Independent Physician Association in the North Country Sees Dramatic Improvements Through Partnership with HealtheConnections

North Country Initiative (NCI) is a partnership of hospitals, independent physicians, and community providers working together throughout Jefferson, Lewis, and St. Lawrence counties, with a large rural footprint. They’re tasked withsupporting effective, efficient healthcare services and care coordination for patients across all organizations in their network. A key challenge for these kinds of collaboratives lies in transitioning patients from one care setting to another, while still ensuring each part of the patient’s care team is informed and ready to support that patient as they move to the next phase of their health journey. HealtheConnections and NCI teamed up to develop a more impactful transitional care process with some impressive outcomes.

Before using HealtheConnections’ myAlerts service, providers would receive inconsistent and varied discharge notificationswhen a patient moved from one care setting to another. NCI’s transitional care managers needed a simple, effective way to initiate a transitional care plan at discharge – myAlerts was easy to implement and customize to fit the needs of the providers. NCI supplements myAlerts notifications with clinical and claims data to give a clear and concise view of the patient’s needs at discharge prior to developing a Transitional Care Management plan.

NCI's Transitional Care Management process is a coordinated effort to develop, evaluate, and support a patient's care plan after leaving the hospital. myAlerts jumpstarts the process, letting a care team know that Transitional Care Management is needed. From there, the care team initiates planning for crucial follow-up tests and treatments, medication reconciliations, patient education, and medical and social care to prevent future hospitalizations.

“At the onset of our region’s TCM campaign, less than 10% of our inpatient discharges resulted in a TCM engagement; Now, this figure is higher than 52%,” says Jeff Bazinet, Director of Data Analytics at NCI. “We see that the 90-day post-discharge healthcare costs among individuals who had a TCM are approximately 60% less than those who did not have a TCM service following a discharge. Further, the inpatient readmission rates of those with a TCM service within 90 days of discharge are less than half of those without.”

The value of a strong care management process doesn’t stop at the individual patient. This TCM campaign has demonstrated value for the providers, the hospital system, and even the health plans.

“These significant outcomes generate a “win-win-win” scenario in which individuals benefit from patient-centered care and fewer trips back to the hospital, value-based arrangements see reductions in avoidable healthcare costs and readmissions, and practices and providers are able to sustainably provide high-quality care to their patients,” Bazinet explains. “In fact, one of our physician leaders shared that a focus on TCM has been one of the most personally and professionally rewarding projects of their career.”

NCI, its partners, and HealtheConnections are committed to continued efforts to ensure transitional care management is available to all populations in their communities, especially underserved populations and those with unique social needs.

myAlerts clinical alerting is available at no cost to participating organizations and providers. To connect with us about your unique needs, contact

north country logo

Measurable Outcomes:

  • Realized a 5x increase in TCM engagements after implementing myAlerts
  • Significant reduction in inpatient readmission rates for those who have a TCM engagement compared to those who do not
  • A decrease in healthcare costs by up to 60% for individuals with a TCM engagement compared to those who do not