Contract & Network Update

Quality Innovation Collaborative (QIC)

Adirondacks ACO and Northwinds Integrated Health Network are pleased to share that we are working with Coordinated Care Services (CCSI) in developing the Quality Innovation Collaborative (QIC). QIC is the next phase of implementing a provider engagement and quality improvement partnership under our Fidelis contract. Our internal team includes Rebecca Evansky and Carissa Parot with Northwinds and Megan Murphy and Brenda Stiles with the ACO. The QIC goals are to provide support to better understand the Fidelis data, maximize the use of EMRs, understand the measures and improve patient outcomes and engagement.

The team will use the newly minted Fidelis data dashboards developed with Monroe Plan using our behavioral health network attribution to inform the path ahead. We are working with CCSI to provide expertise and guidance in support of creating a train the trainer model. The first step in the process is an organizational assessment focusing on quality and data. The assessment will be sent to Northwinds providers by the end of July.


2021 Citizenship Criteria Update

We are mid-way through the year and many of our providers have already met a number of the Citizenship Criteria. The ACO and Northwinds teams are here to support our participants in satisfying requirements and en­suring we are focusing together as a network on improving quality and cost outcomes while providing excellent care to our beneficiaries.


  • 100% of the ACO and Northwinds organizations provided the ACO with their quality improvement plans.
  • Our first gap lists were given to our primary care providers last month and many actively used them to improve our quality scores with Excellus and UHC – Empire Plan
Care Coordination
  • All of the ACO providers and many Northwinds originations are participating in the North Country Care Coordination Collaborative or have an EMR that is risk stratifying the people that they serve
  • All ACO primary care providers received updated risk coding reports and should be using them for pre-visit planning and to ensure that we have an accurate picture of our patient population.
  • 81% of the ACO and 75% of Northwinds organizations had providers that attended the April Provider Meeting
  • 71% of the ACO and 50% Northwinds organizations had staff that have attended two ACO Quality Meetings/Trainings
To meet your Citizenship Criteria you can work your gap lists, use your risk work book, use codes to document depression screening, hypertension, and diabetes, take advantage of the ACO Office Hours, Practice Transformation meetings and participate in the Quality Improvement, North Country Care Coordination Collaborative and the Community & Beneficiary Engagement Work Group. Please contact Megan Murphy by email or call 518-314-3682 to learn more.

ACO Office Hours
Date: Wednesday, July 28
Time: 12:15 – 1:00
Click here to join the meeting

Practice Transformation meeting
Date: Thursday, August 19
Time: 8:00am – 9:00am
Email Louann Villani to join the meeting

Quality & Performance Update

ACO Provider Report Package (V2.0)

ADKs ACO has distributed the most recent update of your all-payer ACO Provider Report Package (V2.0). These reports look at claims in 2021,year to date. Each ACO practice has a quality lead that has access to the ADK Share Portal to download and distribute the reports. These reports should be considered working data, intended to inform your practice providers and staff of your 2021 ACO claims activity, thus far. Please reach out to Lisa Cyphers with any questions or feedback about the reports.

Quality Gap Closure with Supplemental Data

In May and June, the ACO data team reached out requesting supplemental data to close gaps for 2020.  We had an overwhelming response from our providers, to support our network’s Commercial Quality Score.  The ACO was able to negotiate with Excellus to accept supplemental data, which in the past was not allowed.  Supplemental data for breast, cervical and colorectal cancer screening was accepted since these measures have a longer look back period.  The following are the Excellus results:

The ACO is awaiting the results of the United Health Care supplemental data submission, final results are due in the near future. UHC accepted data for all measures and we can report tentative results for three of them:

Supplemental data is important in the ACO overall quality score and can be the difference in realizing shared savings.

