AMCH PPS PAC Meeting May 23, 2016

Agenda PMO Updates Finance Workforce Population Health Projects Accenture Clinical Integration Update

PMO Updates –June (DY2Q1) Deliverables –Mid-Point Assessment –Status of BHNNY –On-going Collaboration –Community Engagement –KPMG Internal Review –Upstate PPS Learning Collaborative –Regional Listening Session

June Deliverables –Clinical Integration Strategy: in progress –Workforce Strategy and Plan: in progress –Population Health IT Roadmap: in progress –Population Health Bed Reduction Plan: in progress –IT QE Patient Engagement Plan: in discussion –CCHLC Training Strategy: draft presented to committee –Governance Agency Coordination Plan: –Performance Reporting Training Strategy: in discussion 4

Finance DY1Q3 – AV Scorecard DY1Q4/DY1 - Cumulative Revenue Projection COPE Health Solutions Status of Contracts CBO Planning Grant VBP Boot Camps

Finance – DY1Q3 AV Scorecard

Finance – DY1Q4/DY1 Cumulative Revenue Projection

Finance – COPE Health Solutions C URRENT S TATUS COPE Health Solutions began its engagement with Albany Medical Center Hospital PPS in April 2016 to support the development and implementation of the Phase I partner funds flow and contracting strategy. The following activities have been completed to date by COPE: Review initial data provided by AMCH Develop Phase I contracting workplan Initial call with AMCH team to review and discuss Phase I contracting workplan and data requests Onsite meetings and check in calls to review status of Phase I contracting workplan and discuss budget for partner payments Initial review and recommendations for partner metrics to include in Phase I contracts Provide partner reporting and payment process guidance and support Assessment, feedback, and recommendations for follow up of baseline partner VBP assessment

Finance – COPE Health Solutions N EXT S TEPS COPE will continue to work closely with AMCH PPS to fully execute the Phase I contracting workplan within the next month. Immediate next steps include: Finalize partner metrics for Phase I contracting Develop and finalize partner specific eligible allocations Provide support in development and execution of partner reporting and payment process Develop partner specific Phase I contracts with eligible allocation, applicable metrics, and value per metric Continue to provide support and guidance on PPS reporting related matters as requested by AMCH

Finance – Status of Contracts

CBO Planning Grant Announcement The New York State Department of Health, Office of Health Insurance Programs is issuing a Request for Applications (RFA) to announce the availability of funds to support strategic planning activities for Community Based Organizations to facilitate their engagement in DSRIP activities. CBOs are trusted stakeholders in their communities and may be able to impact the social determinants of health. With major initiatives such as DSRIP, smaller community organizations are often challenged in how to engage and contract with larger, lead organizations, such as the PPS in DSRIP. These organizations tend to be administratively lean, have fewer resources and also compete with other CBOs for similar funding grants. Additionally, it may be challenging to analyze and present their service mission and enterprise in a business framework for contract arrangements. The administrative time and resources required for such engagements often exceed what individual CBOs have available to analyze the business requirements, and to successfully formulate a business strategy and proposition. Further, such demands may burden the CBO and undermine the resources needed for the CBO to continue to deliver its core services. As such, this RFA is designed to provide funding to non-Medicaid billing Community Based Organizations who address the social determinants of health. This RFA is intended to solicit applications for grants to assist CBO Consortiums in planning activities to identify business requirements and formulate strategies for short-term needs as well as longer term plans that the CBO consortium may envision for sustainability in system transformation. Overall, this will allow them to better position themselves for continuing engagement with PPSs in DSRIP projects, and consequently, value based payment and contracting. It is the Department's intent to award one award for each of the three regions outlined in the RFA. The three regions consist of New York City, Long Island and Mid-Hudson, and Rest of State. A maximum funding amount for each region is $2,500,000. To learn more about this opportunity, please go to the NYS Grants Gateway at the following web address: To locate the opportunity on Grants Gateway, search by the opportunity name: Community Based Organization (CBO) Planning Grant. Anticipated Contract Term: 12/1/ /30/2017 Due Date for Applications: 8/16/2016 by 4:00 p.m. ET Questions must be submitted to by 6/17/2016 by 4:00 p.m. Questions, Answers and Updates Posted (on or about): 6/30/2016

