CCACO's mission is to meet our patients' healthcare needs, with the goals of simultaneously improving health, promoting positive patient experiences and reducing per capita costs. We are a clinically integrated group working together to seamlessly coordinate patient care, and we aspire to the highest levels of transparency and honesty. We wish to enhance the quality of healthcare for this population that has special health needs, unique medical profiles, and varying proficiency in English. We aim to do this by bringing together physicians who are uniquely engaged with the Chinese community, and familiar with its health and linguistic challenges.
CCACO will coordinate care based on the specific needs of the Chinese communities within New York City. Our approach centers on the primary care physician (PCP), and is intended to reduce overall healthcare costs and disparities by identifying high risk populations, and proactively managing diseases in their early stages. We will establish a network of health organizations by partnering with hospitals, nursing homes, visiting nurse services, house call programs, home care agencies, community pharmacies and senior centers. For example, CCACO has established strong relationships with hospitals in Manhattan, Queens and Brooklyn, which will facilitate coordinated patient care during hospital stays and help with appropriate discharge planning. We expect these efforts will significantly reduce or prevent emergency room visits and re-admissions to the hospital within 30 days of discharge. CCACO providers also have privileges at New York City hospitals that include Lutheran Medical Center and Maimonides Medical Center in Brooklyn; Beth Israel Medical Center and New York Downtown Hospital in Manhattan; and New York Hospital Queens and Flushing Hospital Medical Center in Queens.
CCACO will coordinate the care of our Medicare Fee-for-Service patients by referring patients to specialists within our network who share in CCACO's mission of reducing costs and improving care. Physicians within the network may share information and avoid duplicating services to reduce unnecessary costs and improve the quality of patient care. However, Medicare Fee-for-Service patients are not restricted to seeing physicians within the CCACO network. Another key element of our approach to controlling costs of care is to avoid unnecessary emergency room visits and hospitalizations. We will also work to encourage appropriate use of certain services that have high utilization in the Chinese community, such as pain management, rehabilitation, and radiology services.
CCACO will work to improve the quality of care provided to Medicare Fee-for-Service patients by using as a guideline the 33 quality measures defined by the Medicare Shared Savings Program. These measures are designed to assess the performance of the ACO and to determine whether it has truly improved patient care; they encompass: Patient experience of care; Care coordination/patient safety; Preventive health; At-risk population. In addition, many primary care practices within CCACO are in the process of obtaining NCQA certification as patient centered medical homes (PCMHs). This program, which has been recognized and promoted by the Department of Health of New York City, strongly emphasizes the use of quality metrics, enabled by electronic medical records (EMRs), to improve the process of care. Finally, CCACO will strongly encourage our providers to adopt and achieve meaningful use of certified electronic health records (EHRs) for practice coordination. The use of EHRs will streamline and improve patient care by allowing physicians to easily share information and thus minimize unnecessary tests and procedures.
