Connections: September 2017

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Issue 9: September 2017

Interconnecting Regional Healthcare

Feature Story:

On the Path to Wellness


Carthage woman has seen health improve drastically with care management assistance

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NCI’s “Speed Networking” Event was a Success!

Building a Network


hen one thinks about first aid, they usually imagine bandages, CPR, splinting broken bones, or something of the like...But what about first aid for the mind? Mental Health First Aid ƒ which offers initial help to those in a mental health crisis and connects them with appropriate care ƒ is a relatively new practice in the United States. However, it has begun to take hold here in the North Country, as a handful of community members have become certified trainers. "The training really works to reduce stigma around mental health challenges, making it okay to talk about it," said Anne Garno, a certified trainer of both Adult and Youth Mental Health First Aid. Ms. Garno, who serves as Director of Education and Enrollment at the North Country Prenatal/ Perinatal Council in Watertown, has been a Youth Trainer for almost a year, and she recently became an Adult Trainer in July. "My staff and I had worked in a lot of school disctricts and with a lot of young people out of school, and we soon had people asking us if we were certified to train in Mental Health First Aid for adults as well," she said. Because of her experience as a Youth Trainer, she was able to take an expedited, 2½ day training in Manchester, New Hampshire, to gain her Adult Training certification. Ms. Garno has not yet facilitated an Adult Training, but she said she is eager to start, confident that these trainings will be as well-received by the community as the Youth Trainings have been. "We've gotten really good feedback, and people definitely

of Support The Anne Garno File Hometown: Cranberry Lake, NY Occupation: Director of Education

and Enrollment at North Country Prenatal/Perinatal Council

Education: Bachelor and Master's Degrees in Education from St. Lawrence University, Canton, NY

recognize this as an issue and a concern," she said. To clarify, both Youth and Adult Trainings are geared toward adult participants ƒ the "Youth" aspect of the training teaches adults how to help youths who are in crisis. Both trainings teach participants a 5-step action plan (called ALGEE) to suppport someone developing signs and symptoms of a mental illness or in an emotional crisis. The 5 steps are:

concerned about," she added. Ms. Garno said she is proud to play a role and help "build a network" of support in the North Country. "I really enjoy doing it," she said. "I think it's a great program to facilitate. Every group makes it different, because they bring their own experience and background to it. It's great knowing there will be some more people in the community to help with this."

1. Assess for risk of suicide or

Upcoming Trainings

2. 3. 4. 5.

harm Listen nonjudgmentally Give reassurance and information Encourage appropriate professional help Encourage self-help and other support strategies

"We're not training people to diagnose, and we're not training people how to treat," Ms. Garno said. "We're teaching them how you approach someone, talk to them and connect them to help." "I think it really gives people more confidence and it shows them how to approach someone they are

Free Youth Mental Health First Aid trainings will be held at the Watertown American Red Cross Office, 203 N. Hamilton St., from 8:30 a.m. to 4 p.m. on the following dates: Monday, October 2 Tuesday, October 17 Friday, November 3 Participants must attend the full day to receive credit. To register please email Anne Garno at



Speed Networking Event

t the North Country Initiative, we know care coordination is a key component to transforming healthcare across the region. Every month, NCI facilitates Care Coordination Collaborative meetings to discuss relevant healthcare and educational topics. We also try to provide opportunities for meaningful networking among care managers from hospital, primary care, and community-based organizations. We believe these are both key aspects of care coordination that can help the care team stay informed and fill the gaps in patient care. On July 20th, NCI hosted a “Speed Networking Event” at Savory Downtown in Watertown, bringing together PCP care coordinators, hospital discharge planners, and community-based care managers for an afternoon of fun and engaging networking activities. The goal of this event was to create an awareness among primary care clinics and hospitals of the resources available throughout our region to help support the

Was a Success!

health outcomes of their patients. Participants left with a greater understanding of area resources, which will continue to help foster relationships in the community.

