Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) Project Implementation Plan Development Asthma (3dii)

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 Expand asthma home-based self-management program to include home environmental trigger reduction, self-monitoring, medication use, and medical follow-up. Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions. Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests, mold, and second hand smoke. Develop and implement evidence based asthma management guidelines. DSRIP Project Review: Meeting #1 Project Requirement Development (PIP)

7 Implement training and asthma self- management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. Ensure coordinated care for asthma patients includes social services and support. Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what happened and how to avoid future events. DSRIP Project Review: Meeting #2 Project Requirement Development (PIP)

8 Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary care providers, and specialty providers. Use EHRs or other technical platforms to track all patients engaged in this project. DSRIP Project Review: Meeting #3 Project Requirement Development (PIP)

9 DSRIP Project Review: Meeting #3 PIP Risk & Mitigation The primary challenge for this project is the adherence to home based treatment regimens once determined by the PCP, non PCP, pulmonologists and other health care providers. A population health management strategy will be developed using IT software that will be determined to best connect with the attributed patient population, to serve as a trigger for compliance, with medication reminders, appointment reminders, and general asthma health reinforcement. The tool will assist with patient tracking and planning, and serve as a component of a proposed Asthma Resource Center for care coordination. Alternative ways for monitoring for adherence, such as one way communication such as text reminders will help move the efforts already in place with the Pediatric Asthma Center to more all- inclusive care coordination with improved patient outcomes and better management of a home based program. Interconnectivity with PPS school systems will be a concern and prove a risk to the successful achievement of milestones and metrics. Electronic school based health records are in different stages of technology development and the connection to an Asthma Resource Center will have to be recognized by the PPS leads to ensure that pathways to share the Medication Administration Form (MAF) with providers to coordinate care for the children associated with the project. The plan is to develop coalitions, protocols, and best practice technology based platforms to enhance bidirectional transfer of information to best support this patient population. Another risk to the expansion project of asthma home-based self-management program is the ability for providers to gain access to conduct the initial environmental assessment for trigger identification and subsequent visits to monitor and adjust recommendations once triggers are identified. Financial reimbursement and lack of funding for these visits is a component and risk for this project also. The Pre-existing Pediatric Asthma Center will serve as a model the PPS best practice, led by Dr. Jabbar, who will leverage existing collaborations among community organizations to ensure all CBO, including schools, shelters, housing representatives, and other organization are in alignment with risk modification once identified. The initiative will take pre-existing best practice and expand to repeat visit needs to determine compliance with recommendations for home environment adjustments. The team is leveraging established asthma community based programs to support PCPs, non-PCPs and health care providers on evidence based practice guidelines to support home management, including repeat home visits when necessary with financial components/incentives.

10 DSRIP Project Review: Meeting #3 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 11 Next Steps / Next Meeting

12 Questions / Open Discussion

Website: Maureen Buglino, VP, Community & Emergency Medicine Maria D’Urso, Administrative Director, Community Medicine Crystal Cheng, Data Analyst, DSRIP 13 PMO Resources