1. Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) June 9, 2015 Home Health Collaborations (2bviii)

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: Caroline Keane -cakeane@nyp.orgcakeane@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 Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice. Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence- based medicine and chronic care management. Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer. Educate all staff on care pathways and INTERACT-like principles. Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care. Create coaching program to facilitate and support implementation.

11. 11 DSRIP Project Review: Project Requirements Educate patient and family/caretakers, to facilitate participation in planning of care. Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management. Utilize telehealth/telemedicine to enhance hospital-home care collaborations. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. Use EHRs and other technical platforms to track all patients engaged in the project.

12. 12 DSRIP Project Review: Scale & Speed: Committed Providers NYS Designated Categories Total # committed providers Home care facilities participating in INTERACT program meeting all project requirements 8 All Committed Providers8

13. 13 Engaged Patient Definition: The number of participating patients who avoided home care to hospital transfer, attributable to INTERACT-like principles established within the project requirements. DSRIP Project Review: Scale & Speed: Patient Engagement DY1, Q2DY1, Q3DY1, Q4DY2, Q1DY2, Q2DY2, Q3DY2, Q4 Patients Engaged241331542145482627964 DY3, Q1DY3, Q2DY3, Q3DY3, Q4DY4, Q1DY4, Q2DY4, Q3DY4, Q4 18160378412051816037841205

14. DSRIP Project Review: Clinical Project Requirements: Metrics 14 Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 Potentially Avoidable Emergency Room Visits ± Number of preventable emergency visits as defined by revenue and CPT codes Number of people (excludes those born during the measurement year) as of June 30 of measurement year 24.27 per 100 Medicaid enrollees *High Perf Elig # SW measure NYS DOH P4RP4P Potentially Avoidable Readmissions ±Number of readmission chains (at risk admissions followed by one or more clinically related readmission within 30 days of discharge) Number of people as of June 30 of the measurement year 0.00 per 100,000 Medicaid Enrollees *High Perf Elig # SW measure NYS DOH P4RP4P PQI 90 – Composite of all measures ±Number of admissions which were in the numerator of one of the adult prevention quality indicators Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P PDI 90– Composite of all measures ±Number of admissions which were in the numerator of one of the pediatric prevention quality indicators Number of people 6 to 17 years as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P

15. 15 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 Percent of total Medicaid provider reimbursement received through sub- capitation or other forms of non-FFS reimbursement Dollars paid by MCO under value based arrangements Total Dollars paid by MCOsNA – Pay for Reporting measure only NYS DOH P4R Percent of eligible providers with participating agreements with RHIOs, meeting Meaningful Use criteria and able to participate in bidirectional exchange Number of Eligible qualified entities with participation agreement with a RHIO, meeting meaningful use criteria, and able to participate in bidirectional exchange Number of qualified entities in the PPS network NA – Pay for Reporting measure only # SW measure NYS DOH P4R Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards Number of PCP meeting PCMH or Advance Primary Care Standards Number of PCP providers in the PPS network NA – Pay for Reporting measure only # SW measure PPSP4R Primary Care - Usual Source of Care - Q2Percent of Reponses Yes to Q2All Responses100%^ # SW measure NYS DOH P4RP4P

16. 16 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 Primary Care – Length of Relationship – Q3 Percent of Responses at least 1 year or longer All Responses100%^ # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 20 to 44 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 20 to 44 as of June 30 of the measurement year 91.1% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 45 to 64 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 45 to 64 as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 65 and older Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 65 and older as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P

17. 17 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 Children’s Access to Primary Care – 12 to 24 months Number of children who had a visit with a primary care provider during the measurement period Number of children ages 12 to 24 months as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 25 months to 6 years Number of children who had a visit with a primary care provider during the measurement period Number of children ages 25 months to 6 years as of June 30 of the measurement year 98.4% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 7 to 11 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 7 to 11 years as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 12 to 19 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 12 to 19 years as of June 30 of the measurement year 98.8% # SW measure NYS DOH P4RP4P

