In 2021, AgeWell New York implemented a new Chronic Care Improvement Program (CCIP) to encourage its beneficiaries to utilize preventive services and maintain kidney health. Encouraging self-monitoring is key to not only improving the health of our beneficiaries but their quality of life as well.
Quality Improvement Program
AgeWell New York leads in its efforts for diabetes management with its Chronic Care Improvement Program (CCIP), a 3-year program focused on improving the kidney health of its beneficiaries with a diabetes diagnosis. Our primary goal is to encourage our members with diabetes to complete their annual wellness visits, and kidney health evaluation through specified blood and urine tests as directed by their healthcare provider. An annual wellness visit will enable our beneficiaries to complete preventive services and address any questions and/or concerns with their provider.
What you can do to stay healthy and up-to-date with your care
- Schedule regular visits and preventive screenings as needed.
- Communicate with your primary care physician/specialist(s) about your questions and/or concerns.
- Make a full list of all medications—including prescription, over-the-counter (OTC), and supplements you are taking. Make sure your physicians and pharmacist are aware to prevent harmful drug interactions.
- Keep your advanced care directives up-to-date. This is a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself.
- Exercise, eat healthily, and take time for yourself to do things you enjoy.
Managed Long Term Care (MLTC)
AgeWell New York’s 2022-2023 performance improvement project (PIP) for MLTC and MAP lines of business focuses on improving the rates of Social Determinants of Health (SDOH) screening to assess at least 5 domains of SDOH: housing security, safety, food insecurity, social isolation, and financial security. Through this performance improvement project, the plan intends to increase screening rates, and follow-up for SDOH needs among MLTC and MAP members using clinical and non-clinical interventions by the end of measurement year 2023.
The project has five focus areas that will aid in improving Social Determinants of Health screening rates:
- Indicator One – The percentage of new enrollees with a completed stand-alone SDOH Assessment.
- Indicator Two – The percentage of continuously enrolled members with a completed stand-alone SDOH assessment.
- Indicator Three – The percentage of care manager contacts where an SDOH screen is conducted.
- Indicator Four – The percentage of members with a positive SDOH assessment.*
*A positive assessment is one wherein a member has one or more documented needs identified.
- Indicator Five: The percentage of members with a positive SDOH assessment who have documented interventions to address the need(s).
AgeWell New York has put together a list of resources to assist with SDOH. Click here to review the list.
If you have any questions about our quality improvement projects, contact our member services department at 1-866-237-3210 TTY/TDD 1-800-662-1220.