Why Technology-Enabled Patient Outreach is Crucial to the Success of the New York State DSRIP Program

The New York State Delivery Reform Incentive Payment (DSRIP) program is said to be the most ambitious state DSRIP program thus far. After watching California, Texas, New Jersey and a few other states go through their first five-year DSRIP programs, the Center for Medicaid and Medicare (CMS) decided to significantly redesign the program, and New York would be the guinea pig.  A large part of this redesign would be tougher metrics to meet, and paying the Performing Provider Systems (PPSs) in small increments for performance.

The goal of NY State DSRIP is to reduce avoidable hospital admissions by 25% over the five years of the program. While the many projects, committees and deliverables seem like a lot of work and money for only a 25% reduction,  reducing hospital admissions across the state is no easy feat. Achieving this goal will require significant investment in preventative medicine and behavioral health, i.e. teaching people who regularly use hospitals for healthcare how to take care of their own health at home. And if care is needed, to try to visit less expensive facilities.

As this transformation begins, targeted patient outreach will be a key component. The few dozen DSRIP projects are focused on a variety of specific goals for specific patient populations, from reducing premature births through prenatal education and maternal health, to increasing tobacco cessation, to encouraging exercise and developing a healthier diet for chronic disease patients.

A crucial component of these projects’ successes following initial education will be keeping patients on track by checking on them regularly to make sure they have not fallen off their health goals or care plans. To successfully meet DSRIP project goals, a consistent method of patient outreach must be established. The consistent outreach is important not only to check in with patients and remind and encourage them to stay on track to becoming healthy, empowered people, but also to have a sophisticated enough alerting system for when those patients become high-risk for a hospital admission or readmission.

The more I have learned about the New York State DSRIP program over the past year, the more I have realized the incredible need for solutions like my company, CipherHealth’s, Voice solution. Voice uses the scale, data analytics and alerting capabilities that technology enables to ask the right questions to a certain patient population, or for a certain DSRIP project or initiative.

As the DSRIP project managers begin outreach to their target populations in the community, I wonder how, without a technology-enabled solution like Voice, the PPSs will be able to get the right data analytics and spot trends on who they are reaching and what patients are saying at home. How will these PPSs successfully scale to engage tens of thousands of people daily, or route those patients in need of immediate attention to the right person at each organization? How will they set automated reminders for when patients should receive another follow-up call or text, or offer enough languages to meet the needs of a state as diverse as New York? Most of all, how will they make sure the right questions are being asked in the same way each time, ensuring accountability, visibility and consistency?

Without this kind of communication and outreach infrastructure in place, I fear a lot of time will be wasted logging manual outreach and paperwork, and more likely than not, that many patients will fall through the cracks in the program.  I also fear that those PPSs that record their efforts digitally will use free text comments, which cannot be easily turned into actionable reports or data analytics.

Despite the good intentions of the program to encourage patients in the community to take care of themselves, without reaching out to these patients in a structured way to see how, what, where, who, and why they are succeeded or failing, it will inevitably become a whole bunch of bureaucracy and wasted taxpayer money.  Yes, we will have the measurable results and performance metrics set by New York State and CMS, but how the PPSs met or fell short of these metrics will be left a mystery. The New York State DSRIP program is well timed with the Digital Health revolution, let’s just hope the PPSs lay the right foundation to capitalize on it.

For more information on strategies to meet the DSRIP project goals, contact us today.


Elizabeth Lagone, MPH, is the Vice President of Government Programs at CipherHealth. Prior to her current role at CipherHealth, Lagone served as the Primary Care Strategy and Improvement Director for DSRIP Initiatives at One City Health, a subsidiary of NYC Health + Hospitals focused on population health, care management, and implementation of the state’s DSRIP program.