1. Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) June 9, 2015 Primary Care : Behavioral Health Integration (3ai)

2. Agenda 2 Welcome & IntroductionsClinical LeadershipMeeting PurposeScope of Clinical Sub-CommitteePPS Updates & TimelineDSRIP Project ReviewClinical Case Vision & ExampleClinical PlanningSWOTNext Steps / Next MeetingQuestions / Adjourn

3. Chair: Maureen Buglino, NYHQ, VP, Community & Emergency Medicine Co-Chair: Maria D’Urso, NYHQ, Administrative Director, Community Medicine Subject Matter Expert: John Lavin, MHPWQ, Senior Officer Development and Clinical Services 3 Clinical Leadership

4. Initiate the clinical planning process of the NYHQ PPS DSRIP projects in order to complete the Project Implementation Plans due July 31, 2015, develop strategies for actualization of projects, identify operational process, IT, budget, or workforce needs, and ensure all engaged partners are actively engaged in planning & implementation. 4 Meeting Purpose

5. Engage PPS network partners to operationally plan, develop, and design the clinical program outlined in the DSRIP application submitted in December 2014 Focus on collaborative planning processes that meet project requirements, metrics, and scale & speed expectations associated with the clinical program Complete the Project Implementation Plans due July 31 Inform budgets and operational needs such as workforce & IT Guide partners by becoming a resource and communication channel to ensure effective engagement 5 Scope of Clinical Sub-Committee

6. Clinical planning will include, but is not limited to: Implement project design to include all committed PPS partners Establish and meet performance reporting expectations Establish expectations for evidence based medicine protocols & best practice standards Communicate internally and externally on program development and progress Explain variances of project requirement or metric progress Ensure success of the project by improving clinical quality and meeting expectations of project requirements, scale & speed, and metrics Work with other committees and sub-committees to ensure cross communication & feedback 6 Scope of Clinical Sub-Committee

7.  Organization Implementation Plans – Submitted  PPS Valuation Notification – Received  Project Implementation Plans – Due 7/31/2015  Executive Committee Meeting – 6/11/2015  PAC Meeting – 6/19/2015  Workforce Data Due – 10/31/2015  Budgets, Funds Flow, Business Agreements – In Development  Clinical Planning Meetings – Begin week of 6/8/2015 7 PPS Updates & Timeline

8. Clinical Planning & Development Project Implementation Plans Due (7/31/15) DY1 Quarterly Report Due (7/31/15) Workforce Data Due (10/31/2015) 8 PPS Updates & Timeline Organization Development, Budget & Funds Flow Development, Committee & Governance Structure Development, Clinical Planning & Implementation, IT Development, Workforce Planning, Partner Engagement, etc.

9. 99 Bi-annual payments driven by quarterly reports of milestone, metric, & scale & speed achieved deliverables DSRIP Year/Quarter Dates CoveredQuarterly Report DuePayment Date DY1, Q1April 1, 2015 – June 30, 2015July 31, 2015 January 2016 DY1, Q2July 1, 2015 – September 30, 2015October 31, 2015 DY1, Q3October 1, 2015 – December 31, 2015January 31, 2016 July 2016 DY1, Q4January 1, 2016 – March 31, 2016April 30, 2016 DY2, Q1April 1, 2016 – June 30, 2016July 31, 2016 January 2017 DY2, Q2July 1, 2016 – September 30, 2016October 31, 2016 DY2, Q3October 1, 2016 – December 31, 2016January 31, 2017 July 2017 DY2, Q4January 1, 2017 – March 31, 2017April 30, 2017 PPS Updates & Timeline

10. 10 DSRIP Project Review: Project Requirements Co-locate behavioral health services at primary care practice sites. Primary care practices must meet 2014 NCQA level 3 PCMH or Advance Primary Care Model standards by DY3 Co-locate primary care services at behavioral health sites Develop collaborative evidence-based standards of care including medication management and care engagement process Conduct preventive care screenings, including behavioral health screenings (PHQ-9, SBIRT) implemented for all patients to identify unmet needs Use EHRs or other technical platforms to track all patients engaged in this project

11. 11 DSRIP Project Review: Scale & Speed: Committed Providers Total Committed Providers Primary Care Physicians15 Non-PCP Practitioners142 Clinics9 Behavioral Health53 Substance Abuse7 Community Based Organizations1 All Others49 Total276 NYS Designated Categories

