NYP Queens PPS PAC Meeting April 27, 2017

Key Upcoming Dates April, 2017 May, 2017 April 30, 2017: DY2Q4 Reporting Submission Deadline April, 2017 May 3, 2017: Cultural Competency/Health Literacy PPS Leads Training May 9, 2017- HPCANYS-CAPC DSRIP Palliative Care Project Forum , featuring eMOLST End of May: Payment# 4 distribution to partners May, 2017 NYP/Q PPS PAC Meeting

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

DSRIP Updates PPS Presentation to PAOP Members in Albany On February 2, 2017, NYP Queens PPS leadership team presented project highlights and primary care plan to Project Approval and Oversight Panel (PAOP) in Albany The PPS did not have any formal recommendations from IA in Midpoint Assessment. Continued to have no recommendations after PAOP presentation Recognized by the PAOP members to be doing great job with limited resources NYPQ PPS PAC Meeting

DSRIP Updates DY2Q3 Achievement Values (AV) Scorecard NYP Queens PPS has achieved all AVs (except cardio and Asthma patient engagement last quarter)to date till DY2 Q3- December 2016

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

PPS Updates Highlights: First Town Hall of 2017 NYP Queens PPS had their first Town hall meeting for 2017 on April 6th. Very good turnout PPS updates were provided by Maria D’urso, Administrative Director Community Medicine and Co-executive lead for PPS Guest speakers included Valentine Hernandez, Executive Director, QCCP (Queens Coordinated Care Partners) who discussed the health home program’s role in providing an individual with needed medical, social, and educational services. Lisa Cole, NAI Coordinator, from New Americans Welcome Center under YMCA talked about the health literacy workshops for new immigrants that provide access to doctors, health insurance, emergency Medicaid, and shared referral information for additional resources. NYPQ PPS PAC Meeting

PPS Updates Rapid Cycle Evaluation Updates Rapid Cycle Evaluation work is well in progress Charter has been finalized First kickoff meeting - April 20, 2017 Next step: Present performance metrics to the Clinical Integration Quality committee and to each project committee meeting; work on the intervention strategies NYPQ PPS PAC Meeting

PPS Updates MAX Updates On October 2016, NYP Queens signed up for the MAX Series which is a Rapid Cycle Continuous Improvement program that focused on “Targeting Avoidable Hospital Readmissions for High Utilizers” with the goal of reducing 30-day readmissions and overall hospital utilization High Utilizers are defined as any patient that has 4+ Inpatient Admissions in a 12-month timeframe MAX Action team members included ambulatory care Medical Director, case manager, social worker, nursing rep and attending ED physician from NYP Queens and the PI staff from Silvercrest SNF The action team suggested and implemented various action plans, some of which include warm handoff from the hospital to SNF, collection of capabilities list from all SNF partners, Health Home on site, etc. MAX session ended on April 25, 2017 Two Train the Trainers from PMO certified Ongoing QI efforts NYPQ PPS PAC Meeting

PPS Updates Finance WOW!!! Total disbursement of Payment #4 will be: $1,806,689.27 Expected release towards the end of May 2017 Additional funding not included in this number is for our RHIO participants: $25,000 has been allocated (10) sites can be paid in this current distribution, but some will be delayed As they are made available, we will release funding and deduct from this pre-approved balance NYPQ PPS PAC Meeting

PPS Updates Bed Utilization Summary & Plan NYP Queens PPS has finalized document that summarizes hospital bed utilization statistics for the NYP Queens hospital, which is the lead hospital of the PPS, and outlines a plan for future changes anticipated as a result from the improvements made by the DSRIP program Submitted to NYSDOH for DY2Q4 reporting The average bed utilization rate for the hospitals listed in Queens County is 79.16% as compared to the New York State average of 61.80% of staffed beds The only hospital within the PPS network maintains a bed utilization rate of 93% of staffed beds which is 14% above the local Queens average and 31% above the state average Along with high utilization rates of staffed beds, the Definitive Healthcare information system reports a 4.64% Medicaid utilization of inpatient days for the NewYork-Presbyterian Queens hospital as compared to the community average of 11.41% As per the Community Needs Assessment, Queens County has a bed rate per 1,000 persons of 1.49 as compared to the overall NY State average of 3.0 and the national average of 2.6 beds per 1,000. This is 1.51 beds less that the state average and 1.11 beds less than the national average. NYPQ PPS PAC Meeting

