1. Central New York Care Collaborative (CNYCC)
Cayuga County Regional Project Advisory Committee(RPAC)
Thursday, January 26th, 2016
The Commons on St. Anthony

2. CNYCC Project Dashboards

3. Actively Engaged Patients: April 1 – December, 2016
DY2 Q3 Targets
Project
Target
Actual
Gap
Status
DSRIP Care Management (2aiii)
4,450
198
4,252
ED Care Triage (2biii)
4,800
3,979
821
Care Transitions (2biv)
2,475
6,549
(4,074)
Patient Activation (2di)
9,750
1,522
8,228
Primary Care/Behavioral Health Integration (3ai)
17,500
20,684
(3,184)
Behavioral Health Crisis Stabilization (3aii)
10,500
9,884
646
Cardiovascular Disease Management (3bi)
5,100
5,090 10
Green = Meets or Exceeds 80% of Target (AV reached)
Yellow = Between 79% and 65% of Target
Red = Below 65% of Target

4. Primary Care/Behavioral Health Integration Actively Engaged Patients
Actively Engaged Patient Definition:
The total number of patients receiving appropriate preventive care screenings that include mental/substance abuse.
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in Primary Care/Behavioral Health Integration:
ARISE Child and Family Services (13)
Community Memorial Hospital (936)
Crouse Hospital (313)
FamilyCare Medical Group (2,209)
Farnham Family Services (152)
Faxton-St. Luke’s Healthcare (3,049)
Harbor Lights (41)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
17,500
20,684
(3,184)
Hutchings PC (178)
Liberty Resources (176)
Lewis County General Hospital (18)
Mohawk Valley PC (337)
NOCHSI (1,548)
Oneida Healthcare (106)
Oswego Hospital (521)
Planned Parenthood of Mohawk Hudson (1,586)
Regional Primary Care Network (797)
St. Elizabeth Medical Center (2,436)
St. Joseph’s Hospital (2,439)
Syracuse Behavioral Healthcare (733)
Upstate Cerebral Palsy (159)
Upstate University Hospital (2,937)
Orange Text Indicates Participation in Cayuga County RPAC

5. Primary Care/Behavioral Health Integration Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

6. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for Primary Care/Behavioral Health Integration?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
17,500
20,684 (0)
(3,184)
Cayuga County (6.82%)
DY2 Q4
25,000 (1,705)
1,705
Contracted Partner Organizations:
Auburn Community Hospital Cayuga County Mental Health
ARISE Liberty Resources
Cayuga Counseling Services

7. Behavioral Health Crisis Stabilization Actively Engaged Patients
Actively Engaged Patient Definition:
Participating patients receiving crisis stabilization services from participating sites, as determined in the project requirements.
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in Behavioral Health Crisis Stabilization:
ARISE Child and Family Services (247)
Cayuga County Community Mental Health Center (205)
Circare (3,846)
Central New York Services (39)
Farnham Family Services (19)
Hutchings Psychiatric Center (10)
Liberty Resources (988)
Mohawk Valley Psychiatric Center (76)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
10,500
9,884
616
North Country Transitional Living Services (42)
Oswego County Opportunities (7)
Oswego Hospital (1,722)
St. Joseph’s Hospital (1,092)
Syracuse Behavioral Health (1,451)
The Neighborhood Center (115)
Unity House of Cayuga County (9)
Upstate University Hospital (16)
Orange Text Indicates Participation in Cayuga County RPAC

8. Behavioral Health Crisis Stabilization Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

9. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for Crisis Stabilization?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
10,500
9,884 (1,202)
646
Cayuga County (6.82%)
DY2 Q4
15,000 (1,023)
Contracted Partner Organizations:
Cayuga County Mental Health Center
Liberty Resources
Unity House

10. DSRIP Care Management Actively Engaged Patients
Actively Engaged Patient Definition: The number of participating patients who completed a new or updated comprehensive care management plan. DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in DSRIP Care Management:
Oneida Healthcare (57)
Circare (2)
St. Joseph’s Hospital (139)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
4,450
198
4,252
Orange Text Indicates Participation in Cayuga County RPAC

11. DSRIP Care Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

12. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for DSRIP Care Management?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
4,450
198 (2)
4,252
Cayuga County (6.82%)
DY2 Q4
6,700 (457)
455
Contracted Partner Organizations:
ACR Health CNYHHN
Auburn Community Hospital Hillside Children’s Center
Circare Liberty Resources