18. 18 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) Number responses Usuall LJ o ƌ Al ǁ a LJ s got appt for urgent care or routine care as soon as needed, got answers the same day if called during the day or response as soon as needed if called after hours Number who answered they called for appointments or called for information 100%^ # SW measure NYS DOH P4RP4P Helpful, Courteous, and Respectful Office Staff (Q24 and 25) Number responses Usuall LJ o ƌ Al ǁ a LJ s that clerks and receptionists were helpful and courteous and respectful All responses100%^ # SW measure NYS DOH P4RP4P Medicaid Spending on ER and Inpatient Services ± Total spending on ER and IP services Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R Medicaid spending on Primary Care and community based behavioral health care Total spending on Primary Care and Community Behavioral Health care as defined by MMCOR categories Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R

19. 19 DSRIP Project Review: Clinical Project Requirements: Metrics Measure NameNumerator DescriptionDenominator Description Performance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 and 3 Payment: DY 4 and 5 H-CAHPS – Care Transition Metrics (Q23, 24, and 25) Sum of Hospital specific results for the Care Transition composite Hospitals with H-CAHPS participating in the PPS network 100%^ NYS DOH P4RP4P CAHPS Measures – Care Coordination with provider up-to-date about care received from other providers Number responses Usuall LJ o ƌ Al ǁ a LJ s that doctor informed and up- to-date about care received from other providers All responses with member seeing more than one provider 100%^ # SW measure NYS DOH P4RP4P

20. 20 DSRIP Project Review: Project Implementation Plan 2.b.viii Hospital-Home Care Collaboration Solutions 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. A major risk to the hospital-home care collaboration project is the engagement of the patients. In order for this project to be successful, patients need to accept and participate in the home care plan upon discharge from the hospital. This risk will be mitigated by educating the patients on the benefits of home care and will utilize a mutil-disciplinary discharge team comprised of a transition care coordinator, home care staff, social services, PCMH, and the patient and family members as appropriate. A second risk to this project is the duplication of efforts surrounding the implementation of an INTERACT like tool with the 2.b.vii project requirements of implementing INTERACT. The PPS has grouped the selected projects into 3 large buckets and the SNF/home care projects have been grouped together to work the "Long Term Care" projects. The LTC committee will be working together to streamline implementation of these projects which will help avoid duplication of efforts and resources between this project and project 2.b.vii. A final risk for this project is the lack of infrastructure and reimbursement from MCOs for telehealth visit. In order to expand the telehealth infrastructure, several PPS partners requested CRFP funds through the state process. Additionally, the PPS has set aside a portion of the DSRIP funds to pay for these types of uncovered services. Both of these funding sources will help to mitigate this risk and ensure this is project requirement is met by the PPS.

21. 21 DSRIP Project Review: Project Implementation Plan Project Requirements/sub-stepsTarget Completion DateUnit Level Reporting 1. Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 2. Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence- based medicine and chronic care management. DY2, Q4 Provider Level: Home Care Facility Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 3. Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer. DY2, Q4 Provider Level: Hospital Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 4. Educate all staff on care pathways and INTERACT-like principles. DY2, Q4Provider Level: Home Care Facility Step 1… Step 2… [Please add additional steps based on your plan and timeline]

22. 22 DSRIP Project Review: Project Implementation Plan 5. Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 6. Create coaching program to facilitate and support implementation. DY2, Q4 Provider Level: Home Care Facility Step 1… Step 2… [Please add additional steps based on your plan and timeline] 7. Educate patient and family/caretakers, to facilitate participation in planning of care. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 8. Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

23. 23 DSRIP Project Review: Project Implementation Plan 9. Utilize telehealth/telemedicine to enhance hospital-home care collaborations. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 10. Utilize interoperable EHR to enhance communication and avoid medication errors and/or duplicative services. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 11. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 12. Use EHRs and other technical platforms to track all patients engaged in the project. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

24. Clinical Case Vision & Example 24

25. 25 Space / LocationIT NeedsPatient TrackingBillingClinical ImplementationWorkforce Impact / NeedNon-Covered Services Anticipated Clinical Planning

26. 26 StrengthsWeaknessesOpportunitiesThreats SWOT Analysis

27. 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 27 Next Steps / Next Meeting

28. 28 Questions / Open Discussion

29. 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 29 Resources