Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) June 9, 2015 Long Term Care (2bv, 2bvii)

Agenda 2 Welcome & IntroductionsClinical LeadershipMeeting PurposeScope of Clinical Sub-CommitteePPS Updates & TimelineDSRIP Project ReviewClinical Case Vision & ExampleClinical PlanningSWOTNext Steps / Next MeetingQuestions / Adjourn

Chair: Caroline Keane 3 Clinical Leadership

Initiate the clinical planning process of the NYHQ PPS DSRIP projects in order to complete the Project Implementation Plans due July 31, 2015, develop strategies for actualization of projects, identify operational process, IT, budget, or workforce needs, and ensure all engaged partners are actively engaged in planning & implementation. 4 Meeting Purpose

Engage PPS network partners to operationally plan, develop, and design the clinical program outlined in the DSRIP application submitted in December 2014 Focus on collaborative planning processes that meet project requirements, metrics, and scale & speed expectations associated with the clinical program Complete the Project Implementation Plans due July 31 Inform budgets and operational needs such as workforce & IT Guide partners by becoming a resource and communication channel to ensure effective engagement 5 Scope of Clinical Sub-Committee

Clinical planning will include, but is not limited to: Implement project design to include all committed PPS partners Establish and meet performance reporting expectations Establish expectations for evidence based medicine protocols & best practice standards Communicate internally and externally on program development and progress Explain variances of project requirement or metric progress Ensure success of the project by improving clinical quality and meeting expectations of project requirements, scale & speed, and metrics Work with other committees and sub-committees to ensure cross communication & feedback 6 Scope of Clinical Sub-Committee

 Organization Implementation Plans – Submitted  PPS Valuation Notification – Received  Project Implementation Plans – Due 7/31/2015  Executive Committee Meeting – 6/11/2015  PAC Meeting – 6/19/2015  Workforce Data Due – 10/31/2015  Budgets, Funds Flow, Business Agreements – In Development  Clinical Planning Meetings – Begin week of 6/8/ PPS Updates & Timeline

Clinical Planning & Development Project Implementation Plans Due (7/31/15) DY1 Quarterly Report Due (7/31/15) Workforce Data Due (10/31/2015) 8 PPS Updates & Timeline Organization Development, Budget & Funds Flow Development, Committee & Governance Structure Development, Clinical Planning & Implementation, IT Development, Workforce Planning, Partner Engagement, etc.

99 Bi-annual payments driven by quarterly reports of milestone, metric, & scale & speed achieved deliverables DSRIP Year/Quarter Dates CoveredQuarterly Report DuePayment Date DY1, Q1April 1, 2015 – June 30, 2015July 31, 2015 January 2016 DY1, Q2July 1, 2015 – September 30, 2015October 31, 2015 DY1, Q3October 1, 2015 – December 31, 2015January 31, 2016 July 2016 DY1, Q4January 1, 2016 – March 31, 2016April 30, 2016 DY2, Q1April 1, 2016 – June 30, 2016July 31, 2016 January 2017 DY2, Q2July 1, 2016 – September 30, 2016October 31, 2016 DY2, Q3October 1, 2016 – December 31, 2016January 31, 2017 July 2017 DY2, Q4January 1, 2017 – March 31, 2017April 30, 2017 PPS Updates & Timeline

10 DSRIP Project Review: Project Requirements (2bv) Partner with associated SNFs to develop a standardized protocol to assist with resolution of the identified issues. Engage with the Medicaid Managed Care Organizations and Managed Long Term Care or FIDA Plans associated with their identified population to develop transition of care protocols, ensure covered services including DME will be readily available, and that there is a payment strategy for the transition of care services. Develop transition of care protocols will include timely notification of planned discharges and the ability of the SNF staff to visit the patient and staff in the hospital to develop the transition of care services. Ensure that all relevant protocols allow patients in end of-life situations to transition home with all appropriate services. Establish protocols for standardized care record transitions to the SNF staff and medical personnel.

11 DSRIP Project Review: Project Requirements (2bv) Ensure all participating hospitals and SNFs have shared EHR system capability and HIE/RHIO/SHIN-NY access for electronic transition of medical records by the end of DSRIP Year 3. Use EHRs and other technical platforms to track all patients engaged in the project.

12 DSRIP Project Review: Project Requirements (2bvii) Implement INTERACT at each participating SNF, demonstrated by active use of the INTERACT 3.0 toolkit and other resources available at Identify a facility champion who will engage other staff and serve as a coach and leader of INTERACT program. 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. Educate all staff on care pathways and INTERACT principles. 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.

