ln Lhe sLaLe.
ln many acuLe condlLlons, shorLer LransporL Llmes lncrease a paLlenL's chances for survlval and poslLlve ouLcomes.
MosL emergency paLlenLs ln new ?ork have a LoLal LMS comblned response Llme of 24 mlnuLes, wlLh an average
LransporL Llme of 13 mlnuLes. ln Lhe norLh CounLry, average response Llmes are comparable aL 11 mlnuLes. 8uL Lhe
average LransporL Llme ls longer aL 23 mlnuLes, brlnglng Lhe LoLal comblned response and Lravel Llme Lo 34
mlnuLes. 1ransporL Llme ls Lhe hlghesL ln PamllLon CounLy, where an ambulance rlde Lakes an average of 33
mlnuLes. Comblned LransporL and response Llme ls lowesL ln !efferson CounLy aL 26 mlnuLes.
AlLhough Lhere are no offlclal regulaLlons regardlng maxlmum response and LransporL Llmes, belng able Lo respond
qulckly Lo acuLe slLuaLlons ls lmporLanL for lncreaslng chances of survlval and poslLlve ouLcomes. ln Lhe
neLherlands, Lhe only counLry LhaL has laws regardlng maxlmum response and LransporL Llmes, Lhe maxlmum
comblned Llme has been seL aL 43 mlnuLes. WlLhln Lhe norLh CounLry, Lssex and PamllLon counLles are above Lhe
43-mlnuLe wlndow for mean comblned LMS response and Lravel Llmes.

5+&.(+2 *(+, 3,+4&1,$
rlmary care physlclans are rare ln Lhe norLh CounLry. Many resldenLs ln Lhe norLh CounLry have no prlmary care
physlclans ln Lhelr zlp code or [usL a few. 1he shorLage ls parLlcularly acuLe ln PamllLon and Lssex counLles, where
one prlmary care physlclan serves an average of 4,833 and 3,024 resldenLs, respecLlvely.
9
1hese paLlenL panels are
more Lhan Lwlce Lhe slze of Lhe average prlmary care physlclan ln new ?ork SLaLe, who sees 1,222 paLlenLs
10
. 1he
spread of physlclan asslsLanLs, nurse pracLlLloners and mldwlves also lags far behlnd sLaLe averages, even when
accounLlng for new ?ork ClLy.
1he norLh CounLry has a dlsproporLlonaLe number of prlmary care shorLage areas. AlLhough Lhe reglon ls home Lo
only 3 of LoLal sLaLe populaLlon, Lhe norLh CounLry conLalns 17 or 30, of Lhe geographlc areas ln Lhe enLlre SLaLe
(178) LhaL ls underserved by prlmary care professlonals.
As a resulL, Lhe proporLlon of resldenLs who do noL have a regular healLh care provlder ls hlgher ln Lhe norLh
CounLry Lhan elsewhere ln Lhe SLaLe. 1he lack of prlmary care ls vlslble ln meLrlcs LhaL demonsLraLe unmeL care
needs, such as avoldable Lu vlslLs or poLenLlally avoldable hosplLal admlsslons for ambulaLory care senslLlve
condlLlons, problems mosL noLable ln Lhe norLhwesL reglon of Lhe norLh CounLry. oLenLlally avoldable admlsslons
for bacLerlal pneumonla are hlgh LhroughouL Lhe norLh CounLry, whlle poLenLlally avoldable admlsslons for urlnary
lnfecLlons are less frequenL. 1he Adlrondack Medlcal Pome demonsLraLes Lhe lmpacL of sLrengLhenlng prlmary
care boLh on Lhe ouLcomes of care (readmlsslons and paLlenL saLlsfacLlon) as well as on Lhe LoLal cosLs of care, boLh
for Medlcald and commerclal payers.
1he lack of prlmary care servlces close Lo home presenLs a slgnlflcanL barrler Lo addresslng Lhe healLh care needs of
Lhe local populaLlon and Lo rolllng ouL effecLlve care managemenL and care coordlnaLlon for Lhe chronlcally lll, and
Lhe frall and elderly.

9
Source: ?ear 2013 www.counLyhealLhranklngs.com
10
Source: ?ear 2013 www.counLyhealLhranklngs.com
16

6#0/ 7,+. *(+, 8(1&)&'&,$
1he norLh CounLry has 12 cerLlfled home healLh agencles (CPPA) and 29 resldenLlal healLh care faclllLles, or
nurslng homes. 8esldenLlal healLh care faclllLles ln Lhe norLh CounLry have an average case mlx lndex LhaL ls
slgnlflcanLly lower Lhan Lhe resL of new ?ork SLaLe. ln oLher areas of Lhe sLaLe, many norLh CounLry nurslng home
resldenLs would noL be LreaLed aL resldenLlal healLh care faclllLles.
ln Lerms of sLafflng, resldenLlal healLh care faclllLles reporL lssues when Lrylng Lo aLLracL adequaLely Lralned long
Lerm care professlonals.

5())&('&4, *(+,
1he norLh CounLry has a hlgher-Lhan-average raLe of prevenLable admlsslons for serlous chronlc lllness. A 2011
sLudy reporLed ln Lhe 9#:+0() #; 5())&('&4, <,=&1&0, found LhaL palllaLlve care servlces ln four new ?ork hosplLals
produced a savlngs of $6,900 per person. alllaLlve care servlces have demonsLraLed LhaL Lhey reduce
admlsslons, lower cosLs, and lmprove paLlenL ouLcomes.

CuLslde of hosplce care for people who are wlLhln slx monLhs of deaLh, lnLerdlsclpllnary palllaLlve care programs
are unavallable LhroughouL mosL of Lhe norLh CounLry. new ?ork also spends more on care ln Lhe lasL year of llfe,
and, compared Lo all sLaLes, ranks only above Alaska ln Lhe uLlllzaLlon of hosplce care.

<,0'() ",()'> 3,+4&1,$
1he norLh CounLry ls home Lo 12 of Lhe 144 areas underserved by menLal healLh care professlonals. ln almosL all
parLs of Lhe norLh CounLry, Lhe nearesL lnpaLlenL psychlaLrlc faclllLy ls over 30 mlles away.
1he reglon has over 200 n?S Cfflce of MenLal PealLh (CMP)- llcensed, funded, and operaLed programs, lncludlng
20 ouLpaLlenL cllnlcs, elghL crlsls lnLervenLlon programs, and flve general hosplLal psychlaLrlc unlLs. 1here are
llcensed, as well as unllcensed resldenLlal programs, wlLh dlfferenL levels of LreaLmenL and supporLs, lncludlng
approxlmaLely 400 llcensed LreaLmenL beds and addlLlonal supporLed houslng (unllcensed beds) across Lhe reglon.
Cver 130 supporL and care coordlnaLlon programs exlsL ln Lhe norLh CounLry, lncludlng recovery cenLers, school-
based menLal healLh, educaLlonal and vocaLlonal programs, and care managemenL/healLh home. norLh CounLry
resldenLs are served by four CMP psychlaLrlc cenLers: SL. Lawrence, CaplLal ulsLrlcL, PuLchlngs, and Mohawk
valley.

llscal vulnerablllLy of laclllLles
Many of Lhe healLh care faclllLles ln Lhe norLh CounLry reglon are ln a very poor flnanclal sLaLe. 1he average
operaLlng and neL marglns of norLh CounLry hosplLals have been conslsLenLly negaLlve over Lhe lasL couple of years
and are less favorable Lhan Lhe average of all new ?ork sLaLe hosplLal. Cnly a handful of hosplLals ln Lhe norLh
CounLry have managed poslLlve operaLlng marglns ln Lhe lasL year, and abouL half have less Lhan a monLh's cash ln
hand. PosplLals derlve abouL 43 of Lhelr lncome from lnpaLlenLs covered by prlvaLe payers ln Lhe norLh CounLry.
Llke Lhe hosplLals, mosL of Lhe nurslng homes ln Lhe norLh CounLry are operaLlng aL a loss, wlLh abouL half of Lhe
homes showlng operaLlng marglns of -10 or worse. 1hls performance ls well below Lhe performance of oLher
nurslng homes ln Lhe sLaLe.
17

Many of Lhe hosplLal faclllLles ln Lhe norLh CounLry are sLruggllng Lo sLay afloaL. Clven Lhe low populaLlon growLh,
lL ls unllkely LhaL hosplLals wlll experlence any slgnlflcanL growLh ln comlng years, wlLh equally low growLh
expecLed ln revenues. WlLh pro[ecLed revenues sLagnanL, hosplLals are faced wlLh Lhe challenge of cuLLlng cosLs
and overcapaclLy Lo maLch currenL and fuLure demand. ln addlLlon, Lhe move Loward lncreaslng ouLpaLlenL and
communlLy-based servlce capaclLy wlll llkely furLher reduce hosplLal lnpaLlenL volume, placlng addlLlonal sLress on
flscal sLablllLy.
new ?ork SLaLe ls ln Lhe process of flnallzlng Lhe deLalls of lLs $8 bllllon Medlcald walver, whlch wlll be used ln parL
Lo help sLablllze safeLy neL provlders. 1he Commlsslon urges LhaL crlLerlon for such fundlng speclflcally LargeL
safeLy neL enLlLles provldlng servlces ln geographlcally lsolaLed communlLles. AddlLlonally, Lhe Commlsslon
belleves conslderaLlon of payer mlx as a crlLerlon needs Lo examlne Lhe lmpacL of all publlc payers, noL [usL
Medlcald. 1he norLh CounLry, for example, has an above average senlor populaLlon, buL lLs Medlcare hosplLal
relmbursemenL raLes are among Lhe lowesL ln Lhe naLlon. CLher provlders clLe problems wlLh publlc paymenL
levels as well. As sysLems Lransform and lnLegraLe, sLaLe and federal savlngs wlll be secured ln Medlcald and oLher
publlc programs. 1hey should be parL of Lhe calculaLlons ln deLermlnlng LransformaLlonal supporL.
1he sLaLus of our hosplLals musL be carefully consldered as we move forward, Loo. Several of Lhe smaller hosplLals
ln Lhe norLh CounLry are elLher CrlLlcal Access PosplLals or are ln Lhe process of applylng Lo become one. 1he
federal subsldy of Medlcare paymenLs ls usually losL when a CAP ls consolldaLed wlLh oLher hosplLals. lL ls
lmperaLlve LhaL Lhe sLaLus of a CAP be consldered as a key flnanclal facLor when assesslng poLenLlal lnLegraLlons
and consolldaLlons.
1ransformlng Lhe flnances of Lhe healLh care sysLem ln Lhe norLh CounLry Lhen, ls abouL more Lhan creaLlng value
and lowerlng cosLs. We need Lo creaLe a sysLem LhaL ls susLalnable, where Lhe adapLaLlons become permanenL. ln
Lhls reglon of Lhe sLaLe, Lransformlng healLh care Lo be more efflclenL goes well beyond shared savlngs. new
paymenL models should lncenLlvlze efflclenL healLh sysLems Lo relnvesL marglns, as conLlnuous lmprovemenL ls Lhe
mosL susLalnable way forward.

Lack of Access and Caps ln Servlce
1he rural seLLlng of Lhe norLh CounLy affecLs access Lo servlces ln many ways. Longer LransporL Llmes for LMS are
concenLraLed ln Lhe mosL sparsely populaLed areas of Lhe Adlrondack ark, ln Lhe counLles of PamllLon, Warren,
and Lssex. 8esldenLs ln Lhese areas are also much farLher away from hosplLals Lhan Lhe remalnder of Lhe norLh
CounLry. AddlLlonally, paLlenLs may need Lo Lravel even furLher for some Lypes of care, slnce Lhe nearesL hosplLal
may be one of Lhe smaller CrlLlcal Access PosplLals, whlch as deflned by Medlcare have fewer beds and llmlLed
sLays, and provlde emergency care. 8uL when complex or lnLense servlces are requlred or a paLlenL has more acuLe
needs, Lhese faclllLles refer paLlenLs Lo larger hosplLals LhaL are farLher away.
Cur daLa reveals slzable areas lacklng key healLh and behavloral servlces, wlLh a lack of LransporLaLlon, and
slgnlflcanL geographlc and soclo-demographlc facLors exacerbaLlng problems of access. Servlce provlders ln Lhese
communlLles are Lhe safeLy neL for Lhe healLh care of Lhe people as well as cornersLones of Lhe economy ln Lhe
reglon. PealLh care ls essenLlal Lo Lhe economlc vlLallLy and vlablllLy of Lhe norLh CounLry. As some of Lhe largesL
employers ln Lhe reglon, hosplLals noL only drlve money lnLo Lhe economy buL are a source for sLeady employmenL
as well. LlghL hosplLals wlLhln !efferson, Lewls and SL. Lawrence counLles pumped $777,638,000 lnLo Lhe local
economy, accordlng Lo 2010 daLa. Long-Lerm care provlders play a slgnlflcanL role as well and accounLed for more
Lhan $322 mllllon ln 2010 PealLh care faclllLles are also a slgnlflcanL employer ln Lhe norLh CounLry, supporLlng
3,677 [obs. 1he servlces and supplles provlders purchase and Lhe wages Lhey pay creaLe a rlpple effecL ln local
economles and supporL oLher buslnesses as well. 1he Commlsslon recognlzes LhaL reducLlons ln lnpaLlenL hosplLal
and nurslng home beds wlll llkely have an economlc lmpacL. 8uL we anLlclpaLe LhaL lncreases ln oLher communlLy-
based servlces sLarLlng wlLh prlmary care, wlll ulLlmaLely offseL Lhose losses and dlmlnlsh Lhe adverse effecL on Lhe
reglonal economy.
18


3+.%*8+/, '( +/% -'.+/ )'0*+.1
Whlle Lhe norLh CounLry ls faced wlLh challenges, we belleve lL ls also lmporLanL Lo recognlze lLs exlsLlng sLrengLhs.
Slnce lLs flrsL meeLlng ln uecember, Lhe nCPS8C heard numerous presenLaLlons from provlders LhaL already
engaged ln varylng degrees of coordlnaLlon, collaboraLlon and lnLegraLlon of sysLems of care. As a guldlng
prlnclple, Lhe nCPS8C was noL prepared Lo endorse any parLlcular lnlLlaLlve, buL recognlzes and applauds Lhe
remarkable work already underway. 1he Commlsslon's recommendaLlons are lnLended Lo bulld upon and supporL
Lhose efforLs.
AnoLher asseL ln Lhe norLh CounLry ls Lhe $81.3 mllllon ln economlc developmenL fundlng from Lhe SLaLe as parL of
Covernor Andrew M. Cuomo's sLraLegy Lo [umpsLarL Lhe economy and creaLe [obs. 1he norLh CounLry 8eglonal
Lconomlc uevelopmenL Councll ls movlng full-speed ahead wlLh LransformaLlve pro[ecLs. ln 2013, Lhelr sLraLegles
reflecLed Lhe reglon's dlverslLy wlLh several prlorlLles, lncludlng helplng farmers and small buslness owners Lo
lmprove producLlvlLy, addresslng Lhe need for more hoLel rooms ln Lhe reglon Lo Lake advanLage of Lhe Lourlsm
economy, and growlng [obs and lnvesLlng ln hlgh-Lech lndusLrles.
8y Lhe Llme Lhe Commlsslon began lLs work lasL fall, some local lnlLlaLlves were already underway. We need Lo
promoLe and supporL Lhose efforLs, whlch demonsLraLe Lhe exLraordlnary work of governmenL, and communlLy
and provlder plannlng aL all levels. 1he Commlsslon dld noL have Lhe Llme Lo revlew and assess every good
lnlLlaLlve ln Lhe norLh CounLy, buL some noLable collaboraLlve efforLs are already worklng Lowards lncreaslng
access, galnlng efflclencles, lncreaslng quallLy and lowerlng cosLs.

?=&+#0=(1@ ",()'> A0$'&':',
1he Adlrondack PealLh lnsLlLuLe's (APl) mlsslon ls Lo promoLe, sponsor, and coordlnaLe lnlLlaLlves and programs
LhaL lmprove healLh care quallLy, access, and servlce dellvery ln Lhe Adlrondack reglon by expandlng reglonal
collaboraLlon among healLh care and soclal servlce provlders. 1he APl addresses rapld changes and challenges Lo
Lhe healLh care lndusLry by worklng wlLh local provlders and organlzaLlons Lhrough Lhe coordlnaLlon of plannlng,
recrulLlng, cllnlcal acLlvlLles, ouLreach and managlng of granL-supporLed programs. Challenges Lhe APl faces
lnclude a conLlnued LhreaL of physlclan and prlmary care provlder shorLages, fragmenLed and wldely dlspersed
servlces, as well as Lhe need Lo LranslLlon medlcal, behavloral and long Lerm care servlces Lo ouLpaLlenL seLLlngs.

?=&+#0=(1@ <,=&1() "#., B,.#0$'+('&#0 5&)#'
1he Adlrondack 8eglon Medlcal Pome lloL was creaLed ln 2010 as a flrsL sLep Lo Lransformlng Lhe healLh care
dellvery sysLem ln Lhls reglon. 1he pro[ecL was a collaboraLlve efforL LhaL lnvolved boLh provlders and publlc and
prlvaLe lnsurers 1he goal ls Lo lmprove quallLy, ensure access and conLaln cosLs for healLh care. 8ecause of Lhe
enormous slze of Lhe reglon - 7,000 square mlles - Lhe plloL ls dlvlded up lnLo Lhree geographlc reglons. lLs goals
are allgned wlLh Lhose of Lhe 1rlple Alm.
unllke LradlLlonal fee-for-servlce healLh care, Lhe Adlrondack 8eglon Medlcal Pome shlfLs Lhe focus from acuLe
care Lo prevenLlve care and emphaslzes beLLer managemenL of chronlc condlLlons. 1he plloL creaLes fundlng
lncenLlves LhaL reward provlders for keeplng people as healLhy as posslble raLher Lhan paylng for procedures
wlLhouL regard Lo effecLlveness. 1hls approach helps keep paLlenLs healLhy and frees up docLors Lo focus on Lhe
quallLy of care raLher Lhan volume of care. aLlenLs also en[oy more conLacL wlLh Lhelr prlmary care docLors, whlch
19

wlll enable earller dlagnoses for problems and beLLer malnLenance of exlsLlng condlLlons. Larly dlagnosls resulLs ln
early LreaLmenL, whlch ln Lurn, leads Lo lower cosLs.
Accordlng Lo early daLa, Lhe Adlrondack pro[ecL ls movlng ln Lhe rlghL dlrecLlon. ln Lhe Clens lalls-Cueensbury
reglon for lnsLance, Lhe numbers of dlabeLlc paLlenLs recelvlng a low-denslLy llpoproLeln (LuL) LesL has gone up
from 80 Lo 89 beLween Lhe end of 2012 and 2013. ln LhaL Llme, Lhe percenLage of people who have lowered
Lhelr LuL Lo Lhe recommended level below 100 mg/dL, has gone up from 49 Lo 33. 1he same reglon has also
seen lncreases ln prevenLlve screenlngs such as ap smears, mammograms and colonoscoples.
ln Lhe laLLsburgh area, pedlaLrlc paLlenLs, especlally Leenagers, have experlenced slgnlflcanL welghL loss. 8y glvlng
paLlenLs Lhe Lools for welghL loss such as nuLrlLlon educaLlon and lnformaLlon on venues for physlcal acLlvlLy, Lhe
reglon has seen a decllne ln Lhe numbers of overwelghL youLhs. ln 2012, 4 of chlldren ages blrLh Lo 19 lowered
Lhelr 8Mls from above 83 (consldered overwelghL) Lo below LhaL. ln Lhe second quarLer of 2013, 14 had done
Lhe same.
Across Lhe Adlrondack reglon, more paLlenLs wlLh dlabeLes lmproved Lhelr conLrol over blood sugar levels and
reduced Lhelr blood pressure Lo below 140/90. Some hosplLals are also sLarLlng Lo lower Lhelr readmlsslon raLes. AL
Champlaln valley hyslclans PosplLal for example, readmlsslon raLes have decllned, Lhanks largely Lo Lhe
lnsLallaLlon of a LranslLlonal care supporL Leam LhaL follows up wlLh paLlenLs, pre- and posL-dlscharge. 1he
Adlrondack Medlcal Pome pro[ecL demonsLraLes whaL ls posslble when Lhe focus ls on prevenLlon, noL LreaLmenL.

