NYP/Q PPS PAC Meeting NYP/Q PPS September 29, 2016

NYP/Q PPS PAC Meeting DSRIP Updates NYP/Q PPS PAC Meeting

Key Upcoming Dates for DSRIP 9/30: End of DY2, Q2 September 10/1: DY2, Q3 Begins 10/6: Midpoint Assessment by Independent Assessor (IA) of NYSDOH October 11/18: Town Hall Meeting November NYP/Q PPS PAC Meeting

DSRIP Updates September Learning Symposium The Department of Health hosted the Second Annual DSRIP Statewide Learning Symposium in Syracuse NY from Sep 20-22, 2016. In keeping with DSRIP’s stated goal of restructuring the health care delivery system, the symposium focused on system transformation, clinical management and population health. NYP/Queens PPS’s Partner, Brightpoint Health, presented our success story in MAX series. NYPQ PPS PAC Meeting

DSRIP Updates Midpoint Assessment The Mid-Point Assessment is a required component of the DSRIP Program for all PPSs   The Mid-Point Assessment will focus on the progress made by the PPSs through the end of the first quarter of DY2 towards establishing the necessary organizational foundation and towards the implementation of the project requirements consistent with the approved DSRIP Project Plan. Verifying active engaged patients that were reported by the partners. Audit on October 6, 2016 NYPQ PPS PAC Meeting

DSRIP Updates 360 Survey Independent Assessor (IA) conducted a 360 survey on a selected sample of PPS network partners; the intention was to obtain feedback on their experience working with the PPSs. The survey included questions covering the following areas: Governance/Leadership Participation Project Implementation Planning and Execution Funds Flow Performance for participation in DSRIP PPS Communication to partners 360 Survey by partners completed on September 15, 2016 Expect feedback to be included in the report out of the midpoint assessment NYPQ PPS PAC Meeting

DSRIP Updates Financial Stress Test All PPSs had to complete the Lead Financial Stability Test. NYP/Queens PPS passed the financial stress test successfully and submitted on August 19, 2016. NYP/Queens PPS is financially viable. NYPQ PPS PAC Meeting

DSRIP Updates Primary Care Plan All PPSs are required to submit the primary care Plan to NYSDOH which addressed the following: Current status of their primary care capacity Plans for reaching primary care-specific project milestones Progress toward primary care goals addressing areas of access, capacity, and quality Submitted on August 31, 2016 Strategies to address gaps: Expanding Primary Care Access at Behavioral Health Sites Integrating Behavioral Health into Primary Care Sites Implementing Open Access to Primary Care Sites Connection of Partners to IT Tools (RHIO & Population Health Management Tool) Conducting Gap Assessment Periodically NYPQ PPS PAC Meeting

DSRIP Updates Network Re-Opening NYSDOH had a network reopening window scheduled for all PPSs from Aug 8- Sep 8, 2016 to allow for PPS network additions only. 3 new partners added. All partners will be engaged in Pediatric Asthma project. NYPQ PPS PAC Meeting

DSRIP Updates Medical Record Review Independent vendor, Medical Review, appointed by NYSDOH conduct the quality review of 2 measures for every PPS NYP/Queens 2 measures selected for record review Depression Screening Hypertension Control Effective October 2016, Medical Review team will work directly with the providers to perform the sample pull and record reviews NYPQ PPS PAC Meeting

PPS Updates & Project Specific Highlights NYP/Q PPS PAC Meeting PPS Updates & Project Specific Highlights NYP/Q PPS PAC Meeting

PPS Updates Quarterly Reports Submission DY2, Q1 Report was successfully submitted on July 31, 2016 PPS received AV (Achievement Value) Scorecard for DY1, Q4 from the IA on June 30, 2016 NYP/Q PPS has received all the AVs to date NYP/Q PPS PAC Meeting

PPS Updates Statewide Health Care Facility Transformation Program A total of up to $195 million is available under this Request for Applications (RFA) to health care providers A minimum of $30 million of this total amount is available for community-based health care providers Priority given to projects that were not funded in whole or part, in response to the RFAs for the Capital Restructuring Financing Program (CRFP) NYPQ grant submission: HIT Infrastructure project plan NYP/Q PPS PAC Meeting

PPS Updates IT Updates Cureatr On July 2016, the PPS kicked- off the Cureatr Integration project with 12 selected SNFs who are currently using the Sigmacare (EMR). Integration with the Cureatr App will support care Transition Notifications and Secure Text Messaging. The Cureatr App, was also launched and roll-out to PPS partners in June, 2016 to support data exchange including engaged patient count data. 10 out of 12 PPS Partner sites have been engaged by the vendor and IT (August 2016) 3 out of 12 PPS Partner sites have received a demo of the tool (August 2016) Data Exchange agreement has been sent to 10 of 12 PPS Partners (August 2016) Performance Logic Project management application is set to go-live in December, 2016. Partners will be trained on how to access and report project task status, using the application – Training (November, 2016)   NYP/Q PPS PAC Meeting

