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level of competency to better address fluctuating patient needs as individuals continue to transition to more appropri- ate levels of care under the structure of popu lat ion hea lt h ma na gement , Wa lker-Czyz adds. FEASIBILITY AND THE BOTTOM LINE B y u n d e r t a k i n g a n d s u c c e s s f u l l y implementing the continuum of care, St. Joseph's Health established the feasi- bility and benefits of this model in today's healthcare environment, even as many other institutions are just beginning to lay the groundwork for community-based programs. Such groups face many hurdles to their progress, such as establishing how to maintain operational and economical feasibility as they ride out this momentum shift over the next few years. "There is a necessary and natural time prog ression between when you sta r t investing into population health — and the continuum of care — and when you start seeing benefits in terms of overall health of the population, as well as to the bottom line," Luke says. "If this works correctly, you are going to start seeing volume decrease in the inpatient setting as you successfully keep the popula- tion healthier." As this momentum shifts, resources are allocated to community programs and the sustainability of the health system increases greatly, Luke adds. This allows St. Joseph's Hea lth to ser ve a greater population than in the past. St. Joseph's Health partners with local providers to accomplish this, offering them participa- tion in its Clinically Integrated Network (CIN). The CIN provides the framework for the continuum, controls costs, and ensures higher quality of care with part- nered primar y care and subspecia lty physicians, as well as the opportunity for practices to collaborate with commercial payor organizations. "The partnership between hospita l administration and physicians is para- mount to the success of the CIN," says Pau l Fiacco, MD, a fa mi ly medicine doctor in East Syracuse who is a ffili- ated with St. Joseph's Hea lth and the physician leader and medica l director of the St. Joseph's Hea lth ACO/CIN. "It is incumbent upon both groups to be more accountable for the delivery of higher qua lity and more efficient care delivered at a lower cost. Physicia ns drive the overa ll care management of the patient as they navigate through the continuum while administration focuses on streamlining operations that a re threatened by thinning ma rg ins due t o a n i ncrea sed cos t s t r uc t u re a nd rei mbu rsement decl i nes a s we move away from the fee-for-ser v ice environment. Clinical integration helps improve qua lity, enha nce the patient experience, reduce cost a nd waste in the system, and positions providers to ta ke on higher levels of accountability to effectively manage utilization and the hea lth of populations in the future. By working together and putting patient needs at the center of our continuum, we w i ll enha nce ca re, decrea se cost and demonstrate considerable va lue to the consumer." The St. Joseph's Hea lth shif t from pay-for-service to the continuum of care model, Luke says, allows the entire system to collectively improve and maintain eff iciency, insura nce incentives a nd financial viability over time. St. Joseph's Hea lth a lso increased its access to capital, resources, knowledge, best practices in population hea lth and scope of services by partnering with local group Trinity Hea lth in 2015 to further supplement the continuum framework that wa s a lready set in motion. This move a l s o ch a n nele d more dol l a r s i n t o t h e o r g a n i z a t i o n s ' m u t u a l l y shared Franciscan philosophy, placing increased emphasis on their mission to ca re for the needs of underser ved populations, Luke says. "As caregivers, a ll of us go into this busi ness to ta ke ca re of people a nd help them to be well or become well," Luke says. "The shif t to a population hea lth model mirrors the core of our very purpose of existence. To achieve that mission while maintaining to be operationally and financially viable is a win-win for everyone." For more information, visit sjhsyr.org. n A St. Joseph's Home Care patient can benefit from a spectrum of services: skilled nursing, physical therapy, registered dieticians and social work. M D N E W S .C O M /// M D N E W S C E N T R A L N E W Y O R K ■ 2 017 0 9