Duane Schielke MS, Sanjay Seth MD, and Vincent Siasoco, MD MBA
Population health management for patients with intellectual and developmental disabilities (IDD) offers a unique healthcare improvement opportunity along with specific practice challenges. The New York City-based Alliance for Integrated Care of New York, LLC (AICNY) recognizes IDD patients as one of the most medically underserved and vulnerable populations. In 2014, the AICNY was approved by CMS as a Medicare Shared Savings Program Accountable Care Organization (ACO) with approximately 350 physicians and other healthcare professionals providing care for about 6000 Medicare beneficiaries, the majority of whom were patients with IDD who are dually eligible for Medicaid and Medicare. This article describes how AICNY set out to strengthen its population health management platform to support advanced value-based care and risk management strategies for ACO participants and patients. Objectives, unique challenges, and case scenarios from one of AICNY’s provider groups show how disparate data can be aggregated and transformed into information to help physicians and caregivers improve patient care for this unique, at-risk population.