8#+' B+:.
LocaLed [usL 30 mlles from Lhe Canadlan border and abouL 90 mlles from Syracuse, lorL urum ls a mlllLary
communlLy, wlLh almosL 20,000 acLlve duLy mlllLary and Lhelr famllles. 1he lorL urum 8eglonal PealLh lannlng
CrganlzaLlon's (lu8PC) mlsslon ls Lo analyze Lhe exlsLlng healLh care sysLem avallable Lo lorL urum soldlers, Lhelr
famllles, and Lhe surroundlng clvlllan communlLy. 1he lu8PC ldenLlfles gaps ln care, and leverages addlLlonal
healLh care resources Lo flll Lhose gaps. 1he organlzaLlon has creaLed parLnershlps wlLh provlders Lo sLrengLhen
and coordlnaLe healLh servlces and ls worklng Lo develop a hlgh-quallLy, value-drlven reglonal healLhcare sysLem.
More speclflcally, Lhe lu8PC ls ln Lhe process of developlng Lhe reglon's healLh lnformaLlon Lechnology (l1) Lo
enable Lhe use of elecLronlc healLh records (LP8s), and Lo creaLe a healLh lnformaLlon exchange, dlsease reglsLry,
and LelehealLh servlces. 1he lu8PC ls also helplng prlmary care provlders achleve level ll or level lll meanlngful
use, bulldlng local capaclLy Lo educaLe healLh care workers, lncludlng nurse pracLlLloners and llcensed soclal
workers, developlng Lhe norLh CounLry PealLh Compass, a web-based source of populaLlon daLa and communlLy
healLh lnformaLlon for Lhree !efferson, Lewls and SL. Lawrence counLles, and formlng a physlclan-led Cllnlcally
lnLegraLed neLwork Lo lmprove quallLy and reduce cosLs.

C#+'> *#:0'+2 D,>(4&#+() ",()'> C,'E#+@
1he norLh CounLry 8ehavloral PealLh neLwork (nC8Pn) ls a neLwork of behavloral healLh and chemlcal
dependency provlders who collaboraLe on lssues LhaL lmpacL Lhese provlders and provlde supporL Lo sLrengLhen
Lhe healLh care dellvery sysLem. 1he neLwork was lncorporaLed ln 1997 as Lhe norLhern new ?ork 8ural PealLh
lnsLlLuLe, (dolng buslness as norLh CounLry 8ehavloral PealLhcare neLwork), and conLlnues Loday as a leadlng volce
for norLhern new ?ork's behavloral healLh care conLlnuum.
1he neLwork ls currenLly engaged ln Lhe 8eglonal 8ehavloral PealLh AllgnmenL ro[ecL (8A), whlch ls worklng Lo
asslsL our members wlLh LranslLlonlng Lo paLlenL-cenLered Medlcald managed care. Members of Lhe neLwork wlll
be beLLer able Lo collecL, reporL on, and manage cosL, quallLy, and ouLcome daLa Lo meeL Lhe needs of managed
20

care organlzaLlons and evolvlng prlmary care neLworks. 8A ls provldlng publlc pollcy educaLlon and advocacy Lo
ensure boLh provlders and pollcy makers are aware of lssues around Lhe lmplemenLaLlon of healLh care reform.
1he neLwork ls also worklng Lo reduce and end homelessness, prevenL sulcldes and advance Lhe sLaLe's revenLlon
Agenda, especlally Lhe promoLlon of behavloral healLh. ln addlLlon, Lhe nC8Pn ls worklng Lo lmplemenL healLh l1
and LP8s ln behavloral healLh, develop parLnershlps wlLh prlmary care provlders, lncrease access Lo behavloral
healLh care ln Lhe prlmary care seLLlng uslng LelehealLh, faclllLaLe developmenL and adopLlon of besL-pracLlce
proLocols for rural behavloral healLh LreaLmenL boLh ln prlmary car and ln behavlor and subsLance abuse cllnlcs,
and coordlnaLe behavloral healLh care beLween lnpaLlenL, emergency, prlmary care and ouLpaLlenL menLal healLh
servlces.

C#+'> *#:0'+2 ",()'>1(+, 5+#4&=,+$
norLh CounLry PealLhcare rovlders (nCP) ls made up of a group of hosplLals based ln Lhe four counLles ln Lhe
norLhernmosL parL of Lhe sLaLe. 1he nCP was formed ln 1998 Lo address managemenL, admlnlsLraLlve, quallLy of
care, and communlLy healLh lssues ln order Lo lmprove Lhe dellvery of healLhcare ln norLhern new ?ork. 1he reglon
ls spread ouL over 8,410 square mlles and ls home Lo over 400,000 people. 1he reglon has a populaLlon denslLy of
47.7 people/square mlle compared Lo Lhe sLaLe average of 411.2 people/square mlle. ln 2010, Lhe member
hosplLals had nearly 40,000 lnpaLlenL cases and almosL 189,000 ouLpaLlenL cases.
1he mlsslon of Lhe nCP ls Lo lead healLh care organlzaLlons ln Lransformlng Lhe reglonal healLh care sysLem
Lhrough collaboraLlon, engagemenL, plannlng, and developmenL. nCP has ldenLlfled currenL capaclLy and gaps,
assessed opporLunlLles and assoclaLed cosLs, and ls provldlng a reLurn on lnvesLmenL ln LelehealLh, professlonal
developmenL, and volceover lnLerneL proLocol servlces. 1he nCP ls worklng Lo llnk prlmary care Lo behavloral
healLh as well as speclalLy and crlLlcal care Lo medlcal cenLers, and Lo lncrease Lhe use of home LelehealLh for
chronlc dlsease managemenL.

D):, 6&0, F+#:%
1he recenLly formed 8lue Llne Croup (8LC) conslsLs of Lhe four prlvaLe, non-proflL nurslng homes ln Lhe easLern
Adlrondacks. 8LC was formed on Lhe premlse LhaL nurslng homes face a shared seL of challenges LhaL can besL be
meL Lhrough collaboraLlon. 1he goal of Lhe 8LC ls Lo ensure LhaL people who choose Lo llve a long and full llfe ln
Lhe Adlrondacks have access Lo a mlx of LradlLlonal and new communlLy-based alLernaLlves for care, dellvered by a
flnanclally sLable sysLem and well-Lralned workforce. 1he 8LC ls worklng Lo creaLe a formal governance sLrucLure
for lLs members, lncrease quallLy, and develop efflclencles, and coordlnaLe care on a reglonal basls.

3'G 6(E+,01, ",()'> 32$',.
1he relaLlvely new SL. Lawrence PealLh SysLem (SLPS) was formed Lo creaLe a dlverse sysLem of hlgh quallLy
provlders and currenLly lncludes Lwo hosplLals ln Lhe counLy. 1he SLPS ls worklng Lo lncrease lLs members'
flnanclal sLrengLh, so LhaL operaLlng marglns are conslsLenLly poslLlve and balance sheeLs are sLrong, make
lnvesLmenLs ln healLh l1, achleve advances ln quallLy and ensure LhaL quallLy raLlngs lmprove annually, and
conLlnue Lo be naLlonally recognlzed ln paLlenL safeLy and process lmprovemenL lnlLlaLlves.


21

8),'1>,+ ?)),0 ",()'> 5(+'0,+$
AlLhough lLs members are based prlmarlly ln vermonL, lleLcher Allen PealLh arLners (lAP) ls a collaboraLlon LhaL
lncludes Lwo hosplLals ln new ?ork. lL ls afflllaLed or parLnerlng wlLh Lhree oLhers ln vermonL and has a reglonal
neLwork of servlces, lncludlng speclallsL cllnlcs, conLlnulng medlcal educaLlon workshops, and a communlcaLlon
exchange of cllnlcal lnformaLlon and besL pracLlces. 1he goal of lAP ls Lo develop an lnLegraLed dellvery sysLem
LhaL provldes hlgh-value healLh care Lo Lhe members' respecLlve communlLles.





















22

@4A%."+7?%, "*6 @4A$7:"+7'*, '( 2%"$+/ 5%('.4

1he geography and demographlcs of Lhe norLh CounLry are boLh breaLhLaklng and appeallng for resldenLs ln Lhls
vasL reglon of upsLaLe new ?ork. 8uL concerns abouL Lhe dellvery of healLh care servlces ln Lhls area have
lnLenslfled ln recenL years amld sweeplng changes ln Lhe naLlon's healLh care dellvery sysLem, aL boLh Lhe federal
and sLaLe levels. LxperLs agree LhaL radlcal reforms have become necessary Lo Lransform Lhe u.S. healLh care
sysLem, whlch desplLe lLs hlgh cosLs, has produced a lacklusLer sysLem LhaL dellvers aL besL, medlocre care. 1o
frame Lhe changes LhaL are needed, mosL healLh care leaders and governmenLal pollcy makers - lncludlng new
?ork SLaLe - have adopLed Lhe lnsLlLuLe for PealLhcare lmprovemenL's 1rlple Alm as Lhe governlng prlnclples for
Lhese reforms: beLLer paLlenL care, lmproved populaLlon healLh and lower healLh care cosLs. LxperLs conLend LhaL
for LransformaLlon Lo occur, all Lhree goals musL be pursued wlLh equal rlgor and slmulLaneously.

8eforms aL Lhe lederal Level
Cverhaullng Lhe world's cosLllesL healLh care sysLem has been an enormous Lask and a dlfflculL process, one
fraughL wlLh conLroversy, debaLe and seLbacks. 1he process Look a momenLous leap ln 2010, when resldenL
8arack Cbama slgned Lhe aLlenL roLecLlon and Affordable Care AcL (ACA) lnLo law. Cne of Lhe key goals of Lhe
ACA was Lo expand healLh lnsurance coverage Lo more Amerlcans. 1he law exLended healLh coverage for adulL
chlldren Lo age 26, prohlblLed lnsurance companles from refuslng Lo cover preexlsLlng condlLlons, barred healLh
plans from lmposlng a llfeLlme llmlL on Lhe amounL of money spenL Lo cover medlcal cosLs for an lndlvldual, and
requlred lnsurers Lo offer healLh coverage Lo an lndlvldual regardless of LhaL person's healLh sLaLus. 1hese new
measures have helped Lo guaranLee access Lo healLh lnsurance coverage for more people, especlally for
populaLlons LhaL ofLen lacked or losL coverage due Lo [ob loss or lllness.
erhaps Lhe mosL vlslble and conLroverslal change lmplemenLed by Lhe ACA so far has been Lhe creaLlon of Lhe
onllne healLh markeLplaces or exchanges, whlch wenL llve on CcLober 1, 2013. All sLaLes, elLher on Lhelr own or
wlLh asslsLance from Lhe federal governmenL, were requlred Lo offer healLh lnsurance plans Lo lndlvlduals and
small buslnesses Lhrough Lhese onllne healLh markeLplaces. 1he exchanges gave Lhe naLlon's esLlmaLed 48 mllllon
unlnsured lndlvlduals an opporLunlLy Lo obLaln healLh lnsurance from a source oLher Lhan an employer. Whlle
pavlng Lhe way for Lhese Amerlcans Lo galn access Lo healLh care, Lhe ACA has creaLed new pressures on Lhe healLh
care sysLem bulld a work force Lo dellver LhaL care.
1he law has also glven rlse Lo new models of fundlng LhaL emphaslze value-based purchaslng over volume-based
relmbursemenL. ln place of a fee-for-servlce sLrucLure, Lhe healLh care sysLem of Lomorrow wlll have flnanclal
lncenLlves Lo keep a paLlenL well by dellverlng hlgh quallLy care, Lhe klnd of care LhaL wlll prevenL LhaL paLlenL from
belng admlLLed Lo a hosplLal ln Lhe flrsL place.
Cne way Lo do LhaL ls wlLh bundled paymenLs ln whlch a slngle paymenL covers an eplsode of care. As a corollary
efforL, Lhe ACA ls also LesLlng and lmplemenLlng accounLable care organlzaLlons comprlsed of hosplLals, physlclans
and oLher provlders who assume responslblllLy for Lhe healLh care needs of a glven populaLlon and are held
flnanclally accounLable for Lhe cosL and quallLy of LhaL populaLlon's care. rovlders ln Lhese arrangemenLs are
moLlvaLed Lo lnvesL ln prevenLlve and wellness care Lo keep paLlenLs healLhy, Lhereby lowerlng cosLs and allowlng
Lhe provlders Lo share ln Lhe cosL savlngs. Cf Lhe 606 Medlcare ACCs operaLlng around Lhe counLry ln 2014, 18 are
locaLed ln new ?ork, Lwo of Lhese programs are locaLed ln new ?ork's norLh CounLry. ShlfLlng Lhe focus from
volume of servlce Lo one of value, wlll undoubLedly pose slgnlflcanL challenges for ACCs ln rural reglons, where
sparse populaLlons already place a burden on healLh care enLlLles.
23

Changes ln paymenL sLrucLure are Laklng place aL Lhe same Llme Lhe landscape of healLh care dellvery ls
undergolng a rapld meLamorphosls. new models of care deslgned Lo make healLh care more efflclenL, more
effecLlve and less cosLly are emerglng even as care lncreaslngly shlfLs Lo an ouLpaLlenL seLLlng. AL Lhe forefronL are
paLlenL-cenLered medlcal homes (CMPs), ln whlch a prlmary care docLor serves as a paLlenL's care coordlnaLor
and leads a Leam of speclallsLs based on Lhe paLlenL's needs. 1he ACA also creaLed Lhe Medlcald SLaLe lan 8eneflL
Lo encourage sLaLes Lo esLabllsh healLh homes as a way Lo coordlnaLe care for people who have complex and
mulLlple healLh condlLlons. Lllglble healLh home paLlenLs have Lwo or more chronlc condlLlons, one chronlc
condlLlon and be aL rlsk for anoLher, or one serlous and perslsLenL menLal healLh condlLlon. ln a healLh home,
paLlenLs recelve comprehenslve and coordlnaLed care from a Leam of provlders who also encourage self-care,
oversee LranslLlonal care or follow-up servlces, and provlde referrals Lo communlLy and soclal supporL servlces.
lor healLh homes and CMPs Lo succeed, provlders requlre healLh l1 Lo llnk provlders elecLronlcally across healLh
lnformaLlon exchanges. 1haL's why Lhe federal governmenL has been presslng for Lhe adopLlon of healLh l1 such as
elecLronlc healLh records (LP8s). 1he Amerlcan 8ecovery and 8elnvesLmenL AcL A88A lncluded Lhe PealLh
lnformaLlon 1echnology for Lconomlc and Cllnlcal PealLh (Pl1LCP) AcL, whlch was Lhe federal governmenL's
aLLempL Lo spur Lhe adopLlon of and use of healLh l1, and ln parLlcular elecLronlc healLh records. Pl1LCP lncluded
$30 bllllon ln lncenLlves as well punlLlve measures ln Lhe fuLure for fallure Lo adopL LP8s. Lllglble hosplLals and
healLh care professlonals recelved Lhese lncenLlves by demonsLraLlng meanlngful use" of LP8s, whlch ln essence,
meanL applylng Lhe Lechnology Lo lmprove care and lower cosLs. Lxamples lnclude elecLronlc prescrlblng of
medlcaLlons and provldlng paLlenLs wlLh access Lo Lhelr dlglLal records.
lor rural communlLles llke Lhe norLh CounLry, Lhe ACA presenLs opporLunlLles as well as challenges. Among Lhem ls
Lhe poLenLlal Lo develop place-based pollcles ln whlch fundlng and pollcy declslons are based on Lhe sysLems ln a
geographlc locaLlon, noL on speclflc programs. LxperLs belleve LhaL place-based pollcles have greaLer poLenLlal for
lnLegraLlng healLh care servlces ln a reglon and are more adepL aL meeLlng broader goals such as lmprovlng
populaLlon healLh.
11
lace-based pollcles requlre greaLer lnvolvemenL of publlc healLh, whlch by lLs very naLure,
lnvolves more componenLs of any communlLy.

8eforms aL Lhe SLaLe Level
lederal lnlLlaLlves are only parL of Lhe reforms Laklng place ln healLh care. new ?ork has been aL Lhe forefronL of
promoLlng healLh care reforms and aggresslvely pursulng lnlLlaLlves LhaL are dlrecLly allgned wlLh whaL's happenlng
aL Lhe naLlonal level. Llke many oLher governmenLal enLlLles, new ?ork SLaLe has made Lhe 1rlple Alm Lhe
cenLerplece of lLs reform lnlLlaLlves. Several lnlLlaLlves have sLarLed Lo bear frulL, demonsLraLlng subsLanLlal
changes ln care quallLy and cosLs. 8elow are some of Lhe mosL noLable.

H,4(.%&0/ <,=&1(&=
Among Lhe flrsL and blggesL challenges Lhe sLaLe underLook was new ?ork's enormous and cosLly Medlcald sysLem.
When Covernor Andrew M. Cuomo began lmplemenLlng reforms ln early 2011, new ?ork's Medlcald program cosL
$33.3 bllllon and was responslble for 40 of Lhe sLaLe's healLh care expendlLures. lL was also growlng aL Lhe
unsusLalnable raLe of 13 each year, whlle provldlng subsLandard care. Accordlng Lo Lhe CommonwealLh lund's
2009 sLaLe scorecard, new ?ork's healLh care sysLem was 22
nd
ln Lhe counLry for quallLy and lasL ln readmlsslons,
whlle expendlng more Lhan Lwlce per reclplenL on average compared Lo Lhe resL of Lhe counLry.

