1. Albany Medical Center AMCH PPS Clinical & Quality Affairs Committee Kallanna Manjunath MD, FAAP, CPE Medical Director – AMCH PPS December 16, 2015

2. AMCH PPS: Clinical & Quality Affairs (CQA) Committee Presentation Objectives: Year-end deliverables: o Practitioner Communication & Engagement Plan o Practitioner Training & education Plan o Clinical Integration Needs Assessment – Accenture Project Overview: Implementation of Patient Activation Activities

3. AMCH PPS: CQA Committee Roles & Responsibilities: CQAC will lead or take an active role in the following PPS organizational areas: Practitioner Engagement –Develop practitioner communication & engagement plan –Develop Practitioner Training & Education plan Clinical Integration –Perform ‘needs assessment’ –Develop a Clinical Integration Strategy Population Health –Develop population health management roadmap Performance Reporting IT Systems & Processes

4. AMCH PPS: CQA Committee Practitioner Engagement: Effective communication with and engagement of practitioners is fundamental to our performance and ability to deliver high- quality patient-centered care across the continuum of care. AMCH PPS is committed to a strong engagement of clinical stakeholders representing participating member organizations and other clinical organizations. Practitioner training & education are vital to engagement.

5. Milestone 1: Develop Practitioners communication & engagement plan.DY1Q4 The plan should include: –Plans for creating PPS-wide professional groups / communities and their role in the PPS structure –Development of standard performance reports to professional groups –Identification of profession / peer-group representatives for relevant governing bodies, including (but not limited to) Clinical Quality Committee Practitioner Communication & Engagement: Deliverables

6. Milestone 2: Develop training / education plan targeting practitioners and other professional groups, designed to educate them about the DSRIP program and PPS-specific quality improvement agenda. DY1Q3 Refer to draft plans for details Practitioner Communication & Engagement: Deliverables

7. AMCH PPS: CQA Committee Clinical Integration: Definition “Clinical integration is the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients.” Stephen M. Shortell, Robin R. Gillies, David A. Anderson, Remaking Health Care in America, 2000

8. Clinical Integration: Structural Aspects William Agel MD 2012

9. Milestone 1 (DOH). Perform a clinical integration needs assessment - DY1Q3 Clinical integration 'needs assessment' document, signed off by the Clinical Quality Committee, including: –Mapping the providers in the network and their requirements for clinical integration (including clinical providers, care management and other providers impacting on social determinants of health) –Identifying key data points for shared access and the key interfaces that will have an impact on clinical integration –Identify other potential mechanisms to be used for driving clinical integration Clinical Integration: Deliverables

10. Milestone 2 (DOH). Develop a Clinical Integration strategy - DY2Q1 Clinical Integration Strategy, signed off by CQAC, including: –Clinical and other info 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 –Training for providers across settings (inc. ED, inpatient, outpatient) regarding clinical integration, tools and communication for coordination –Training for operations staff on care coordination and communication tools Clinical Integration: Deliverables

11. Copyright © 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. Insight Driven Health Clinical Integration Milestone – Current State Gap Analysis Slides December 14, 2015

12. AMCH PPS Project: Implementation of Patient Activation Activities Kallanna Manjunath MD Kendal Pompey Ronald Santiago Mark Quail December 14, 2015

13. Implementation of Patient Activation Activities Presentation Objectives: Project Overview: –Review of Organizational and Project Components –Actively engaged definition, Speed & Scale –Performance Metrics Patient Activation Measure ® (PAM ® ) –What is Activation and Why it’s Important – 7 min Video –Overview of (PAM ® ) Coaching for Activation ® (CfA ® ) –Health Coaching by Level of Activation Proposed AMCH PPS PAM/CfA implementation process

14. Domain 1: Organizational Components Domain 2, 3 & 4: Project Components Better care, less cost Domain 2: System Transformation A.Create Integrated Delivery Systems 1.Create IDS for PHM 2.Health Home At-Risk 3.Create Medical Village in Nursing Homes A. Behavioral Health 6.Integration of PC & BH services 7.BH community crisis stabilization services B. Care Coordination &Transitional Care Programs 4.ED Care Triage for At-Risk Population Governance Financial Stability Cultural Competency & Health Literacy Workforce Strategy Population Health Management Practitioner Engagement Clinical Integration Performance Reporting IT Systems & Processes Domain 3: Clinical Improvement Domain 4: Population Wide Projects B. Prevent Chronic Diseases 10.Promote tobacco use cessation among low SES populations 11.Increase Access to Preventive Care and Management (Cancer) B. Cardiovascular Health 8.E-B strategies for managing Hypertension D: Utilizing Patient Activation to Expand Access 5.Implement Patient Activation Activities (PAM) C. Asthma 9.Implement E-BM guidelines