12. 12 Engaged Patient Definition: The total number of patients engaged per each of the three models in this project including: A. PCMH Service Site: Number of patients screened (PHQ-9/SBIRT) B. Behavioral Health Site: Number of patients receiving primary care services at a participating mental health or substance abuse site DY3, Q11005 DY1, Q21148DY3, Q23349 DY1, Q31579DY3, Q34497 DY1, Q42584DY3, Q47177 DY2, Q1643DY4, Q11914 DY2, Q22143DY4, Q26379 DY2, Q32878 DY4, Q38293 DY2, Q44593 DY4, Q412759 DSRIP Project Review: Scale & Speed: Patient Engagement

13. DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibilit y Payment: DY 2 & 3 Payment: DY 4 & 5 Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) ± Number of preventable emergency visits as defined by revenue and CPT codes Number of people with a BH diagnosis (excludes those born during the measurement year) as of June 30 of measurement year 0.0^ per 100 Medicaid enrollees with Behavioral Health Qualifying Service *High Perf Elig NYS DOHP4P Antidepressant Medication Management – Effective Acute Phase Treatment Number of people who remained on antidepressant medication during the entire 12-week acute treatment phase Number of people 18 and older who were diagnosed with depression and treated with an antidepressant medication 60.0% *High Perf Elig NYS DOHP4P Antidepressant Medication Management – Effective Continuation Phase Treatment Number of people who remained on antidepressant medication for at least six months Number of people 18 and older who were diagnosed with depression and treated with an antidepressant medication 43.5% *High Perf Elig NYS DOHP4P Diabetes Monitoring for People with Diabetes and Schizophrenia Number of people who had both an LDL-C test and an HbA1c test during the measurement year Number of people, ages 18 to 64 years, with schizophrenia and diabetes 89.8% *High Perf Elig NYS DOHP4P Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication Number of people who had a diabetes screening test during the measurement year Number of people, ages 18 to 64 years, with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication 89.0%NYS DOHP4P 13

14. Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibil ity Payment: DY 2 & 3 Payment: DY 4 & 5 Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia Number of people who had an LDL-C test during the measurement year Number of people, ages 18 to 64 years, with schizophrenia and cardiovascular disease 92.2% (health plan data) *High Perf Elig NYS DOHP4P Follow-up care for Children Prescribed ADHD Medications – Initiation Phase Number of children who had one follow-up visit with a practitioner within the 30 days after starting the medication Number of children, ages 6 to 12 years, who were newly prescribed ADHD medication 72.3% NYS DOHP4RP4P Follow-up care for Children Prescribed ADHD Medications – Continuation Phase Number of children who, in addition to the visit in the Initiation Phase, had at least 2 follow-up visits in the 9- month period after the initiation phase ended ages 6 to 12 years, who were newly prescribed ADHD medication and remained on the medication for 7 months 78.7% (health plan data) NYS DOHP4RP4P Follow-up after hospitalization for Mental Illness – within 7 days Number of discharges where the patient was seen on an ambulatory basis or who was in intermediate treatment with a mental health provider within 7 days of discharge Number of discharges between the start of the measurement period to 30 days before the end of the measurement period for patients ages 6 years and older, who were hospitalized for treatment of selected mental health disorders 74.2% *High Perf Elig NYS DOHP4P Follow-up after hospitalization for Mental Illness – within 30 days Number of discharges where the patient was seen on an ambulatory basis or who was in intermediate treatment with a mental health provider within 30 days of discharge Number of discharges between the start of the measurement period to 30 days before the end of the measurement period for patients ages 6 years and older, who were hospitalized for treatment of selected mental health disorders 88.2% *High Perf Elig NYS DOHP4P 14 DSRIP Project Review: Clinical Project Requirements: Metrics

15. Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Screening for Clinical Depression and follow-up Number of people screened for clinical depression using a standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen Number of people with a qualifying outpatient visit who are age 18 and older 100%^ PPS and NYS DOH P4RP4P Adherence to Antipsychotic Medications for People with Schizophrenia Number of people who remained on an antipsychotic medication for at least 80% of their treatment period Number of people, ages 19 to 64 years, with schizophrenia who were dispensed at least 2 antipsychotic medications during the measurement year 76.5%NYS DOHP4P Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) Number of people who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the index episode Number of people age 13 and older with a new episode of alcohol or other drug (AOD) dependence 86.0% NYS DOHP4P Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) Number of people who initiated treatment AND who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit Number of people age 13 and older with a new episode of alcohol or other drug (AOD) dependence 31.4%NYS DOHP4P 15 DSRIP Project Review: Clinical Project Requirements: Metrics