PPS Updates Finance NYP/Queens Funds Flow We have been distributing funds to partners bi-annually To date, $458,954.13 have been distributed to the partners, which includes Community Based Organizations (CBOs) as well. We will also distribute approximately 56k to the partners once we receive pending contracts, W9s and BAAs from them. Total of $514,954.13 funds flow to partners NYPQ PPS PAC Meeting

PPS Updates Cardio Project According to our Community Needs Assessment (CNA), NYP/Queens service area has a lot of patients with cardiovascular disease. The goal of this project is to ensure clinical practices in the community and ambulatory care setting use evidence based strategies to improve management of cardiovascular disease. Provided office visits to all the cardio project partners for support. PMO team in process of analyzing network quality data. NYP/Q PPS PAC Meeting

PPS Updates Pediatric Asthma Project Ensure implementation of asthma self-management skills including home environmental trigger reduction, self-monitoring, medication use and medical follow-up to reduce avoidable ED and hospital care. Site visits to all the asthma project partners for providing support and clarifying home assessment process Challenges: Getting buy-in from community providers to start referring Training and education Reporting enough patients to meet the DSRIP requirements Mitigation Strategies: 3 new provider practices added to the PPS network NYP/Q funded Asthma Coalition to start the School Based Education program Initiated with 2 schools which has the potential to impact 947 children Asthma Coalition and St. Mary’s team working with NYP/Q ED team and educating them on referring eligible pediatric asthma patients for home care assessment NYP/Q PPS PAC Meeting

PPS Updates SNF Care Transition, INTERACT and Home Care Projects Provide a supported transition period after a hospitalization to ensure discharge directions are understood and implemented for skilled nursing home patients at high risk of readmission, particularly those with cardiac, renal, diabetes, respiratory and/or psychiatric disorders. Best practices from each partner organization presented at the committee meetings INTERACT training dates scheduled for late October and early November 2-day INTERACT Training Development of Root Cause Analysis workgroup- 2 RCA sessions since May 2016 Utilizing the RCA lessons learned to make local performance improvement changes to clinical operations in order to avoid ED utilization, admissions and readmissions. NYP/Q PPS PAC Meeting

PPS Updates Palliative Care Project Integration of palliative care into nursing homes, provide on site management of pain and symptoms and support the end of life goals of residents with advanced, life-limiting conditions. Ongoing training on eMOLST EPEC training offered courses and modules that the employees from long term care partners would be encouraged to complete Union Plaza working on a pilot project for using Palliative Care Outcome scale (PCOS) on the palliative care patients to measure the improvement over time. NYP/Q PPS PAC Meeting

PPS Updates Workforce/Cultural Competency and Health Literacy Contracted with outside vendor, BDO, to perform workforce analysis for our PPS and identify areas of workforce shortages NYP/Q PPS has adopted Healthstream solutions as the vendor to facilitate online learning modules The modules allow interactive learning and quiz which makes the training enjoyable! NYP/Q PPS has four modules currently rolled out to partners: DSRIP 101 Module Cultural Competence - Background and benefits Cultural Competence - Providing Culturally Competent Care Health Literacy Module Started the 2 week pilot program with 5 sites effective Monday, September 19, 2016 NYP/Q PPS PAC Meeting

PPS Updates Clinical Integration Updates In progress: Clinical Integration Strategy that outlines the following: Clinical and other information for sharing Data sharing systems and interoperability A specific Care Transitions Strategy, including: hospital admission and discharge coordination; and care transitions and coordination and communication among primary care, mental health and substance use providers. Population Health Roadmap that outlines the following: IT Tools to facilitate alerts and registry Data collection, population monitoring and stratification Action plan to manage the patient population associated with the network of partners PMO team in process of analyzing network quality data, specifically Asthma, Cardio & HIV NYP/Q PPS PAC Meeting

NYP/Q PPS PAC Meeting Next Steps NYP/Q PPS PAC Meeting

Next Steps All PPSs are in Measurement Year 3 where the focus is on Pay-for-Performance and not only Pay-for-Reporting Build a Rapid Cycle Evaluation (RCE) Unit utilize performance data reported by partners as well as data available by NYSDOH and other tools for quality improvement efforts. develop a focused strategy will be developed to outline partners, data sources, process improvement strategies, follow- up methods for improvements, and risks associated by quality based outcomes. PMO in process of building performance scorecards that will be distributed to partners on a regular basis and discuss intervention strategies for improvement Adopt best practices from high performing partners and providers Discuss with partners about their need for resources to perform Work with partners for Medical Record Review NYP/Q PPS PAC Meeting

NYP/Q PPS PAC Meeting Questions? NYP/Q PPS PAC Meeting