15. Objective: Focus on persons not utilizing the health care system, assess readiness for change using PAM tool and work to engage those individuals to utilize primary care services. Three main components of the project: –Patient activation –Financially accessible health care resources –Partnerships with primary and preventative care services Participating Providers: PCMHs, CBOs, Hospitals & other community settings. Project Overview: Implementation of Patient Activation Activities

16. Core Components (ED setting): Execute agreements with partners to implement PAM tool in hot-spot areas including EDs. Screen patient status (UI, NU, LU) and for collect the most recent contact information for the patient at the time of the visit. Identify eligible patients and assess them through PAM survey (preferably electronic) and determine the PAM score & level of activation. Utilize data from PAM to develop strategies for patient engagement. Ensure appropriate and timely access to primary care and other community-based services. Communicate results of PAM assessments to a PCP setting Project Overview: Implementation of Patient Activation Activities

17. Actively Engaged Definition: The number of individuals who completed PAM® or other patient engagement techniques PAM® surveys completed by parents/guardians on behalf of younger patients would count for active engagement. Speed & Scale: Project Overview: Implementation of Patient Activation Activities Patient speed of implementation table Expected # of actively engaged patients (total, as per project plan application) 34872 DY1, Q4 (Mar 2016) DY2, Q4 (Mar 2017) DY3, Q4 (Mar 2018) DY4, Q4 (Mar 2019) Patients Engaged 17436 28980 34872 34872

18. Implementation of Patient Activation Activities - Eligible Patients (DOHCriteria-10/29/2015) Target population for this project is non-utilizing and low utilizing Medicaid members and the uninsured Non-utilizer: –Medicaid member who has no claims for qualifying services during the previous 12 months –Services include primary care, specialist care, care received in an emergency department or an inpatient hospital admission Uninsured individual: –Individual who is not enrolled in Medicaid, does not have commercial insurance, or any other comprehensive insurance coverage at the time the PAM survey is administered. 18

19. Patient Activation Activities- Eligible Patients (DOH -10/2015 – subject to change) Low-utilizer: –Individual enrolled in Medicaid for the previous 12 months and: Has two or more chronic conditions and has no PCP visits in the previous 24 mo. Has received services from his/her PCP two or fewer times in the previous 12 mo. Has received three or fewer qualifying medical services in the previous 12 months, including primary care, specialist care, emergency room care or an inpatient hospital admission Has only received emergency room, inpatient hospital services, eye care, and/or dental services in the previous 12 months Exclusions: –Received services for developmental disabilities, nursing home, or ongoing BH care –Currently enrolled in a Health Home, if known –Patients who may not be in a frame of mind or physical condition for sufficient self- assessment (e.g., inebriated patients or those in crisis) 19

20. Performance Metrics Performance is measured through the following key metrics: Measurable increase in PAM levels for surveyed patients (through pre- and post-assessments). Measurable increase in patients’ use of primary and preventative care services. Marked decrease in ED utilization for non-critical issues by target populations (this project links closely with ED Care Triage and its use of patient navigators). Improvement in patient satisfaction levels related to the health services provided within our PPS. Project Overview: Implementation of Patient Activation Activities

21. Copyright © 2015 Insignia Health Proprietary & Confidential Using Patient Activation Measure® to Improve Patient Outcomes

22. Patient Activation: Interview with Dr. Judith Hibbard https://www.youtube.com/watch?v=9NQZCK3vi3M&app= desktophttps://www.youtube.com/watch?v=9NQZCK3vi3M&app= desktop 22

23. Copyright © 2015 Insignia Health Proprietary & Confidential Knowledge + Skills + Confidence = Patient Activation Individuals possessing these three domains are actively engaged in their health and change behaviors where needed to achieve better health outcomes.

24. Copyright © 2015 Insignia Health Proprietary & Confidential PAM-10

25. Copyright © 2015 Insignia Health Proprietary & Confidential Measuring Patient Activation What does Patient Activation help us discover? Who needs more support How to tailor the support and information our patients need to be successful self-managers How to measure performance and to have a marker for quality care

26. Copyright © 2015 Insignia Health Proprietary & Confidential Lower patient activation is associated with higher rates of hospitalization / ER visits A PAM score is predictive of future utilization and costs Lower patient activation is associated with poor disease self- management, including medication taking & self-monitoring Higher patient activation is associated with stronger lifestyle behaviors and increased use of preventive care services Higher patient activation is associated with increased use of decision support resources Higher patient activation associates with more productive encounters with healthcare providers PAM accurately predicts…

27. Copyright © 2015 Insignia Health Proprietary & Confidential Copyright © 2015 Insignia Health Proprietary & Confidential

