Regional Project Advisory Committee Oneida County Regional Project Advisory Committee Oneida County Department of Mental Health

“Value Based Payment and the Year Ahead” https://youtu.be/jqFipBmg2Rs

There are Three Primary Objectives of the DSRIP Program Goals of DSRIP There are Three Primary Objectives of the DSRIP Program Promote community-level collaboration via performing provider systems (PPSs) that support the formation of Integrated Delivery Networks… IDN Preserve and transform the State’s fragile health care safety net system and prepare providers for success in Value Based Payment… VBP Improve health outcomes and reduce avoidable hospital readmissions and emergency department utilization by… 25%

Characteristics of an Integrated Delivery Network (IDN) An Integrated Delivery Network (IDN) is Defined by a System of Health Care Organizations Created to Drive Greater Value and Improve Care Standardized Protocols and Procedures of Care Implementation of Evidence Based Best Practices Care Coordination and Care Management Functions Robust Data Analytics and Data Sharing Collaborative Governance Structure Communication Across Providers 1 2 3 4 5 6 PPS Projects PPS PHM Infrastructure PPS Corporate Functions

Patient Roadmap: Janine Carzo & Robin O’Brien Christine Stegel, I-PRO

MAX PROJECT UTICA

goal PPMH will integrate behavioral health and limited primary care.

MISSION STATEMENT To create an interdisciplinary health and wellness environment for the community that can assess factors that impact health and wellness. Overcome barriers to care, provide care that achieves measurable outcomes and patient goals.

Three action plans 1. Reduce duplicative information gathering. Expand PHQ2/9 screenings. 3. Establish regular weekly meetings.

Action plan 1- Reduce duplicative info gathering Staff meeting on 3/1/16. The Utica clinic team worked on how we could streamline the clinic flow so that the length of the visit is not increased when PHQ2/9 is added to the visit. Flow Chart

report We are running a 5 Stage Athena report to enable us to compare the time frames regarding check in, intake, exam, check out, total time in chart, and length of visit.

METRICS CK IN INTAKE EXAM CK OUT VISIT TIME VISIT LENGTH average 3/21/2016   0:13:09 0:19:53 0:23:55 0:00:53 0:24:27 1:14:41 2/15/2016 0:15:57 0:19:56 0:23:25 0:02:31 1:08:46 1:56:53 save 2.48min save 3 sec up 30sec SAVE1.78MIN save 35min save 42min 3/23/2015 0:09:37 0:18:07 0:22:04 0:00:51 0:34:40 1:15:31 UP 3.72MIN UP 1.46MIN UP 1.51MIN UP 2SEC SAVE 10.13 MIN SAVE 1MIN

Action plan 2- Expand phq2/9 Previously, PHQ2/9 was assessed only with new and established ANNUAL visits. PHQ2/9 is now assessed at ALL visits (annual wellness AND problem visits), excluding Cancer Services Program (CSP) and Resource Center for Independent Living (RCIL).

report We are running weekly reports to collect data on how may PHQ2/9 screenings we have completed. The report includes the date, chart number, patient age, gender, insurance, appointment type and score.

METRICS Utica-466 patients were screened from 7/1/15 – 2/29/16. Average, 58/month, 14/wk. Utica-165 patients were screened the week of 3/21/16 – 3/29/16. 8 of these patients moved from the PHQ2 to the 9.

Action plan 3- Establish regular weekly meetings 1. PPMH team and KPMG meet every Monday at 9:30am via conference call. 2. PPMH team and Lesley Teitelbaum, Ph.D. meet every Friday at 9:00am via conference call.

Additional changes Created an office space for Ph.D. in clinic. We have moved nurse/staff office to the second floor. When a patient has Medicaid or Medicaid Managed Care, we are referring/making an appointment with Community Behavioral Health Services or Mental Health Connections. When a patient has private insurance, we are referring/making an appointment with a private practice from our referral list.

2017 Program Information A total of 88 appointments for behavioral health so far in 2017 Recently added the PHQ2/9 to the Phreesia pad in all centers, which allows us to screen 100% of patients and identify the highest number of patients in need. As of April 2017, 23% of patients affiliate-wide scored a 3 or higher on the PHQ2/9

CNYCC Project Crosswalk Cross-setting Relevance Mohawk Valley Health System (MVHS) RPAC/Care Transition Coalition Meeting June 1, 2017

Relationships Among CNYCC Forums Full PPS Community Partner & RPACs

Care Transition Coalitions Project Crosswalk 2ai 2aiii 2biii 2biv 2di 3ai 3aii 3bi 3gi 4aiii 4di Settings Integrated Delivery Network DSRIP CM ED Triage Care Transition PAM PC/BH Integration BH Crisis Stabilization CVDM Palliative Care BH Infrastructure Premature Births BH x    CBO Health Home  x Home Health Hospice Hospital PCP x SNF  x 

