Quality & Performance Update

Thank you to all of our provider organizations that took the time to provide supplemental data to Adirondacks ACO over the past few weeks to support our network’s commercial quality score! This data helps to give us a better picture of our patients, increases our shared savings, and helps meet your ACO Citizenship Criteria.



Please join us and our providers at the Adirondacks ACO data team Provider Office Hour!

This is an opportunity to ask questions and share your experience. The hour will focus on our new reports – Care Opportunity and Pharmacy – Medicare voluntary alignment, and ECQMs.  Your suggestions and/or feedback will enhance the next version of reports that will be coming out soon and attending will meet your ACO Citizenship Criteria.
Adirondacks ACO Office Hours
Date: Wednesday, June 23, 2021
Time: 8:00 AM – 9:00 AM

Where: Microsoft Teams Meeting

If you have any questions or would like to register, please feel free to reach out to Brenda Stiles at bstiles@cvph.org. Please forward this invite to other members of your team.

                                      Contract & Network Update

North Country Care Coordination Collaborative: Strategic Plan Development

The North Country Care Coordination Collaborative, convened with HRSA funding, leveraging a strong, decade’s long history of regional collaboration that includes efforts to make the health care system more patient centered and change the payment model from volume to value based payments.

The North Country has long been recognized by NYS as a locale where providers work together to address health care needs through innovative programs and policies. With this in mind – we took a three step approach to develop a plan that will support a long-term strategy for the region:

  • Surveyed the collaborative members ranking factors that are key components of care coordination.
  • Identified the top three initiatives that members would like the collaborative to achieve.
  • Completed a SWOT analysis to support long range planning.

NCCCC Vision: High-risk residents of New York’s North Country region, transitioning from hospital to community-based care, will be offered care coordination that promotes health and well-being leading to positive outcomes.

Strategic Purpose Statement: The NCCCC ensures a collaborative approach to serve high-risk residents of New York’s North Country region transitioning from hospital to community-based care.  We seek to assure that health is promoted and needs are effectively and efficiently met through collaborative leadership, aligned strategies, sufficient workforce, common platforms for sharing information, strong patient engagement and shared goals.

Shared goals of the North Country Care Coordination Collaborative:

  • Build a sustainable Transitions Care Coordination Collaborative.
  • Create and implement regional, multi-sector care coordination protocols that ensure alignment and coordination for people transitioning from the hospital to community supports.
  • Enhance care coordination communication strategies that focus on whole person care and minimize duplication of supports.
  • Optimize current regional, multi-sector care coordination workforce and implement alternative models to ensure all levels of care coordination
For additional information, please contact Mary McLaughlin, Project Director at mmclaughlin@ahihealth.org or Melissa Joyce, Project Coordinator at mjoyce@cvph.org.

Empowering Patients through Voluntary Alignment 

Voluntary alignment is the process that lets Medicare fee for service (FFS) beneficiaries select (voluntarily align with) a primary clinician. CMS believes that voluntary alignment will strengthen beneficiaries’ engagement in their health care and empower clinicians to better coordinate care.

When to start: A Medicare FFS beneficiary that selects their primary care clinician by 09/30/21 will be attributed to the ACO for 2022.

How it works: Beneficiaries have to login to MyMedicare.gov to select their primary clinician. They must have one visit with the provider to be eligible for ACO attribution.

What will happen: The beneficiary’s selection will override prospectively the claims-based assignment methodology. Beneficiaries may change their designation at any time through MyMedicare.gov and the changes will be incorporated into the next performance year.

Resources for Providers & Beneficiaries:
Patient ACO Voluntary Alignment Fact Sheet can be given to Medicare FFS beneficiaries
Voluntary Alignment ACO Fact Sheet for participating providers

Impact on Beneficiaries: Voluntary alignment is optional for beneficiaries and does not affect their Medicare benefits or restrict their ability to choose a doctor in any way. Regardless of ACO assignment or designation of a primary clinician, Medicare FFS beneficiaries may continue to see any Medicare provider.

