Serving in a role as both leader and educator, Emily Pape has brought a wealth of knowledge to Care Compass Network, enabling the PPS to make far-reaching progress in how organizations in the 9-county region manage data. This information helps guide healthcare providers as they keep Population Health top of mind. “Rather than waiting for people to become sick or have a significant healthcare need, Population Health is focused on keeping people in a healthy state and avoiding declines in health”, explains Pape. This aligns with one of the key goals of CCN’s mission and vision.
Emily is the Director of Population Health for CCN and while important, it’s just one of the many areas to which Emily’s department dedicates its focus. The Population Health team creates informational tools and programs to support the PPS and its partners. One such initiative well underway is the Cohort Management Program. It exists as a network of partner organizations, coordinating the care management for Medicaid members. Their integrated service areas hold each other accountable, aiming for the best possible outcomes for their patients. In a joint-effort, the program was designed to help partners transition to the new Value-Based Payment (VBP) model of care.
“The Population Health team monitors program activities and looks at everything going on at the highest level, across 18 different networks involved in the process,” shared Pape. The team analyzes patient engagement, panel sizes, Needs Assessment information, and health outcomes. “We’re always asking ourselves if our partners are experiencing challenges that we can address.”
Last year, the United Hospital Fund in partnership with the New York State Department of Health published “DSRIP Promising Practices: Strategies for Meaningful Change for New York Medicaid.” In the document, CCN’s Cohort Management Program (CMP) was cited as an example of a developing network focused on better serving defined populations of complex patients.
Lourdes Hospital, has joined forces through CMP with fellow CCN partner organizations including the Addiction Crisis Center, Truth Pharm, Reach Medical PLLC and Southern Tier AIDS Program (STAP). Together they serve nearly 100 Medicaid members that have a substance use diagnosis. To support their efforts, Emily’s team provides a dashboard and reports that enable the partners to look at information collected from each partner related to their patients. “With the help of these tools, partners in the Cohort Network are able to respond to statistics,” explained Emily. “The dashboard might reveal the fact that 75% of their patients have a housing issue and as a result, the group can be proactive and explore ways to help.”
In addition to her role at CCN, Emily teaches one course each semester as an adjunct professor in the Masters for Public Health program at Binghamton University. In the fall, she instructs Foundations of Public Health, helping graduate students think about methodologies, statistics and health services research. They also explore topics like epidemiology, environmental health, maternal and child health as well as chronic issues such as obesity, poor nutrition and cardiovascular disease.
“In the Foundations class, the idea is to introduce students to the major fields of public health so they can get an initial idea about how healthcare is constructed,” Emily said describing the curriculum. “We also cover the role of government – both state and federal, the role of profit and non-profit and how these domains interact with the medical system.”
Emily’s spring course is Health Policy, Finance & Management and delves a bit deeper into the medical care system. The subject matter requires that the students think critically about individual healthcare rights, how medical services are paid and how policies play a role in the process.
Due in large part to Emily’s role in the classroom, student interns have become involved in furthering Population Health initiatives at CCN. Their work involves program evaluation and data analysis. Most recently, a student worked on a social determinants project, identifying different sources of information from the 9-county area that would best fit into a cohesive and helpful dashboard of population information.
Another intern had the opportunity to be involved in a CCN-funded pilot telehealth program using a new system named Tap Cloud. Gerould’s Pharmacy provides in-home respiratory care services for patients with COPD and uses Tap Cloud as a self-assessment tool. “Patients are asked to complete a self-assessment on a device such as a smart phone or computer, relaying information about their respiratory health status,” Emily explained. Based on the information received, a respiratory therapist from Gerould’s will follow-up with the patient as necessary. This offers providers a more frequent means for monitoring their patients’ progress. The Spirometry tool used by the patient calculates how much oxygen can be held in the lung or pushed out with each breath. “Tap Cloud simultaneously educates the patient, while giving providers an opportunity to help before symptoms require an Emergency Room visit that could otherwise have been avoided.”
When Emily started working at CCN, she joined the team as a project manager for behavioral health. She’s now into her fifth year with the PPS and holds a PhD in Public Health from the University of Michigan.