Hudson Heights Reach ACO

THE MISSION AND GOAL OF HUDSON HEIGHTS REACH ACO

The manifest mission of Hudson Heights REACH ACO is to aggressively work toward the building of healthier neighborhoods and communities by providing and connecting Medicare beneficiaries with the health, psychosocial and social services they need to not simply survive, but also thrive.

The operational goal of Hudson Heights REACH ACO directly corresponds with the established mission. Hudson Heights REACH ACO is dedicated  to

1) alleviating disparities among individuals who are the most vulnerable;

2) fostering equity in access to health, behavioral health, and social services in the target population;

3) transporting the experienced benefits of accountable care and a value-based approach to the service delivery to traditionally underserved communities and;

4) building and promoting leadership and governance within and between the provider community and residents of the neighborhoods and communities that the ACO serves.

BRIEF SNAPSHOT OF HUDSON HEIGHTS REACH ACO

Hudson Heights REACH ACO is a new company born from and affiliated with Bronx United IPA.  The ACO is part of a relatively small and inaugural group of ACOs in the country approved by the Centers for Medicare and Medicaid Services Innovation (CMMI) Center to implement their new Realizing Equity, Access, and Community Health (REACH) Model Accountable Care Organization.

The parent company and its affiliated independent community-based providers have, for over 18 years, dedicated their time and expertise to making available quality care to neighborhoods and communities with high rates of poverty, low health status, limited health literacy, racial disparities, and limited accessibility to comprehensive health, behavioral, and social resources and services.

Some of the key features of Hudson Heights REACH ACO include:

A mature, experienced, and value-based care savvy Leadership Team.

A physician controlled Governing Board with a long and vibrant history of investment in and commitment to the communities and neighborhoods they serve.

An Oversight Committee Structure with dedicated representation from the Participating Provider Network, Medicare beneficiaries, and Consumer Advocates.

A Participating Provider Network with a time honored history of providing services to neighborhoods and communities characterized by poverty, racial and ethnic diversity, language barriers, and a host of other social and environmental factors that limit opportunities to efficiently access the health, behavioral health, and social services to satisfy needs.

Application of a time-tested Care Management and Care Coordination Model to guide the provision of physical, behavioral, and social services, with particular attention to moderate to high risk Medicare beneficiaries.

Use of a state-of-the-art Population Health Management IT architecture, to drive components of the Care Management and Care Coordination Model.

Engagement of an interdisciplinary team-based approach to the provision of care and services to Medicare beneficiaries, including the development and monitoring of individualized team consensus based care plans.

Implementation of a comprehensive approach to enhancing patient adherence to medications.

Implementation of a Quality and Preventive Services Gap Compliance Program that provides a timely, efficient, and patient specific process for Participating Providers to close gaps in quality performance measures and, screening and preventive service measures.

Deployment of an Outreach Program that reflects national outreach guidelines established for underserved and vulnerable populations.

Deployment of a Referral Management Program (RPM) designed to increase Participating Providers engagement in the referral process, with particular attention to expanding referral patterns to include behavioral health providers and social service agencies and organizations to address the diverse and unique behavioral and social needs of beneficiaries.

Installation of a Patient Experience and Satisfaction Monitoring Program to systematically and longitudinally assess and monitor beneficiary (and caregiver) experiences and satisfaction with the care and services provided.

Implementation of actions and activities dedicated to elevating understanding of and igniting attention to the impact of Social Determinants of Health (SDOH) on the lives of residents (particularly Medicare beneficiaries) in the neighborhoods and communities served by the Hudson Heights REACH ACO, with special attention to alleviating disparities among the most vulnerable and foster equity in access to health, behavioral health, and social services. The actions and activities include, at a minimum: