Improving Health Outcomes

CDPHP improving health

CDPHP considers the optimal health of its members to be its paramount goal, which is why we set high standards for quality care, work to remove barriers to care, collaborate with our network providers to identify gaps in care, research and implement programs and benefits to support members’ health goals, and follow up to evaluate health outcomes.

Don’t Delay Care Campaign

Because of the fear of contracting coronavirus, many patients delayed much-needed care, especially at the onset of the pandemic. In fact, a review of CDPHP data compared to the same timeframe in 2019 revealed the following:

  • A 10-percent drop in care related to diabetes

  • A 4-percent drop in well-child visits

  • Two- and 3-percent declines in breast and cervical cancer screenings, respectively

Recognizing that delayed care could lead to more serious illness or even death, CDPHP launched a Don’t Delay Care campaign to encourage its members, especially those with serious underlying health conditions such as diabetes, heart or lung disease, and high blood pressure, to stay on top of their health needs and keep regularly scheduled check-ups.

Social Determinants of Health

CDPHP is committed to addressing the social determinants of health (SDOH) that can negatively impact a community’s health awareness, access, risks, and outcomes. Low income, unstable housing, poor safety conditions, substandard education, and limited access to transportation and healthy foods all hamper our members’ ability to maintain or improve their health and get access to the care they need. 

In 2020, in addition to its established programs, CDPHP partnered with several community organizations to tackle food insecurity and connect its members to healthy food sources.

  • Nutritional Support for Recently Hospitalized Members.  CDPHP is collaborating with Mom’s Meals, a leading national provider of home-delivered meals, to offer no-cost meals to recently hospitalized Medicare Advantage members needing additional support upon returning home. Studies have consistently shown that medically tailored meals support patient recovery after hospitalization, decrease instances of readmission, help patients manage chronic conditions, reduce food insecurity, and preserve health and independence, in addition to relieving caregiver burden. 

  • Enhanced Community Access to Healthy Foods.  CDPHP and Healthy Alliance Independent Practice Association (Healthy Alliance IPA) launched a partnership with The Food Pantries for the Capital District to connect CDPHP members affected by food insecurity with programs offering healthy, reliable food sources, including: 

    • Food Pantry Plus – a food pantry package that includes fresh produce, lean meats, and whole grain items, plus milk and egg cards redeemable at local grocers.

    • Medically Tailored Food Packages – food pantry packages tailored for medical conditions such as diabetes and hypertension, accompanied by nutritional education and support.

    • Healthy Prepared Meals – delivery of two healthy prepared meals per day, with hot and cold options, and fresh fruits and vegetables.

    • Food Pantry On-The-Go – a food pantry delivery option that can be added to Food Pantry Plus or Medically Tailored Food packages.

In addition, CDPHP collaborated with the Glens Falls Farmers Market and Comfort Food Community (CFC) to provide access to fresh, wholesome food for residents of three New York counties. CFC representatives were on hand to support marketgoers in their efforts to improve their health and eating habits and to connect them with CDPHP resources, which included $10 healthy food vouchers for CDPHP Medicaid members.

Enhanced Primary Care

Since our Enhanced Primary Care (EPC) program was established in 2012, our version of the medical home has grown exponentially – from 19 EPC practices to 191, and from 147 EPC practitioners to 850, serving the health needs of 228,000 members. Even more impressive than the numbers, though, is the impact that this model of care has had on the health of our members. For many of them, EPC has meant that more health care gaps have been closed, health outcomes and experience of care have improved, and those who are sicker have been able to receive the level of care they need, at the right time and in the right setting. 

Specialty Care Transformation 

In 2020, CDPHP® applied many of the strategies implemented for our EPC program to launch a value-based program for specialty care.  The program is designed to align financial incentives for our specialty physicians with the “Quadruple Aim," a concept focused on improving the health of the population, enhancing the experience of care for both members and providers, and reducing – or at least controlling – the cost of care. By offering increased financial and clinical administrative support for our network specialists, we also hope to improve members’ health outcomes and close any gaps in care, decrease the incidence of hospital readmission, improve transitions of care, and reduce physician burnout.

For now, we are focusing our efforts on six areas: cardiology, nephrology, behavioral health, gastroenterology, hematology/oncology and pulmonology. As an example, for cardiology, we have: 

  • Waived or reduced cost share for eligible members with congestive heart failure.

  • Incentivized cardiology specialists to educate their patients about the value of cardiac rehab services and collaborated with Moving Analytics to offer eligible members a virtual cardiac rehab program that can be completed at home, at their convenience, and at no or reduced out-of-pocket cost.

  • Secured a grant for ReDS devices, which measure lung fluid, to be used by area hospitals and specialty practices to evaluate patients with heart failure.

  • Established a plan, in partnership with QURE HealthcareTM, to offer our network cardiology specialists a collaborative way – using clinical simulations – to keep pace with national best-practice guidelines for cardiac care. Participants also have the opportunity to earn continuing medical education credits.

Member Health Support

To keep members focused on their health during a stressful year, CDPHP went the extra mile to reach out to at-risk members to help keep them happy, healthy, safe, and secure.

  • Fall Prevention Kits.  Falls are the leading cause of injury, hospital stays, and injury-related deaths among older Americans, and can take a serious toll on a member's quality of life and independence. As there are simple steps people can take to avoid falls, CDPHP sent fall prevention kits to members at increased risk for falling, including those with a history of falls, congestive heart failure, or vestibular disorders, as well as those who completed an online wellness class related to fall prevention. The prevention kits included tips for avoiding falls, as well as night-lights and anti-slip socks. 

  • Wellness Kits.  CDPHP also mailed Stay Well Kits to all Medicare Advantage individual and group members. The kit contained hand sanitizer, a face mask, tissues, a health tracker, and a magnet with information about topics to discuss with a doctor. 

  • Cancer Kits.  A diagnosis of cancer can be stressful, overwhelming, and scary, which is why CDPHP mailed care packages to CDPHP members who were newly diagnosed with cancer and undergoing chemotherapy or radiation for the first time. Each package included a postcard from a CDPHP care manager highlighting the support we can offer, along with a blanket, hand sanitizer, and Lemonheads candy. 


Qualifying CDPHP members who have Type 2 diabetes and chronic kidney disease (diabetic kidney disease or “DKD”) are eligible for KidneyIntelX testing and score reporting, which can help predict their risk of rapid progression of kidney disease. This artificial-intelligence-enabled clinical diagnostic tool, developed by Renalytix, is designed to improve risk stratification and clinical management of patients with DKD in an effort to improve patient outcomes and avoid or delay the need for more complicated and expensive interventions.