If you have any questions on voluntary alignment, please reach out to Karen Ashline at kashline@cvph.org.

All health care providers – primary care, behavioral health, substance use, specialists and others – are a convenient and trusted resources for our community members, including for COVID-19 vaccination.

If your organization would like to vaccinate here are the steps:

Step One – Register for the Immunization Information System: If your organization is not yet registered, follow this link for instructions, NYSIIS for providers in NYS.

Step Two – Enroll in the COVID-19 Vaccination Program: Providers in NYS, outside of NYC, will enroll in the NYS COVID-19 Vaccination Program through the Health Commerce System application “COVID-19 Vaccine Program Provider Enrollment” and should review the NYSDOH COVID-19 Vaccination Program Enrollment Letter for guidance.

Step Three – Ordering, Receiving and Administering Vaccine: Providers order COVID-19 vaccine through NYSIIS (for providers in NYS, outside of NYC). Orders are reviewed and approved by NYS DOH and shipped directly from the vaccine manufacturer or CDC distributor. Providers will monitor vaccine inventory; enter doses administered and/or perform data exchange (uploading and downloading data) between the provider’s electronic health system and NYSIIS; enter vaccine returns and wastage; and generate reports for internal review (e.g. doses administered) in NYSIIS.

Health care providers interested in learning more about the COVID-19 Vaccine Program may contact the NYS DOH at covid19vaccine@health.ny.gov.

For detailed instructions and additional guidance please visit the NYS DOH web page.

ACO Spotlight

In recognition of PTSD awareness month, Northwinds Integrated Health Network is proud to spotlight our partner, St. Josephs’s, and their Veterans Residential Treatment program

The Col. C. David Merkel, MD Veterans’ Residence is at the center of the St. Joseph’s program for the long-term treatment of male veterans who suffer from both substance use and post traumatic stress disorder or other co-occurring disorders.

The program and services are trauma-informed; based on an understanding of the vulnerabilities and triggers of military trauma survivors and their loved ones to best support our clients in achieving treatment goals without re-traumatization.

Nestled in the Adirondacks, the 25-bed facility offers a holistic, integrated recovery approach specifically tailored to the needs of veterans and their families. The core of the program focuses on healing the individual as well as assisting in the reintegration into the family and community.

Services center upon evidence-based, trauma-informed therapeutic approaches, recreation and sober socialization skills, physical health restoration and somatic therapies, the fostering of the independence, reintegration with family and community, educational and vocational assistance training, and family therapy and support.

The admission process is simple and confidential. Prospective veterans across New York State including service members from any branch of the military, any length of service and regardless of their discharge status may call us on their own, or be referred by case managers, physicians, employers, school personnel, insurance companies, and other loved ones.  The administrative team at the Col. C. David Merkel, MD Veterans’ Residence is here to help the veteran, their families, and referral sources to begin the pre-admission process to the Veterans Facility.  Please do not hesitate to contact us if we can be of further assistance.

The Wall That Heals will be on display June 24 – 27 at The Great Chazy River Memorial VFW Post 1418. It will be open 24 hours a day and free to the public.

The Wall That Heals exhibit includes a three-quarter scale replica of the Vietnam Veterans Memorial along with a mobile education center. The traveling exhibit honors the more than three million Americans who served in the U.S. Armed Forces in the Vietnam War and it bears the names of the 58,281 men and women who made the ultimate sacrifice in Vietnam.

For more information, Click HERE.


June is Pride Month, so be sure to check out ARHN’s 5 excellent LGBTQ+ mini, on-demand training modules (15 minutes each), 7 facilitated trainings, other training resources as well events, support groups and other resources for you and your patients of all ages on their web site.

Resources for LGBTQ Youth, Click HERE

The May Viewpoint in JAMA, Designing a Successful Primary Care Physician Capitation Model, outlines 7 elements that are important for a successful PCP capitation initiative. 

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