How it worked We had the stations set up similar

to those at “speed dating” events,

with the PCP care managers and hospital discharge planners acting as the “daters." The community-based organization care managers moved through each station and talked about their organizations and the services they provide. This allowed everyone participating in the event to meet and talk about their services and programs, as well as put a face to a name, which will hopefully help with building strong relationships between PCP and hospital care managers and community-based organizations. Afterwards, we had each PCP/ hospital care manager and each CBO care manager enter the name of the person they felt was most engaging

throughout the event, and the winners received a prize. Dave Gunderson, from Carthage Area Hospital, and Kelly Meade, from Northern Regional Center for Independent Living (NRCIL), were both chosen as winners for the evening. Overall, we feel the event was a huge success, and we received much positive feedback from our participants. Trisha Kelly, of ACR Health, said: “I was thrilled to be able to talk with providers about how, together, our roles in the community can help others. I think this event is another step in the right direction to bridging the gaps between community health workers and providers. I have several appointments with providers to continue the conversation that was started at this event.” We feel care coordination is a crucial part of improving our region’s health and reducing fragmentation within the healthcare delivery system. The North Country Initiative is committed to creating an effective and sustainable care management platform across Jefferson, Lewis and St. Lawrence counties.

Diabetes Education Workshops The North Country Initiative is proud to announce the launch of its first Diabetes Education Workshop series. This 3-part workshop series will focus on improving patient adherence with topics such as: clinical education, diabetes medications, device training, and shared decision making. Providers, nursing staff, and clinical care managers of all backgrounds and experience are welcome to attend. The Diabetes Education Workshop will be led by Mary Lou Barrette, a registered dietitian and certified diabetes educator who has been in practice for more than 30 years. Her vast experience with helping fight diabetes in communities throughout Central New York and the east coast comes from 8 years in a diabetes clinic in Auburn, NY; 17 years in private practice; 3 years working for Roche Diagnostics as a Regional Clinical Specialist in insulin pump therapy, and for the past 4 years as a diabetes educator with Novo Nordisk. Mary Lou maintains excellent relationships with several practices in the PPS, and her knowledge and passion are a true asset to the region.

Fast Facts on Diabetes

11% of adults in the

North Country report having diabetes (Jefferson, Lewis & St. Lawrence counties)

NCI will host the workshop series in both Jefferson and St. Lawrence counties.

Jefferson/Lewis County Ć’ NCI Conference Room 120 Washington St., Watertown 3:30-5:00 PM Workshop 1: September 19 Workshop 2: October 19 Workshop 3: November 16

St. Lawrence County

Ć’ Hess Auditorium Claxton-Hepburn Medical Center, 214 King St., Ogdensburg 3:00-4:30 PM Workshop 1: September 26 Workshop 2: October 24 Workshop 3: November 28

1 in 4

Nearly seniors (aged 65+) in the North Country have diabetes

1 in 5 North

Country adults with a household income below $25,000/year have diabetes *from the 2016 Tug Hill Seaway Region Community Health Survey

ACO News >>


Medicare Contract Renewed, New Partners Added

ealthCare Partners of the North Country, the region’s Accountable Care Organization, recently renewed its Medicare Shared Savings Program contract with CMS for another 3-year agreement period, effective January 1, 2018. “It’s very exciting,” said Brian Marcolini, CEO of HealthCare Partners of the North Country. “We learned a lot during our first contract as an ACO and we’re going to use what we’ve learned to continue to improve care in our region and reduce costs.” “I’m very proud of the work that our partners have done,” he added. "Without a doubt, our ACO is preparing our region to thrive in a value-based payment environment.” With support from the NCI Board and the NCI Medical Directors, Mr. Marcolini has opted for another contract as a Track 1 MSSP participant, meaning this contract is upside-risk only. He and his team are optimistic about the possibility of signing a risk-bearing contract in the future. As part of its contract with CMS, HealthCare Partners of the North Country is responsible for the quality of care and cost for approximately 9,500

Medicare beneficiaries across the region. Currently, the ACO partners include six hospitals, six independent practices and one Federally-Qualified Health Center (FQHC).

NEW PARTNERS As of January 1, 2018, two practices from St. Lawrence County will join HealthCare Partners of the North Country: Ogdensburg Family Practice, LLC and St. Lawrence Surgery. Mr. Marcolini said he is very excited about the two new additions: “We are so excited to add two additional partners from St. Lawrence County,” he said. “Dr. Comeau’s group is a true asset to the North Country; their robust

knowledge of quality measures, cost-reduction strategies, and the top-notch patient care they provide will be invaluable to our ACO; and St. Lawrence Surgery comes highly respected and we are honored to have them as a part of our team.” Ogdensburg Family Practice has one MD, Dr. Christopher Comeau; one nurse practitioner, Kristin LaMay; and two physician assistants, Trudy Kiah and Stephen Senenko. They provide primary medicine and family healthcare to patients ages 5 and older. St. Lawrence Surgery has four doctors — Chris Brandy, Kiri Brandy, Michael Oakley, and Noah Zucker — and three physician assistants: Alicia Flint, Chris LaPoint, and Allison Smith.