11
Mueller, k! and Macklnney, AC. lace-based pollcles and publlc healLh: Lhe road Lo healLhy rural people and
places. 8ural ollcy 8esearch lnsLlLuLe. March 2011.
24

WlLhln days of Laklng offlce, Covernor Cuomo creaLed Lhe Medlcald 8edeslgn 1eam Lo drafL a flrsL year Medlcald
budgeL proposal and develop a mulLlyear reform plan. Pe assembled key Medlcald sLakeholders from across Lhe
sLaLe ln a collaboraLlve forum Lo see whaL could be achleved collecLlvely Lo reduce Medlcald spendlng, whlle aL Lhe
same Llme lmprovlng Lhe quallLy of care. unllke oLher sLaLes LhaL ellmlnaLed beneflLs or cuL provlder paymenL raLes
as Lhelr prlmary cosL-cuLLlng measures, Lhe M81 acLlon plan launched a serles of lnnovaLlve soluLlons deslgned Lo
beLLer manage care and reward provlders LhaL help keep people healLhy. 1he sLraLegy ensured LhaL Lhe focus
wasn'L slmply on conLrolllng cosLs, buL also on lmprovlng paLlenL care and populaLlon healLh. ln all, new ?orkers
across Lhe sLaLe submlLLed more Lhan 4,000 ldeas, Lhe LeglslaLure ulLlmaLely approved 78 of Lhem as parL of Lhe
enacLed budgeL.
1he Medlcald reforms have proved Lo be a success on many levels. Changes ln coverage, reducLlons ln
lnapproprlaLe servlces and a LlghL focus on Lhe cosL of care resulLed ln slgnlflcanL savlngs. 1he reforms saved Lhe
sLaLe and federal governmenLs a comblned $4.6 bllllon ln Lhe flrsL year alone. Cver Lhe nexL flve years, Lhey are
esLlmaLed Lo save $34 bllllon ln all. 1he federal governmenL recenLly awarded new ?ork an $8 bllllon Medlcald
walver, uslng funds from Lhose savlngs. 1he reducLlons ln cosL came even as Medlcald 217,000 members ln
C?2012, a 4.33 percenL lncrease ln enrollmenL.
12

ln addlLlon Lo conLalnlng cosLs, Lhe M81 reforms launched several lmporLanL programs LargeLlng quallLy
lmprovemenL. Cne mllllon addlLlonal Medlcald members are now uLlllzlng nCCA-accredlLed prlmary care
provlders, and healLh homes are now avallable ln almosL every counLy ln Lhe sLaLe wlLh more Lhan 121,000
members recelvlng healLh home servlces.
13
uaLa from early healLh home enrollees suggesL Lhe program ls drlvlng
down boLh lnpaLlenL uLlllzaLlon and L8 use.
14
AnoLher lmporLanL quallLy reform ls Lhe lnLegraLlon of physlcal and
behavloral healLh servlces for hlgh needs populaLlons, a move LhaL wlll LranslLlon behavloral healLh servlces lnLo a
managed care envlronmenL. 1he change wlll lmpacL approxlmaLely 693,000 beneflclarles and wlll be managed by a
new speclalLy needs managed care producL called PealLh and 8ecovery lans.
13


5+,4,0'&#0 ($ ( 5+&#+&'2
new ?ork SLaLe accounLs for approxlmaLely 7.8 of Lhe naLlon's LoLal $2.7 Lrllllon healLh blll, Lhe second hlghesL ln
Lhe naLlon, behlnd Callfornla.
16
?eL, ln splLe of Lhose expendlLures 10.4 of new ?orkers have dlabeLes, and 30
have predlabeLes. ln addlLlon, 23 of Lhe sLaLe's populaLlon ls obese and 36 ls overwelghL.
17
Llke Lhe resL of Lhe
counLry, Lhe growlng prevalence of chronlc dlsease has placed a slgnlflcanL burden on healLh care cosLs and has
surpassed acuLe dlsease as Lhe prlmary drlver of Lhese hlgh cosLs. new ?ork ls well aware of Lhese lssues and has
Laken dramaLlc sLeps Loward maklng prevenLlon of dlsease a blgger prlorlLy Lhan Lhe LreaLmenL of dlsease.
1o address Lhe lssue, Lhe ubllc PealLh and PealLh lannlng Councll formed an ad hoc commlLLee ln 2012 made up
of 140 sLakeholder organlzaLlons, who drafLed and adopLed Lhe revenLlon Agenda 2013-2017. 1he agenda has Lhe
amblLlous goal of maklng new ?ork Lhe healLhlesL sLaLe ln Lhe naLlon and alms Lo achleve LhaL goal by focuslng on
flve prlorlLles: reduclng chronlc dlsease, promoLlng healLhy women, lnfanLs and chlldren, promoLlng healLhy and
safe envlronmenLs, promoLlng menLal healLh and prevenLlng subsLance abuse, and prevenLlng Plv, vacclne-
prevenLable dlseases, sexually LransmlLLed dlseases, and hosplLal-acqulred lnfecLlons. no doubL, lL wlll requlre a
slgnlflcanL efforL Lo achleve LhaL goal, glven LhaL new ?ork was ranked Lhe 18Lh healLhlesL sLaLe ln Lhe naLlon ln

12
new ?ork's aLhway Lo Achlevlng Lhe 1rlple Alm: 8educlng Avoldable PosplLal use Lhrough uellvery SysLem
8eform.
13
lbld
14
lbld
13
lrom leglslaLlve LesLlmony background maLerlals.
16
kalser PealLh lacLs. hLLp://kff.org/oLher/sLaLe-lndlcaLor/LoLal-healLh-spendlng-2/
17
revenLlon for a PealLhler Amerlca," 1rusL for Amerlca's PealLh, leb. 2009.
23

2012 by Lhe unlLed PealLh lund.
18
8y seLLlng Lhe bar hlgh, new ?ork hopes Lo make a ma[or lmpacL on lmprovlng
Lhe healLh and well-belng of lLs clLlzens.
1he revenLlon Agenda also serves a pracLlcal purpose. lL gave local healLh deparLmenLs and hosplLals a roadmap
on how Lo geL lnvolved ln prevenLlon efforLs ln Lhelr communlLy. new ?ork has ln place new sLaLe mandaLes LhaL
requlre local healLh deparLmenLs and hosplLals Lo work LogeLher Lo develop, respecLlvely, CommunlLy PealLh
AssessmenLs and CommunlLy Servlce lans LhaL address aL leasL Lwo prlorlLles ln Lhe agenda and one healLh
dlsparlLy, based on ldenLlfled communlLy needs. 1hese parLnershlps are encouraged Lo lnvolve oLher communlLy
sLakeholders, lncludlng schools, buslnesses, soclal servlce agencles and communlLy healLh organlzaLlons.

"#:$&0/ ($ ",()'> *(+,
1he growlng emphasls on prevenLlon has glven publlc healLh a blgger role ln healLh care. SLudles show LhaL healLh
care accounLs for [usL 10 of our longevlLy, whlle soclal facLors such as envlronmenL and behavlor lmpacL 60.
19

Accordlng Lo a recenL arLlcle ln Lhe C,E -0/)(0= 9#:+0() #; <,=&1&0,, Lhe unlLed SLaLes ranks 1
sL
among
CrganlzaLlon for Lconomlc and Co-operaLlve uevelopmenL (CLCu) counLrles ln healLh care spendlng, buL ls 23
Lh
ln
spendlng on soclal servlces.
20
8esearch shows LhaL Lhe hlgh cosLs of healLh care may be a dlrecL consequence of
spendlng Loo llLLle on Lhe soclal deLermlnanLs" of healLh, whlch lnclude safe houslng, healLhy food, and
opporLunlLles for educaLlon and employmenL, all facLors LhaL have a slgnlflcanL lmpacL on healLh.
21
ln general,
counLrles LhaL spend more on soclal servlces Lend Lo spend less on healLh care.
22

new ?ork ls Laklng sLeps Lo make publlc healLh a blgger player ln Lhe healLh care sysLem. As Lhe only sLaLe ln Lhe
counLry lnvesLlng lLs own money ln supporLlve houslng, new ?ork has esLabllshed lLself as a Lrallblazer ln Lhe
Medlcald SupporLlve Pouslng arena. SupporLlve houslng provldes affordable aparLmenLs and access Lo lndlvldual-
based healLh servlces Lo populaLlons LhaL ofLen sLruggle Lo remaln safely housed. 1hls lnnovaLlve model of care
offers an lnLegraLed soluLlon Lo a group LhaL has slgnlflcanL healLh care needs, and who ofLen sLruggle Lo meeL
Lhem as a resulL of lnadequaLe houslng. 1oo ofLen, Lhey wlnd up uslng cosLly healLh servlces such as emergency
room care, whlch could be avolded lf Lhey were properly housed. 1o address Lhe complex healLh and soclal needs
of Lhls fraglle populaLlon, new ?ork has lnvesLed $73 mllllon Lo bulld 12 new bulldlngs ln Lhe nexL 24 Lo 36 monLhs,
whlch wlll creaLe 483 supporLlve houslng unlLs. 1he lnvesLmenL wlll provlde affordable houslng for more Lhan
3,000 lndlvlduals and glve Lhem access Lo Lhe servlces and healLh care Lhey need.
23

3'(', ",()'> A00#4('&#0 5)(0
new ?ork SLaLe ls meeLlng Lhe goals of Lhe 1rlple Alm head on wlLh Lhe SLaLe PealLh lnnovaLlon lan (SPl), our
roadmap Lo beLLer care, lmproved populaLlon healLh and lower cosLs. 1he goal's plans are amblLlous: alm Lo
achleve Lop quarLlle performance among sLaLe for adopLlon of besL pracLlces and ouLcomes ln dlsease prevenLlon

18
Amerlca's PealLh 8anklngs: unlLed SLaLes Cvervlew 2012," by Lhe unlLed PealLh loundaLlon. Avallable aL:
hLLp://www.amerlcashealLhranklngs.org/ranklngs.
19
Schroeder, SA. We can do beLLer - lmprovlng Lhe healLh of Lhe Amerlcan people. new Lngland !ournal of
Medlclne. SepL. 20, 2007, 337:1221-1228.
20
8radley LP, Llklns 88, Perrln !, Llbel 8. PealLh and soclal servlces expendlLures: assoclaLlons wlLh healLh
ouLcomes. D<9 I:() 3(;G 2011,20:826-31.
21
uoran kM, Mlsa L! & Shah, n8. Pouslng as healLh care - new ?ork's boundary crosslng experlmenL. n Lngl ! Med
2013, 369:2374-2377 .

22
8radley LP, Llklns 88, Perrln !, Llbel 8. PealLh and soclal servlces expendlLures: assoclaLlons wlLh healLh
ouLcomes. D<9 I:() 3(;G 2011,20:826-31
23
n?S LeglslaLlve 8udgeL Pearlng background. need orlglnal source.
26

and healLh lmprovemenL wlLhln flve years, achleve hlgh sLandards for quallLy and consumer experlence, lncludlng
aL leasL a 20 reducLlon ln avoldable hosplLal admlsslons and readmlsslons wlLhln flve years, and generaLe $3 Lo
$10 bllllon ln cumulaLlve savlngs by reduclng unnecessary care, shlfLlng care Lo approprlaLe seLLlngs, and curblng
lncreases ln unlL prlces for healLh care producLs and servlces noL Lled Lo quallLy wlLhln flve years.
A key feaLure of Lhe SPl ls Advanced rlmary Care (AC), a model of care LhaL elevaLes Lhe currenL nCCA
sLandards for CMP recognlLlon and challenges all CMPs ln new ?ork Lo aLLaln AC sLaLus by lnLegraLlng
behavloral healLh care servlces lnLo Lhe prlmary care seLLlng, and parLlclpaLlng ln lnlLlaLlves LhaL focus on lmprovlng
communlLy healLh. 8ecomlng an AC wlll occur on a Lhree-Ller process, and each pracLlce wlll advance Lo Lhe
premlum level based on Lhe pracLlce's ablllLy Lo manage populaLlon healLh, lnLegraLe care and adopL more
sophlsLlcaLed healLh Lechnologles LhaL supporL Lhe pracLlce.
1he SPl has several oLher goals as well. lL alms Lo lmprove access Lo healLh care by enhanclng coverage and
promoLlng Lhe sLaLe's prlmary care workforce. lL lnLends Lo bolsLer healLh daLa Lransparency, so consumers,
provlders and payers can make beLLer lnformed declslons abouL Lhe quallLy and cosLs of Lhe care Lhey recelve. lL
wlll encourage payers and lnsurers Lo lncorporaLe value-based paymenL arrangemenLs by rewardlng Lhose who
help paLlenLs say healLhy and achleve quallLy healLh care ouLcomes. And lL wlll bolsLer populaLlon healLh by
connecLlng prlmary care provlders Lo communlLy organlzaLlons and promoLlng reglonal plannlng Lhrough 8eglonal
PealLh lmprovemenL CollaboraLlves (8PlCs). 1hese are lofLy goals, buL lf achleved, promlse Lo Lransform healLh
care LhroughouL new ?ork SLaLe.

5+&., 7&., ;#+ 5+&.(+2 *(+,
A healLh sysLem cenLered on prevenLlon requlres a sLrong prlmary care workforce, whlch has become a prlorlLy for
new ?ork's reform efforLs as growlng numbers of new ?orkers galn access Lo healLh lnsurance. new ?ork currenLly
has a shorLage of 1,100 prlmary care pracLlLloners, based on a paLlenL panel of 2,000 paLlenLs for every physlclan.
1he shorLage ls especlally acuLe ln Lhe norLh CounLry, buL ls also found ln urban areas of Lhe sLaLe. 1hrough lLs
workforce lncenLlve programs, Lhe sLaLe ls worklng Lo reduce LhaL shorLage. LasL fall, Lhe uocLors Across new ?ork
loan repaymenL program gave ouL $2.2 mllllon ln awards Lo 16 physlclans who ln exchange, wlll work ln
underserved communlLles. 1he sLaLe also doled ouL $3 mllllon ln racLlce SupporL awards Lo help 32 physlclans
sLarL or [oln pracLlces ln Lhese underserved communlLles.
8uL new ?ork lsn'L [usL looklng Lo lncrease Lhe numbers of prlmary care docLors. 1he sLaLe ls acLlvely encouraglng
prlmary care physlclans Lo embrace Lhe paLlenL-cenLered medlcal home model (CMP). CMPs are now regarded
as Lhe besL model for dellverlng prlmary care. lL lnvolves a prlmary care docLor aL Lhe helm of a paLlenL's care,
worklng ln parLnershlp wlLh speclallsLs, nurses and oLher care provlders Lo oversee LhaL paLlenL's healLh. 1he
Amerlcan College of hyslclans recenLly deflned Leam-based care: A cllnlcal care Leam for a glven paLlenL conslsLs
of Lhe healLh professlonals - physlclans, advanced pracLlce reglsLered nurses, oLher reglsLered nurses, physlclan
asslsLanLs, cllnlcal pharmaclsL, and oLher healLh care professlonals - wlLh Lhe Lralnlng and skllls needed Lo provlde
hlgh-quallLy, coordlnaLed care speclflc Lo Lhe paLlenL's cllnlcal needs and clrcumsLances."
Covernor Cuomo has creaLed lncenLlves Lo spur Lhe esLabllshmenL of more CMPs ln new ?ork. 1hese new laws
glve flnanclal lncenLlves for provlders Lo become nCCA-recognlzed CMPs, expanded Lhe CMP concepL Lo Lhe
sLaLe's Chlld PealLh lus healLh lnsurance program for low-lncome chlldren, and creaLed a mulLl-payer medlcal
home demonsLraLlon ln slx upsLaLe counLles called Lhe Adlrondack 8eglon Medlcal Pome lloL LhaL Lransformed
provlders ln Lhe norLhern parL of Lhe sLaLe lnLo nCCA-recognlzed CMPs.
27

1he lncenLlves have succeeded ln ralslng Lhe number of CMPs ln new ?ork. Slnce 2010, Lhe number of CMP
provlders ln new ?ork has rlsen from 633 Lo 4,461 ln 2013.
24
As of mld -2012, more Lhan 1.4 mllllon Medlcald and
Chlld PealLh lus enrollees are asslgned Lo CMP provlders.
23
new ?ork ls home Lo one-slxLh of all CMPs ln Lhe
u.S., wlLh 17 of Lhe naLlon's CMPs worklng ln Lhe sLaLe.
26
new ?ork ls worklng Lo advance Lhe sophlsLlcaLlon of
Lhe CMP model by maklng lL Lhe cenLerplece of lLs SPl.

J4,+$&/>' ;#+ J:'%('&,0' 3,+4&1,$
lor more Lhan a cenLury, hosplLals have prevalled as cenLers of healLh care ln mosL communlLles. 1oday, LhaL ls
changlng. Whlle hosplLals remaln essenLlal Lo Lhe healLh sysLem, growlng numbers of paLlenLs are geLLlng healLh
care ln ambulaLory care seLLlngs. 1he shlfL has glven rlse Lo new models of healLh care dellvery, lncludlng reLall
cllnlcs and urgenL care cenLers.
PealLh care dellvered ln Lhese new seLLlngs are cerLalnly creaLlng challenges. 8uL Lhese new klnds of faclllLles also
presenL opporLunlLles for maklng healLh care more accesslble. new ?ork recognlzed Lhe rapld growLh of Lhese
faclllLles and recenLly esLabllshed overslghL of ambulaLory care faclllLles, boLh as a way Lo ensure paLlenL safeLy and
Lo encourage lnnovaLlon ln Lhe fleld. 1he new regulaLlons deflned and ouLllned Lhe funcLlons of llmlLed servlces
cllnlcs (formerly called reLall cllnlcs), urgenL care cenLers and freesLandlng emergency deparLmenLs, and
esLabllshed new regulaLlons for offlce-based surgery. 1he servlces dellvered ln Lhese ambulaLory care seLLlngs wlll
boLh complemenL and supporL Lhe care provlded by prlmary care docLors.

7>, H#), #; ",()'> A7
A robusL neLwork of healLh lnformaLlon Lechnology ls essenLlal Lo a redeslgned healLh care sysLem LhaL seeks Lo
lnLegraLe and coordlnaLe care. 8oLh CMPs and healLh homes wlll be fully funcLlonal only lf Lhe Lechnology exlsLs
Lo connecL provlders, paLlenLs and healLh care seLLlngs. Cn LhaL fronL, new ?ork has made slgnlflcanL progress ln
recenL years, beglnnlng wlLh Lhe SLaLewlde PealLhcare lnformaLlon neLwork of new ?ork, or SPln-n?.
1he SPln-n? ls an lnLeroperable healLh lnformaLlon exchange LhaL enables Lhe secure exchange of healLh
lnformaLlon across parLlclpaLlng enLlLles and provldes docLors wlLh Lhe medlcal lnformaLlon Lhey need Lo dellver
approprlaLe care Lo lndlvldual paLlenLs. LlecLronlc healLh records are sLored and accessed Lhrough reglonal healLh
lnformaLlon organlzaLlons known as 8PlCs, whlch manage Lhe local neLworks and serve as healLh lnformaLlon
exchanges.
Cnce paLlenLs glve consenL Lo make Lhelr records avallable on Lhe 8PlCs, any provlder on Lhe 8PlC can access LhaL
lnformaLlon. lor example, docLors operaLlng on an unconsclous paLlenL ln an emergency room ln 8uffalo wlll have
access Lo Lhe paLlenL's elecLronlc healLh records ln 8rooklyn, whlch provldes essenLlal lnformaLlon abouL Lhe
paLlenL's medlcaLlons, allergles and pre-exlsLlng condlLlons Lo provlders unfamlllar wlLh Lhe paLlenL. 1hls
connecLlvlLy wlll allow docLors Lo beLLer coordlnaLe care and care LranslLlons whlle also enabllng paLlenLs Lo Lake
on more responslblllLy for Lhelr own care Lhrough a paLlenL porLal.

24
1he aLlenL-CenLered Medlcal Pome lnlLlaLlve ln new ?ork SLaLe Medlcald," reporL Lo Lhe LeglslaLure, Aprll
2013. n?S ueparLmenL of PealLh.

23
lbld.
26
"Advanclng aLlenL-CenLered Medlcal Pomes ln new ?ork,unlLed PosplLal lund reporL, 2013.
28

A second parL of new ?ork's Lechnology lnlLlaLlve ls Lhe sLaLe's All-ayer uaLabase, whlch wlll house clalms daLa
from all ma[or publlc and prlvaLe payers, such as lnsurance carrlers, healLh plans, Lhlrd-parLy admlnlsLraLors,
pharmacy beneflL managers, Medlcald, and Medlcare. 1he Au wlll also lnclude SLaLewlde lannlng and 8esearch
CooperaLlve SysLem, or SA8CS, daLa (faclllLy dlscharge daLa), and daLa from publlc healLh reposlLorles (e.g. cancer
reglsLry, lmmunlzaLlon reglsLry). 1he Au wlll provlde a beLLer undersLandlng of new ?ork's healLh care cosLs by
evaluaLlng Lhe charges and expendlLures across payers, provlders, and communlLles. When Lhls daLa ls publlcly
avallable, consumers wlll have Lhe knowledge Lhey need Lo compare cosL and quallLy for lmporLanL healLh care
declslons. ln addlLlon, feedback Lo provlders can lead Lo lmprovemenL ln performance and quallLy. lnLegraLlng Lhe
daLa ln Lhe SPln-n? wlLh Lhe daLa ln Lhe Au wlll provlde populaLlon level lnformaLlon so LhaL publlc healLh efforLs
can be beLLer allgned wlLh care dellvery needs.
new ?ork has made Lhe developmenL of Lhls neLwork a prlorlLy. 1he SPl ls sLrlvlng Lo achleve 80 parLlclpaLlon ln
Lhe Au and healLh lnformaLlon exchange whlle engaglng 20 of consumers ln acLlve use of Lhelr paLlenL porLal.
lunds ln Lhe recenL 2014-13 budgeL wlll allow Lhe sLaLe Lo Lurn Lhe SPln-n?/Au efforL lnLo a publlc uLlllLy, on par
wlLh companles LhaL provlde elecLrlclLy, naLural gas and LelecommunlcaLlons.
1he push for more paLlenL engagemenL wlll lnvolve developlng a sLaLewlde paLlenL porLal LhaL uses Lhe 8lue 8uLLon
Lechnology from Lhe veLerans AdmlnlsLraLlon. 8y Lhe end of 2014, paLlenLs wlll have ready access Lo all Lhelr healLh
records on a user-frlendly, secure and easy-Lo-navlgaLe porLal LhaL provldes lnformaLlon on everyLhlng from Lhe
sLarL daLe of a medlcaLlon Lo resulLs of Lhe mosL recenL cholesLerol LesL. new ?orkers wlll be able Lo share Lhose
records wlLh Lhelr provlders, so LhaL medlcal declslons are made wlLh Lhe mosL up-Lo-daLe lnformaLlon. 1he porLal
wlll enable paLlenLs Lo become more acLlvely engaged and lnvolved wlLh Lhelr own care.

H,/&#0() ",()'> A.%+#4,.,0' *#))(K#+('&4,$
SLaLe and federal governmenLs can seL Lhe Lone and Lhe agenda, and enacL rules and regulaLlons, buL Langlble
healLh reforms ofLen Lake place on a reglonal level. 1o LhaL end, Lhe LxecuLlve 8udgeL proposed Lo esLabllsh
8eglonal PealLh lmprovemenL CollaboraLlves (8PlCs) Lo spearhead reglonal healLh plannlng. Cn lebruary 19, 2014,
Lhe Commlsslon heard a presenLaLlon ln WaLerLown abouL Lhls lnlLlaLlve. 8PlCs are neuLral enLlLles LhaL wlll
convene key sLakeholders ln a reglon for Lhe purpose of furLherlng Lhe 1rlple Alm. 8PlCs wlll develop consensus on
acLlonable sLraLegles LhaL allgn publlc healLh and healLh sLraLegles and resources wlLh Lhe needs of a populaLlon
LhaL area. ln accordance wlLh PPC recommendaLlons, 8PlCs wlll:
Convene sLakeholders,
CaLher, analyze and reporL daLa,
Make recommendaLlons abouL reglonal needs,
uevelop sLraLegles Lo allgn healLh care resources wlLh populaLlon need, and
Lead and coordlnaLe reglonal lnlLlaLlves.
1he ueparLmenL's presenLaLlon emphaslzed LhaL 8PlCs would be expecLed Lo focus on boLh populaLlon healLh and
healLh care, lncludlng behavloral healLh, and address healLh and healLh care dlsparlLles. Moreover, Lhe work of Lhe
8PlCs wlll help advance prlorlLy lnlLlaLlves lncludlng Lhe SPl, Lhe new ?ork SLaLe revenLlon Agenda 2013-2017,
Lhe M81 Walver/uellvery SysLem 8eform lncenLlve rogram (uS8l) lan, and Lhe new ?ork SLaLe of PealLh. 8PlCs
are also expecLed Lo promoLe LxecuLlve 8udgeL lnlLlaLlves such as Lhe CaplLal llnanclng 8esLrucLurlng rogram,
descrlbed ln furLher deLall below.
1he budgeL proposes LhaL one 8PlC wlll be esLabllshed ln each of Lhe 11 geographlc reglons of Lhe sLaLe. 1en wlll
be selecLed Lhrough a requesL for appllcaLlons. 1he exlsLlng llnger Lakes PealLh SysLem Agency (lLPSA) wlll serve
as Lhe 11Lh 8PlC and asslsL Lhe sLaLe ln coordlnaLlng Lhe acLlvlLles of Lhe oLher 8PlCs, and provlde Lechnlcal
29

asslsLance and dlssemlnaLlon of besL pracLlces. 1he lLPSA has achleved several slgnlflcanL ouLcomes ln lLs reglon,
lncludlng scorlng ln Lhe Lop 10 percenL naLlonwlde on healLh sysLem performance as measured by Lhe
CommonwealLh lund's local reporL card. Powever, Lhe lLPSA ls noL Lhe only successful model of reglonal
plannlng. lor example, Lhe lorL urum 8eglonal PealLh lannlng CrganlzaLlon presenLed a comprehenslve overvlew
of lLs work Lo Lhe Commlsslon demonsLraLlng lLs reglonal approach and commlLmenL Lo llnklng soldlers, Lhelr
famllles and Lhe local communlLy wlLh hlgh quallLy healLh care. Among lLs pro[ecLs, Lhe lu8PC ls examlnlng Lhe
behavloral healLh needs of reLurnlng mlllLary, worklng Lo recrulL and reLaln healLh care provlders Lo Lhe reglon and
developlng Lhe Lechnology LhaL wlll resulL ln more coordlnaLed care. 1he ueparLmenL lnLends Lo revlew oLher
models ln developlng Lhe 8PlC sollclLaLlon. AddlLlonally, Lhe ueparLmenL wlll confer wlLh a broad range of
sLakeholders ln creaLlng Lhe 8PlCs.
1he nlne counLles of Lhe norLh CounLry are dlvlded lnLo reglons, and each wlll have lLs own 8PlC: Lhe 1ug Plll
Seaway (!efferson, Lewls and SL. Lawrence counLles) and Lhe norLh CounLry 8PlC (CllnLon, Lssex, lranklln,
PamllLon, Warren and WashlngLon counLles). 1he Lwo reglons have many common concerns, and are lncreaslngly
parLnerlng across LradlLlonal easL-wesL llnes as evldenced by Lhe work of Lhe norLh CounLry 8eglonal Lconomlc
uevelopmenL Councll as well as exploraLlons of healLh care collaboraLlons across Lhe norLhern Ller. 1he Lwo 8PlCs
wlll need Lo coordlnaLe some of Lhelr efforLs and sLraLegles, and seek Lo reflecL and supporL approprlaLe
opporLunlLles for cross reglonal cooperaLlon and parLnershlp.
ulLlmaLely, reglonal healLh plannlng ls an lmporLanL lnlLlaLlve LhaL, llke Lhe work of Lhe Commlsslon, ls deslgned Lo
promoLe sLraLegles LhaL respond Lo Lhe unlque needs of each reglon. ln addlLlon, Lhe esLabllshmenL of Lwo 8PlCs
wlll provlde Lhe norLh CounLry wlLh more plannlng resources. 1he Commlsslon sLrongly recommends each of Lhe
Lwo 8PlCs commlL Lo regularly consulL wlLh each oLher ln order Lo ldenLlfy opporLunlLles for collaboraLlve cross-
boundary opporLunlLles. 8egular dlscusslons wlLh varlous sLakeholders wlll ald ln LhaL process.













30

!/% 9#7$7+1 +' B%%+ C'A0$"+7'* -%%6,

WhaL are Lhe healLh care needs of Lhe people ln Lhe norLh CounLry, and whaL ls Lhe currenL sysLem's ablllLy Lo
meeL Lhese needs? 1o answer Lhese quesLlons fully would have requlred more Llme and resources Lhan were
avallable for Lhls Commlsslon. ln addlLlon, even lf Llme and resources were abundanL, Lhe necessary daLa were noL
always avallable. 1he daLa analyzed lncludes Medlcald daLa and (ln- and ouLpaLlenL) all-payer hosplLal daLa, as well
as provlder's flnanclal reporLs, publlc healLh daLa and a hosL of more dedlcaLed, separaLe daLa sources.
1he framework sLarLs wlLh a focus on %#%:)('&#0$ and Lhelr healLh care needs. ulfferenL cosLs and volumes are
assoclaLed wlLh each caLegory of care. ln order Lo achleve a sense of volume ln Lerms of cosL and paLlenL numbers,
we analyzed boLh SA8CS and Medlcald daLa. A proxy for LoLal paLlenL numbers ls measured by counLlng Lhe
number of unlque paLlenLs who had lnpaLlenL admlsslons ln 2012 SA8CS daLa. 1hls number wlll :0=,+,$'&.(', Lhe
acLual number of paLlenLs slnce Lhe daLaseL does noL lnclude hosplLals ouLslde Lhe new ?ork SLaLe border (llke
vermonL's lleLcher Allen hosplLal).
LeL's Lake a look aL four of Lhese caLegorles -- chronlc care and mulLlmorbldlLy, wlLh a focus on dlabeLes, acuLe
sLroke care, and behavloral and addlcLlon care -- LhaL represenL dlfferenL Lypes of paLlenL needs especlally relevanL
Lo Lhe norLh CounLry. 1he dlverse Lypes of paLlenL needs wlll Lhe showcase Lhe dlfferenL Lypes of healLh care
capablllLles and capaclLy, whlch wlll lead Lo dlfferenL Lypes of recommendaLlons regardlng Lhe fuLure of Lhe norLh
CounLry's healLh care landscape.

Chronlc CondlLlons and MulLlmorbldlLy
ln Lhe norLh CounLry, Lhe mosL common chronlc condlLlons
27
among Medlcald beneflclarles are depresslon,
followed closely by dlabeLes, rheumaLold arLhrlLls/osLeoarLhrlLls, and lschemlc hearL dlsease. When analyzlng
payer clalms lnformaLlon (SA8CS) for hosplLal care, Lhe mosL common chronlc dlseases among hosplLal
admlsslons are lower resplraLory dlsease, non-speclflc chesL paln and chronlc obsLrucLlve pulmonary dlsease
(CCu) and bronchlecLasls. 1he mosL common chronlc condlLlons seen ln ouLpaLlenL vlslLs are dlabeLes, cardlac
dysrhyLhmlas, and oLher allerglc reacLlons.
CpLlmal chronlc care lnvolves dlsease managemenL, a pro-acLlve, communlLy-based focus on secondary prevenLlon
and empowerlng Lhe paLlenL Lo opLlmally manage hls or her own healLh. 1ackllng chronlc dlsease wlLh Lhls mulLl-
pronged approach can avold exacerbaLlons of Lhe dlsease and Lhe developmenL of compllcaLlons.
Many people wlLh chronlc condlLlons have more Lhan one condlLlon. lL ls well known LhaL one of Lhe largesL
challenges of our healLh care sysLem - currenLly sLlll prlmarlly geared Lo LreaLlng acuLe condlLlons - ls deallng wlLh
people who have slgnlflcanL, chronlc mulLlmorbldlLy (deflned as havlng Lhree or more chronlc condlLlons). 1hese
paLlenLs need a hollsLlc approach, noL focused on managlng Lhe lndlvldual condlLlons ln parallel, buL on achlevlng
paLlenL-speclflc goals LhaL are sLlll wlLhln reach: avoldlng hosplLallzaLlon or lnsLlLuLlonallzaLlon where posslble, and
lmprovlng quallLy of llfe. 1hese forms of LreaLmenL focus much more on so-called 'secondary prevenLlon.'



27
Measured uslng CMS meLhodology. lor Lhe Medlcald analyses, people wlLh Lhree or more chronlc condlLlons are
counLed as 'mulLlmorbld'.
31

ulabeLes
ApproxlmaLely 6 of Lhe norLh CounLry Medlcald populaLlon suffers from dlabeLes. 1hls populaLlon requlres
dlsease-managemenL and a pro-acLlve focus on secondary prevenLlon.
28
Slnce Medlcald enrollees represenL only
parL of Lhe populaLlon, an analysls of SA8CS daLa was used Lo reach a more compleLe esLlmaLe of Lhe number of
persons wlLh dlabeLes ln Lhe reglon. ConservaLlve esLlmaLes place Lhe LoLal number of paLlenLs sufferlng from
dlabeLes ln Lhe norLh CounLry aL 3,344.
1he 6 Medlcald beneflclarles wlLh dlabeLes (excludlng Lhose wlLh > 2 oLher chronlc condlLlons) accounLed for 12
of LoLal Medlcald spendlng ln 2012. 1he average per beneflclary per year (8?) Medlcald cosL for dlabeLes ln Lhe
norLh CounLry ls approxlmaLely $13,700 whlch ls $2,300 lower Lhan Lhe 8? cosL for Lhe resL of new ?ork SLaLe.
MosL of Lhe annual Medlcald spend on beneflclarles wlLh dlabeLes occurs ln nurslng homes (24.9). CLher
spendlng ls allocaLed Lo home healLh (24.8), pharmacy (13.2) and lnpaLlenL servlces (12.6). ulabeLes spendlng
ls hlgher ln Lhe norLh CounLry Lhan lL ls elsewhere ln Lhe sLaLe. 1he use of lnpaLlenL servlces for paLlenLs wlLh
dlabeLes ls hlgher ln SL. Lawrence and CllnLon counLles, where Lhere are a hlgh number of avoldable admlsslons for
chronlc dlseases ls hlgh. 1he norLh CounLry also has a hlgher dlabeLes morLallLy raLe.

MulLlmorbldlLy
ApproxlmaLely 1.4 of Lhe norLh CounLry Medlcald populaLlon suffers from mulLlmorbldlLy. 1ogeLher, Lhey
accounL for 4.3 of LoLal Medlcald spendlng. new ?ork SLaLe spends an average of $32,649 ln per beneflclary per
year for a mulLlmorbld paLlenL, as compared Lo $12,236 8? cosLs for an average Medlcald enrollee ln Lhe norLh
CounLry.
A closer look reveals LhaL 21 of Medlcald spend on beneflclarles wlLh mulLlmorbldlLy ls on lnpaLlenL hosplLal care,
and 34 ls on nurslng home care. ln Lhe resL of new ?ork, Lhe cosLs of care are spread very dlfferenLly, wlLh a
much larger porLlon golng Lo nurslng home care (31) and less Lo lnpaLlenL hosplLal care (13). 1he spendlng
paLLern for mulLlmorbld paLlenLs ls very slmllar Lo whaL's spenL on end-of-llfe care ln Lhe lasL slx monLhs of llfe. ln
boLh cases, a more opLlmal care paLLern would show lower lnpaLlenL cosLs and lncreased ouLpaLlenL and prlmary
care cosLs, lncludlng home care.
Medlcald paLlenLs wlLh mulLlmorbldlLy ln Lhe norLh CounLry see on average four Lo flve dlfferenL hosplLal
speclallsLs per year. An ldeal care paLLern would show lower numbers of speclallsLs worklng ln parallel, and a
sLronger focus on lnLegraLed, communlLy based care.