Finance – VBP Boot Camps Announcement We are pleased to share with you the launch of the new Value Based Payment (VBP) Bootcamps webpage. The VBP Bootcamps are regional learning series created by the Department of Health with a goal to equip future VBP contractors with the knowledge necessary to implement NYS Payment Reform. The website will provide you with the Bootcamps schedule, content outlines and ability to register for sessions in your region. Please remember to visit and sign up, as the first session for the Capital Region kicks-off on June 2 nd. Registrations will open 3 weeks in advance and close 1 week before the event. These events are free and open to the public. For those who are unable to attend the Bootcamps, sessions 1, 2, and 3 of Region 1 (Capital region, Mid-Hudson, and the Southern Tier) will be webcast live. The link will be sent out when it becomes available. Please follow this link to see the VBP Bootcamps page and a VBP library: orm.htm orm.htm

15 Workforce Coordinating Council (WCC) Compensation & Benefits Analysis DY2Q1 Preliminary Summary Results BDO Consulting Target Workforce State DY2Q1 Gap Analysis DY2Q2 Workforce Transition Roadmap DY2Q2 Impact Analysis (Baseline DY2Q1, subsequently Q2 and Q4 of each DY) New Hire Redeployed Retrained Training Strategy DY2Q2 Preliminary Assessment of Needs- Who, What, When, How Refine needs assessment through committees/ sub-committees Survey available training resources Identify training gaps Select training solutions Collaboration- AFBHC/ AHI, CCHLC All PPS Meeting- June 21 st

Population Health Management Milestone #1: Develop population health management roadmap Due: June 30, 2016 Must include: IT infrastructure required to support a population health management approach. Plans for achieving PCMH 2014 Level 3 certification in relevant provider organizations. Identification of priority target populations and define plans for addressing their health. disparities by establishing goals that reflect the State of New York’s Prevention Agenda. Aligning with Domain 4 projects A list of PCMH 2014 Level 3 certified provider organizations. Screenshot or reports from the IT system used to support the PPS’s population health management roadmap. Milestone #2: Finalize PPS-wide bed reduction plan Due: June 30, 2016 Must include: A copy of the bed reduction plan that lays out the PPS’s plan for bed reductions across its network, including behavioral health units/facilities, in line with planned reductions in avoidable admissions and the shift of activity from inpatient to outpatient settings. Milestone to align with bed reduction plans as they pertain to project 2av.

Project Overview Updates: Collaboration with Clarkson University Graduate students is nearing completion  Deliverables to PMO by June 1 st will include: recommended services to implement in potential Medical Villages based on the SNF survey results, hotspot and community analysis  Project findings will be available for key stakeholders upon review and approval Project leads remain committed to actively seeking out additional project participation Upcoming 03/31/2017 Milestones: 17 2av – Medical Village Transformation Update

Project 2.d.i Update Implementation of Patient Activation Activities to Engage, Educate and Integrate the Uninsured and Low and Non-utilizing Medicaid Populations into Community-based Care PAM trainings facilitated with our 3 major hospital partners (AMCH, Columbia Memorial & Saratoga Hospital). CBO partners & local government entities trained re: PAM and Coaching for Activation: Total PAM trained individuals as of 05/20/2016 = 120. Total number of patient activation measures completed as of 05/20/2016 = 7,789. Catholic Charities Planned Parenthood Columbia Healthcare ConsortiumColumbia County Mental Health Greene County Family PlanningCommunity Caregivers The Alliance for Positive HealthCommunity Health Center Koinonia Primary Care Black Nurses Coalition