13 DSRIP Project Review: Project Requirements (2bvii) Create coaching program to facilitate and support implementation.Educate patient and family/caretakers, to facilitate participation in planning of care. Establish enhanced communication with acute care hospitals, preferably with EHR and HIE connectivity. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. Use EHRs and other technical platforms to track all patients engaged in the project.

14 DSRIP Project Review: Scale & Speed: Committed Providers NYS Designated Categories Total # committed providers Primary Care Physicians 97 Non-PCP Practitioners 72 Hospitals1 SNF27 CBO0 All Other102 All Committed Providers 299 Total # providers committed (as per project plan application) SNFs participating in the INTERACT program meeting all project requirements 27 All Committed Providers 27 2bv 2bvii

15 Engaged Patient Definition: The number of participating patients with a care transition plan developed prior to discharge and not readmitted within that 30-day period. **Duplicate counts of patients are allowed provided that they meet the criteria more than once during a 1- year measure DSRIP Project Review: Scale & Speed: Patient Engagement (2bv) Total Expected # of actively engaged patients 1865 DY1, Q2DY1, Q3DY1, Q4DY2, Q1DY2, Q2DY2, Q3DY2, Q4 Patients Engaged per Quarter DY3, Q1DY3, Q2DY3, Q3DY3, Q4DY4, Q1DY4, Q2DY4, Q3DY4, Q

16 Engaged Patient Definition: The number of participating patients who avoided SNF to hospital transfer, attributable to INTERACT principles established within the project requirements. DSRIP Project Review: Scale & Speed: Patient Engagement (2bvii) Expected # of actively engaged patients 1765 DY1, Q2DY1, Q3DY1, Q4DY2, Q1DY2, Q2DY2, Q3DY2, Q4 Patients Engaged DY3, Q1DY3, Q2DY3, Q3DY3, Q4DY4, Q1DY4, Q2DY4, Q3DY4, Q

DSRIP Project Review: Clinical Project Requirements: Metrics 17 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 2 – System Transformation Potentially Avoidable Emergency Room Visits ± Number of preventable emergency visits as defined by revenue and CPT codes Number of people (excludes those born during the measurement year) as of June 30 of measurement year per 100 Medicaid enrollees *High Perf Elig # SW measure NYS DOH P4RP4P Potentially Avoidable Readmissions ± Number of readmission chains (at risk admissions followed by one or more clinically related readmission within 30 days of discharge) Number of people as of June 30 of the measurement year 0.00 per 100,000 Medicaid Enrollees *High Perf Elig # SW measure NYS DOH P4RP4P PQI 90 – Composite of all measures ± Number of admissions which were in the numerator of one of the adult prevention quality indicators Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P PDI 90– Composite of all measures ± Number of admissions which were in the numerator of one of the pediatric prevention quality indicators Number of people 6 to 17 years as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 18 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Primary Care – Length of Relationship – Q3 Percent of Responses at least 1 year or longer All Responses100%^ # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 20 to 44 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 20 to 44 as of June 30 of the measurement year 91.1% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 45 to 64 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 45 to 64 as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 65 and older Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 65 and older as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 19 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Children’s Access to Primary Care – 12 to 24 months Number of children who had a visit with a primary care provider during the measurement period Number of children ages 12 to 24 months as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 25 months to 6 years Number of children who had a visit with a primary care provider during the measurement period Number of children ages 25 months to 6 years as of June 30 of the measurement year 98.4% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 7 to 11 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 7 to 11 years as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 12 to 19 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 12 to 19 years as of June 30 of the measurement year 98.8% # SW measure NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 20 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) Number responses Usuall LJ o ƌ Al ǁ a LJ s got appt for urgent care or routine care as soon as needed, got answers the same day if called during the day or response as soon as needed if called after hours Number who answered they called for appointments or called for information 100%^ # SW measure NYS DOH P4RP4P Helpful, Courteous, and Respectful Office Staff (Q24 and 25) Number responses Usuall LJ o ƌ Al ǁ a LJ s that clerks and receptionists were helpful and courteous and respectful All responses100%^ # SW measure NYS DOH P4RP4P Medicaid Spending on ER and Inpatient Services ± Total spending on ER and IP services Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R