AcuLe SLroke Care
Accordlng Lo research by Lhe new ?ork SLaLe ueparLmenL of PealLh, Lhe prevalence of cardlovascular dlseases
(Cvu) has been sLable over Lhe lasL decade. Powever, as a dlsease group, Cvu affecLs almosL 8 of adulLs ln Lhe
sLaLe and accounLs for almosL 40 of all deaLhs annually, Lhereby placlng lL flrmly on Lhe llsL of condlLlons LhaL
requlres aLLenLlon.
30

1he LreaLmenL of acuLe cerebrovascular accldenLs (or sLroke) ls a good proxy measure (boLh efflclency and quallLy)
for Lhe larger caLegory of acuLe cardlovascular dlseases. lor all of Lhese acuLe cardlovascular condlLlons, Llme Lo

28
1hese numbers ,L1):=, Medlcald enrollees LhaL have been ldenLlfled wlLh mulLlmorbldlLles.
30
88lSS 8rlef. Cardlovascular ulsease, new ?ork SLaLe AdulLs, 2010.
32

Lhe acuLe LreaLmenL faclllLy as well as capablllLles and experlence of Lhese faclllLles are key predlcLors of lnlLlal
ouLcomes. Plgher volume cenLers Lend Lo achleve hlgher evldence-based LreaLmenL scores and have beLLer
ouLcomes. ln Lhe posL-acuLe phase, good ouLcomes are faclllLaLed by shorL lengLhs of sLay, skllled rehablllLaLlon
and a focus on rapld reacLlvaLlon.
31

1he laLesL baslc llfe supporL proLocols for new ?ork SLaLe sLlpulaLe LhaL paLlenLs wlLh a pre-hosplLal Llme (Llme
from onseL of sympLoms and expecLed arrlval aL SLroke CenLer) of less Lhan Lwo hours be LransporLed Lo Lhe
nearesL new ?ork SLaLe ueparLmenL-deslgnaLed SLroke CenLer, unless Lhe paLlenL ls sufferlng from cardlac arresL
or oLher condlLlons LhaL warranL LransporL Lo Lhe closesL Lu.
32
ln Lhese proLocols, LransporL Lo hlgh volume
speclallzed LreaLmenL faclllLles such as a deslgnaLed SLroke CenLer, ls prlorlLlzed over proxlmlLy and speed of acuLe
LreaLmenL. 1he norLh CounLry does noL house a deslgnaLed SLroke CenLer, meanlng LhaL mosL paLlenLs (lf deLecLed
early enough) should be LransporLed ouL of Lhe norLh CounLry for adequaLe sLroke LreaLmenL.
Cn average, 966 resldenLs from Lhe norLh CounLry were admlLLed for sLroke Lo hosplLals ln or ouLslde of Lhe norLh
CounLry every year beLween 2010 and 2012. ApproxlmaLely 40 of all norLh CounLry resldenLs are admlLLed Lo
faclllLles ouLslde of Lhe norLh CounLry.
33
aLlenLs leavlng Lhe norLh CounLry for sLroke LreaLmenL mosLly go Lo
lleLcher Allen PealLh ln vermonL and unlverslLy PosplLal Sun? PealLh CenLer ln Syracuse. 1he percenLage of
paLlenLs leavlng Lhe norLh CounLry for LreaLmenL ls mosL slgnlflcanL ln Lhe norLheasLern parLs of Lhe reglon. lor
example, 33 of paLlenLs from CllnLon CounLy seek LreaLmenL ouLslde of Lhe counLy, wlLh mosL of Lhese paLlenLs
(27) endlng up aL lleLcher Allen PealLh ln vermonL. ln lranklln and Lssex, 33 and 27 of Lhe sLroke paLlenLs go
Lo lleLcher Allen PealLh, respecLlvely. 1he Clens lall PosplLal ln Warren CounLy LreaLs Lhe hlghesL number of sLroke
paLlenLs ln Lhe norLh CounLry, averaglng 136 sLroke paLlenLs a year, followed closely by Champlaln valley
hyslclans PosplLal Medlcal CenLer aL 90 sLroke paLlenLs a year.
34

1he LoLal cosLs of care up unLll one year afLer dlscharge for norLh CounLry Medlcald beneflclarles who suffered a
sLroke ls approxlmaLely $17,000.
33
MosL of Lhls spendlng goes Lo lnpaLlenL servlces (36), nurslng homes (29)
and home healLh (11).
36

lor acuLe cardlovascular care, boLh Lhe Llme Lo acuLe LreaLmenL and Lhe volumes LreaLed aL Lhe acuLe faclllLy are
key predlcLors of lmproved ouLcomes. A slgnlflcanL porLlon of norLh CounLry resldenLs are LransporLed Lo sLroke
cenLers, buL many sLlll remaln ln Lhe norLh CounLry.
AlLhough Lhe dlsLances ln Lhe norLh CounLry wlll always presenL a challenge Lo opLlmal, ln-Llme LreaLmenL, Lhe
slgnlflcanL number of people LhroughouL Lhe norLh CounLry who are LransporLed Lo a deslgnaLed sLroke cenLer
lllusLraLe LhaL a furLher sLreamllnlng of Lhls care may be posslble Lo balance Lhe Llme Lo LreaLmenL wlLh Lhe
LreaLmenL capablllLles and experLlse per cenLer.



31
Cgbu, u.C., eL al., PosplLal sLroke volume and case-faLallLy revlslLed. Med Care, 2010. 48(2): p. 149-36.
Saposnlk, C., eL al., PosplLal volume and sLroke ouLcome: does lL maLLer? neurology, 2007. 69(11): p. 1142 -31.
voLruba, M.L. and 8.u. Cebul, 8edlrecLlng paLlenLs Lo lmprove sLroke ouLcomes: lmpllcaLlons of a volume based
approach ln one urban markeL. Med Care, 2006. 44(12): p. 1129-36.
32
SLaLe of new ?ork ueparLmenL of PealLh. n?S SuspecLed SLroke roLocol, 2009.
33
SA8CS daLa uslng lnLernaLlonal PosplLal 8enchmark markeL share Lool (2010-2012), numbers of paLlenLs
admlLLed Lo non n?S hosplLals esLlmaLed on Lhe basls of exLrapolaLlon of Medlcald daLa.
34
uaLa from norLh CounLry resldenLs only.
33
SallenL n?S Medlcald SysLem uaLa verslon 6.4 daLa analysls (2010-2012).
36
SallenL n?S Medlcald SysLem uaLa verslon 6.4 daLa analysls (2010-2012).
33

MenLal PealLh and SubsLance Abuse Care
Among chronlcally lll paLlenLs, depresslon ls one of Lhe mosL common dlagnoses ln Lhe norLh CounLry. MenLal
healLh condlLlons wlll ofLen manlfesL Lhemselves ln comblnaLlon wlLh oLher healLh condlLlons, approxlmaLely 30
of people wlLh a severe menLal healLh dlsorder suffer from subsLance abuse problems.
37
lL ls lmporLanL, Lherefore,
LhaL menLal healLh professlonals work closely LogeLher wlLh oLher healLh professlonals ln order Lo provlde lnLegral
soluLlons for boLh Lhe paLlenLs and Lhelr surroundlngs. As ls emphaslzed ln new ?ork SLaLe's SPl, opLlmal menLal
healLh and subsLance abuse care lnvolves Llmely and adequaLe access Lo menLal healLh speclallsLs, lnLegraLed
communlLy based servlces and prlmary care. A blg lssue ls early deLecLlon and LreaLmenL, whlch can prevenL
desLrucLlve and llfe-alLerlng consequences Lo paLlenLs and Lhelr surroundlngs.
ln Lhe norLh CounLry, menLal healLh condlLlons
38
among Medlcald beneflclarles are more prevalenL Lhan subsLance
abuse. 1he mosL commonly LreaLed menLal dlsorders ln 2012 were mood dlsorder (33), followed by anxleLy
(27), psychosls (8) and posL LraumaLlc sLress dlsorder (1Su) (6).
39
Sulclde morLallLy raLes ln Lhe norLh CounLry
are above sLaLe average, lndlcaLlng a need for servlces LhaL address menLal healLh condlLlons.
ApproxlmaLely 13 of Medlcald beneflclarles ln Lhe norLh CounLry are LreaLed for a menLal healLh condlLlon, and
4.8 had subsLance abuse problems.
40
Alcohol ls Lhe prlmary cholce among paLlenLs wlLh addlcLlon problems, buL
Lhe use of prescrlpLlon drugs, heroln, and meLhampheLamlne ls lncreaslng. Many lndlvlduals wlLh addlcLlons are
admlLLed Lo hosplLals for care.
41

1ogeLher, Lhe 13 of Lhe Medlcald beneflclarles wlLh menLal healLh condlLlons accounL for 30 of LoLal Medlcald
spendlng. Compared Lo Lhe resL of Lhe sLaLe, beneflclarles wlLh a menLal healLh problem accounL for a larger
porLlon of hosplLal uLlllzaLlons Lhan Lhe same Lype of beneflclarles do ln Lhe resL of Lhe sLaLe. ln Lhe norLh CounLry,
11 of all admlsslons Lo hosplLals are relaLed Lo a menLal healLh condlLlon. ln Lhe resL of Lhe sLaLe, Lhls ls only 8.
Slmllarly, almosL 10 of all paLlenLs who go Lo a hosplLal ln Lhe norLh CounLry have one or more of Lhe selecLed
menLal healLh condlLlons, whereas only 6 do ln Lhe resL of Lhe sLaLe.
42

1he norLh CounLry reglon counLs 12 areas LhaL are underserved by menLal healLh professlonals and varlous
counLles reporL shorLages of capaclLy Lo LreaL paLlenLs wlLh menLal healLh problems. sychlaLrlc faclllLles and
LreaLmenL programs LhaL are able Lo admlL paLlenLs for LreaLmenL are ofLen more Lhan 30 mlles away from norLh
CounLry resldenLs. 1hls could explaln why such a hlgh proporLlon of admlsslons Lo hosplLals ln Lhe norLh CounLry
are relaLed Lo menLal healLh condlLlons when compared Lo hosplLals ln Lhe resL of Lhe sLaLe. 1he lack of menLal
healLh professlonals and need for supporLlve houslng ln Lhe reglon may be drlvlng paLlenLs Lo lnpaLlenL hosplLal
servlces as Lhe only alLernaLlve Lo care. Clven Lhe large absoluLe number of paLlenLs sufferlng from menLal healLh
problems, and Lhe very slgnlflcanL cosL assoclaLed wlLh Lhls group of paLlenLs, a dedlcaLed focus on resLrucLurlng
Lhe care for Lhls paLlenL caLegory ls cruclal.
As wlLh menLal healLh, subsLance abuse ls very much a communlLy lssue LhaL requlres LreaLmenL ln a communlLy
and home seLLlng close Lo home. SubsLance abuse provlders are Lhlnly spread, lf aL all presenL ln Lhe norLh
CounLry, forclng paLlenLs Lo lnpaLlenL servlces.

37
lsaacs, S. eL al. new ?ork SLaLe PealLh loundaLlon: lnLegraLlng MenLal PealLh and SubsLance Abuse Care. PealLh
Affalrs (vol 32, 10), 1846-1830.
38
AffecLlve dlsorders, anxleLy, somaLoform, dlssoclaLlve, personallLy dlsorders, menLal reLardaLlon, oLher menLal
condlLlons, oLher psychoses, preadulL dlsorders, schlzophrenla and relaLed dlsorders, senlllLy and organlc menLal
dlsorders, alcohol-relaLed menLal dlsorders, and subsLance-relaLed menLal dlsorders.
39
resenLaLlon by S. CllleLLe, dlrecLor of CommunlLy MenLal PealLh Servlces CllnLon CounLy. resenLed Lo Lhe
nCPS8C on !anuary 21
sL
, 2014.
40
ueparLmenL of PealLh, new ?ork SLaLe, 2012.
41
ueparLmenL of PealLh, new ?ork SLaLe, 2012. Lvldence from CllnLon CounLy.
42
SallenL n?S Medlcald SysLem uaLa verslon 6.4 daLa analysls (2010-2012).
34

CosLs for paLlenLs wlLh a subsLance abuse problem are sLrlklngly hlgher Lhan ln Lhe resL of Lhe sLaLe, mosLly due Lo
hlgher spend on hosplLal and pharmacy servlces. 1he slgnlflcanL cosLs assoclaLed wlLh carlng for Lhls group of
paLlenLs calls for a dedlcaLed focus on resLrucLurlng Lhe care for Lhls paLlenL caLegory as well.
1he reglon's lack of prlmary care and menLal healLh servlces means LhaL many paLlenLs wlLh chronlc condlLlons or
reduced moblllLy have few opLlons for care close Lo home. 1hls causes more paLlenLs go Lo Lhe hosplLal when Lhelr
condlLlon deLerloraLes. lor example:
A large porLlon of Lhe servlces provlded Lo paLlenLs wlLh a chronlc condlLlon Lakes place aL an lnpaLlenL level, as
seen by Lhe large porLlon of avoldable admlsslons for Lhese condlLlons. uesplLe Lhe more lnLense levels of care,
ouLcomes remaln poor mosL llkely due Lo Lhe facL LhaL Lhe lnLense LreaLmenL phases are Lhe resulL of a crlsls ln Lhe
paLlenL's condlLlon.
1yplcally, Lhe managemenL of chronlc dlseases requlres a heavy focus on llfesLyle lnLervenLlons ln a seLLlng close Lo
home. Powever, Lhe norLh CounLry lacks Lhe necessary prlmary care and care coordlnaLlon resources. lor chronlc
paLlenLs, lL ls worLh explorlng Lhe posslblllLy of converLlng some of Lhe lnpaLlenL-focused servlces Lo more
ouLpaLlenL communlLy cenLers.
lor paLlenLs wlLh mulLlple chronlc condlLlons, leadlng pracLlces and llLeraLure all polnL Lo Lhe lmporLance of
focuslng on Lhe paLlenL's goals, and Laklng a unlfled, lnLegraLed and person-cenLered approach raLher Lhan on
lndlvldual dlsease managemenL proLocols for each condlLlon. 1hls lmplles subsLlLuLlng lnpaLlenL and slngle dlsease-
focused speclallsL care for more nurse-led, communlLy care wlLh a sLrong focus on well-belng, prevenLlon of
furLher compllcaLlons and exacerbaLlons, and psychosoclal supporL.
CurrenLly, paLlenLs sufferlng from mulLlmorbldlLles spend a slgnlflcanL porLlon of Llme (and relaLed cosLs) on
lnpaLlenL servlces and speclallsL vlslLs. arL of Lhe reasons for Lhls may be dlcLaLed by supply. PosplLals are ofLen
easler Lo reach and more accesslble Lhan Lhlnly spread ouLpaLlenL faclllLles and prlmary care docLors.
1hese examples demonsLraLe LhaL bulldlng more prlmary care and ouLpaLlenL servlces wlll allow paLlenLs wlLh
chronlc condlLlons Lo seek care sooner and more frequenLly, closer Lo home, and produce beLLer healLh and quallLy
of llfe ouLcomes.









33

!%$%/%"$+/

1elehealLh ls a rapldly expandlng fleld dedlcaLed Lo provldlng healLh care and healLh-relaLed servlces aL a dlsLance
uslng Lechnology. Wldespread adopLlon of LelehealLh can llnk dlverse aspecLs of Lhe healLh care sysLem Lo
lncrease paLlenLs' access Lo prlmary and speclalLy care, lmprove shorLages of prlmary care and speclalLy physlclans
ln rural and medlcally underserved communlLles, and enable healLh care servlces Lo be provlded more efflclenLly ln
Lhe areas where Lhey are needed mosL.
uellvery of healLh care Lhrough LelehealLh has Lhe poLenLlal Lo reduce healLh care dellvery cosLs, enhance paLlenL
saLlsfacLlon, and lmprove cllnlcal care and paLlenL ouLcomes ln Lhe norLh CounLry. Several reglonal facLors exlsL
LhaL drlve Lhe need for an alLernaLlve Lo Lhe LradlLlonal face-Lo-face dellvery of healLh care. 1hese lnclude a
growlng aglng, chronlcally lll and home-bound populaLlon, exLenslve healLh care provlder shorLages, and a large
geographlcally lsolaLed area wlLhln whlch paLlenLs musL Lravel Lo access care.
AlLhough some provlders ln Lhe norLh CounLry have successfully esLabllshed LelehealLh programs and lnlLlaLlves,
lmplemenLaLlon challenges perslsL LhaL LhreaLen Lhelr susLalnablllLy. Lven lf provlders are able Lo effecLlvely
lmplemenL LelehealLh, malnLalnlng lL wlLhouL adequaLe relmbursemenL from lnsurers renders Lhe program
unsusLalnable. ln addlLlon, provlders who have noL yeL lmplemenLed LelehealLh clLe numerous flnanclal,
Lechnologlcal, and regulaLory barrlers Lo dolng so LhaL exlsL boLh ln Lhe norLh CounLry and sLaLewlde. As such, Lhe
poLenLlal and opporLunlLy for LelehealLh Lo poslLlvely lmpacL Lhe healLh care dellvery sysLem ln Lhe norLh CounLry
has noL been fully reallzed.
1he norLh CounLry can beneflL greaLly from a coordlnaLed, planned efforL Lo expand LelehealLh capaclLy
LhroughouL Lhe reglon, bulldlng on exlsLlng successes and lnfrasLrucLure. A flber opLlc LelecommunlcaLlons and
LelehealLh neLwork has been bullL LhaL currenLly llnks many rural norLh CounLry healLh care slLes Lo urban cenLers
for consulLaLlon, speclalLy care and dlagnosLlc resources. CrganlzaLlons such as Lhe norLh CounLry PealLh Care
rovlders, lorL urum 8eglonal PealLh lannlng CrganlzaLlon, and oLher experlenced provlders are polsed Lo
expand Lhelr efforLs and collaboraLe wlLh oLher enLlLles Lo lmplemenL LelehealLh more wldely.