Project 2.d.i Updates Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/ non-utilizing Medicaid populations into Community Based Care The project team is continuing to roll out the “train the trainer” method across the AMCH PPS network; training dates set for: The project team is planning on forming a workgroup to promulgate best practices in PAM administration and coaching. The team will also be seeking the advice of workgroup members related to the project’s next steps in placing patient navigators in the 5 counties’ hot spots. Trinity Alliance Albany Medical College – Dept. of Family and Community Medicine

AMCH PPS / 5-County Service Area -- Targeting Hotspots “Train the trainer” trainings 1.Columbia Memorial Hospital 2.AMCH Practice Administrators 3.Saratoga Hospital 4.Various CBOs Future Trainings The PMO Project Team continues to roll out the “train the trainer” method across our PPS network.

AMCH PPS: CQAC Updates Committee Update: –Meeting on May 18 th –Adoption of two Clinical Guidelines –Project updates

AMCH PPS CQAC: Project Update Project nameProject ID Start dateSC 1. Integrated Delivery Systems2.a.iNov/Dec ED Care Triage2.b.iiiNov/Dec Patient Engagement – PAM & CFA2.d.iNov/Dec Asthma Evidence-Based Guidelines3.b.iiiDec 2015/Jan Cardiovascular - Hypertension2.a.iiiDec 2015/Feb Integration of PC & BH – Part I (Models 1 & 3)3.a.iJan 2016/Feb Health Home At-Risk Intervention Program3.b.iJan 2016/Feb BH Community Crisis Stabilization3.a.iiJan 2016/Feb Integration of BH & PC – Part II (Model 2)3.a.iJan 2016/Mar Medical Village – SNF2.a.vApr 2016/Mar Tobacco Cessation4.b.iJun Cancer Screening4.b.iiJun 2016

2.a.iii – Health Home At-Risk Intervention Project Objective: Expand access to community primary care services (PCMH 2011 Level III certified sites) and develop integrated care teams to meet the individual needs of higher risk patients who do not currently qualify for NYS Health Home services. Co-Chairs: Kallanna Manjunath, MD & Stephanie Lao Key updates: – Health Home At-Risk sub-committee meeting held on 5/9/16 NYS Health Home overview educational session provided by Alliance for Positive Health Reviewed a draft process for referrals from PCMH to Health Home Care Management agencies Capacity concerns for our downstream providers Next steps:June meeting rescheduled for 6/20/16 PCMH involvement Development of Care Management Plan – Update from Accenture CCM Workgroup sessions 23

2.b.iii – ED Care Triage Project Objective: – To develop a care coordination/care transition program that will assist patients to link with a PCP – To provide supportive assistance to transitioning members to the least restrictive environment Chair: Denis Pauze, MD Key Updates: – ED Care Triage Subcommittee meeting held on May 2 nd Approved Opioid Prescription Guidelines for Use in ED Settings One City Health ED Care Triage Care Model MAPP Dashboard and Performance Measures Next Steps: – Next meeting TBD on the week of June 13 th – Review of Patient Education Materials for Appropriate ED Use – Review of Draft Document for ED Care Triage Program (Milestone 1) 24

3.b.i - Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) Project Objective: To support implementation of evidence-based best practices for disease management in medical practice for adults with cardiovascular conditions. May 6 Meeting included: Presentation by Albany County DOH: Local IMPACT (Initiatives for Multi-Sector Public Health Action) Program – Four major components: Environmental approaches Lifestyle change program participation Health system changes Community-clinical linkages One City Health CVD Care Model Self-management plans to be adopted; – AMC’s Lifestyle Goals – Million Heart’s Measure Up Pressure Down® EHR Structured Fields Document ICD-10 Codes for HTN Next Meeting: June 3, 8-9am, A207D/ WebEx 25

