Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) Home Health Collaborations (2bviii)

Agenda 2 Welcome & IntroductionsPurpose of MeetingPPS UpdatesReview TimelineReview Action ItemsProject Requirement Step DevelopmentNext Steps / Next MeetingQuestions / Open Discussion

3 PPS Updates NYS DSRIP Updates PPS DSRIP Updates

4 Timeline June 15 – June 19 Clinical Development Meeting Develop PIP Requirements June 22 – June 26 Clinical Development Meeting Develop PIP Requirements June 19 – July 3 No Meetings July 6 – July 10 Clinical Development Meeting Develop PIP Requirements July Meeting: Finalize Draft PIP July 20 – 24 Present PIP(s) to Clinical Integration Committee July 27 – July 31 PMO input PIP into MAPP July 31st PIP’s Due

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6 Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice. Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer. Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care. Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. DSRIP Project Review: Meeting #1 Project Requirement Development (PIP)

7 Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence- based medicine and chronic care management. Educate all staff on care pathways and INTERACT-like principles.Create coaching program to facilitate and support implementation.Educate patient and family/caretakers, to facilitate participation in planning of care.Utilize telehealth/telemedicine to enhance hospital-home care collaborations.Use EHRs and other technical platforms to track all patients engaged in the project. Utilize interoperable HER to enhance communication and avoid medical errors and/or duplicate services. DSRIP Project Review: Meeting #2 Project Requirement Development (PIP)

8 DSRIP Project Review: Meeting #3 PIP Risks & Mitigations A major risk to the hospital-home care collaboration project is the engagement of the patients. In order for this project to be successful, patients need to accept and participate in the home care plan upon discharge from the hospital. This risk will be mitigated by educating the patients on the benefits of home care and will utilize a multi-disciplinary discharge team comprised of a transition care coordinator, home care staff, social services, PCMH, and the patient and family members as appropriate. A second risk to this project is the duplication of efforts surrounding the implementation of an INTERACT like tool with the 2.b.vii project requirements of implementing INTERACT. The PPS has grouped the selected projects into 3 large buckets and the SNF/home care projects have been grouped together to work the "Long Term Care" projects. The LTC committee will be working together to streamline implementation of these projects which will help avoid duplication of efforts and resources between this project and project 2.b.vii. A final risk for this project is the lack of infrastructure and reimbursement from MCOs for telehealth visit. In order to expand the telehealth infrastructure, several PPS partners requested CRFP funds through the state process. Additionally, the PPS has set aside a portion of the DSRIP funds to pay for these types of uncovered services. Both of these funding sources will help to mitigate this risk and ensure this is project requirement is met by the PPS.

9 DSRIP Project Review: Meeting #4 PIP Review & Revisions Review Draft Project Implementation Plan Revise Draft PIP

Team “Homework” Distribution of Draft PIP Action Item Tracking & Clarification Next Meeting Scheduled Any additional attendees Presentations needed 10 Next Steps / Next Meeting

11 Questions / Open Discussion

Website: Maureen Buglino, VP, Community & Emergency Medicine Maria D’Urso, Administrative Director, Community Medicine Crystal Cheng, Data Analyst, DSRIP 12 PMO Resources