OneCity Health / NYC Health + Hospitals Action Teams Showcase Success Reducing Avoidable Hospitalizations at MAX Series Symposium

Through the New York State Department of Health (NYS DOH) Medicaid Accelerated eXchange (MAX) Series, teams from four NYC Health + Hospitals facilities have demonstrated rapid and significant success reducing avoidable hospitalizations in collaboration with OneCity Health. Last month, the NYS DOH Medicaid Redesign Team hosted a MAX Series Symposium to celebrate and reflect on the combined work of the Action Teams across the state, and share leading practices and success stories.

Launched by the NYS DOH in 2015, the MAX Series is an innovative 6-month program that puts front-line clinicians from hospitals in a position to lead rapid change and help achieve Delivery System Reform Incentive Payment (DSRIP) program goals. The objective of the MAX Series is to empower cross-organizational teams in their care redesign efforts, increase patient and workforce satisfaction and reduce avoidable hospitalizations for high-utilizer patients by a minimum of 10 percent over six months.

Since January 2017, Action Teams from NYC Health + Hospitals/Bellevue (two teams), NYC Health + Hospitals/Elmhurst, NYC Health + Hospitals/Lincoln and NYC Health + Hospitals/Queens have participated in program, leading to significant results. Highlights include:

  • In an initial MAX Series, an Action Team from NYC Health + Hospitals/Bellevue coordinated with the NYC Health + Hospitals Health Home and Home Care teams to follow patients in the community from January 2017 – June 2017, leading to a 17 percent decrease in their readmission rate. In a second series, an inpatient Action Team began bedside huddles to identify drivers of utilization, leading to a 13 percent decrease in post 90 day utilization, which exceeded the state’s goal by three percent.
  • Focusing on patients with five or more inpatient admissions within 12 months, the Action Team from NYC Health + Hospitals/Elmhurst assessed the drivers of high utilization through real-time huddles with the entire interdisciplinary team, with particular emphasis on behavioral health patients. Unique high-utilizer admissions as a percent of admissions decreased by 38 percent from October 2018 – April 2018.
  • Over six months beginning in January 2017, the Action Team from NYC Health + Hospitals/Lincoln established four linkage pathways for high utilizers – Patient-Centered Medical Home (PCMH) program, Health Home, a transition manager or care management. A majority of patients were connected to services post-discharge and received warm hand-offs to key services.
  • In addition to identifying and determining the root causes of high-utilizers, the Action team from NYC Health + Hospitals/Queens collaborated with families to help determine appropriate community services or care strategies, leading to a steady decline in the readmission rate in the six months since improvement work began in October 2017.
Israel Rocha, NYC Health + Hospitals Vice President and CEO for OneCity Health, participated in the Executive Panel Fireside Chat at the 2018 MAX Series Symposium

While the MAX Series Symposium was a moment to celebrate, it was also an opportunity to look toward the next phase to continue to learn from these programs to build a value-driven system.