16. 16 DSRIP Project Review: Project Implementation Plan

17. 17 DSRIP Project Review: Project Implementation Plan

18. Clinical Case Vision & Example 18 Mental Health Providers of Western Queens John Lavin, Senior Officer Development and Clinical Services

19. Reverse Co-Location Case Example Mr. Jones receives treatment at MHPWQ mental health clinic and is referred to MHPWQ care management for care coordination services – Care coordinator identifies poor engagement in medical care – Care coordinator explores options for primary care treatment and presents opportunities to Mr. Jones, including options of treatment by PCP co-located at WQCC Mr. Jones elects to enter primary care treatment at co-located PCP based on familiarity with MHPWQ programs – Utilization of co-located medical care results in improved treatment engagement – Communication between medical and behavioral health providers improves symptom monitoring and early intervention – Ability to schedule same day, same location medical and behavioral health appointments improves Mr. Jones’s satisfaction with care “Mr. Jones” referred to MHPWQ mental health clinic upon discharge from hospital following inpatient psychiatric treatment – Chronically depressed with history of isolating behavioral and suicidality – Obesity, hypertension, and diabetes – Poor engagement in medical services

20. Mental Health Providers of Western Queens (MHPWQ) Reverse Co-Location NYHQ affiliated PCP will co-locate at MHPWQ behavioral health site PCP will maintain separate records and billing but communicate and coordinate with MHPWQ behavioral health providers On-site medical services will be delivered to improve access- to-care and treatment engagement MHPWQ clients without PCP or with poor engagement in medical care will be referred to co-located primary care Community PCPs without capacity to serve SMI population will refer clients to co-located primary care at MHPWQ Community residents seeking accessible primary care services may enroll in co-located primary care practice

21. Co-Located Collaborative Care Case Example Behavioral health professional conducts assessment and diagnoses panic disorder – 6 session psychotherapy for panic disorder provided by behavioral health professional – Reduction in panic symptoms experienced but presence of persistent anxiety remains – Mrs. Jones offered referral to mental health provider for continued treatment – Mrs. Jones enrolled in care coordination (based on asthma and anxiety disorder) Mrs. Jones declines mental health referral but maintains treatment with PCP – Option of future consultation with behavioral health professional communicated – Follow-up coordination between behavioral health professional and PCP “Mrs. Jones” enters outpatient primary care treatment and reports fear of “heart problems” and “losing control” to PCP – PCP conducts initial medical screening and diagnoses asthma but no cardiac illness – PCP refers Mrs. Jones to on-site behavioral health professional

22. Mental Health Providers of Western Queens (MHPWQ) Co-Located Collaborative Care MHPWQ behavioral health professionals co-located at NYHQ outpatient medical facility Medical patients will be screened for behavioral health conditions using screening instruments, self-report, and clinical observation All patients presenting possible behavioral health conditions will be referred to behavioral health professional for assessment and triage Patients with mild to moderate behavioral health conditions will receive on-site intervention (1-6 consultations) from behavioral health professionals Behavioral health professionals will coordinate with medical staff More complex behavioral health cases will be referred to specialty mental health and substance abuse treatment MHPWQ staff will maintain separate records and billing Behavioral health professionals will be available for walk-in consultation

23. 23 Space / LocationIT NeedsPatient TrackingBillingClinical ImplementationWorkforce Impact / NeedNon-Covered Services Anticipated Clinical Planning

24. 24 StrengthsWeaknessesOpportunitiesThreats SWOT Analysis

25. Additional webinar based clinical planning meetings – TBD Project Implementation Plan drafting & distribution Executive Team Development of budgets, funds flow, agreements Executive Committee review & approval Partner agreement completion PAC meeting 6/19/15 25 Next Steps / Next Meeting

26. 26 Questions / Open Discussion

27. Website: www.nyhq.org/dsripppswww.nyhq.org/dsrippps Maureen Buglino, VP, Community & Emergency Medicine mabuglin@nyp.org Maria D’Urso, Administrative Director, Community Medicine mda9005@nyp.org Crystal Cheng, Data Analyst, DSRIP crc9038@nyp.org 27 Resources