PPS Updates Bed Utilization Summary & Plan, cont’d RECOMMENDATIONS: Engage critical network partners to implement 9 DSRIP projects meeting project requirements, scale and speed expectations. Align project implementation to quality process improvement efforts of the Rapid Cycle Evaluation Unit utilizing care coordination efforts, best practice utilization, technology connectivity and integration, and other population health strategies. Forecast impact to hospital inpatient indicators monitored by the RCE and partner with the Hospital Quality Team to plan action items associated with direct impact. Implement connectivity tools such as RHIO (Healthix) and population health management tools (Allscripts & Cureatr) to streamline network communication and ensure access of patient record activity in order to reduce utilization and improve outcome quality. Complete analytics utilizing the Rapid Cycle Evaluation Unit to identify high-risk patient populations for inpatient and emergency department utilization in order to establish action plans by MCO designated provider to create outreach or educational opportunities for access or connectivity to care coordination. Incentivize network partners utilizing the PPS funds flow model to reward quality improvements and high-risk care coordination activities that align with the RCE findings of inpatient & emergency department utilization. Partner with the hospital Quality Team to partner quality based process improvement efforts to maximize efforts & network impact NYPQ PPS PAC Meeting

PPS Updates IT Updates Allscripts Care Director (ACD) Updates NYP Queens PPS Population Health Management Tool- ACD roll out is expected to happen sometime in summer. Trainings on basic navigation have been completed in March 2017 Next step is to finalize the utilization strategy Performance Logic Training & Rollout PPS Project Management Tool, Performance Logic, has been rolled out. Webforms with deliverables have been pushed out to all partners Several training sessions were completed in March   NYP/Q PPS PAC Meeting

PPS Updates Workforce Training Updates INTERACT Train-the-Trainer sessions and trainings in SNF partner sites Performance Logic Training Allscripts Care Director Training Cardiovascular best practices and protocols refresher webinar eMOLST Webinar NYPQ PPS PAC Meeting

PPS Updates Website & Newsletter NYP Queens PPS restructured website http://www.nyhq.org/dsrippps More updates posted. Please continue to visit our website First quarterly newsletter released in January 2017 Next newsletter release- anticipated mid-May Highlights on PPS achievements Partner Interview Community events Best practices Educational opportunities Job opportunities In order to add any recipient to the newsletter distribution, please contact Coleen or Sadia in PMO NYP/Q PPS PAC Meeting

PPS Updates Patient Centered Medical Home Project Initially, NYP Queens PPS committed to 35 PCPS getting certified under Level 3 2014 PCMH To date, PPS has 45 PCPs in this project 25 PCPs already Certified Level 3 2014 PCMH – 56% 20 PCPs in process of transformation WOW!!! NYP/Q PPS PAC Meeting

PPS Updates SNF Care Transition, INTERACT and Home Care Projects All 27 SNFs implemented INTERACT All home care partners we committed in the project implemented INTERACT Silvercrest successfully implemented warm handoff protocol in their facility Next step is to roll out to all other SNF partners All 27 SNFs signed RHIO participation agreements. Next step is to start data sharing WOW!!! WOW!!! NYP/Q PPS PAC Meeting

PPS Updates Palliative Care Project WOW!!! EPEC first round will be completed on May 10, 2017 Tremendous success and turnout rate in all sessions so far Partners were surveyed and requested to make up for following modules   Plenary 1 & 2: Gaps in End -of-Life Care & Legal Issues Modules 1 & 2 : Advance Care Planning & Communicating Bad News Modules 3 & 4 : Whole Patient Assessment & Pain Management Next step: Explore to bring guest speakers for Pediatric Palliative Care NYP/Q PPS PAC Meeting

PPS Updates Cardiovascular Project Standardized protocols in place for network; Training Completed Home Blood Pressure monitoring Blood Pressure Measure Competency Medication Management Tobacco Cessation Protocols, 5A’s Care Coordination Health Home Trainings completed with more than half of the cardio project partners ED Health Home Training- April 12, 2017 15 ED staff trained WOW!!! NYP/Q PPS PAC Meeting

PPS Updates Pediatric Asthma Project Pediatric Asthma Center was one of the few centers who received award from NYP for best Patient Experience Asthma Coalition of Queens trained 5 staff in ED who will be getting certified as Asthma Educators this summer WOW!!! NYP/Q PPS PAC Meeting

Questions NYP/Q PPS PAC Meeting