13. ED Care Triage Actively Engaged Patients
Actively Engaged Patient Definition: The number of participating patients presenting to the ED, who after medical screening examination were successfully redirected to a PCP or Health Home care manager as demonstrated by a scheduled appointment. The term successfully redirected means that the patient had or was made aware of an appointment with a PCP or Health Home care manager within 30 days after ED presentation and medical screening. It is expected that the redirection could occur within or en route to the ED.
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients ED Care Triage:
Auburn Community Hospital (65)
Crouse Hospital (97)
Faxton St. Luke’s Healthcare (171)
Lewis County General Hospital (215)
Oneida Healthcare (413)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
4,800
3,979
821
Oswego Hospital (459)
Rome Memorial Hospital (1,286)
St. Elizabeth Medical Center (559)
St. Joseph’s Hospital Health Center (356)
Upstate University Hospital (358)
Orange Text Indicates Participation in Cayuga County RPAC

14. ED Care Triage Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

15. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for ED Care Triage?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
4,800
3,979 (65)
821
Cayuga County (6.82%)
DY2 Q4
9,600 (655)
590

16. Care Transitions Actively Engaged Patients
Actively Engaged Patient Definition:
The number of participating patients with a care transition plan developed prior to discharge.
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in Care Transitions:
Auburn Community Hospital (453)
Crouse Hospital (61)
Faxton St. Luke’s Healthcare (194)
Lewis County General Hospital (54)
Oneida Healthcare (441)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
2,475
6,549
(4,074)
Oswego Hospital (94)
Rome Memorial Hospital (430)
St. Elizabeth Medical Center (801)
St. Joseph’s Hospital (1,829)
Upstate University Hospital (2,192)
Orange Text Indicates Participation in Cayuga County RPAC

17. Care Transitions Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

18. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for Care Transitions?
Where is there ability to partner together to increase project work and outcomes?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
2,475
5,784 (453)
(3,309)
Cayuga County (6.82%)
DY2 Q4
3,300 (225)

19. Patient Activation Actively Engaged Patients
Actively Engaged Patient Definition:
The number of individuals who completed PAM® or other patient engagement techniques.
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in Patient Activation:
ACR Health (22)
ARISE Child & Family Services (10)
Auburn Community Hospital (115)
Catholic Charities of Onondaga County (137)
Crouse Hospital (35)
ElderChoice (4)
Finger Lakes Community Health (7)
Lewis County Public Health Agency (23)
NOCHSI (31)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
9,750
1,522
8,228
North Country Prenatal Perinatal Council (38)
Oneida Healthcare (219)
Planned Parenthood of Mohawk Hudson (265)
Regional Primary Care Network (45)
Resource Center for Independent Living (23)
St. Elizabeth Medical Center (13)
Syracuse Recovery Services (37)
The Salvation Army (498)
Orange Text Indicates Participation in Cayuga County RPAC

20. Patient Activation Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

21. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for Patient Activation?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
9,750
1,522 (154)
8,228
Cayuga County (6.82%)
DY2 Q4
13,900 (948)
794
Contracted Partner Organizations:
ACR Health Finger Lakes Community Health
ARISE Hillside Children’s Center
Auburn Community Hospital Liberty Resources
CNYHHN The Salvation Army

22. Cardiovascular Disease Management Actively Engaged Patients
Actively Engaged Patient Definition:
The number of participating patients receiving services from participating providers with documented self-management goals in medical record (diet, exercise, medication management, nutrition, etc.).
DY2 Q3 Targets
Partner Organizations Actively Engaging Patients in Cardiovascular Disease Management:
Auburn Community Hospital (37)
Community Memorial Hospital (185)
Family Care Medical Group (371)
Faxton St. Luke’s Healthcare (557)
Lewis County General Hospital (133)
NOCHSI (90)
Oneida Healthcare (80)
Q DUE
Target
Actual
Gap
Status
DY2 Q3
5,100
5,090 10
Oswego Hospital (107)
Physician Care, PC (31)
Port City Family Medicine (15)
Rome Memorial Hospital (682)
Rochester Primary Care Network (282)
St. Elizabeth Medical Center (769)
St. Joseph’s Hospital (1)
Syracuse Community Health Center (478)
Upstate University Hospital (1,272)
Orange Text Indicates Participation in Cayuga County RPAC

23. Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

24. Actively Engaged Patients
Discussion
What partnerships are currently occurring within Cayuga County for Cardiovascular Disease Management?
Where is there ability to partner together to increase Actively Engaged Patient numbers?
METRICS
Actively Engaged Patients
DUE
Target
Actual
Gap
Status
DY2 Q3
5,100
5,090 (37) 10
Cayuga County (6.82%)
DY2 Q4
6,800 (464)
427
Contracted Partner Organizations:
Auburn Community Hospital
Finger Lakes Community Health