New Partners: Ogdensburg Family Practice, LLC and St. Lawrence Surgery have joined our region's ACO!

On the Path to Wellness

A Care Management Success Story BY ERIN SHUSTACK ACO Project Coordinator


ebbie Platt describes the fall of 2016 as one of the most difficult times in her life, and although she didn’t know it at the time, it turned out to be the biggest turning point for her health. Debbie – along with her husband, Kenny, and her son, Josh – had recently moved out of Port Leyden, a small Lewis County village she and her family had called home for 22 years. Due to multiple medical issues and limited mobility, Debbie no longer felt safe in their home and decided to relocate to Carthage. Shortly after her move, Debbie developed a severe leg infection and was rushed to the emergency

department at Carthage Area Hospital. It was during that hospital stay that she met Dr. Hardik Patel, who would eventually become her Primary Care Provider. Already upset with the way her life was going, this visit to the hospital brought Debbie to her breaking point. She remembers breaking down during one of her follow-up visits with Dr. Patel: “I was at my wit’s end,” she said. “I just couldn’t seem to get better. Physically and emotionally, I was not in a good place. I needed some help but I didn’t even know where to start.” Recognizing that Debbie could benefit from care management services, Dr. Patel introduced her to Tammy Potter, an RN care manager

at Carthage Family Health Center. It was at that moment that Debbie’s path to wellness began. Care management aims to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminating duplication, and helping patients and caregivers more effectively manage their health and wellness. While this concept is relatively new to the primary care setting, it has proven to be extremely effective in managing patients like Debbie who have multiple chronic conditions. Debbie’s care management program began by working with her husband and Tammy on a care plan. A care plan is a detailed approach to care, customized to an individual

patient’s needs. “We created Debbie’s care plan with a very patient-centered approach,” Tammy said. “We really focused on encouraging her to become an advocate for her own health care.” During the initial care plan meeting, the trio set and prioritized goals for Debbie’s health. Her goals included: setting up reliable transportation; prioritizing and scheduling referrals; stabilizing her blood pressure; losing weight; increasing mobility, and improving mood. Because of her medical issues, Left: Debbie Platt sits in her home in Carthage, NY. Over the past year, she has lost nearly 100 pounds and improved her health with the help of Care Management services. Bottom: Debbie receives a hug from Tammy Potter, her care manager from Carthage Area Hospital. Photos by Erin Shustack.

Debbie had always struggled to find transportation, which prohibited her from attending appointments in the past. However, since forming her care plan, she has received help from the Volunteer Transportation Center. She credits much of her success to her driver, Darin Keggins. “I can’t even begin to tell you how amazing Volunteer Transportation is,” she said. “Darin always treated me like a person. He always puts me in the front seat right next to him. He’s never treated me like I’m ‘cargo’, he treats me like a person, like a friend.” Tammy and Debbie both agree that open, honest communication and a willingness to change are crucial to a successful care management program. “Tammy has a way about her,” Debbie said. “She is honest with me and tells me what I need to do but she also motivates me. She never judges me. I feel like no matter what happens, I can get through it with her by my side.” Tammy and Debbie’s genuine relationship feels more like a friendship than a care manager/patient relationship. They talk on the phone at least once during the week and meet in person any time Debbie has an appointment at the clinic. However, Debbie’s path to wellness has not been a flat road. She has met her share of challenges along the way. In May 2017, she presented to the Emergency Room with pain, swelling, and drainage in her right index and middle fingers after slamming her hand in a car door three weeks prior. This accident ultimately resulted in a partial amputation of her

fingers. Thankfully, though, Debbie had her entire care team there to help get her through the traumatic experience. The Volunteer Transportation Center provided her with transportation to her appointments at Syracuse Orthopedic Specialists, and once she returned home, Samaritan Home Health provided in-home physical therapy, occupational therapy, and nursing – all the while, continuing to communicate with Tammy about her progress. “I couldn’t have done it without them,” Debbie said. Currently, Debbie is working with Susie Kim, a nutritionist at Carthage Area Hospital, to address nutritional deficits and continue to work on a plan for weight loss and management. She has lost nearly 100 pounds and decreased her BMI from 56.5 to 49.6. She uses the “My Fitness Pal” app on her iPhone to log all her meals and exercise activities, and Susie can login to see her progress and make suggestions. Debbie had Bariatric Surgery 7 years ago and lost 110 pounds in 6 months, but unfortunately gained all the weight back, plus some additional weight. This time, however, with the support of Tammy and Susie, she is confident about her weight loss, saying it feels good to do it “the right way.” “Care management has changed my life; I have a whole new outlook,” Debbie said. “I can’t wait to see what’s in store for me. I know it’s only going to go up from here.” Before Care Management, Debbie estimates she had 22 emergency room visits in the past five years. Those visits resulted in 20-22 inpatient hospitalizations, six of which were crisis situations. Since enrolling in Care Management, she has not had any hospitalizations or emergency room visits, other than the one for her hand in May.