DSRIP Project Review: Clinical Project Requirements: Metrics 21 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Medicaid spending on Primary Care and community based behavioral health care Total spending on Primary Care and Community Behavioral Health care as defined by MMCOR categories Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R H-CAHPS – Care Transition Metrics (Q23, 24, and 25) Sum of Hospital specific results for the Care Transition composite Hospitals with H-CAHPS participating in the PPS network 100%^NYS DOH P4RP4P CAHPS Measures – Care Coordination with provider up-to- date about care received from other providers Number responses Usuall LJ o ƌ Al ǁ a LJ s that doctor informed and up- to-date about care received from other providers All responses with member seeing more than one provider 100%^ # SW measure NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 22 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Prevention Quality Indicator # 7 (HTN) ± Number of admissions with a principal diagnosis of hypertension Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Prevention Quality Indicator # 13 (Angina without procedure) ± Number of admissions with a principal diagnosis of angina without a cardiac procedure Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Cholesterol Management for Patients with CV Conditions – LDL-C Testing Number of people who had at least one LDL-C screening performed during the measurement year Number of people, ages 18 to 75 years, with a cardiovascular condition 96.8%PPS and NYS DOH P4RP4P Cholesterol Management for Patients with CV Conditions – LDL-C > 100 mg/dL Number of people whose most recent LDL- C result during the measurement year was below 100mg/dL Number of people, ages 18 to 75 years, with a cardiovascular condition 55.0%PPS and NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 23 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Controlling High Blood PressureNumber of people whose blood pressure was adequately controlled (below 140/90) or if diabetes below 140/80. Number of people, ages 18 to 85 years, who have hypertension 73.3% (2012 Data) *High Perf Elig PPS and NYS DOH P4RP4P Aspirin UseNumber of respondents who are currently taking aspirin daily or every other day Number of respondents who are men, ages 46 to 65 years, with at least one cardiovascular risk factor; men, ages 66 to 79 years, regardless of risk factors; and women, ages 56 to 79 years, with at least two cardiovascular risk factors 100%^NYS DOH P4RP4P Discussion of Risks and Benefits of Aspirin Use Number of respondents who discussed the risks and benefits of using aspirin with a doctor or health provider Number of respondents who are men, ages 46 to 79 years, and women, ages 56 to 79 years 100%^NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 24 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Medical Assistance with Smoking and Tobacco Use Cessation – Advised to Quit Number of respondents who were advised to quit Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^NYS DOH P4RP4P Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Medication Number of respondents who discussed or were recommended cessation medications Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^NYS DOH P4RP4P Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Strategies Number of respondents who discussed or were provided cessation methods or strategies Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^ *High Perf Elig NYS DOH P4RP4P Flu Shots for Adults Ages 18 – 64 Number of respondents who have had a flu shot Number of respondents, ages 18 to 64 years 100%^NYS DOH P4RP4P

DSRIP Project Review: Clinical Project Requirements: Metrics 25 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Health Literacy (QHL13, 14, and 16) Number responses Usuall LJ o ƌ Al ǁ a LJ s that instructions for caring for condition were easy to understand, described how the instruction would be followed and were told what to do if illness/condition got worse or came back Number who answered they saw provider for a illness or condition and were given instructions 100%^NYS DOH P4RP4P

26 DSRIP Project Review: Project Implementation Plan 2.b.v Care Transitions Intervention for Skilled Nursing Facility (SNF) Residents 1. Measurable milestones and implementation risks Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. A risk to implementing this project is the requirement that partners engage with Medicaid Managed Care Organizations to develop standardized protocols that will include covered services as this PPS is utilizing a collaborative contracting model for the Governance structure. This risk will be mitigated by using the PPS project participants to determine best practices and develop a standardized care transition plan for engaged patients within the PPS. Partners will be able to leverage this approach when negotiating with the MCOs. Another risk for this project is recognizing the learning curve for members of the care transition teams that will manage this project and the subsequent overlapping projects. Specifically for this project, NYHQ will adapt an incremental approach to care transitions focusing on the current workforce and possible pilot program to switch established case managers to care transition teams to ensure a smooth integration of roles and responsibilities. This component of the project will need to align with the Workforce Plan the recruitment, retention and training of care transition coaches. This project must also be linked with the Cultural Competency / Health Literacy implementation plan to increase awareness of transition coaches to the intricacies of the patient population in a culturally-sensitive manner. Finally, the necessity of an interoperable EHR system is a risk for this project. The PPS has committed to engaging patients beginning DY1 Q2, but the interoperable EHR system will not be implemented in that time frame. This is a risk as the project requires that that SNFs have access to the patient record and hospital staff prior to discharge to ensure that that the patient is transitioned appropriately. This risk will be mitigated by implementing interim care transition solutions until the EHR system is installed in the PPS.