28. Copyright © 2015 Insignia Health Proprietary & Confidential Overwhelmed & disengaged Becoming aware, but still struggling Taking action Maintaining behaviors and pushing further Level 1 Level 2 Level 3 Level 4 0-100 point scale 10-20% 20-35% 20-30%

29. Copyright © 2015 Insignia Health Proprietary & Confidential Health Activation Profiles

30. Copyright © 2015 Insignia Health Proprietary & Confidential Coaching for Activation®

31. Copyright © 2015 Insignia Health Proprietary & Confidential PAM scores are changeable Source: 2012 Insignia Clients: State Medicaid, NW Health System, Western Health Plan, NW Health Plan, East Coast Health Plan Average time between administration of 4.3 months

32. Copyright © 2015 Insignia Health Proprietary & Confidential Interaction is driven by the patient The patient possesses answers and solutions within themselves Help the patient overcome any sense of being overwhelmed Help the patient engage in their health and become active Promote the patient’s problem solving skills Promote positive belief in his/her abilities and skills to be actively involved in their health CfA Core Principles

33. Copyright © 2015 Insignia Health Proprietary & Confidential Understanding a member’s level of activation Active and reflective listening (listen for barriers) Spending more time asking than telling Understanding & focusing on the member’s agenda Guiding member’s choices toward level appropriate and attainable goals & action steps Coach’s Role with CfA

34. AMCH PPS PAM/CfA Procedure - Draft

35. Registration/Greeter Point of contact with patients Determine patient’s eligibility for screening depending on insurance status Navigator (if available) Assist with insurance needs Obtain data for successful linkage Track # of patients who went to see a provider Clinician/RN Determine patient’s eligibility based on clinical condition Referral to Care Coordinator for screening and appropriate coaching if part of target population Encourage patient to engage in self-management efforts Reinforce key components of CfA Care Coordinator Determine patient’s eligibility for screening Administer the PAM 10 survey Input data into Flourish to obtain pt. level of engagement and score Provide CfA based on level of activation Share information with clinician/RN, if feasible Arrange linkages with PCMHs and provide assistance as needed Share information with PCP, if known or identified If uninsured, referral to facilitated enroller/navigator for assistance Electronic PAM Administration Each ED designates staff who are PAM trained to serve as Care Coordinators The PMO provides training for those who are not PAM trained After PAM administration (step 3), care coordinator will enter completed survey into Flourish to obtain patient level of activation/score and to determine appropriate approach for coaching Coaching will be conducted by Care Coordinator upon determination of level of engagement Paper PAM Administration If organizations are unable to enter PAM survey into Flourish, completed paper PAM surveys will be forwarded to the AMCH PMO for processing Initial CfA provided by care coordinator based on responses to survey questions AMCH PMO will enter paper PAM surveys into Flourish to obtain patient level of activation Organizations will be able to access patient data in Flourish within 5-10 business days from initial patient interaction Additional CfA to be provided based on the level of activation and most recent score on Flourish PC BH 1 3 4 56 DRAFT-4 2.d.i Patient Activation Workflow- PAM/CFA Integration Emergency Department 2

36. Registration/Greeter Point of contact with patients Determine patient’s eligibility for screening Referral to Care Coordinator for screening and appropriate coaching if part of target population If uninsured, referral to facilitated enroller/navigator for assistance Navigator Assist with insurance needs Obtain data for successful linkage Track # of patients who went to see a provider Care Coordinator Determine patient’s eligibility for screening Administer the PAM 10 survey Input the data into Flourish to obtain pt. level of engagement and score Provide CfA based on level of activation Share information with clinician Repeat PAM 10 survey every 4 months Clinician/RN Review PAM scores and coaching interventions Acknowledge patient’s desire to engage in self-management efforts Reinforce key components of CfA Electronic PAM Administration Each primary care site designates staff who are PAM trained to serve as Care Coordinators The PMO provides training for those who are not PAM trained After PAM administration (step 2), care coordinator will enter completed survey into Flourish to obtain patient level of activation/score and to determine appropriate approach for coaching Coaching will be conducted by Care Coordinator or during primary care interaction upon determination of level of engagement Paper PAM Administration If organizations are unable to enter PAM survey into Flourish, completed paper PAM surveys will be forwarded to the AMCH PMO for processing Initial CfA provided by care coordinator/clinician based on the responses to survey questions AMCH PMO will enter paper PAM surveys into Flourish to obtain patient level of activation Organizations will be able to access patient data in Flourish within 5-10 business days from initial patient interaction Additional CfA to be provided based on the level of activation and most recent score on Flourish PC BH 1 2 3 4 56 DRAFT-4 2.d.i Patient Activation Workflow- PAM/CFA Integration Primary Care Practice