P h y s i c i a n L ea d e rs h i p Will Guide Our Region Through Healthcare Reform


s I sit writing this column, Hurricane Harvey is wreaking havoc on the Gulf Coast. This is the storm of the century for Houston, but strong leadership is helping guide the victims through the wrath of this tempest. Meanwhile… silent, less notorious storms are brewing. Health care in the United States is being rocked by uncertainty and change. Gone are the days of seeing your physician, paying a co-pay and living happily ever after. Cue in numerous quality measures, payfor-performance, bundled charges, proving use of a secure electronic health record in a meaningful way, and capitation. Social media is plastered daily with commentary about similar storms. Teachers are being rated based on the test scores of their students, a notion that has caused quite a stir among educators and parents alike. There is tremendous support from both sides attempting to influence the powers that be to affect educational reform. Meanwhile, the relatively silent healthcare storm continues to brew. The healthcare crisis is not all mysterious and unknown. Everyone seems to recognize that there is a formidable shortage of

primary care physicians. Access to care is neither an urban or rural issue; it is a problem everywhere. Undeniably, the general population experiences the cost issue – cost of insurance, cost of deductibles, cost of co-pays, cost of prescriptions, cost of NOT being insured. Dollar signs are ubiquitous. And while there may be no readily definable solutions or answers, these storms have adequate enough coverage in the media to be recognized as real and important. However, there is still an elephant in the room. The remainder of this healthcare storm, which is rarely discussed publicly, is raw and real for physicians in private practice. Employed physicians are starting to feel the heat as we come to grips with being “paid for performance” in a “fee for service” world. This translates into decreased reimbursement, increased documentation requirements, and less time to address the particular needs of each individual patient. Physicians are held accountable for specific quality metrics, and an educated and informed decision is irrelevant as far as “quality” is concerned. Yet, while this sounds undesirable, it is not all doom

and gloom. At this point, no one should throw in the towel or raise the white flag and surrender. The current tumultuous state of our healthcare system is the spark that will bring out the best in physicians. Undoubtedly, behind closed doors and one-on-one with patients, physicians do great work – day in and day out. In the matter of one 10-minute encounter, a physician can serve as problem solver, peacekeeper, counselor, educator and even lifesaver (literally, not figuratively). Lather, rinse and repeat 20-30+ times per day, every day. That scenario is a physician’s comfort zone. The vast majority of physicians have no formal business or leadership training. Perhaps that is why they generally sell themselves short with regard to leadership ability. However, if you survey a group of physicians, it is more than likely that each one will answer “yes” to captain of a sports team, president of a club, active participant in student government, or mentor in the past. These same physicians are also quietly deploying their leadership skills in the community through involvement with various volunteer organizations. The point is, physicians are

“The current tumultuous state of our healthcare system is the spark that will bring out the best in physicians.” not focused on leadership and therefore tend to underestimate their innate leadership skills. They fail to recognize that guiding a patient through a difficult diagnosis or lifestyle change is no different than leading a team of providers, nurses, and administrative personnel through a practice transformation. As we navigate these murky waters through the healthcare transformation storm, physician leadership will become less about the “suit” in the executive suite and more about each individual physician playing to his or her leadership strengths. And just like two rain clouds are never the same, each physician will find an individual leadership niche. When physicians leave the comfort zone

of the closed door, innovative solutions will emerge. Arguably, no individual is better suited than the physician is to lead the way through the uncertainty that lies ahead. Despite their lack of formal training, physicians have prepared for this storm their entire career. In the words of author and pastor John Maxwell: “The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sails.” With the ultimate focus being the needs and wellbeing of their patients, I’m confident that physicians will harness the winds of change and guide their colleagues, patients, and communities through the storm safely.




founder of Complete Family Care & Laser Center, 18983 U.S. Route 11 in Watertown, where she and her staff provide primary care for patients of all ages, as well as cosmetic laser services. She is a former Fort Drum soldier and currently serves as part-time medical director for the North Country Initiative, helping to guide the tri-county region through state and federal healthcare transformation.