3.d.iii - Evidence-Based Medicine Guidelines for Asthma Management Project Objective: To ensure access for all patients with asthma to care consistent with evidence-based medicine guidelines for asthma management. May 13 Meeting included: Review of NHLBI Guidelines – Four Components of Asthma Care – Subcommittee approved the adoption of guidelines – CQAC approved PPS-wide adoption of guidelines at 5/18 meeting Asthma Action Plans – Discussed practice/ work flow issues and opportunities – Questionnaire disseminated to subcommittee Please respond by June 1! Performance Measures – PDI #14, PQI #15, Asthma Medication Ratio, Medication Management) AMCH Asthma Pathway: Possible webinar session with Saratoga Hospital, Columbia Memorial Health, and Alliance for Better Health Care Partners. Next Meeting: TBD 26

3.a.i Integration of Primary Care and Behavioral Health Services Updates: The 3 rd 3.a.i Sub-Committee meeting was held on 5/19/2016 : Finalized the proposal for required preventative care depression screening instruments for adults and adolescents, for CQAC approval. Reviewed Behavioral Health performance measures, and discussed interventions aimed at supporting PPS-wide progress on these. Identified Year 2 workgroup priorities, based on 03/31/2107 milestones: –Developing collaborative evidence-base standards of care including medication management and care engagement process. –Using EHRs or other technical platforms to track all patients engaged in this project.

3.a.i Integration of Primary Care and Behavioral Health Services Updates (continued.): –Continue to meet with individual participating provider organizations to support participation and address barriers. –Attended HANYS Behavioral Health SWAT, with presentations on integrated behavioral health by Intermountain Healthcare by Montefiore Hudson Valley Collaborative PPS, Beacon Healthcare, Refuah Community Health Collaborative PPS, Fort Drum Regional Health Planning Organization, Westchester Medical Center, East Tennessee State University.

3.a.i Integration of Primary Care and Behavioral Health Services Next Steps (contd.): –Develop and finalize proposal for required preventative care substance use disorder screening instruments, for CQAC approval. –Begin Primary Care and Behavioral Health-based Workgroup meetings. –Begin the process of identifying, disseminating, implementing, and documenting policies and procedures regarding preventative care screenings, and also evidence-based standards of care for integrated treatment.

3.a.ii Behavioral Health Community Crisis Stabilization Services Updates: The second 3.a.ii Sub-Committee meeting for this project was held on 5/9/2016. –Reviewed important details of project, including reporting requirements, actively engaged patients definitions, speed and scale requirements, and PPS-wide progress on key performance measures. –Presented, reviewed, and considered adoption of Montefiore Hudson Valley Collaborative’s guidance document for Actively Engaged Patients.

3.a.ii Behavioral Health Community Crisis Stabilization Services Updates(contd.): –Introduced Maryland Health Commission’s White Paper on Best Practices for Crisis Response and Diversion Strategies, and proposed its use as a guide to identify core components of crisis stabilization programs throughout our PPS. –Formed a workgroup to focus on identifying the core components of regional crisis stabilization service(s) for the PPS, and develop a proposal for how to phase components. –Reviewed performance measures, and began a discussion of interventions aimed at supporting PPS-wide progress.

3.a.ii Behavioral Health Community Crisis Stabilization Services Next Steps: The 3 rd 3.a.ii sub-committee meeting will be held on 6/13/16. Agenda items may include: –A presentation on relevant upcoming changes in reimbursement for crisis services. –A presentation by the PPS Clinical Integration team on the proposed future state of PPS care management/care coordination services, as they pertain to crisis stabilization services. –Revisit the discussion of Actively Engaged patients, to ensure we are capturing the range of crisis services provided throughout our PPS, and to support meeting speed and scale projections.

3.a.ii Behavioral Health Community Crisis Stabilization Services Next Steps (contd.): –Continue to identify best-practice models of crisis stabilization programs. –Convene workgroup to review best-practice models, identify core components for regional crisis stabilization services throughout our PPS, and develop proposal for how to phase the development of these components.

Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 34 Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. Insight Driven Health PAC May 23, 2016

Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 35 Draft for discussion Clinical Integration Project Status 5/16/16 – 5/20/16 Key activities for next period: (from 5/23/16 – 5/27/16) Review Training Approach with PAC on 5/23/16 Finalize training materials, criteria and implementation plan for upcoming DOH required training Conduct 2 introductory training sessions on 5/26/16, one for providers and one for operations Request approval for CCM to Oversight Committee on 6/3/16 Request approval for CCM at CQAC on 6/22/15 Accomplishments this period: (from 5/16/16 – 5/20/16) Incorporated updates from future state workgroup sessions and executive sponsors into Care Coordination Model (CCM) and CI CCM Functions/Processes/Protocols Sent updated CCM, CI CCM Functions/Processes/ Protocols, Staffing Model, and technology process flows to future state group participants, Steering Committee, and Project Leadership Team Continued to finalize training session materials, criteria, timeline and implementation plan for DOH requirements Socialized Care Coordination Model to Steering Committee and Project Leadership Team on 5/19/16 Issues & Risks: Key Project Milestone Progress: We are here – Week 13 Project Status Risk / IssueResolution / Mitigation Risk: Tight timelines require quick review turnaround and buy-in from stakeholders Socialize deliverable calendar and importance of meeting deadlines

Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 36 Training Approach

Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 37 Draft for discussion Accenture will collaborate with AMCH PMO to produce the training materials, criteria and implementation plan for upcoming DOH required training CI Training Materials and Considerations Materials for 5/26 Session Materials CCM and CI Overview presentation hr. session materials in PowerPoint format Sign-in sheet / attendance tracker Training Criteria Objectives for CI session Criteria for evaluation of CI session (pre- and post- tests) Training Implementation Plan Outline of CI training approach, including format, participants, mentoring opportunities, etc. Recommended timeline of CI training opportunities through 2016 Considerations for Training Training session participants and trainers (Accenture to train the trainer, PMO, for further dissemination across PPS) Access to intranet / internal system for recording and circulating training materials and sessions Additional technology / systems access and training requirements or prerequisites (i.e. Hixny-led computer-based onboarding) Future Continuing Education Units eligibility (for continuing education modules) Lessons learned from past trainings Availability of “mentors” for ongoing support Implications / recommendations captured during work group sessions Required DOH documentation (Schedule Template, sign-in, sample materials, etc.)

Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 38 Draft for discussion CI Training CI CCM Overview Session Course Name:AMCH PPS DSRIP Clinical Integration Overview Audience:  8-10am: PPS Providers across settings (inc. ED, inpatient, outpatient)  1-3pm: Operations staff (nurses, CM, SW, PN, Care Coordinators) across settings (inc. ED, inpatient, outpatient) Course Delivery Method:Instructor-led training  PowerPoint; in person  Computer Based Training (CBT) / Recorded; available via webinar for further dissemination Course Delivered by:  Initial session: Accenture (5/26)  Additional sessions: Select training representatives from PMO Course Description:The overall purpose of this module is to increase awareness and understanding of:  PPS’ framework for care coordination  Recommendations for strategies, processes, tools, data sharing, and timing standards as they relate to care coordination across the PPS Learning Objectives:Upon completion of this course, participants will be able to:  Describe the vision, framework and key elements / assumptions of the care coordination model  Identify the high level care coordination process flows and the technology that supports the process  Identify points of communication and elements for data exchange to further coordinated transitions of care  Identify the tools and templates which will be used to facilitate care coordination and ToC  Understand the roles of the interdisciplinary care team members  Understand the patient navigator role and identify key components and functions The initial training session will offer an introduction into the standard CC processes / functions, recommended tools, templates, and data sharing guidelines developed by the CI Work Group

Questions DSRIP Project Management Office Visit us at: 39