Transforming Care & Improving Health for the Entire Community

Improving Health for the Entire Community

The Central New York Care Collaborative (CNYCC) is a network that connects over 2,000 healthcare and community-based providers across six counties in central New York (Cayuga, Madison, Lewis, Oneida, Onondaga, Oswego).

CNYCC’s mission is to improve the health of the community by coordinating services and building partnerships throughout the healthcare system.

CNYCC has partnered with IBM Watson Health to create the regions ONLY regional Population Health Management System.

CNY Cares Population Health Management System
Powered by IBM Watson Health

The PHM system offers a full suite of solutions that transform Insight into Action. Powered by IBM Watson Health, the PHM system includes advanced data analytic capabilities and custom tools that can improve care delivery, reduce costs, and support organizations in value-based care.

Population Health Management (PHM) is an approach to healthcare delivery across a general population or group of individuals that focuses on gaining insight in to the many factors that can impact health.

CNY Care’s PHM system features innovative technology that connects information from clinical, financial, claims, social/behavioral and other sources into a single platform and offers a fully-integrated approach that supports informed decision making, greater collaboration across the care continuum, and enhanced patient communication and outreach.

 

The IBM Watson Health PHM system product suite includes:

  • Enterprise Performance Manager

  • Watson Care Manager

  • Watson Engagement Manager

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ENTEPRISE PERFORMANCE MANAGER

Enterprise Performance Manager is an interactive performance management tool with advanced data analytics and quality measurement reporting.

FEATURES:

  • Measure: Library of measures that shows performance outcomes at all levels within the organization
  • Inform: Program-centric scorecards of performance outcomes for organizational measures
  • Registry: Targeted patient lists to manage populations of patients using relevant clinical data points and risk stratification
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WATSON CARE MANAGER

Watson Care Manager is a cloud-based application with team-based care management and coordination capabilities.

FEATURES:

  • Establish referral process
  • Review/Manage care transitions across services
  • Identify potential care gaps based on patient record
  • Identify community-based resources (ex. shelter, food service etc.)
  • Generate customized care plans based on patient assessments
  • Customize alert notifications for downstream providers
  • Customize patient assessment/workflow
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WATSON ENGAGEMENT MANAGER

Watson Engagement Manager is an automated communication and outreach system that allows providers to stay connected to patients.

FEATURES:

  • Transition: Automated post discharge assessment designed to identify patients to measure patient experience, identify care needs and avoid unnecessary readmissions
  • Outreach: Protocol-based outpatient engagement tool designed to connect with patients in need of follow-up or preventative services (ex. Well Child Visits)
  • Campaign: Customized outpatient engagement tool designed to remind patients of necessary services (ex. Flu shots)

Connecting the Dots

CNY Care’s PHM system connects information from across the community to offer a comprehensive view of care, regardless of where a patient receives services. This community-wide insight, made possible through patient consent, allows healthcare providers to better understand the full spectrum of health issues and risk factors that could impact a patient’s care.

By collaborating with IBM Watson Health, CNYCC will be able to integrate data from a variety of care settings including — primary care, acute & post-acute, behavioral health, community-based services and other services.

Connecting critical information that will assist providers in delivering the best possible care for patients through a fully-coordinated team-based approach.

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Unlocking the power of information to gain critical insight that will improve patient care.

  • Community Level View of Patient Care

  • Informed Care Planning

  • Identify Gaps in Care

  • Improved Efficiency