Primary Care

Project Title

Sustaining the Success of the Primary Care Medical Home Model in the Adirondacks

Grant Amount


Priority Area

Primary Care

Date Awarded

June 28, 2012


Hudson Valley




In January 2010, the Adirondack Health Institute became the central administrator of New York State’s only multi-payer regional medical home demonstration pilot.

The success of this demonstration could have far-reaching implications for how the State can advance the health home model across New York. While AHI had begun aggregating data from providers and payers, it still required the analytical capacity to demonstrate that the investments made to date yield the desired outcomes of improved health and reduced health care costs. With support from NYHealth, AHI developed a robust capacity to analyze data and secured a sustainable financing stream to strengthen the primary care sector by negotiating payment contracts with providers.

AHI’s first round of data analysis focused on patients with one or more chronic conditions, and it prioritized analysis for patients with diabetes, mental illness, heart disease, and Chronic Obstructive Pulmonary Disease. Results that did not yield the expected outcomes were used to create actionable steps to improve the results. Further analysis of claims data helped identify which participating sites required more support to execute the best care practices for high-need patients. To improve operating capacity at these sites, AHI teamed with nationally known physician consultants, such as Geisinger Consulting Group, to provide in-depth training for local physicians who can serve as mentors to their peers. In addition, AHI developed shared savings payment models that will incentivize providers to take more responsibility in managing care for their patients.