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

Agenda Welcome & Introductions Purpose of Meeting PPS Updates Review Timeline Review Action Items Project Requirement Step Development Next Steps / Next Meeting Questions / Open Discussion

PPS Updates NYS DSRIP Updates PPS DSRIP Updates

Timeline June 15 – June 19 June 22 – June 26 June 19 – July 3 Clinical Development Meeting Develop PIP Requirements June 22 – June 26 Clinical Development Meeting June 19 – July 3 No Meetings July 6 – July 10 July 13 - 17 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

DSRIP Project Review: Meeting #1 Project Requirement Development (PIP) Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol. Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management. Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment. Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment. Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit.

DSRIP Project Review: Meeting #2 Project Requirement Development (PIP) Prescribe once-daily regimens or fixed-dose combination pills when appropriate. Document patient driven self-management goals in the medical record and review with patients at each visit. Follow up with referrals to community based programs to document participation and behavioral and health status changes Develop and implement protocols for home blood pressure monitoring with follow up support. Engage a majority (at least 80%) of primary care practices in this project

DSRIP Project Review: Meeting #2 Project Requirement Development (PIP) Generate lists of patients with hypertension who have not had a recent visit and schedule a follow up visit. Facilitate referrals to NYS Smoker's Quitline. Perform additional actions including “hot spotting” strategies in high risk neighborhoods, linkages to Health Homes for the highest risk population, group visits, and implementation of the Stanford Model for chronic diseases. Adopt strategies from the Million Lives Campaign. Form agreements with the Medicaid Managed Care organizations serving the affected population to coordinate services under this project

DSRIP Project Review: Meeting #3 Project Requirement Development (PIP) Actively share EHR systems with local health information exchange/RHIO/SHIN-NY and share health information among clinical partners, including secure notifications/messaging, by the end of Demonstration Year 3. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards by the end of Demonstration Year (DY) 3. Use EHRs or other technical platforms to track all patients engaged in this project. Use the EHR or other technical platform to prompt providers to complete the 5 A's of tobacco control (Ask, Assess, Advise, Assist, and Arrange).

DSRIP Project Review: Meeting #4 PIP Risks & Mitigations A high level risk that is associated with the implementation of a cardiovascular evidence-based standardized care pathway is coordinating with the implementation speed of the Patient Centered Medical Home recognition (Project 2.a.ii) and meeting PCMH level 3 targets. This risk may directly associate with the level of speed and scale attributed to this project. Inherent to a successful mitigation strategy for adaptation of evidence-based care pathways and standardization for cardiovascular disease risk reduction is to coordinate timing of standardized strategies with implementation of the PCMH initiatives. The PPS will need to coordinate activities within the different project work plans to ensure collaboration with the PCMH initiatives, without slighting either of these two projects or undermining the other projects, such as behavioral health integration. Current state assessment of cardiovascular disease prevention initiatives that are already a component of the existing PCMH framework will be used as a springboard to enhance collaboration with health care providers to heighten cardiovascular prevention awareness as a means to improve patient outcomes. Another risk to the project is the inability to meet patient engagement and improvement in health outcomes due to a shortage of community health workers in the targeted community that could serve as a liaison between health and social service to establish trusting relationships with the patient population. The PPS will align with the resources of workforce plan to collaborate with community leaders to develop, strengthen and empower community health team workers to integrate culturally sensitive patients into the engaged population. Specific focus will begin with those patients that require complex core coordination for hypertension and one or more comorbidities. If needed, a project plan to actively recruit community health workers to fill gaps in workforce will be coordinated at the PPS level. Another risk for this project is the potential for low compliance of both patients and practitioners. This risk will be mitigated by utilizing the practitioner engagement committee to ensure that providers are knowledgeable about DSRIP and utilizing best practices across the PPS. Patients will be engaged through education, possible IT solutions including portal messaging etc. to ensure that they are compliant with their self-management goals.

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

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

Questions / Open Discussion ?

PMO Resources Website: www.nyhq.org/dsrippps Maureen Buglino, VP, Community & Emergency Medicine mabuglin@nyp.org Maria D’Urso, Administrative Director, Community Medicine mda9005@nyp.org Crystal Cheng, Data Analyst, DSRIP crc9038@nyp.org