To decrease the burden of supplemental data submission, it is important to look at the workflows in the practice.  Are we efficiently utilizing pre-visit planning to look at the preventive gaps that are identified? Are you utilizing CPT – 2 codes and/or Z codes to close gaps in care at the time of a well visit?   Here are several examples:

  • If a patient has had a total hysterectomy utilize the code Z90.710 – acquired absence of both cervix and uterus, to remove from future gap lists.  Documentation in the patient history of a hysterectomy will not close a gap in care – documentation must state “Total” or “Complete” to close a gap in care if utilizing a visit note
  • If you provide point of care A1c testing the following CPT 2 codes can  close a gap, allow you to monitor the control of your diabetic patients on your panel, and there may be an incentive available through payer incentive programs:
    • 3044F:   HbA1c < 7
    • 3051F:   HbA1c greater than or equal to 7.0 and < 8.0
    • 3052F: HbA1c greater than or equal to 8.0 and less than or equal to 9.0
These are just a couple of examples of the efficiencies that can be built into your processes that will decrease the burden to you and your staff and reflect and capture the quality care being delivered to patients every day without having to take the time ad effort to supply duplicative documentation to close gaps.

Network Spotlight

Hudson Headwaters Health Network Launches Mobile Health Center

Hudson Headwaters Health Network (HHHN) has established a mobile health program. In June, HHHN’s new mobile health center began bringing primary care services to Warren and Washington counties. A second mobile health center, anticipated to arrive in 2022, will serve the central and northern Adirondacks.

Hudson Headwaters Mobile Health visits are by appointment only. Appointment types include primary care visits for adults and children, women’s health services, chronic disease management and preventive health screenings. Same-day appointments for injury or illness may also be scheduled.

The mobile health center will be located at the courthouse in Salem on Mondays and Tuesdays. Additional sites are being finalized in partnership with regional health care partners, community leaders and town officials. To learn more or to take a virtual tour of the new mobile health center visit

The Dual Recovery Team at WWAMH

This July, we are excited to celebrate the first anniversary of our Road to Recovery peer newsletter! It is a unique source of support for individuals in recovery, and we were thrilled to get it off the ground in the midst of the pandemic. Each newsletter focuses on different topics related to mental health and addiction with the goals of empowering individuals on their recovery path, raising awareness of mental health and substance use disorders, and educating the community. The peer-to-peer connection is incredibly valuable to one’s recovery, so we are always looking for more volunteers willing to share a piece of their story. If you or anyone you know is interested in contributing to our  newsletter (contributions can be anonymous), please contact Rebecca Ryan at We’d love to hear from you!

To check out our 2021 newsletter archives and for more information on the Dual Recovery Program, please visit our website:


Save the Date for the virtual 2021 North Country Leadership Summit

The National Council for Mental Wellbeing and the American Association of Geriatric Psychiatry (AAGP) Webinar Series

Thursday, July 15, 2-3 p.m. ET
National Council and AAGP Webinar Series: Webinar #1 – Aging and Mental Health
The first in a series of six webinars with the American Association of Geriatric Psychiatry (AAGP), as we discuss aging and mental health in our country today

Wednesday, August 11, 2-3 p.m. ET
National Council and AAGP Webinar Series: Webinar #2 – Caregiver-focused Caregiving
The second episode in the series to gain a deeper understanding of self-care for community, community-based and primary caregiving.

Thursday, September 9, 2-3 p.m. ET
National Council and AAGP Webinar Series: Webinar #3 – Major and Mild Neurocognitive Disorders: An Evidence-based Approach to Evaluation and Treatment
The third episode in the webinar series to discuss the etiologies of cognitive impairment and the differentiation of major cognitive disorders. This webinar will also highlight current and potential best practice clinical approaches to treating those with reversible cognitive impairment

Billing and Coding Training

This training will provide guidance on appropriate coding and billing to ensure an accurate picture of your treatment encounters. There will be a focus on different insurance types to ensure financial sustainability of services.

Briggette Shaheen and Amanda Frazier from St. Joseph’s Addiction Treatment and Recovery Centers  will be presenting.

To register, choose the session you’d like to attend and complete the registration information:


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