36

D'*8 !%.4 3%.?7:%, "*6 30AA'.+, ED!33F

Across Lhe counLry, we are experlenclng a graylng of Lhe populaLlon as growlng numbers of 8aby 8oomers enLer
reLlremenL and beyond. 1he norLh CounLry ls no excepLlon. Much of Lhe brlcks and morLar of modern" healLh
care ln norLhern new ?ork was developed ln a dlfferenL era. Long Lerm care ln Lhls reglon developed slmllarly Lo
Lhe resL of new ?ork, whlch was ln response Lo Lhe esLabllshmenL of Medlcare and Medlcald. ln Lhe early 70's
Lhese faclllLles were fllled wlLh senlors, many of whom would noL be -- nor wanL Lo be-- admlLLed Loday.
1he proflle of Lhe earllesL admlsslons Lo long-Lerm care seLLlngs would beLLer maLch Lhose consldered approprlaLe
for supporLlve houslng or home care. Chronlc and acuLe condlLlons LhaL demanded hosplLal admlsslons four
decades ago are managed dlfferenLly Loday, wlLh dramaLlc shlfLs ln whaL we now conslder Lhe proper use of Lhe
long Lerm care sysLem. A greaLer knowledge of how Lhlngs can be done, changlng expecLaLlons of Lhe senlor
populaLlon and more recognlLlon of Lhe hlgh cosLs of ln-paLlenL care alLered Lhe use of nurslng homes and gave
rlse Lo more home-based servlces. new ?ork SLaLe developed lncenLlves Lo admlL only Lhe mosL ln need of skllled
care and dlslncenLlves Lo admlL anyone Lo skllled nurslng faclllLles whose care needs could be served ln lower cosL
seLLlngs.
rovldlng approprlaLe long Lerm care servlces and supporL ln Lhe norLh CounLry has proven Lo be a challenge, boLh
ln Lhe provlslon of servlces and Lhe flnanclal feaslblllLy of long Lerm servlces and supporLs. Many nurslng homes are
far flung and separaLed by vasL dlsLances beLween each oLher. 1hey exlsL ln areas where Lhey are underserved by
downsLream provlders who can supporL Llmely dlscharges from nurslng homes or Lhelr alLernaLlves for acuLe care
dlscharges. Some are locaLed ln communlLles wlLh small populaLlons LhaL no longer need Lhe bed capaclLy or
where a shorLage of healLh care workers has made lL dlfflculL Lo flll sLaff poslLlons. Lesser levels of care, such as
asslsLed llvlng, are also needed ln Lhe norLh CounLry.
noL all counLles are equally challenged. ln WashlngLon CounLy, Lhere appears Lo be adequaLe home care as well as
sufflclenL -- even sllghL excess -- of nurslng home beds, wlLh reasonable Lravel from Lhe ma[orlLy of populaLlon
cenLers. Some counLles appear Lo be well served, buL Loo ofLen home care provlders have dlfflculLy coverlng Lhe
whole counLy due Lo Lhe geographlc dlverslLy ln Lhe norLh CounLry. 1he sLralns on Lhe sysLem are conslsLenL
LhroughouL Lhe reglon, and lnclude a shrlnklng workforce, an aglng lnfrasLrucLure, and lack of broadband access.
8uL all L1SS provlders ln Lhe norLh CounLry suffer from a lack of opLlons, a shorLage of naLural parLnershlps wlLhln
reasonable dlsLances, and low markeL volume.
Medlcald has evolved Lo become Lhe prlmary payer for L1SS ln Lhe reglon, flnanclng 43 percenL, or nearly half, of
all spendlng on L1SS ln new ?ork SLaLe. Cnly 6 percenL of Lhe Medlcald populaLlon ln 2007 used L1SS, buL such
servlces cosL nearly half of LoLal Medlcald spendlng. 1he use of L1SS ls cosLly. Among Lhose uslng L1SS ln 2007, Lhe
average annual spendlng per Medlcald beneflclary was $43,296 compared Lo [usL $3,694 for Medlcald beneflclarles
who dld noL use long-Lerm care servlces. 1he heavy use of lnsLlLuLlonal servlces such as hosplLals and nurslng
homes ls a blg drlver of Lhose hlgh cosLs. Lven so, mosL L1SS ls provlded aL home by famlly members and lnformal
careglvers who have llmlLed servlce and flnanclal supporL.
new ?ork SLaLe ls LranslLlonlng vlrLually all Medlcald enrollees Lo care managemenL for all" by 2018. 1hls lnlLlaLlve
began ln Sl? 11/12 as a Medlcald 8edeslgn 1eam (M81) proposal and ls lnLended Lo lmprove beneflL coordlnaLlon,
quallLy of care, and paLlenL ouLcomes over Lhe full range of healLh care, lncludlng menLal healLh, subsLance abuse,
developmenLal dlsablllLy, and physlcal healLh care servlces. lL wlll also redlrecL almosL all Medlcald spendlng ln Lhe
sLaLe from fee-for-servlce Medlcald (under whlch healLh servlces provlders blll dlrecLly Lo Lhe sLaLe) Lo care
managemenL," ln whlch a managed care organlzaLlon ls pald a caplLaLed raLe by Lhe sLaLe and ls Lhen responslble
for managlng paLlenL care and relmburslng servlce provlders. As Lhe *(+, <(0(/,.,0' ;#+ ?)) lnlLlaLlve moves
ahead, enrollmenL ln care managemenL wlll rlse Lo 93 of Lhe Medlcald populaLlon, whlle fee-for-servlce spendlng
wlll ulLlmaLely drop Lo only 4 of all Medlcald spendlng.
37

CurrenL Lrends suggesL LhaL Lhe norLh CounLry does noL have sufflclenL capaclLy for home care, asslsLed llvlng and
lnformal supporLs Lo address Lhe reglon's L1SS needs. 1he capaclLy ls golng Lo dwlndle even furLher as Lhe
populaLlon ages, and Lhe prevalence of chronlc dlsease grows. Several nurslng homes ln Lhe reglon are sLruggllng
flnanclally, wlLh a few near compleLe collapse. Some nurslng homes are essenLlal provlders and are parL of Lhe
safeLy neL for famllles, buL are noL parL of healLh neLworks or fully lnLegraLed. Managed long Lerm care programs
LhaL do exlsL are noL aL scale or noL avallable Lo Lhose ln Lhe communlLy who need Lhem. Medlcald does noL
relmburse nurslng homes aL Lhe level of cosLs, whlch causes serlous flnanclal challenges for many L1SS provlders
such as nurslng homes and home care. 1he fragmenLed array of L1SS servlces poses enormous challenges for
lndlvlduals and famllles desperaLe Lo provlde care Lo aglng loved ones.
8ulldlng L1SS lnLo any healLh sysLem reform ls essenLlal, buL ls especlally lmporLanL ln a reglon where Lhe
populaLlon ls aglng. 1hese servlces musL be lnLegraLed lnLo any reform lnlLlaLlves, lncludlng Lhe SLaLe PealLh
lnnovaLlon lan. 1he goal ls Lo expand L1SS across smaller reglons of Lhe vasL norLh CounLry wlLh Lhe
undersLandlng LhaL due Lo Lhe small populaLlon, lL ls posslble LhaL some provlders may never reach Lhe polnL of
efflclency Lo Lhrlve under lncenLlve-based paymenLs. lnsLead, Lhe reglon may be rellanL on person-cenLered
plannlng LhaL uses navlgaLors, healLh homes and managed long-Lerm care plans and lnformal neLworks of careglver
supporL.













38

8ecommendaLlons

1he norLh CounLry PealLh SysLems 8edeslgn Commlsslon (nCPS8uC) has based lLs recommendaLlons on Lhe
framework and prlorlLles of Lhe SLaLe PealLh lnnovaLlon lan (SPl), whlch ls new ?ork SLaLe's roadmap for
achlevlng Lhe 1rlple Alm.
lor each prlorlLy of Lhe SPl, Lhe nCPS8C has Lhe followlng recommendaLlons and LhoughLs:

lmprovlng Access and lnLegraLlng Care
MG 5+&.(+2 *(+,
Lndorse care dellvery models LhaL lnclude enhanced care managemenL and care coordlnaLlon approaches
such as Lhe Advanced rlmary Care (AC) and PealLh Pomes models.
Lndorse Lhe SPl's healLh care workforce prlorlLles:
a) lncreaslng Lhe recrulLmenL and reLenLlon of a prlmary care workforce LhroughouL Lhe SLaLe,
lncludlng expanslon of Lhe uocLors Across new ?ork (uAn?) program,
b) updaLlng and allgnlng sLandards and educaLlonal programs for all Lypes of healLh care workers
wlLh Lhe AC model, parLlcularly Lralnlng ln care coordlnaLlon, mulLldlsclpllnary Leamwork, and
necessary admlnlsLraLlve and buslness skllls,
c) ldenLlfylng regulaLory reform needed for prlmary care-relaLed workforce flexlblllLy opporLunlLles
by puLLlng ln place Lhe lnfrasLrucLure Lo LesL and evaluaLe workforce models of care and Lhelr
lmpllcaLlons for professlonals Lo work closer Lo Lhe Lop of Lhelr llcenses,
d) Assurlng adequaLe educaLlon and Lralnlng LhroughouL Lhe SLaLe and developlng more robusL
worklng daLa, analyLlcs and plannlng capaclLy.
e) Advanclng regulaLory reform so LhaL advanced nurses and care managers and oLher Lypes of
healLh care professlonals can dellver a wlder scope of prlmary care servlces.
SuggesL Lhe SLaLe provlde prlmary care provlders access Lo caplLal lnvesLmenLs funds LhaL would address
Lhelr needs and rlsks, and provlde flnanclng for resLrucLurlng LhaL ls allgned wlLh lnLegraLlon.
AuLhorlze Lhe Commlssloner of PealLh Lo allow collaboraLlve pro[ecLs ln Lhe norLh CounLry Lo proceed
wlLhouL exLenslve CerLlflcaLe of need (CCn) revlew.
Lxpand Lhe Medlcal Pome model, whlch applles ln Long 1erm Care as well as prlmary care seLLlngs.
!."*,('.4"+7'* '( +/% -'.+/ )'0*+.1 2%"$+/ 31,+%4, 7*+' " :'$$"#'."+7?% "*6 7*+%8."+%6 4'6%$ '( /78/ ?"$0%
/%"$+/ :".% .%G07.%, "* 7*7+7"$ 7*?%,+4%*+ +' ":/7%?% ,78*7(7:"*+ ,"?7*8, ", " #1A.'60:+H I% "AA$"06 +/%
%(('.+, '( +/% )0'4' 9647*7,+."+7'* +' ,%:0.% JK #7$$7'* 7* (%6%."$ ,0AA'.+ ", A".+ '( +/% -L3 <"7?%.
6%4'*,+."+7'*H !/% -)235) 0*"*74'0,$1 .%:'44%*6, +/"+ 67,+.7#0+7'* '( +/7, (0*67*8 #% #",%6 '* " ,"(%+1
*%+ 6%(7*7+7'* +/"+ .%($%:+, +/% .%"$7+1 '( A.'?767*8 :".% +' "$$ ?0$*%."#$% A'A0$"+7'*, 7* '0. .%87'*H !/"+
4%"*, "*1 ('.40$" 40,+ "66.%,, +/% :/"$$%*8%, +' A.'?76%. ,+"#7$7+1 +/"+ .%,0$+ (.'4 " /78/ '?%."$$ A0#$7:
A"1'. 47>H @+ ,/'0$6 "$,' .%($%:+ ?0$*%."#7$7+1 ",,':7"+%6 <7+/ 8%'8."A/7: 7,'$"+7'* "*6 +/% "++%*6"*+ "::%,,
A.'#$%4, ('. A'A0$"+7'*, 7* *%%6H
39

urge ueparLmenL of llnanclal Servlces Lo supporL Lhe expanded parLlclpaLlon ln Medlcal Pomes by all
lnsurers acLlve ln Lhe norLh CounLry.
laclllLaLe expanslon of prlmary care across Lhe reglon lnLo approprlaLe communlLy seLLlngs lncludlng
schools and places of employmenL.
1he n?S ueparLmenL of PealLh should conLlnue daLa analysls Lo ldenLlfy gaps ln prlmary care as evldenced
by facLors such as avoldable Lmergency ueparLmenL vlslLs.

NG D,>(4&#+() ",()'>
lnLegraLe prlmary care and behavloral healLh servlces Lhrough regulaLory and flnanclal reform Lo promoLe
value-based models LhaL are supporLlve of Lhe SPl. Whlle Lhe movemenL Lo managed care ls expecLed Lo
achleve lnLegraLlon, Lhe Commlsslon recommends flnanclal lncenLlves Lo embed prlmary care and
behavloral healLh servlces lnLo Lhe healLh care conLlnuum across Lhe reglon.
Lnhance collaboraLlon among prlmary care provlders and behavloral healLh provlders Lo co-locaLe
screenlng, assessmenL and brlef ouLpaLlenL LreaLmenL servlces Lo lmprove lnLegraLed person-cenLered
care.
lmprove access and avallablllLy of prevenLlon and wellness servlces ln prlmary care seLLlngs Lhrough
parLnershlps wlLh local prevenLlon organlzaLlons (behavloral healLh agencles, PealLhy PearL neLworks,
eLc.).
8eform paymenL for servlces Lo lnclude care provlded by non-cllnlcal soclal workers and oLher llcensed
menLal healLh professlonals.
Lxplore alLernaLlve paLhways Lo Lhe llcenslng of menLal healLh professlonals.
SupporL provlders ln aLLalnlng asslsLance Lo possess a vlable healLh l1 sLrucLure.
SupporL efforLs Lo lncrease supporLlve houslng.
LsLabllsh a mulLl-agency Leam Lo ldenLlfy regulaLory barrlers Lo lnLegraLe healLh and behavlor healLh
servlces Lo achleve Lhe goals of Lhe SPl.

OG 6#0/ 7,+. *(+,
Lxplore converslon of skllled nurslng faclllLles (Snls) lnLo a new deslgn known as Skllled Care Campuses
(SCCs). An SCC could be a group of vlrLual expanded servlces provlded by Lhe currenL Snl LhaL would
supporL a reducLlon ln Snl bed capaclLy, and reuse Lhe exlsLlng Snl space and lnfrasLrucLure Lo supporL
adulLs needlng oLher servlces. Servlces mlghL lnclude ouLpaLlenL Lherapy, asslsLed llvlng, soclal day care,
supporLlve houslng wlLh meals and acLlvlLles.
a) LsLabllsh wlLh fundlng supporL as needed, one or more SCC plloLs Lo explore and evaluaLe Lhe
concepL and Lo connecL lL Lo prlmary care, emergency care and behavloral healLh.
b) Allow Snls Lo reduce cerLlfled bed numbers whlle allowlng Lhe remalnlng space Lo carry 100 of
Lhe caplLal cosL burden. CreaLe lncenLlves for some form of senlor houslng Lo be developed
elLher ln Lhe spaces no longer used as Snl beds or ln new consLrucLlon ln close proxlmlLy Lo Lhe
Snl.
c) CranL ouLpaLlenL Lherapy llcenses Lo Lhe Snl assoclaLed wlLh Lhe SCC, so Lhelr Lherapy
deparLmenLs can supporL posL- dlscharge rehablllLaLlon.
40

d) Allow cerLlfled nurslng asslsLanL sLaff employed by Lhe Snl Lo serve oLher lndlvlduals recelvlng
servlces Lhrough Lhe SCC wlLhouL addlLlonal cerLlflcaLlon or provlde a sLreamllned paLh for dual
cerLlflcaLlon.
e) Lnable llcensed professlonal sLaff of Lhe Snl Lo supporL Lhe resldenLs, perhaps wlLh a consulLlng
cerLlfled home healLh alde avallable.
f) ln con[uncLlon wlLh oLher organlzaLlons, allow Snls Lo be lnvolved ln deflnlng Lhe prlorlLy
admlsslon llsL Lo Lhe houslng Lo faclllLaLe approprlaLe dlscharges from Lhe Snl.
g) lnLegraLe sllos of care managemenL, so prlmary care managers (e.g. Medlcal Pome Model) and
long-Lerm care managers are worklng ln a coordlnaLed manner.
h) Conslder fundlng for houslng on Lhe SCC slLes or oLher free sLandlng locaLlons from Pouse n?
program or M81 SupporLlve Pouslng program.
uevelop lnlLlaLlves such as consumer-dlrecLed care models LhaL supporL famllles and recognlze LhaL
lnformal careglvlng provldes mosL of Lhe long-Lerm servlces and supporLs ln Lhe norLh CounLry.
Change Lhe flnanclal paradlgm of Medlcald Lo pay for a broad seL of supporLlve servlces, wlLh lncenLlves Lo
keep Lo an lrreduclble mlnlmum Lhe number of people ln expenslve skllled beds, buL wlLh enough fundlng
Lo keep essenLlal rural faclllLles vlable.
a) vlLal Access rovlder (vA) fundlng may provlde brldge fundlng Lo a reformed landscape, buL
susLalnablllLy may requlre an LssenLlal CommunlLy PealLh neLwork (LCPn) deslgnaLlon or
anoLher program. lor example, Lhe Commlsslon supporLs Lhe vA fundlng of Lhe 8lue Llne
Croup. lf an LCPn program goes lnLo effecL, Lhe 8lue Llne Croup should be evaluaLed for such
supporL.
SupporL Lhe expanslon of asslsLed llvlng parLlcularly for low-lncome lndlvlduals LhroughouL Lhe reglon.
Conslder easlng any appllcable equlLy conLrlbuLlon requlremenLs and/or provldlng access Lo granL
fundlng.
8equesL ueparLmenL of PealLh Lo carefully evaluaLe and conslder for lmplemenLaLlon Lhe
recommendaLlons LhaL are made on or abouL SepLember 30, 2014, as a resulL of Lhe granL, A 8oadmap Lo
a 8aLlonal, SusLalnable and 8epllcable SysLem of L1C Servlces ln Lhe LasLern Adlrondacks," whlch ls belng
conducLed by Lhe loundaLlon for Long 1erm Care and LeadlngAge new ?ork and funded by Lhe n?S
PealLh loundaLlon.
romoLe Lhe expanslon of managed long-Lerm care ln Lhe norLh CounLry.
Clve small provlders asslsLance Lo aLLaln a vlable healLh l1 sLrucLure.
We recommend sLrengLhenlng home care, ln Lhree areas:
a) Lxpand Lhe use of Lhe consumer-dlrecLed home care model,
b) losLer developmenL of para-professlonal resources (home healLh alde, personal care asslsLanLs).
c) lncrease Medlcald relmbursemenL raLes ln Lhe norLh CounLry Lo supporL Lhe recrulLmenL and
reLenLlon of Lhe para-professlonal workforce ln Pome PealLh Care
d) Lxpand access Lo LelehealLh by flrsL ensurlng access Lo Lhe lnLerneL ln Lhe reglon, and Lhen
Lhrough lnvesLmenL ln remoLe monlLorlng LelehealLh equlpmenL.
lncrease access Lo palllaLlve care programs for persons wlLh serlous, advanced lllness and Lhose aL Lhe end
of llfe Lo ensure care end of llfe plannlng needs are undersLood, addressed, and meL, whlch wlll ln Lurn
reduce Lhe need for hosplLal care ln Lhese slLuaLlons.

41

PG "#$%&'()$
Lncourage all hosplLals Lo engage ln collaboraLlve efforLs Lo lnLegraLe servlces across Lhe specLrum of
medlcal and healLh servlces, wlLh Lhe walver focused on reduclng unnecessary and prevenLable hosplLal
uLlllzaLlon.