CNYCC DSRIP Project Crosswalk DSRIP Projects Care Transition Coalitions Patient Centered Medical Home (PCMH) - PCP Patient Activation Measure (PCP, BH, CBO, HHA, HH, SNF, Hosp) DSRIP Care Management (PCP, CBO, HH) Palliative Care (PCP, HHA, SNF, Hos, Hosp, BH) Behavioral Health Crisis Stabilization (BH, CBO, Hosp, HH, PCP) Behavioral Health Integration (PCP, CBO, HH, SNF, Hosp) Cardiovascular Disease (PCP, HHA, SNF, Hosp, BH)

Operational Report

Digital Billboard

Proposed Allocation of CY17 Baseline Partner Share w/ Rollover Total Partner Share for CY17/FY17: approx. $49M Phase II Contracting Funds Copyright © 2017 COPE Health Solutions. All rights reserved.

Phase II Contracting Phase II Funding: Next Steps: $34 Million Dollars to be allocated to Partner Organizations Formula to Determine Potential Funding Possible per Individual Partner Organization Greater Emphasis on Performance Measurement “Bridge” the network activities from previous payment policies to upcoming Phase II contracts Next Steps: FFWG Recommendation of Phase II Funds Flow Policies BOD Approval (June Board Meeting) Development & Distribution of Phase II (Amended) Project Agreements Friday Webinar – Overview of Bridge Payment and Phase II Contracting Process

Management Dashboards Performance & Outcomes Measures (Measurement Year 2, - MY2 - ) July 2015 to June 2016 Actively Engaged Patients (Demonstration Year 3, (DY3)) April 2017

Performance & Outcomes Measures (Measurement Year 2, (MY2)) July 2015 to June 2016

Performance and Outcomes Measures – Measure Summary CNYCC Performance Measure Summary Total Total Measures 52 # of Measures with Data Available 24 # of Measures with No Data Available 28 # of Measures on Target 10 # of Measures off Target 14 # of Measures with Unknown Performance # of Measures currently Pay for Reporting 39 # of Measures currently Pay for Performance 13

Total Available Funding DY2, Q3 and Q4 Reporting Period

Available Funding for AEP & Performance and Outcomes (Total Available Funding for DY2, Q3 and Q4 - $5,405,492.52)

Performance and Outcomes – Projected Funding Summary Dollar Values reflected in the Dashboards are based on the available funds for DY2, Quarters 3 and 4. Total available to CNYCC is $4,617,291.73 Performance Measures are broken into 4 Tiers based on measure worth Tier 1 – 15 Performance and Outcomes Measures worth $2,624,748.34 Includes Potentially Avoidable Readmissions and Potentially Avoidable ER Visits Measures Tier 2 – 13 Performance and Outcomes Measures worth $1,204,171.27 Includes Follow-up after Hospitalization (7 & 30 Days) & Antidepressant Medication Management Tier 3 – 12 Performance and Outcomes Measures worth $633,986.46 Includes Adult and Children’s Access Measures Tier 4 – 12 Performance and Outcomes Measures worth $154,385.66 Includes Cardiovascular Measures

Performance and Outcomes – Projected Funding Summary (Total Funding Available for DY2, Q3 and Q4 Performance Measures - $4,617,291.73)

Projected NOT to Receive Payment Performance and Outcomes – Projected Funding Summary (Total Funding Available for DY2, Q3 and Q4 Tier 1 Performance Measures - $2,624,748.34) Projected NOT to Receive Payment Pay for Reporting – Guaranteed Funds Performance Unknown – Pay for Performance Projected to Receive Payment

Projected NOT to Receive Payment Performance and Outcomes – Projected Funding Summary (Total Funding Available for DY2, Q3 and Q4 Performance Measures - $4,617,291.73) Projected NOT to Receive Payment Pay for Reporting – Guaranteed Funds Performance Unknown – Pay for Performance Projected to Receive Payment

Performance & Outcomes Measures – Goals & Results (Performance Period: July 2015 – June 2016 [Measurement Year 2]) The Performance and Outcomes Measures below apply to the following projects: Integrated Delivery System (2.a.i) DSRIP Care Management (2.a.iii) ED Care Triage (2.b.iii) Care Transitions (2.b.iv)

Performance & Outcomes Measures – Goals & Results Pay for Reporting Measures (Performance Period: July 2015 – June 2016 [Measurement Year 2]) On or Above Goal Not on Target to Goal – Indicates which direction and how much improvement is needed for CNYCC to meet goal

CNYCC Actively Engaged Patient Dashboards

Actively Engaged Patients: April 1 – April 30th, 2017 Project DY3Q2 Target Actual Gap to DY2Q4 Target Status DSRIP Care Management (2aiii) 5,600 8 5,592 ED Care Triage (2biii) 7,200 700 6,500 Care Transitions (2biv) 2,970 17 2,953 Patient Activation (2di) 11,100 405 10,695 Primary Care/Behavioral Health Integration (3ai) 16,490 2,739 13,751 Behavioral Health Crisis Stabilization (3aii) 10,800 611 10,189 Cardiovascular Disease Management (3bi) 6,460 672 5,788 Palliative Care PCMH Integration (3gi) 1,980  Indicates that 80% of the Q4 target has been reached and the AV should therefore be achieved

DSRIP Care Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

DSRIP Care Management Actively Engaged Patient Targets DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 5,600 8 747 x 6 months $167,000 DY3Q4 (3/18) 16,700 - 1112 x 12 months $144,000 Action Steps To increase partnership between Health Homes, down stream providers and medical entities, a finalized sample Service Agreement and Care Coordination communication work flow will be disseminated to partner organizations to assist with implementation strategies. * 80% AEP needed to meet target

ED Care Triage Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

ED Care Triage Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 7,200 700 960 x 6 months $157,000 DY3Q4 (3/18) 14,490 - 966 x 12 months $134,000 Action Steps Recent change (4/19) to expand AEP Definition by suspending the 2 day business notification of PCP or HH CM appointment. The expanded AEP Definition is: Had either a PCP or Health Home Care Manager appointment scheduled within 30 Days of the ED discharge date OR A PCP or Health Home Care Manager appointment scheduled outside of the 30 Days following the ED discharge BUT had been notified of the appointment within 30 Days of the ED discharge * 80% AEP needed to meet target

Care Transitions Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

Care Transitions Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 2,970 17 396 x 6 months $156,000 DY3Q4 (3/18) 5,940 - 396 x 12 months $134,000 Action Steps Actively Engaged Patient definition is undergoing review and revision that will include a consideration of timing based on the new DY. * 80% AEP needed to meet target

Patient Activation Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

Patient Activation Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 11,100 405 1480 x 6 months $135,000 DY3Q4 (3/18) 22,300 - 1,487 x 12 months $116,000 Action Steps Continuing outreach to engage new organizations to partner with CNYCC to implement project * 80% AEP needed to meet target

Primary Care/Behavioral Health Integration Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

Primary Care/Behavioral Health Integration Actively Engaged Patients DY Target Actual AEP x Month (*) $ At-Risk DY3Q2 (9/17) 16,490 2739 2199 x 6 months $142,000 DY3Q4 (3/18) 39,865 - 2,658 x 12 months $122,000 Action Steps Actively Engaged Patient Reporting Criteria narrows starting April 1st to align with the 3ai Standards of Care * 80% AEP needed to meet target

Behavioral Health Crisis Stabilization Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

Behavioral Health Crisis Stabilization Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 10,800 611 1,440 x 6 months $135,000 DY3Q4 (3/18) 24,480 - 1,632 x 12 months $116,000 Action Steps Convening partner-led discussion about Open Access scheduling as a strategy to improve access to services. Workgroup meeting to develop protocols around mobile crisis, peer respite and warm line. Work of the group will continue, but at the county level; exploring overlap with the Care Transition Coalitions and other forums. * 80% AEP needed to meet target

Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

Cardiovascular Disease Management Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 6,460 672 861 x 6 months $104,000 DY3Q4 (3/18) 12,730 - 849 x 12 months $89,000 Action Steps Supporting partner implementation of Standards of Care. Working with HealtheConnections and other community partners to increase Self-Measured Blood Pressure opportunities to improve patient blood pressure control. Continuing work with Central New York Regional Center for Tobacco Health Systems to support smoking cessation training, 5A’s implementation and connections with the NYS Smoker’s Quitline. DY3 focus on promotion of community resources and population health management particularly for high risk patients. * 80% AEP needed to meet target

Palliative Care Integration Actively Engaged Patient Contribution by Organization by Month

Palliative Care Integration Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 1,980 264 x 6 months $80,000 DY3Q4 (3/18) 3,960 - 264 x 12 months $69,000 Action Steps Exploring alignment with PCMH and working with Karen Joncas to develop a model for delivery within practices to support implementation. Continued outreach to partner organizations considering the Palliative Care project to help eliminate barriers to engagement IPOS training date and registration disseminated to all current and prospective partners Developing repository for IPOS for contracted partners to be able to report * 80% AEP needed to meet target

Next Steps & Wrap-up Oneida Next Meeting: August 24, 2017