1. Refuah Community Health Collaborative
PROJECT ADVISORY COMMITTEE MEETING
September 29, :00 pm – 3:00 pm
400 Rella Blvd, Suite 205
Webinar participation available

2. Agenda Introduction/Housekeeping Project Management Office Update
CMS site visit a success
Upcoming Midpoint Assessment
MAX Train-the-Trainer Program
Workforce Update
Data Sharing Requirements

3. Webinar Instructions
Webinar is being recorded and will be available on our website
Attendees who have called in are muted
To ask a question: Type the question into the box on the sidebar
At the end of the presentation we will read the questions aloud & provide answers

4. Wifi
Network: CHCGuest
Password: Dyt678RB

5. PMO Update
On August 10th representatives from the Centers for Medicare and Medicaid Services as well as the New York State Department of Health did a full-day site visit of Refuah Health Center and some of its partners.
The insights and thinking behind your various approaches showed the true dedication of the Refuah community and its extended partners in making the health care system work better… Many thanks from all of us at DOH and CMS!”
  Peggy Chan, MPH
DSRIP Program Director
Mid-point Assessments by the Independent Assessor scheduled throughout the month of October.

6. Medicaid Accelerated eXchange (MAX) Series on Integration
Free Train-the-Trainer Program to develop facilitators to administer ongoing Rapid Cycle Continuous Improvement Workshops
Workshop topic will be “Avoidable Hospital Readmissions for High Utilizers”
Program begins in November and the MAX Team is recruiting now. Minimum 12 month training commitment. *
This program, offered by the state and administered by KPMG, is a series of rapid cycle improvement workshops
I can’t say enough about how Refuah’s participation in this program has propelled their delivery of care into the next era.
In this case the topic was the integration of mental and physical health care,
You’ll hear more about what they’ve done on the tour
but I suspect the process would work for any topic.
Key elements of the program are:
DSRIP is a program which tries to accomplish a lot in a short amount of time. I think this kind of front-end level setting and spurring progress forward would be valuable to include in any future DSRIP program.

7. Workforce Update

8. Current State Assessment
In accordance with DOH requirements RCHC conducted a current state assessment.
Consisted of partner surveys.
Purpose is to establish a “snap shot” of the current state of the RCHC workforce.
If you would like a copy, please reach out to Anne Cuddy at

9. Target State Design
Developed based upon survey data, industry benchmarks, and modeling.
Projections across the 5 year DSRIP project period.
RCHC must report on actuals semi-annually.
First report on “actuals” for DY1 and the first half of DY2.
If you have not already done so, please provide us with an update on your actual DY1 and DY2 workforce impacts!

10. Target Workforce State
Social Worker Case/Care Management – 20% retraining; 80% new hires
Patient Navigators/Care Coordination – 50% retraining; 50% new hires
Nursing – 96% retraining; 4% new hires
Nursing Care Managers – 88% retraining; 12% new hires
Primary Care Physicians – 100% new hires
Behavioral Health practitioners – 80% retraining; 20% new hires
Administrative Support – 50% new hires; 50% retraining

11. Total Workforce Impact

12. Gap Analysis
RCHC’s analysis has determined that the key roles that need to be addressed in connection with DSRIP are in the following areas, ranked in order of importance:
Social Workers
Patient Navigators/Peer Workers
Behavioral Health Practitioners
Primary Care Physicians
Case & Care Management
Administrative/Support Staff
Nursing Care Managers/Coordinators
Nursing staff

13. Gap Analysis (cont’d)
The gaps in the RCHC workforce are consistent with the transformation are in line with the nature of RCHC’s projects.
Given that 3 of 7 projects are behavioral health projects it is expected that large gaps in BH/mental health workers were observed.
The Patient Navigation and Medication Adherence projects also are driving certain observed gaps in workforce.
The gaps in case/care management and patient navigators/peer workers is also not surprising given that these roles are relatively new in the healthcare field. The need for these roles is further driven by the integrative and community-based philosophies of RCHC.
The need for additional primary care physicians and nursing staff is consistent with regional shortages.

14. Key Takeaways
The impact on the workforce will be in the form of new hires and retraining, with a significant emphasis on retraining.
The observed gaps are largely a function of the projects, but appear to fit in with larger network level trends towards increased integration and “top of the license” practice.
Based upon the FTE projections, RCHC ranked its gaps in staffing in accordance with the greatest needs of the PPS.
Next steps for RCHC are to turn the gap analysis into an actionable “roadmap” and training strategy.

15. Data Sharing and Clinical Interoperability Requirements

16. Overview Set 1 Set 2 Set 3 Set 4
Requirement Description
Healthlinkny Participation Agreement
Set 1
Healthlinkny Patient Consent
Healthlinkny web portal account(s)
DIRECT messaging
Utilize Healthlinkny alerts for care coordination
Set 2
Contribute inpatient admission and discharge alerts to Healthlinkny
Clinical document exchange with Healthlinkny
Set 3
Meaningful Use Stage 2
Set 4
EHR patient registry capabilities
Azara integration

17. Set 1 Applies to:
All Refuah CHC PPS organizations with a completed Master Agreement & designated NYS DOH DSRIP Safety Net in :
PC/NonPC
Hospital
Clinic BH
SNF OR
Entities that are contracted for specific PPS projects:
2.a.ii – (PCMH)
2.c.i - Community-based navigation services
3.a.i – Integration of PC & BH
3.a.ii – BH Crisis stabilization services
3.a.iii – MAP

18. Set 1
DUE DATE: 3/31/2018
Complete a PA with Healthlinkny & for RefuahCHC to receive a copy of monthly report.
Complete consent training. Provide consent materials to patients and staff.
Maintain at least one active Healthlinkny web account for patient record lookup.
Utilize DIRECT messaging for secure communication to coordinate care during transitions or referrals between service providers.

19. Set 2
DUE DATE: 3/31/2018
Contribute inpatient admission and discharge alerts to Healthlinkny – applies to inpatient facilities only
Utilize Healthlinkny alerts for care coordination – applies to PCMH project sites only

20. Set 3 Applies to
Organizations with a completed Master Agreement & designated safety net by NYS DOH DSRIP in categories:
PC/NonPC
Hospital
Clinic BH
SNF OR
Organizations contracted for specific PPS projects:
2.a.ii - PCMH
3.a.i – Integration of PC & BH

21. Set 3
DUE DATE: 3/31/2018
Organization must perform clinical document exchange with Healthlinkny
Clinical documents must use HL7 CCDA format.
Summaries must contain the following structured clinical data elements at the completion of all patient encounters/admissions
Patient demographics
Allergies
Immunizations
Medications
Problems
Procedures
Vitals

22. Set 4: Applies to PCMH hubs
DUE DATE: 3/31/2017
Meaningful Use Stage 2
EHR patient registry capabilities
Azara integration

23. Performance Reporting
Four of the requirements have Performance Reporting guidelines after 4/1/2018:
Healthlinkny Patient Consent
Utilize Healthlinkny alerts for care coordination
Clinical document exchange with Healthlinkny
What is the purpose of performance reporting requirements?
Organizations must continue to use the HIE (Healthlinkny) in specific ways to help ensure data sharing and clinical interoperability of the PPS network.

24. Next Steps
RCHC PMO will be providing each organization with a copy of the guidelines and will mark which requirement applies to the organization with a check mark
EXAMPLE:
Requirement
Performance Reporting after 4/1/2016?
Healthlinkny Participation Agreement No
Healthlinkny Patient Consent
Yes
Healthlinkny web portal account(s)
DIRECT messaging
Clinical document exchange with Healthlinkny
Contribute ADT alerts to Healthlinkny
Meaningful Use Stage 2

25. Next Steps
Organizations will be asked to sign that they “agree….to comply with the above selected requirements during its participation in the Refuah Community Health Collaborative.”

26. Questions or Comments?