Central New York Care Collaborative (CNYCC)

Slides:



Advertisements
Similar presentations
Behavioral Health Providers Network Leadership from the Mental Health and Substance Abuse Providers working together to communicate, coordinate and collaborate.
Advertisements

DSRIP AND PHIP Overview
DSRIP & Bronx Partners for Healthy Communities: An Overview
Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration.
Integrated Health Home for the Homeless in Philadelphia Lara Carson Weinstein, MD, MPH Assistant Professor, Thomas Jefferson University Monica Medina McCurdy,
Central Receiving Center (CRC) System of Care Donna P. Wyche, MS, CAP Manager, Mental Health and Homeless Issues Division Orange County Family Services.
AGENDA I.Our DSRIP: ACP / AW Medical Why ACP? II.The biggest network in New York: III.What Happened to the PAC? Leadership Council IV.Roles and responsibilities.
1 Child Welfare Reform Council August 5, 2014 Transition of Children in Foster Care, Receiving Adoption Assistance and Select Youth in Juvenile Justice.
The Power of Partnerships in today’s changing health care landscape Rebecca Glathar, NAMI Utah Angela Kimball, Oregon Health Authority Delia Rochon, Intermountain.
Missouri’s Primary Care and CMHC Health Home Initiative
MAXIMIZING MENTAL HEALTH PARTNERSHIPS Doreen Bradshaw, Executive Director Shasta Consortium of Community Health Centers.
Alliance for Better Health Care Alliance for Better Health Care, LLC 1.
The Center for Health Systems Transformation
Session 3 August 15, AGENDA Phase III Health Home Designations and Next Steps Phase I and II Updates Enrollment Update.
CMS National Conference on Care Transitions December 3,
Behavioral Health Transition to Managed Care Update APRIL 2015 Certified Community Behavioral Health Clinics (CCBHC) Planning Grant and Demonstration.
2015 DSRIP: OPPORTUNITIES AND QUESTIONS. Agenda: 2  What is DSRIP?  What are the 10 DSRIP projects?  What are the opportunities.
Albany Medical Center Hospital and Columbia Memorial Hospital Delivery System Reform Incentive Payment Program Executive Committee November 12, 2014.
Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) Project Implementation Plan Development Primary Care Medical Home (PCMH)
TRANSFORMING HEALTHCARE & REDESIGNING MEDICAID Delivery System Reform Incentive Payment May 18, 2016 MEDIA - Medical Education and Information Association.
North Carolina Community Care Networks (N3CN): Medical Home Access and Emergency Department (ED) Utilization May 2016.
Children’s MOSAIC Project Update to the Springfield Public Schools Board of Education Jan Gambach, President, Mental Health Centers of Central Illinois,
Refuah Community Health Collaborative (RCHC) PPS
Clinical Project Meeting
How Centerstone can help Improve Outcomes For Mothers and Babies
Project Spotlight ED Care Triage (2biii)
NYS Health Home 101.
Regional Project Advisory Committee
Housing & Homeless Coalition of CNY: State of Homelessness 2016
Embedded Care Management
Region 15 Regional Healthcare Partnership 6th Public Meeting
Central New York Health Home, Inc. (CNYHHN, INC)
Region 15 Regional Healthcare Partnership 13th Public Meeting
Building a Collaborative Community for Population Health Management
NYHQ DSRIP Primary Care & Behavioral Health Committee Kick-Off Meeting
Pre-Work Clinical Changes: What Clinical Practices Have You Changed Or Expanded in the Last Six Months? Provide 2 examples.
Long Island Population Health Improvement Project (LIPHIP)
Allumbaugh House.
Champlain LHIN Collaboration
AMCH PPS PAC Meeting January 26, 2016
Behavioral Health Integration in Texas
PAM©: Moving from Measurement to Action
Albany Medical Center Hospital Columbia Memorial Hospital Executive Committee PAC 1/8/2015.
Cascade Pacific Action Alliance
Community Mental Health Authority of Clinton, Eaton, Ingham Counties
RHP Plan Update Provider Template
Community Care Teams Carl Schiessl, Director, Regulatory Advocacy
April 27, 2018 UMC Neighborhood Health Clinic El Paso, Texas
WE TACKLE THE PROBLEMS MOST SHY AWAY FROM?
WHO WILL TACKLE THE PROBLEMS MOST SHY AWAY FROM?
Challenges Innovations Lessons Learned
Health Home Program Services
OUR MISSION Axis Health System will make a meaningful difference in the health of Southwest Colorado residents by integrating all aspects of healthcare.
Greater Columbia ACH Board of Directors 4/19/17
Community Step Up Program
Synopsis of CCNC Initiatives
& RHP 15 Collaboration.
ED Care Triage Actively Engaged Patient Modifications
Housing and Homeless Coalition of Central New York 2018
CTC-RI Integrated Behavioral Health 2016 Pilot Practices
2019 Model of Care Training University of Maryland Medical Systems Health Plans, Inc. Proprietary and Confidential.
Nassau-Queens PPS Health Home 101
Primary Care Alternatives Update
Optum’s Role in Mycare Ohio
Building a Full Continuum of Integrated Crisis Services
Certified Community Behavioral Health Clinic
Los Cien: Latinos’ Access to Healthcare and Wellbeing
Rhode Island Psychiatry Resource Networks (PRN)
Alabama Coordinated Health Network
Rhode Island Psychiatry Resource Networks (PRN)
Presentation transcript:

