Refuah Community Health Collaborative PROJECT ADVISORY COMMITTEE MEETING September 29, 2016 2:00 pm – 3:00 pm 400 Rella Blvd, Suite 205 Webinar participation available

Agenda Introduction/Housekeeping Project Management Office Update CMS site visit a success Upcoming Midpoint Assessment MAX Train-the-Trainer Program Workforce Update Data Sharing Requirements

Webinar Instructions Webinar is being recorded and will be available on our website www.refuahchc.org Attendees who have called in are muted To ask a question: Type the question into the box on the sidebar At the end of the presentation we will read the questions aloud & provide answers

Wifi Network: CHCGuest Password: Dyt678RB

PMO Update On August 10th representatives from the Centers for Medicare and Medicaid Services as well as the New York State Department of Health did a full-day site visit of Refuah Health Center and some of its partners. The insights and thinking behind your various approaches showed the true dedication of the Refuah community and its extended partners in making the health care system work better… Many thanks from all of us at DOH and CMS!”   Peggy Chan, MPH DSRIP Program Director Mid-point Assessments by the Independent Assessor scheduled throughout the month of October.

Medicaid Accelerated eXchange (MAX) Series on Integration Free Train-the-Trainer Program to develop facilitators to administer ongoing Rapid Cycle Continuous Improvement Workshops Workshop topic will be “Avoidable Hospital Readmissions for High Utilizers” Program begins in November 2016 and the MAX Team is recruiting now. Minimum 12 month training commitment. * This program, offered by the state and administered by KPMG, is a series of rapid cycle improvement workshops I can’t say enough about how Refuah’s participation in this program has propelled their delivery of care into the next era. In this case the topic was the integration of mental and physical health care, You’ll hear more about what they’ve done on the tour but I suspect the process would work for any topic. Key elements of the program are: DSRIP is a program which tries to accomplish a lot in a short amount of time. I think this kind of front-end level setting and spurring progress forward would be valuable to include in any future DSRIP program.

Workforce Update

Current State Assessment In accordance with DOH requirements RCHC conducted a current state assessment. Consisted of partner surveys. Purpose is to establish a “snap shot” of the current state of the RCHC workforce. If you would like a copy, please reach out to Anne Cuddy at acuddy@RefuahCHC.org.

Target State Design Developed based upon survey data, industry benchmarks, and modeling. Projections across the 5 year DSRIP project period. RCHC must report on actuals semi-annually. First report on “actuals” for DY1 and the first half of DY2. If you have not already done so, please provide us with an update on your actual DY1 and DY2 workforce impacts!

Target Workforce State Social Worker Case/Care Management – 20% retraining; 80% new hires Patient Navigators/Care Coordination – 50% retraining; 50% new hires Nursing – 96% retraining; 4% new hires Nursing Care Managers – 88% retraining; 12% new hires Primary Care Physicians – 100% new hires Behavioral Health practitioners – 80% retraining; 20% new hires Administrative Support – 50% new hires; 50% retraining

Total Workforce Impact

Gap Analysis RCHC’s analysis has determined that the key roles that need to be addressed in connection with DSRIP are in the following areas, ranked in order of importance: Social Workers Patient Navigators/Peer Workers Behavioral Health Practitioners Primary Care Physicians Case & Care Management Administrative/Support Staff Nursing Care Managers/Coordinators Nursing staff

Gap Analysis (cont’d) The gaps in the RCHC workforce are consistent with the transformation are in line with the nature of RCHC’s projects. Given that 3 of 7 projects are behavioral health projects it is expected that large gaps in BH/mental health workers were observed. The Patient Navigation and Medication Adherence projects also are driving certain observed gaps in workforce. The gaps in case/care management and patient navigators/peer workers is also not surprising given that these roles are relatively new in the healthcare field. The need for these roles is further driven by the integrative and community-based philosophies of RCHC. The need for additional primary care physicians and nursing staff is consistent with regional shortages.

Key Takeaways The impact on the workforce will be in the form of new hires and retraining, with a significant emphasis on retraining. The observed gaps are largely a function of the projects, but appear to fit in with larger network level trends towards increased integration and “top of the license” practice. Based upon the FTE projections, RCHC ranked its gaps in staffing in accordance with the greatest needs of the PPS. Next steps for RCHC are to turn the gap analysis into an actionable “roadmap” and training strategy.

Data Sharing and Clinical Interoperability Requirements

Overview Set 1 Set 2 Set 3 Set 4 Requirement Description Healthlinkny Participation Agreement Set 1 Healthlinkny Patient Consent Healthlinkny web portal account(s) DIRECT messaging Utilize Healthlinkny alerts for care coordination Set 2 Contribute inpatient admission and discharge alerts to Healthlinkny Clinical document exchange with Healthlinkny Set 3 Meaningful Use Stage 2 Set 4 EHR patient registry capabilities Azara integration

Set 1 Applies to: All Refuah CHC PPS organizations with a completed Master Agreement & designated NYS DOH DSRIP Safety Net in : PC/NonPC Hospital Clinic BH SNF OR Entities that are contracted for specific PPS projects: 2.a.ii – (PCMH) 2.c.i - Community-based navigation services 3.a.i – Integration of PC & BH 3.a.ii – BH Crisis stabilization services 3.a.iii – MAP

Set 1 DUE DATE: 3/31/2018 Complete a PA with Healthlinkny & for RefuahCHC to receive a copy of monthly report. Complete consent training. Provide consent materials to patients and staff. Maintain at least one active Healthlinkny web account for patient record lookup. Utilize DIRECT messaging for secure communication to coordinate care during transitions or referrals between service providers.

Set 2 DUE DATE: 3/31/2018 Contribute inpatient admission and discharge alerts to Healthlinkny – applies to inpatient facilities only Utilize Healthlinkny alerts for care coordination – applies to PCMH project sites only

Set 3 Applies to Organizations with a completed Master Agreement & designated safety net by NYS DOH DSRIP in categories: PC/NonPC Hospital Clinic BH SNF OR Organizations contracted for specific PPS projects: 2.a.ii - PCMH 3.a.i – Integration of PC & BH

Set 3 DUE DATE: 3/31/2018 Organization must perform clinical document exchange with Healthlinkny Clinical documents must use HL7 CCDA format. Summaries must contain the following structured clinical data elements at the completion of all patient encounters/admissions Patient demographics Allergies Immunizations Medications Problems Procedures Vitals

Set 4: Applies to PCMH hubs DUE DATE: 3/31/2017 Meaningful Use Stage 2 EHR patient registry capabilities Azara integration

Performance Reporting Four of the requirements have Performance Reporting guidelines after 4/1/2018: Healthlinkny Patient Consent Utilize Healthlinkny alerts for care coordination Clinical document exchange with Healthlinkny What is the purpose of performance reporting requirements? Organizations must continue to use the HIE (Healthlinkny) in specific ways to help ensure data sharing and clinical interoperability of the PPS network.

Next Steps RCHC PMO will be providing each organization with a copy of the guidelines and will mark which requirement applies to the organization with a check mark EXAMPLE: Requirement Performance Reporting after 4/1/2016? Healthlinkny Participation Agreement No Healthlinkny Patient Consent Yes Healthlinkny web portal account(s) DIRECT messaging Clinical document exchange with Healthlinkny Contribute ADT alerts to Healthlinkny Meaningful Use Stage 2

Next Steps Organizations will be asked to sign that they “agree….to comply with the above selected requirements during its participation in the Refuah Community Health Collaborative.”

Questions or Comments?