Taconic IPA

Successful Implementation of Advanced Patient-Centered Medical Home

Taconic Independent Practice Association (TIPA), a not-for-profit network of more than 5,000 physicians, includes 90% of all physicians in the New York Hudson Valley. One-third are primary care physicians. TIPA is a forward-thinking organization committed to transforming healthcare delivery through meaningful use of technology and pay-for-performance incentives to increase the quality and cost effectiveness of patient care. TIPA’s mission is to optimize the value of medical services through patient-centered care, while maximizing physician satisfaction. TIPA is also part of the Hudson Valley Initiative, an effort to revolutionize healthcare delivery through a shared vision to improve the quality, safety, and efficiency of healthcare in the community.

 

Dr. A. John Blair, III, president of TIPA, sought to implement an advanced patient-centered medical home model with an embedded case manager program across the Hudson Valley community. Dr. Blair reached out to Geisinger Health System for guidance and support as Geisinger demonstrated success in implementing similar programs.

“Having xG Health Solutions and Geisinger’s leadership and direction has been invaluable in moving us light years ahead, not only with the process, but with the way we think. They’ve shown us that you don’t have to be a Geisinger to do this.” Dr. Mark Foster, Chair of the Board, Taconic IPA

TIPA engaged xG Health Solutions to develop and implement an advanced patient-centered medical home program and an embedded case manager program across the Hudson Valley, including the following: 

 

  • Advanced medical home infrastructure development including training support.
  • Complex case manager program development.
  • Physician mentoring and support to implement a 10-site patient-centered medical home pilot.
  • Physician leadership skill development.

 

To accelerate advanced primary care transformation, we incorporated the following approaches:

 

  • A strategic multiyear planning and measurement roadmap with recommended timelines and infrastructure requirements.
  • Ongoing coaching and guidance for participating primary care physicians, administrators, and office staff by ProvenHealth Navigator subject matter experts.
  • Training and certification of a core group of RNs as embedded complex case managers.
  • Operational/administrative tools and templates to expedite and standardize case management tasks.

 

Results

 

Nine of TIPA’s ten pilot practice sites showed substantial improvement, including the following: 

 

  • Physician leaders were substantially more engaged and effective in driving change and continuous quality improvement. 
  • Care managers were better equipped to effectively identify and manage chronic disease. 
  • Fully integrated functional teams supported by automated systems and processes were successfully implemented.
  • Access for acute care was improved.
  • An outpatient acute care center with performance reporting and feedback capabilities was launched.
  • Patient wellness was substantially improved by using a system of reminders and alerts. 

Dr. Mark Foster, TIPA’s chair of the board and lead physician at one of the pilot sites, sums it best:

 

“We are now getting our patients to manage their diseases in a way that keeps them healthier, happier, and out of the hospital. Our clinical peers have been impressed with our results.”

Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

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Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.