Central New York Care Collaborative (CNYCC) Cayuga County Regional Project Advisory Committee(RPAC) Thursday, January 26th, 2016 The Commons on St. Anthony

CNYCC Project Dashboards

Actively Engaged Patients: April 1 – December, 2016 DY2 Q3 Targets Project Target Actual Gap Status DSRIP Care Management (2aiii) 4,450 198 4,252 ED Care Triage (2biii) 4,800 3,979 821 Care Transitions (2biv) 2,475 6,549 (4,074) Patient Activation (2di) 9,750 1,522 8,228 Primary Care/Behavioral Health Integration (3ai) 17,500 20,684 (3,184) Behavioral Health Crisis Stabilization (3aii) 10,500 9,884 646 Cardiovascular Disease Management (3bi) 5,100 5,090 10 Green = Meets or Exceeds 80% of Target (AV reached) Yellow = Between 79% and 65% of Target Red = Below 65% of Target

Primary Care/Behavioral Health Integration Actively Engaged Patients Actively Engaged Patient Definition: The total number of patients receiving appropriate preventive care screenings that include mental/substance abuse. DY2 Q3 Targets Partner Organizations Actively Engaging Patients in Primary Care/Behavioral Health Integration: ARISE Child and Family Services (13) Community Memorial Hospital (936) Crouse Hospital (313) FamilyCare Medical Group (2,209) Farnham Family Services (152) Faxton-St. Luke’s Healthcare (3,049) Harbor Lights (41) Q DUE Target Actual Gap Status DY2 Q3 17,500 20,684 (3,184) Hutchings PC (178) Liberty Resources (176) Lewis County General Hospital (18) Mohawk Valley PC (337) NOCHSI (1,548) Oneida Healthcare (106) Oswego Hospital (521) Planned Parenthood of Mohawk Hudson (1,586) Regional Primary Care Network (797) St. Elizabeth Medical Center (2,436) St. Joseph’s Hospital (2,439) Syracuse Behavioral Healthcare (733) Upstate Cerebral Palsy (159) Upstate University Hospital (2,937) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for Primary Care/Behavioral Health Integration? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 17,500 20,684 (0) (3,184) Cayuga County (6.82%) DY2 Q4 25,000 (1,705) 1,705 Contracted Partner Organizations: Auburn Community Hospital Cayuga County Mental Health ARISE Liberty Resources Cayuga Counseling Services

Behavioral Health Crisis Stabilization Actively Engaged Patients Actively Engaged Patient Definition: Participating patients receiving crisis stabilization services from participating sites, as determined in the project requirements. DY2 Q3 Targets Partner Organizations Actively Engaging Patients in Behavioral Health Crisis Stabilization: ARISE Child and Family Services (247) Cayuga County Community Mental Health Center (205) Circare (3,846) Central New York Services (39) Farnham Family Services (19) Hutchings Psychiatric Center (10) Liberty Resources (988) Mohawk Valley Psychiatric Center (76) Q DUE Target Actual Gap Status DY2 Q3 10,500 9,884 616 North Country Transitional Living Services (42) Oswego County Opportunities (7) Oswego Hospital (1,722) St. Joseph’s Hospital (1,092) Syracuse Behavioral Health (1,451) The Neighborhood Center (115) Unity House of Cayuga County (9) Upstate University Hospital (16) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for Crisis Stabilization? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 10,500 9,884 (1,202) 646 Cayuga County (6.82%) DY2 Q4 15,000 (1,023) Contracted Partner Organizations: Cayuga County Mental Health Center Liberty Resources Unity House

DSRIP Care Management Actively Engaged Patients Actively Engaged Patient Definition: The number of participating patients who completed a new or updated comprehensive care management plan. DY2 Q3 Targets Partner Organizations Actively Engaging Patients in DSRIP Care Management: Oneida Healthcare (57) Circare (2) St. Joseph’s Hospital (139) Q DUE Target Actual Gap Status DY2 Q3 4,450 198 4,252 Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for DSRIP Care Management? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 4,450 198 (2) 4,252 Cayuga County (6.82%) DY2 Q4 6,700 (457) 455 Contracted Partner Organizations: ACR Health CNYHHN Auburn Community Hospital Hillside Children’s Center Circare Liberty Resources

