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Community Partnership for Patient Access to Supportive Services (ComPPASS)

Project Description: Comprising representatives from Yale-New Haven Hospital emergency departments and community health clinics, Federally Qualified Health Centers, Yale University School of Medicine and School of Public Health, RWJ Clinical Scholars, and Yale-New Haven Health System analytical experts, the Community and Emergency Care Assessment Steering Committee analyzed ED frequent user population characteristics, needs, community assistance, and barriers to care, both clinical and structural. After reviewing models employed by other academic and state-wide collaboratives, they developed the ComPPASS initiative, with the goal of reducing avoidable emergency department visits and hospitalizations by up to 10% for targeted adult Medicaid beneficiaries by March 2017. ComPPASS utilizes evidence-based practices from successful initiatives nationwide, medical school research and peer-reviewed literature to create a program that enables patients and providers to develop a care plan that meets needs and preferences while reducing overall care costs. ComPPASS will assess over 64,000 Medicaid beneficiaries (including new ACA-generated beneficiaries) each time they enter six healthcare delivery system portals to identify high-cost, high-risk and potentially at-risk patients and connect them with a comprehensive patient navigation model, applicable behavioral health and chronic diseases supports, Medical Orders for Life Sustaining Treatment (MOLST), a patient hotline and attention to social determinants of health.

These and other systemic changes, including development of a patient database, use of common EHR data and implementation of standardized patient assessments, clinical and administrative protocols, will enable providers and researchers to monitor and improve the health of a defined (underserved) population, a timely endeavor given that many of the 110,179 uninsured people in New Haven County will likely be Medicaid eligible under the Affordable Care Act.

Primary contact: Thomas J. Balcezak, M.D.; Senior Vice President, Patient Safety and Quality and Associate Chief of Staff
Institution: Yale-New Haven Hospital

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