QG H,/&#0() 5)(00&0/
CreaLe 8eglonal PealLh lmprovemenL CollaboraLlves (8PlCs) Lo promoLe reglonal leadershlp and a
populaLlon-based approach Lo healLh sysLem resource evaluaLlon and developmenL.
8PlCs should faclllLaLe reglonal plannlng for care dellvery Lo connecL wlLh Lhe greaLer healLh of Lhe
communlLy. 1hey can achleve Lhls by bulldlng llnkages across prlmary care, hosplLals, behavloral healLh,
LMS long-Lerm care provlders, local healLh deparLmenLs, occupaLlonal healLh, offlces of Lhe aglng and a
varleLy of communlLy sLakeholders.
8PlCs should:
a) SupporL Lhe promoLlon, success and susLalnablllLy of Lhe AC model, lncludlng Lhe provlslon of
Lechnlcal asslsLance Lo local provlders, as parL of Lhelr mandaLe.
b) 8ecelve Llmely and regular daLa seLs Lo monlLor populaLlon healLh ouLcomes and have Lhe
freedom Lo be flexlble and lnnovaLlve.
c) ldenLlfy opporLunlLles for collaboraLlon, lnLegraLlon, and consolldaLlon LhaL wlll malnLaln or
lmprove access and quallLy, and flnanclal vlablllLy, promoLe lnLegraLed care, faclllLaLe
dlscusslons beLween local provlders and payers regardlng [olnL LranslLlon Lo value- based
paymenLs, requlre mandaLory lnvolvemenL wlLh local plannlng and engage reglonal economlc
councll, and co-locaLe screenlng and assessmenL.
d) SupporL fundlng Lo conducL sub-area analyses ln speclflc reglons such as SL. Lawrence, and
PamllLon counLles Lo assess Lhe poLenLlal for elLher a slngle unlfled sysLem or opLlonal
arrangemenLs wlLh oLher provlders.
e) LsLabllsh a [olnL commlLLee of Lhe Lwo 8PlCs Lo coordlnaLe efforLs where approprlaLe, as well as
Lo faclllLaLe Lhe sharlng of lnformaLlon and daLa. 1he commlLLee should meeL once a year or
more ofLen Lo brlde Lhe plannlng beLween Lhe proposed Lwo 8PlCs ln Lhe norLh CounLry.
f) MeeL wlLh Lhe reglonal economlc counclls aL leasL once a year Lo coordlnaLe Lhe economlc
developmenL prlorlLles wlLh economlc developmenL pollcles.

RG S#+@;#+1,
uevelop CraduaLe Medlcal LducaLlon (CML) programs Lo Lraln medlcal graduaLes wlLh flnanclal lncenLlves
for servlce ln Lhe Adlrondacks. 1he Commlsslon urges flnanclal supporL for an expanslon of famlly
medlclne resldency programs.
AdapL medlcal school currlculum Lo allgn and Lraln healLh care provlders aL all sklll levels Lo ouLcome
focused care and Leam based, coordlnaLed care. We supporL lnLegraLlng Advanced Care models lnLo
educaLlonal programs.
urge Lhe LeglslaLure Lo commlL Lo a dlverse and sLrong prlmary care workforce by safeguardlng and
expandlng programs llke rlmary Care Servlce Corps (CSC) and uAn? whlch advance Lhe recrulLmenL and
reLenLlon of prlmary care provlders.
42

rovlde uocLors Across new ?ork SLaLe wlLh annual, conslsLenL fundlng and wlLh Lhe norLh CounLry
deslgnaLed as a LargeLed area.
Allgn SLaLe rules wlLh more currenL federal dlrecLlon wlLh respecL Lo sLandlng orders and pracLlce
proLocols.
n?S should allow for house calls by ArLlcle 28-employed physlclans and physlclan exLenders, and provlde
relmbursemenL for servlces provlded Lo chronlcally lll/home bound paLlenLs, lncludlng expandlng
LelehealLh relmbursemenL.
SLrengLhen posL acuLe servlces, vla agreemenLs Lo cross Lraln and share sLaff across Lhe conLlnuum of care
dependlng on where Lhe need ls greaLesL.
uedlcaLe flnanclal supporL Lo reLraln healLh care workers based upon a movemenL from lnpaLlenL based
Lo communlLy based servlces.
Allgn cerLlfled nurslng alde (CnA) and home care alde Lralnlng, and allow sLackable credenLlals ln order Lo
meeL needs ln mulLlple venues.
Alm for all healLh care provlders Lo operaLe aL Lhe Lop of Lhelr llcense.
LsLabllsh addlLlonal loan repaymenL lncenLlves for physlclans, and mld-level pracLlLloners ln Lhe norLh
CounLry.
Work wlLh SLaLe LducaLlon ueparLmenL Lo recognlze naLlonal llcensure and reclproclLy wlLh oLher sLaLe Lo
speed up access Lo provlders and Canadlan provlnces.

TG 7,),>,()'>
Lxpand LelehealLh LhroughouL Lhe reglon, and supporL efforLs Lo:
a) Llcense and credenLlal LelehealLh provlders (lncludlng developmenL of pollcles relaLlng Lo
lnLersLaLe pracLlce of LelehealLh)
b) uevelop pollcy LhaL encourages and/or requlres all payers Lo supporL LelehealLh relmbursemenL.
c) Allow mulLlple provlder speclalLles Lo parLlclpaLe
d) Address Lechnlcal Lransmlsslon efforLs
e) Lxpand exlsLlng Medlcald LelehealLh relmbursemenL pollcy Lo lnclude ArLlcle 31 cllnlcs, ArLlcle
36 CerLlfled Pome PealLh Agencles, Snls, prlvaLe pracLlces, and federally quallfled healLh
cenLers (lCPCs) as ellglble hub or spoke slLes, regardless of opLlng ln or ouL of ambulaLory
paLlenL groups.
f) uevelop a rural new ?ork SLaLe 1elemedlclne 8esource CenLer ln Lhe norLh CounLry.
g) Lxpand exlsLlng Medlcald relmbursemenL pollcy on ellglble provlders Lo lnclude:
Cllnlcal psychologlsLs
CerLlfled dlabeLes educaLors
hyslclan speclallsLs, lncludlng psychlaLrlsLs
CerLlfled dlabeLes educaLors
CerLlfled asLhma educaLors
sychlaLrlc nurse pracLlLloners
uenLlsLs
CeneLlc counselors
MenLal healLh cllnlclans
hyslcal LheraplsLs for Lhe purpose of supervlslon of physlcal LheraplsL asslsL supervlslon
43


UG -.,+/,012 <,=&1() 3,+4&1,$ V-<3W
lnLegraLe Lhe LMS sysLem lnLo Lhe coordlnaLlon of healLh care ln Lhe norLh CounLry.
lmprove communlcaLlons sysLems and Lechnology Lo allow for beLLer consulLaLlons wlLh physlclan medlcal
conLrol.
Lxplore ways Lo lncenLlvlze poLenLlal work force, lmprove worklng/volunLeerlng condlLlons and salarles.
Lxplore relmbursemenL opLlons Lo lmprove sLablllLy of pre-hosplLal care and lnLer-faclllLy LransporLaLlon,
lncludlng LhaL provlded by alr-ambulance.
lmplemenL alLernaLlve models of communlLy-based care, lncludlng Lhe communlLy para-medlclne model
LhaL leverages Lhe Lmergency Medlcal SysLem for home vlslLs and prevenLlve care.
SupporL leglslaLlve proposal allowlng volunLeer flre deparLmenLs Lo blll for LMS servlces rendered.

llnanclal 8ewards for value
CoordlnaLe Lhe SLaLe's lnvesLmenLs ln caplLal resLrucLurlng wlLh Lhe deploymenL of uellvery SysLem
8eform lncenLlve aymenL (uS8l) funds, and emphaslze Lhe need Lo dlrecL Lhese lnvesLmenLs Lowards:
a) CollaboraLlve efforLs LhaL lnvolve mulLlple sLakeholders and parLnershlps.
b) LnLlLles provldlng servlces Lo populaLlons ln geographlcally lsolaLed communlLles LhaL are
essenLlal Lo Lhe reglon,
c) Lnsurlng LhaL Lhe deflnlLlon of a "safeLy neL provlder" does noL focus solely on Medlcald, buL
raLher on all publlc payors. 1he norLh CounLry has a lower Medlcald proporLlon and Lhe
provlders play a unlque role ln ensurlng access for underserved and lsolaLed populaLlons,
d) Servlces LhaL provlde Llmely, hlgh-quallLy care Lo all, conslsLenL wlLh paLlenL-cenLered,
populaLlon healLh-based, care models LhaL alm for greaLer lnLegraLlon, over appllcaLlons from
slngle organlzaLlons.
CreaLe a new fundlng caLegory Lo address susLalnablllLy called LssenLlal CommunlLy PealLh neLwork
(LCPn) for provlders LhaL are essenLlal and flnanclally dlsLressed due Lo Lhelr engagemenL ln
LransformaLlon.
a) laclllLles may be hosplLals, nurslng homes or some oLher enLlLy LhaL ls a safeLy neL provlder,
glven Lhelr lsolaLlon and/or populaLlon served. 1hey are also commlLLed Lo LransformaLlon
lnlLlaLlves called for by Lhe Medlcald 8edeslgn 1eam or SPl.
b) A collapse of Lhese lnsLlLuLlons wlll [eopardlze Lhe parLlcular lnlLlaLlve wlLh whlch Lhey are
engaged, such as medlcal home expanslon, buL Lhe flnanclal dlsLress may undercuL oLher crlLlcal
servlces supporLed by Lhe LradlLlonal lnpaLlenL and ouLpaLlenL base.
lmplemenL a norLh CounLry Medlcald raLe ad[usLmenL, wlLh revlew afLer Lhree years, when Lhe lmpacL of
managed long-Lerm care and Lhe above changes are evaluaLed.
Lxamlne Medlcald pollcles and programs for vAs Lo ensure Lhey:
a) rovlde flnanclal supporL whlle faclllLles LranslLlon Lo new models of care.
b) ldenLlfy and reduce lncenLlves LhaL conLradlcL a value approach Lo relmbursemenL, such as
pollcles LhaL encourage overuse of expenslve skllled beds.
44

SupporL Lhe Covernor's proposal Lo double Lhe approprlaLlon allocaLed for Lhe vA program ln l? 2014-
13.
Lxpand Lhe PealLh laclllLy 8esLrucLurlng rogram Lo lCPCs, ln order Lo allow uCP Lo work wlLh selecL
provlders Lo access lnLeresL-free loan programs Lo susLaln essenLlal servlces.
Lmbrace varlous paymenL reform lnlLlaLlves LhaL may lnclude: global budgeLs for essenLlal provlders, a
varleLy of bundllng lnlLlaLlves across Lhe specLrum of care provlders, ACC-llke shared savlngs models, eLc.
Call upon ulS Lo esLabllsh mechanlsms LhaL lncenLlvlze Lhe parLlclpaLlon ln Medlcal Pomes by all lnsurers
acLlve ln Lhe norLh CounLry reglon.
Lxpand appllcaLlon of Lhe CerLlflcaLe of ubllc AdvanLage (CCA) Lo allow cllnlcally lnLegraLed provlders,
who demonsLraLe value enhancemenL, Lo negoLlaLe collecLlvely wlLh prlvaLe lnsurers, as slnce Lhelr efforLs
Lo lmprove value ln Medlcald and Medlcare wlll beneflL oLher lnsurers.
Lxplore ways Lo expand lnLermedlaLe levels of care (e.g., parLlal hosplLallzaLlon, crlsls resplLe servlces or
observaLlon programs) Lo reduce unnecessary hosplLallzaLlons and Lu vlslLs.

1ransparency and Consumer LngagemenL
Lncourage Lhe lnpuL of consumers and paLlenLs Lo gauge saLlsfacLlon wlLh healLh care resources ln Lhe
norLh CounLry. 1hls lncludes Lhe exLenL Lo whlch cosL and quallLy are LransparenL and lncorporaLed lnLo
consumer declslon-maklng and commensuraLe wlLh sLaLe and federal reforms.
CreaLe a subgroup Lo lmplemenL a communlcaLlons plan LhaL hlghllghLs Lhe key polnLs ln Lhe
recommendaLlons.
CreaLe a subgroup Lo ldenLlfy and develop regulaLory modlflcaLlons LhaL are necessary Lo asslsL provlders
aL lmplemenLlng Lhe recommendaLlons from Lhls reporL.
8PlCs should engage and lnclude consumer represenLaLlves on Lhe counclls.

MeasuremenL/LvaluaLlon
use Lhe SPl prlnclple of developlng a sLandardlzed, sLaLewlde approach Lo measure and evaluaLe Lhe
quallLy and efflclency of care dellvery.
use measuremenL and evaluaLlon Lo provlde common sLandards and performance meLrlcs by whlch Lo
Lrack and evaluaLe Lhe progress of healLh sysLem susLalnablllLy, performance and LransformaLlon wlLhln
Lhe norLh CounLry.
Lncourage Lhe esLabllshmenL of a sLaLewlde common scorecard" Lo produce meanlngful populaLlon and
reglonal daLa ln order Lo lnform reglonal healLh assessmenL and plannlng efforLs.

romoLe opulaLlon PealLh
use publlc healLh lnlLlaLlves Lo address populaLlon healLh.
SupporL Lhe SLaLe's revenLlon Agenda.
Lncourage physlclan-based besL pracLlces for populaLlon healLh.
Allgn uS8l wlLh communlLy healLh lmprovemenL plans and communlLy healLh plans.
43

)'*:$0,7'*
1he challenges lnvolved ln dellverlng healLh care LhroughouL Lhe norLh CounLy can no longer be lgnored or
delayed. MulLlple Lrends have converged Lo creaLe a precarlous slLuaLlon ln Lhe reglon's healLh care dellvery
sysLem. 8lslng raLes of chronlc dlsease, a growlng dearLh of healLh care workers, LransporLaLlon challenges, and
Lhe flscal dlfflculLles confronLlng Lhe reglon's healLh care faclllLles are maklng lL lncreaslngly dlfflculL for Lhe
resldenLs ln Lhls reglon Lo access quallLy healLh care and for provlders Lo remaln flnanclally vlable. Compoundlng
Lhe problems are Lhe reglon's hlgh raLes of poverLy, Lhe vasL geographlc slze and Lhe pressure from reforms ln Lhe
healLh care dellvery sysLem.
lL has become lncumbenL upon all sLakeholders ln Lhe reglon Lo ad[usL Lhe way Lhey do buslness ln order Lo rebulld
a vlable sysLem, so LhaL resldenLs ln Lhe norLh CounLry can access hlgh quallLy healLh care, be lL acuLe servlces,
prevenLlve care, or lnpaLlenL care. 1he recommendaLlons lald ouL ln Lhls reporL are deslgned Lo help move ln LhaL
dlrecLlon and sLablllze Lhe healLh care dellvery sysLem ln Lhe norLh CounLry. 1hey have been carefully consLrucLed
Lo saLlsfy Lhe demands of Lhe SLaLe PealLh lnnovaLlon lan, whlch ls Lhe roadmap for achlevlng Lhe 1rlple Alm -
beLLer paLlenL care, lmproved populaLlon healLh and reduced cosLs - whlle also Laklng lnLo accounL governmenL
reforms, flnanclal resLralnLs and Lhe reallLy of Lhe reglon's demographlcs and geography.
Achlevlng any slgnlflcanL change wlll requlre Lhe reglon's healLh care provlders Lo ad[usL Lhe way Lhey do buslness.
lL calls upon Lhem Lo resLrucLure, collaboraLe and lnLegraLe ln order Lo develop new models of care LhaL are beLLer
able Lo adapL Lo an evolvlng paymenL sysLem whlle meeLlng Lhe goals of Lhe 1rlple Alm. ursulng Lhese
recommendaLlons wlll Lake years and requlre slgnlflcanL efforL by provlders, paLlenLs and communlLy enLlLles allke.
no doubL, we llve ln Llmes of greaL Lurmoll ln Lhe healLh care lndusLry, and Lhe norLh CounLry ls no excepLlon.
lssues of access, quallLy and cosL conLlnue Lo lmpacL communlLles LhroughouL new ?ork SLaLe as well as Lhe resL of
Lhe counLry. 1he recommendaLlons ln Lhls reporL address all of Lhese concerns and have been carefully deslgned
wlLh a paLlenL-cenLered focus. We belleve LhaL Lhey wlll resulL ln a sLronger, more sLable and vlable healLh care
sysLem, and LhaL Lhe lessons learned here wlll be worLhy of conslderaLlon ln oLher communlLles faclng slmllar
sLruggles.










46

9AA%*67:%,





State Health Commissioner Announces Commission to Create a Sustainable, Integrated Health
Care System for New Yorks North Country
North Country Health Systems Redesign Commission appointed

ALBANY, N.Y. (Dec. 2, 2013) New York State Department of Health Commissioner, Nirav R. Shah,
M.D., M.P.H., today announced the formation of the North Country Health Systems Redesign
Commission (NCHSRC). The goal of the NCHSRC is to create an effective, integrated health care
delivery system for preventative, medical, behavioral, and long term care services to all communities
throughout New Yorks North Country.

Healthcare providers in the North Country are faced with several challenges including a shortage of
physicians and other primary care practitioners as well as fragmented, widely dispersed services.
Moreover, the continuing transition of medical, behavioral, and long term care services to outpatient
settings is threatening the fiscal stability of many hospitals and nursing homes.

This Commission will play a vital role in establishing a sustainable, integrated service-delivery model to
meet the health care needs of New Yorkers in the North Country region, said Dr. Shah. This
exceptional team of commission members shares the states vision to create a viable system of care that
emphasizes prevention, increases primary care supply, establishes more community-based options,
supports critical safety-net providers, monitors and rewards quality, and forges innovative affiliations and
partnerships.

"I am honored to lead this vital initiative to help ensure that our citizens in the North Country have access
to quality health care services, and I thank Governor Cuomo and Commissioner Shah for their leadership
and vision in establishing this commission," said Daniel Sisto, NCHSRC chair. "We are committed to
assisting North Country communities in creating the integrated service delivery systems that are critical to
access, quality, and the health of the region's residents for years to come."

The NCHSRC is charged with:

Assessing the total scope of care in the North Country: community and preventive care,
secondary and tertiary care and long term care.
Assessing the regional populations health care needs and the systems ability to meet them.
Recommending ways in which to ensure that essential providers survive or that appropriate
capacity is developed to replace failing providers; a restructuring and re-capitalization agenda.
Identifying opportunities for merger, affiliation and/or partnership among providers that will
maintain or improve access and quality, financial viability and promote integrated care.
Making specific recommendations that providers and communities can implement to improve
access, coordination, outcomes and quality of care, and population health.
Developing recommendations for the distribution of re-investment grants.




The NCHSRC engages a broad cross section of health care experts, business and community leaders,
elected officials, patients and other key stakeholders who will lead a strategic, regional planning process.
Members have been appointed by Commissioner Shah.