ED Care Triage Actively Engaged Patients Actively Engaged Patient Definition: The number of participating patients presenting to the ED, who after medical screening examination were successfully redirected to a PCP or Health Home care manager as demonstrated by a scheduled appointment. The term successfully redirected means that the patient had or was made aware of an appointment with a PCP or Health Home care manager within 30 days after ED presentation and medical screening. It is expected that the redirection could occur within or en route to the ED. DY2 Q3 Targets Partner Organizations Actively Engaging Patients ED Care Triage: Auburn Community Hospital (65) Crouse Hospital (97) Faxton St. Luke’s Healthcare (171) Lewis County General Hospital (215) Oneida Healthcare (413) Q DUE Target Actual Gap Status DY2 Q3 4,800 3,979 821 Oswego Hospital (459) Rome Memorial Hospital (1,286) St. Elizabeth Medical Center (559) St. Joseph’s Hospital Health Center (356) Upstate University Hospital (358) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for ED Care Triage? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 4,800 3,979 (65) 821 Cayuga County (6.82%) DY2 Q4 9,600 (655) 590

Care Transitions Actively Engaged Patients Actively Engaged Patient Definition: The number of participating patients with a care transition plan developed prior to discharge. DY2 Q3 Targets Partner Organizations Actively Engaging Patients in Care Transitions: Auburn Community Hospital (453) Crouse Hospital (61) Faxton St. Luke’s Healthcare (194) Lewis County General Hospital (54) Oneida Healthcare (441) Q DUE Target Actual Gap Status DY2 Q3 2,475 6,549 (4,074) Oswego Hospital (94) Rome Memorial Hospital (430) St. Elizabeth Medical Center (801) St. Joseph’s Hospital (1,829) Upstate University Hospital (2,192) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for Care Transitions? Where is there ability to partner together to increase project work and outcomes? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 2,475 5,784 (453) (3,309) Cayuga County (6.82%) DY2 Q4 3,300 (225)

Patient Activation Actively Engaged Patients Actively Engaged Patient Definition: The number of individuals who completed PAM® or other patient engagement techniques. DY2 Q3 Targets Partner Organizations Actively Engaging Patients in Patient Activation: ACR Health (22) ARISE Child & Family Services (10) Auburn Community Hospital (115) Catholic Charities of Onondaga County (137) Crouse Hospital (35) ElderChoice (4) Finger Lakes Community Health (7) Lewis County Public Health Agency (23) NOCHSI (31) Q DUE Target Actual Gap Status DY2 Q3 9,750 1,522 8,228 North Country Prenatal Perinatal Council (38) Oneida Healthcare (219) Planned Parenthood of Mohawk Hudson (265) Regional Primary Care Network (45) Resource Center for Independent Living (23) St. Elizabeth Medical Center (13) Syracuse Recovery Services (37) The Salvation Army (498) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for Patient Activation? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 9,750 1,522 (154) 8,228 Cayuga County (6.82%) DY2 Q4 13,900 (948) 794 Contracted Partner Organizations: ACR Health Finger Lakes Community Health ARISE Hillside Children’s Center Auburn Community Hospital Liberty Resources CNYHHN The Salvation Army

Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Definition: The number of participating patients receiving services from participating providers with documented self-management goals in medical record (diet, exercise, medication management, nutrition, etc.). DY2 Q3 Targets Partner Organizations Actively Engaging Patients in Cardiovascular Disease Management: Auburn Community Hospital (37) Community Memorial Hospital (185) Family Care Medical Group (371) Faxton St. Luke’s Healthcare (557) Lewis County General Hospital (133) NOCHSI (90) Oneida Healthcare (80) Q DUE Target Actual Gap Status DY2 Q3 5,100 5,090 10 Oswego Hospital (107) Physician Care, PC (31) Port City Family Medicine (15) Rome Memorial Hospital (682) Rochester Primary Care Network (282) St. Elizabeth Medical Center (769) St. Joseph’s Hospital (1) Syracuse Community Health Center (478) Upstate University Hospital (1,272) Orange Text Indicates Participation in Cayuga County RPAC

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

Actively Engaged Patients Discussion What partnerships are currently occurring within Cayuga County for Cardiovascular Disease Management? Where is there ability to partner together to increase Actively Engaged Patient numbers? METRICS Actively Engaged Patients DUE Target Actual Gap Status DY2 Q3 5,100 5,090 (37) 10 Cayuga County (6.82%) DY2 Q4 6,800 (464) 427 Contracted Partner Organizations: Auburn Community Hospital Finger Lakes Community Health