27 DSRIP Project Review: Project Implementation Plan Project 2.b.v Project Requirements/sub-stepsTarget Completion DateUnit Level Reporting 1. Partner with associated SNFs to develop a standardized protocol to assist with resolution of the identified issues. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 2. Engage with the Medicaid Managed Care Organizations and Managed Long Term Care or FIDA Plans associated with their identified population to develop transition of care protocols, ensure covered services including DME will be readily available, and that there is a payment strategy for the transition of care services. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 3. Develop transition of care protocols will include timely notification of planned discharges and the ability of the SNF staff to visit the patient and staff in the hospital to develop the transition of care services. Ensure that all relevant protocols allow patients in end of-life situations to transition home with all appropriate services. DY2, Q4 Provider Level: PCP, SNF Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 4. Establish protocols for standardized care record transitions to the SNF staff and medical personnel. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

28 DSRIP Project Review: Project Implementation Plan 5. Ensure all participating hospitals and SNFs have shared EHR system capability and HIE/RHIO/SHIN-NY access for electronic transition of medical records by the end of DSRIP Year 3. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 6. Use EHRs and other technical platforms to track all patients engaged in the project. DY3, Q4Provider Level: SN PCP, SNF Step 1… Step 2… [Please add additional steps based on your plan and timeline]

29 DSRIP Project Review: Project Implementation Plan 2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) 1. Measurable milestones and implementation risks Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. A risk to the success of this project is the engagement of practitioners and staff. This project requires that physician champions be nominated and that coaching programs be utilized to train staff throughout the PPS. In order for these mechanisms to be successful, staff and practitioners must be engaged in DSRIP and the implementation of INTERACT. The PPS will mitigate this risk by having a strong, enthusiastic project committee which will pave the way for practitioner engagement and project implementation. The project committee will also partner with the practitioner engagement committee as needed to ensure that information is disseminated in a timely fashion to the PPS members and encourage engagement and a results oriented system for the DSRIP projects. Another risk connected with the INTERACT project is maximizing day to day requirements of front end staff while integrating training that is needed to become proficient and comfortable to support the implementation. Mitigation strategies will contain best practice methods and recruitment to identify champions to motivate, educate and engage among peers. Caregiver training on the components of the INTERTACT need to be recognized at the PPS level as well as at the administrative employer level so that the staff can be supported. Train the trainer options needs to be pursued to maximize training opportunities and change behavior tactics integrated early in the process to enhance acceptance and ownership. The immediate positive outcome to the INTERACT project is that once staff acceptance is recognized and staff become vested in the project, the level of care and positive outcomes will help to drive the project. Staff will recognize their impact, start to explore new ideas and concepts that can be adapted to the current state, and commit to improving patient outcomes. The final risk to this project is the varying levels of EHR systems and interoperability currently implemented across PPS partners. As the PPS moves forward with DSRIP, the goal is to bring all PPS partners up to the same EHR standard and create an interoperable EHR system. As a mitigation strategy to the IT platforms concerns, the INTERACT tool is available in numerous forms i.e.: electronic, paper etc. This will allow partners to implement the tool immediately and then adapt moving forward once the IT systems are upgraded.

30 Project 2.b.vii Project Requirements/sub-stepsTarget Completion DateUnit Level Reporting 1. Implement INTERACT at each participating SNF, demonstrated by active use of the INTERACT 3.0 toolkit and other resources available at DY2, Q4 Provider Level: SNF Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 2. Identify a facility champion who will engage other staff and serve as a coach and leader of INTERACT program. DY2, Q4Provider Level: SNF Step 1… Step 2… [Please add additional steps based on your plan and timeline] 3. 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. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 4. Educate all staff on care pathways and INTERACT principles. DY2, Q4Provider Level: SNF Step 1… Step 2… [Please add additional steps based on your plan and timeline] DSRIP Project Review: Project Implementation Plan

31 5. 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. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 6. Create coaching program to facilitate and support implementation. DY2, Q4Provider Level: SNF Step 1… Step 2… [Please add additional steps based on your plan and timeline] 7. Educate patient and family/caretakers, to facilitate participation in planning of care. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 8. Establish enhanced communication with acute care hospitals, preferably with EHR and HIE connectivity. DY2, Q4 Provider Level: SN PCP, SNF Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] DSRIP Project Review: Project Implementation Plan

32 9. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 10. Use EHRs and other technical platforms to track all patients engaged in the project. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] DSRIP Project Review: Project Implementation Plan

Clinical Case Vision & Example 33

34 Space / LocationIT NeedsPatient TrackingBillingClinical ImplementationWorkforce Impact / NeedNon-Covered Services Anticipated Clinical Planning

35 StrengthsWeaknessesOpportunitiesThreats SWOT Analysis

Additional webinar based clinical planning meetings – TBD Project Implementation Plan drafting & distribution Executive Team Development of budgets, funds flow, agreements Executive Committee review & approval Partner agreement completion PAC meeting 6/19/15 36 Next Steps / Next Meeting

37 Questions / Open Discussion

Website: Maureen Buglino, VP, Community & Emergency Medicine Maria D’Urso, Administrative Director, Community Medicine Crystal Cheng, Data Analyst, DSRIP 38 Resources