NCHSRC members are:
Chair: Daniel Sisto, past president, Hospital Association of New York State (HANYS)
Co-Vice-Chair: Arthur Webb, principal, Arthur Webb Group
Co-Vice-Chair: John Rugge, M.D., president and CEO, Hudson Headwaters Health Network,
Chair of the Committee on Health Planning of the NYS Public Health and Health Planning
Council (PHHPC)
Steven Acquario, executive director, NYS Association of Counties
Cali Brooks, executive director, Adirondack Community Trust
Dan Burke, regional president, Saratoga-Glens Falls Region-NBT Bank
Tedra Cobb, president, Tedra L. Cobb and Associates
Tom Curley, past executive director, Associated Press
Susan Delehanty, chief executive officer, Citizens Advocates, Inc.
Garry Douglas, president and CEO, North Country Chamber of Commerce
Honorable Janet Duprey, New York State Assembly Member
Honorable Betty Little, New York State Senator
Fred Monroe, supervisor, Town of Chester
Honorable Patty Richie, New York State Senator
Neil Roberts, Board member, Fort Hudson Health System
Honorable Addie Russell, New York State Assembly Member
Honorable Dan Stec, New York Assembly Member
Denise Young, executive director, Fort Drum Regional Planning Organization

The NCHSRC will hold its initial early next month and will submit its recommendations to the State
Health Commissioner by March 31, 2014. The NCHSRC will be supported by staff from the State Health
Department, the State Office of Mental Health and the State Office of Alcoholism and Substance Abuse
Services.


##
Contact:
New York State Department of Health
518 474 7354, ext. 1

!""#$%&'( *+,,-$&%. /#'(%0 1#%2+34"

The health caie lanuscape is iapiuly becoming a less fiagmenteu, moie value-uiiven,
patient-centeieu, health caie system. The new system iequiies cieating continuums
of caie, with integiateu teams of seivice pioviueis taking iesponsibility foi the
health of the population, while it giauually ieplacing the cuiient fiagmenteu, costly
anu institutionally ieliant system.
In the Noith Countiy, this complex tiansfoimation is compounueu by an aiiay of
confounuing issues: an absence of public tianspoitation, challenging uemogiaphics,
woikfoice shoitages, a huge iuial anu mountainous geogiaphic lanuscape, a weak
economy, anu an aiiay of inuepenuent, fiagile health pioviueis.
The Commission is as conceineu about ietention anu cieation of appiopiiate
capacity as it is focuseu on uecieasing unnecessaiy institutional utilization, assuiing
access to caie, anu investing in piimaiy caie, population health initiatives anu value-
baseu caie. We seek to builu capacity, value, anu access in a tiansfoimeu health
system.
viitually eveiy pioviuei in the Noith Countiy coulu claim to be a safety net
pioviuei. To the uegiee caie is being pioviueu to a population in neeu anuoi that
seivices woulu be uifficult to access if the pioviuei weie to uisappeai, the claim is
waiianteu. Ceitainly, many institutions aie key employeis in theii communities,
anu pioviue significant health seivices. Natuial anu man-maue uisasteis alone may
valiuate the claim by most pioviueis that they aie safety nets.
With the feueial waivei in place, the teim "safety-net " takes on auueu implications
since Beliveiy System Refoim Incentive Payment funus will be given piimaiily to
safety net pioviueis with the goal of loweiing inpatient aumissions anu
ieaumissions.
Nany factois, incluuing BSRIP, will shaiply ieuuce hospital inpatient ievenue in the
yeais aheau. An incieaseu focus on piimaiy caie, the spieau of meuical homes, anu
the iise in ambulatoiy suigeiy means fewei patients will iequiie inpatient stays.
Even within hospitals, many factois aie uiiving uown ievenues incluuing the
aggiessive iejection of inpatient status foi "obseivation" patients, the intense focus
on eliminating ielateu ieaumissions, efficiency piogiams to ieuuce length of stay
anu suigeiy minimizing technologies.
uiven the limits of public funus to suppoit tiansfoimation, we neeu to piioiitize
safety net institutions. Nost uefinitions of safety net focus on the financially
vulneiable alone. But in the Noith Countiy, the uefinition must take into account
the numbeis of patients who iely on public payeis, the patients who aie uninsuieu,
geogiaphic consiueiations anu access to alteinative seivices.
Even with waivei funus, the public puise will be insufficient to suppoit eveiy
financially uistiesseu hospital, nuising home, feueially-qualifieu health centei anu
othei pioviueis acioss NYS. As a iesult, tapping into these funus iequiies moie
stiuctuieu ciiteiia anu accountability.
In ciicumstances wheie an ailing pioviuei seives a vulneiable population, NYS has
tiauitionally pioviueu vital Access Pioviuei funus oi othei funuing to suppoit that
pioviuei thiough iefoim initiatives anu financial uifficulties, usually with an
obligation to uelivei a uesiiable outcome that ielieves the situation. 0nuei BSRIP,
facilities will ieceive giants to engage in iefoims to ueciease utilization.

B0WEvER, given the alieauy low Neuicaiu anu Neuicaie pioviuei ieimbuisements
in the Noith Countiy, neeueu pioviueis who ieuuce theii utilization by paiticipating
in iefoim initiatives may expeiience a self-liquiuating impact on theii ievenue
stieams beyonu theii ability to sustain coie opeiations.
In aieas, wheie othei pioviuei alteinatives exist, this is not necessaiily a public
policy issue. Patients can go to anothei hospital oi nuising home. But, in othei
moie isolateu locations, essential pioviueis engageu in iefoims cannot be alloweu
to ueteiioiate foi uoing piecisely what the impeiatives of national anu state iefoim
uige them to uo.
Theiefoie, a poition of the "safety net" waivei, anuoi othei funus, neeu to be set
asiue foi a new categoiy calleu "Essential Community Bealth Netwoiks" (ECBN) .
This categoiy of suppoit woulu apply to a veiy limiteu numbei of pioviueis. These
facilities may be hospitals, nuising homes, FQBCs, oi some othei entity. As an
example, think of a bieak-even hospital tiying to ieuuce pieventable aumissions
that iesult fiom social pioblems. What woulu a 2S% ieuuction in such aumissions
uo to the hospital's opeiating maigin if fixeu costs weie 7u% of the pie-iefoim
opeiation but now iemain at the same uollai level with a much smallei patient
base.
By uefinition, these aie safety net pioviueis, given theii isolation anuoi population
seiveu. But ECBNs aie also committeu to tiansfoimation thiough integiation. They
aie engageu in the integiation initiatives calleu foi in the NRT oi SBIP. A collapse of
these institutions not only jeopaiuizes the initiative, but the financial uistiess may
unueicut ciitical seivices suppoiteu by the tiauitional inpatient anu outpatient
base.
0nlike vAP funus, which aie usually of limiteu uuiation, ECBN funuing woulu be
moie long teim to sustain coie seivices uuiing a multiyeai peiiou of
tiansfoimation.
In piioiitizing funus unuei the ECBN piogiam, the State will gauge thiee key
measuies: whethei the pioviuei is tiuly essential to the community, at least uuiing
the tiansfoimation peiiou; if theie aie no alteinatives foi the coie seivices neeueu
in the aiea; anu whethei the entity is seveiely financially impaiieu.
Although pioviueu foi an extenueu peiiou, ECBN funus will not be peipetual. NYS
may make futuie iteiations of funuing moie piecise, uisciete anu shoit-teim. Foi
example, the ECBN pioviuei may be uiiecteu to affiliate with a viable paitnei, when
an alteinative emeiges. ECBN funus may take the foim of a multi-payei
commitment, a Neuicaiu iate inciease to covei fixeu costs, a global buuget oi othei
mechanism.
As the ECBN ieaches a ceitain point of tiansfoimation anu stability, it coulu seek to
integiate with anothei pioviuei in the Noith Countiy. These othei pioviuei might
be stiong enough to absoib the ECBN without majoi uisiuption oi peihaps by
pioviuing a vAP subsiuy to them. uiven feueial iegulation, we may neeu to assuie
ciitical access hospital uesignations aie sustaineu oi finu substitute suppoits uuiing
these tiansitions into laigei netwoiks.
To minimize last-minute financial ciises anu to limit the numbei of ECBNs ovei
time, NYS neeus a foimal watch list to monitoi pioviuei viability anu avoiu
impacting communities. Theie shoulu be a moie iigoious iepoiting of financial
conuitions to B0B fiom any entity whose financial piofile tiiggeis the ciiteiia foi
the watch list. Key financial anu utilization uata will be iepoiteu monthly foi those
pioviueis. Foi example, if a pioviuei's losses ieach a ceitain peicentage of
opeiating costs, , they woulu be placeu on the watch list. To minimize uata
tiansmission, the ciiteiia must be manageable by B0B anu iestiictive enough to not
encumbei the pioviuei community at laige.
If a N0N-essential pioviuei that is not involveu in iefoim activity begins to fail, the
Noith Countiy iepoit shoulu affiim that such institutions aie susceptible to eaily
inteivention fiom B0B. Inteivention staits with close iepoiting. Bowevei, a non-
essential pioviuei is non-essential because theie aie alteinative pioviueis
accessible to the population. Inteivention may leau to the placement of a tempoiaiy
opeiatoi at the institution, while B0B woiks with othei pioviueis to uiscuss
assumption of the jeopaiuizeu institution oi peihaps uevelops a closuie plan.


ECBN Questions anu Answeis:

!"#$ &' #( )*+,-
An Essential Community Bealth Netwoik is a categoiy of safety net pioviuei that
uesciibes a pioviuei who is committeu to tiansfoiming theii health caie ueliveiy
system, but who is stiuggling as a iesult of that effoit. The ECBN must be essential
to the community it seives, which means iesiuents cannot get seivices fiom anothei
pioviuei, anu it must financially stiaineu by the tiansfoimation. The uesignation
will apply to a small numbei of pioviueis.

!". /0 12 (22/ )*+,-
NYS uoes not have a foimal mechanism to suppoit neeueu pioviuei capacity, wheie
a pioviuei's existence is ciitical to the piovision of essential seivices.
ECBN beais some iesemblance to the feueial uesignation, Ciitical Access Bospital,
which pioviues essentially bieak-even Neuicaie ieimbuisement to isolateu, small
iuial hospitals. Both uesignations iecognize that a pioviuei may neeu subsiuies uue
to the natuie of theii payei mix. Bowevei, ECBN is moie stiingent than a CAB. It
uoes not apply only to hospitals anu is piemiseu not on mileage to the next hospital
but the ieasonable availability of alteinative pioviueis. It iequiies an applicant to
meet financial iequiiements, be essential to a community anu be engageu in
collaboiative iefoim. It is not a peimanent uesignation but one that is peiiouically
ievieweu.
With moie people insuieu unuei the NYS Exchange anu moie manageu caie
expansion thioughout the Neuicaiu piogiam, theie may be moie cooiuinateu caie
aiiangeu by manageu caie plans anu pioviueis. This coulu ieuuce the neeu foi an
ECBN, if pioviueis anu payeis negotiate sustainable iates.
The woiking assumption behinu cieating ECBN is that pioviueis who uevote
significant effoit to caiing foi financially vulneiable anuoi isolateu populations,
anu who engage in iefoim effoits that unueicut theii own viability, iepiesent a key
element in the successful tiansfoimation of health caie in oui state. A piogiam that
biings sustainability to tiansfoimation is neeueu in ceitain key aieas foi a limiteu
numbei of such entities.

+01 /02' )*+, /&3324 3405 678-
vAP has a vaiiety of applications, such as tiansition suppoit, giants to initiate
iefoim impeiatives anu tempoiaiy subsiuies in exchange foi commitment to
initiatives that yielu efficiency. Beliveiy Refoim Incentive Payment uollais will be
tieu to safety net institutions with an attenuant focus on ieuucing hospital
ieaumissions anu PPAs. The ECBN concept uoes not specifically auuiess safety net
uefinitions, noi is it tieu to BSRIP. ECBN cieates a set of ciiteiia that ensuies the
long teim sustainability of essential pioviueis.
Theie will be fai fewei ECBNs than theie aie potential vAP awaiuees. ECBNs aie
limiteu by neeuing to meet seveial stiingent ciiteiia. Fiist, they aie essential. That
is, theie aie no caie alteinatives in the community if they weie to fail. They also
must uemonstiate financial uistiess that can be attiibuteu to theii payei mix, not
inefficiency. Finally, they must show engagement in collaboiative iefoim.

9' )*+, :;'$ #(0$"24 <#&=0;$ 03 /;>=&?#$&@2 "0'>&$#='A (;4'&(B "052' #(/ 0$"24
>40@&/24'-
No. The ECBN is naiiowly focuseu on the sustainability of essential seivices in
communities without seivice options. Financial uistiess is only one factoi is
assessing ECBN status. It may be applieu in situations wheie B0B has ueteimineu
the lack of financial viability of a pioviuei is a function of engaging in health iefoim.
It is the antithesis of a bailout causeu by failuie to tiansfoim anu collaboiate with
otheis.

+01 /0 12 /23&(2 C2''2($&#=D &( )*+, ?4&$24&#-
In its most simplistic foim, a pioviuei is N0T essential if othei alteinative pioviueis
oi seivices exist, anu the patient volume can migiate to those pioviueis because
they aie ieasonably accessible. Pioviueis aie ueemeu essential baseu on theii level
of caie foi financially vulneiable populations (in iuial aieas: uninsuieu plus public
payei component). They pioviue neeueu seivices otheiwise not accessible to the
community.
Fiist, essentiality is tieu to a pioviuei's caie foi financially vulneiable populations.
We woulu incluue Neuicaiu anu uninsuieu populations (inpatient, outpatient,
Emeigency Seivices etc). In iuial aieas, wheie the senioi population is incieasing
anu ieimbuises well unuei costs, incluuing the Neuicaie patient population is
ciitical. This is much less the case in uiban anu subuiban aieas.
Seconu, we neeu to factoi in geogiaphic anu tiavel uistance to an alteinative
pioviuei of neeueu seivices. In effect, is theie a ieasonably pioximate alteinative
pioviuei so the financial collapse of this pioviuei woulu not cause a patient access
issue. If so, the facility is not an ECBN.
Thiiu, utilization ciiteiia neeu to be monitoieu. We uo not want to sustain a
pioviuei that is losing utilization because of geneial quality, piice, oi seivice issues.
The utilization issue is a positive factoi only if the ueclines can be attiibuteu to
engaging in iefoims, anu the iest of the seivice facility is still neeueu in the
community.
It shoulu be noteu that a pioviuei's essentiality level may change if one oi moie
pioviueis in the maiket cease to opeiate. Also, if a pioviuei joins with a laigei
system, its financial viability coulu change. The puipose of ECBN is not to substitute
foi the suppoit pioviueu to one component of a system to a suboiuinate unit of the
system. So, the oveiall financial viability of a system may mitigate against ECBN
status.


+01 /0 .0; 52#';42 3&(#(?&#= @&#<&=&$.-
Theie aie numeious ways that bonu agencies, iegulatois, acauemics anu otheis
measuie a pioviuei's financial viability. Basically, B0B woulu select a subset of
financial inuicatois that ueal with a pioviueis' opeiating anu bottom line maigins,
theii liquiuity, anu theii capital stiuctuie. The metiics aie put in place anu
pioviueis matcheu against them. These shoulu incluue:
0peiating maigin. 0peiating maigin is key because it ieflects the
peifoimance of the coie business.
Bays of cash on hanu. This figuie is a vital measuie since we see too many
suipiise ciises when pioviueis aie unable to meet payioll anu othei
essential expenses anu tuin to NYS foi help. This iequiies a component of
oui iecommenuations to establish an eaily waining system that facilitates
B0B oveisight uuiing tiansfoimation.
Long teim uebt to capitalization. This measuie ieflects leveiage capability
anu stiess anu exposuie of bonu holueis anu cieuitois.

E@24#== 7''2''52($F
Some combination of essentiality anu financial viability scoiing neeus to be
uevelopeu foi compaiison puiposes. Bowevei, foi ECBN puiposes we aie not
builuing a uistiesseu pioviuei suppoit system. ECBN financial suppoit woulu flow
only to those pioviueis who aie engageu in a collaboiative iefoim impeiative
manuateu by state oi feueial goveinment iefoims. Theie aie too many financial
uistiesseu pioviueis in NYS foi this piogiam to suppoit them.
Theiefoie, in applying foi an ECBN uesignation, a pioviuei woulu neeu to
uemonstiate how the collaboiative initiatives have hau a ueleteiious impact on
theii financial viability. Foi example, imagine seveial nuising homes engageu in a
vAP- funueu tiansfoimation foi a pieueteimineu peiiou. aftei incieasing
community-baseu seivice ueliveiy anu uecieasing inpatient nuising home caie, it is
cleai that the iefoims have uebilitateu the financial stiuctuie of the home. If the
home seiveu a financially uistiesseu population, anu theie aie no alteinative
pioviueis who can pioviue the inpatient skilleu nuising facility caie neeueu, then
that pioviuei oi gioup may seek to tiansition to ECBN status.

9' $"&' :;'$ $"401&(B 5042 50(2. #$ # '$4;BB=&(B 3#?&=&$.-
This is not anothei tiauitional piogiam to funu financial failuie of pioviueis,
especially high cost acute anu SNF pioviueis. 0n the othei hanu, some pioviueis
who engage in iefoim, anu who uo not have a significant commeicially insuieu
population to iely upon may become seiiously financially impaiieu. In a poition of
those cases, especially in iuial communities, no alteinative seivice pioviuei may be
able to offei a viable alteinative seivice ueliveiy system. It is then the iesponsibility
of NYS to assuie the sustainability of these pioviueis. This may come fiom a vaiiety
of funuing anu payment iefoims, incluuing an annual oi global buuget, oi an
inciease in the Neuicaiu iate like Neuicaie uoes foi CABs. The ECBN may be pait of
a uemonstiation pioject oi pilot with othei payeis paiticipating in assuiing
sustainability with shaieu savings on top of the basic payment.

!"#$ &' $"2 2#4=. 1#4(&(B '.'$25-
Pioviueis who fall into financial uistiess because they lose patient volume to
alteinative pioviueis aie not the focus of ECBN. Bowevei, it is cleai many will
blame iefoim foi unueicutting theii viability. We woulu iecommenu that pioviueis
who uo not meet a pieueteimineu minimum level of liquiuity be put on a watch list.
Pioviueis will be infoimeu that this will necessitate a meeting involving B0B
oveiseeis anu the Boaiu as well as management. The meeting is to uiscuss the
ueteiioiating situation, heai the stiategy the managementboaiu intenus to
unueitake anu give B0B a chance to iesponu anu lay out the pathway options.
Such events makes the piocess public anu foimal. It iequiies moie fiequent
submissions of financials foi financially uistiesseu, non-essential pioviueis to B0B
(monthly if theie is no quaiteily impiovement foi example). Auuitionally, if the
pioviuei is failing, is not engageu in effoits to eithei integiate oi consoliuate, anu if
the financial peiil continues, pioviueis shoulu know that B0B woulu consiuei
seivice closuie, anuoi tempoiaiy opeiatoi status.
The moie this is unueistoou, the moie likely pioviueis will open up about theii
stiuggles eailiei, anu legislatois will be infoimeu soonei. The ECBN concept
becomes eithei an oppoitunity to help make aujustments oi a life iaft that enables
pioviueis to engage, be tianspaient anu collaboiate.
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