1. Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) June 10, 2015 Asthma (3dii)

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: Hadi Jabbar, M.D. – hmj9001@nyp.orghmj9001@nyp.org 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 Expand asthma home-based self-management program to include home environmental trigger reduction, self-monitoring, medication use, and medical follow-up. Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions. Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests, mold, and second hand smoke. Develop and implement evidence based asthma management guidelines. Implement training and asthma self- management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. Ensure coordinated care for asthma patients includes social services and support. Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what happened and how to avoid future events. Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary care providers, and specialty providers. Use EHRs or other technical platforms to track all patients engaged in this project.

11. 11 DSRIP Project Review: Scale & Speed: Committed Providers NYS Designated Categories Total # committed providers Primary Care Physicians13 Non-PCP Practitioners14 Clinics0 Health Home / Care Management0 Pharmacy2 CBO1 All Other6 All Committed Providers 36

12. 12 Engaged Patient Definition: The number of participating patients based on home assessment log, patient registry, or other IT platform. DSRIP Project Review: Scale & Speed: Patient Engagement DY1, Q2DY1, Q3DY1, Q4DY2, Q1DY2, Q2DY2, Q3DY2, Q4 Patients Engaged per Quarter 259336517104345500863 DY3, Q1DY3, Q2DY3, Q3DY3, Q4DY4, Q1DY4, Q2DY4, Q3DY4, Q4 104345500863104345500863

13. DSRIP Project Review: Clinical Project Requirements: Metrics 13 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Prevention Quality Indicator # 15 Younger Adult Asthma ± Number of admissions with a principal diagnosis of asthma Number of people ages 18 to 39 as of June 30 of the measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Pediatric Quality Indicator # 14 Pediatric Asthma ± Number of admissions with a principal diagnosis of asthma Number of people ages 2 to 17 as of June 30 of the measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Asthma Medication Ratio (5 – 64 Years) Number of people with a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year Number of people, ages 5 to 64 years, who were identified as having persistent asthma 76.0%NYS DOH P4P Medication Management for People with Asthma (5 – 64 Years) – 50% of Treatment Days Covered who filled prescriptions for asthma controller medications during at least 50% of their treatment period Number of people, ages 5 to 64 years, who were identified as having persistent asthma, and who received at least one controller medication 68.6% NYS DOH P4P

14. 14 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Medication Management for People with Asthma (5 – 64 Years) – 75% of Treatment Days Covered who filled prescriptions for asthma controller medications during at least 75% of their treatment period Number of people, ages 5 to 64 years, who were identified as having persistent asthma, and who received at least one controller medication 44.9% NYS DOH P4P

15. 15 DSRIP Project Review: Project Implementation Plan 3.d.ii Expansion of Asthma Home-Based Self-Management Program 1. Measurable milestones and implementation risks Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. The primary challenge for this project is the adherence to home based treatment regimens once determined by the PCP, non PCP, pulmonologists and other health care providers. A population health management strategy will be developed using IT software that will be determined to best connect with the attributed patient population, to serve as a trigger for compliance, with medication reminders, appointment reminders, and general asthma health reinforcement. The tool will assist with patient tracking and planning, and serve as a component of a proposed Asthma Resource Center for care coordination. Alternative ways for monitoring for adherence, such as one way communication such as text reminders will help move the efforts already in place with the Pediatric Asthma Center to more all-inclusive care coordination with improved patient outcomes and better management of a home based program. Interconnectivity with PPS school systems will be a concern and prove a risk to the successful achievement of milestones and metrics. Electronic school based health records are in different stages of technology development and the connection to an Asthma Resource Center will have to be recognized by the PPS leads to ensure that pathways to share the Medication Administration Form (MAF) with providers to coordinate care for the children associated with the project. The plan is to develop coalitions, protocols, and best practice technology based platforms to enhance bidirectional transfer of information to best support this patient population. Another risk to the expansion project of asthma home-based self-management program is the ability for providers to gain access to conduct the initial environmental assessment for trigger identification and subsequent visits to monitor and adjust recommendations once triggers are identified. Financial reimbursement and lack of funding for these visits is a component and risk for this project also. The Pre-existing Pediatric Asthma Center will serve as a model the PPS best practice, led by Dr. Jabbar, who will leverage existing collaborations among community organizations to ensure all CBO, including schools, shelters, housing representatives, and other organization are in alignment with risk modification once identified. The initiative will take pre-existing best practice and expand to repeat visit needs to determine compliance with recommendations for home environment adjustments. The team is leveraging established asthma community based programs to support PCPs, non-PCPs and health care providers on evidence based practice guidelines to support home management, including repeat home visits when necessary with financial components/incentives.

16. 16 DSRIP Project Review: Project Implementation Plan Project 3.d.ii Project Requirements/sub-stepsTarget Completion DateUnit Level Reporting 1. Expand asthma home-based self-management program to include home environmental trigger reduction, self- monitoring, medication use, and medical follow-up. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 2. Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions. Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests, mold, and second hand smoke. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 3. Develop and implement evidence based asthma management guidelines. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 4. Implement training and asthma self- management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

17. 17 DSRIP Project Review: Project Implementation Plan 5. Ensure coordinated care for asthma patients includes social services and support. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 6. Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what happened and how to avoid future events. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 7. Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary care providers, and specialty providers. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 8. Use EHRs or other technical platforms to track all patients engaged in this project. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

18. Clinical Case Vision & Example 18

19. 19 Space / LocationIT NeedsPatient TrackingBillingClinical ImplementationWorkforce Impact / NeedNon-Covered Services Anticipated Clinical Planning

20. 20 StrengthsWeaknessesOpportunitiesThreats SWOT Analysis

21. 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 21 Next Steps / Next Meeting

22. 22 Questions / Open Discussion

23. 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 23 Resources