1. NYP Queens PPS PAC Meeting
April 27, 2017

2. Key Upcoming Dates April, 2017 May, 2017
April 30, 2017: DY2Q4 Reporting Submission Deadline
April, 2017
May 3, 2017: Cultural Competency/Health Literacy PPS Leads Training
May 9, HPCANYS-CAPC DSRIP Palliative Care Project Forum , featuring eMOLST
End of May: Payment# 4 distribution to partners
May, 2017
NYP/Q PPS PAC Meeting

3. NYP Queens PPS PAC Meeting
DSRIP Updates
NYP/Q PPS PAC Meeting

4. DSRIP Updates PPS Presentation to PAOP Members in Albany
On February 2, 2017, NYP Queens PPS leadership team presented project highlights and primary care plan to Project Approval and Oversight Panel (PAOP) in Albany
The PPS did not have any formal recommendations from IA in Midpoint Assessment. Continued to have no recommendations after PAOP presentation
Recognized by the PAOP members to be doing great job with limited resources
NYPQ PPS PAC Meeting

5. DSRIP Updates DY2Q3 Achievement Values (AV) Scorecard
NYP Queens PPS has achieved all AVs (except cardio and Asthma patient engagement last quarter)to date till DY2 Q3- December 2016

6. PPS Updates & Project Specific Highlights
NYP Queens PPS PAC Meeting
PPS Updates & Project Specific Highlights
NYP/Q PPS PAC Meeting

7. PPS Updates Highlights: First Town Hall of 2017
NYP Queens PPS had their first Town hall meeting for 2017 on April 6th.
Very good turnout
PPS updates were provided by Maria D’urso, Administrative Director Community Medicine and Co-executive lead for PPS
Guest speakers included
Valentine Hernandez, Executive Director, QCCP (Queens Coordinated Care Partners) who discussed the health home program’s role in providing an individual with needed medical, social, and educational services.
Lisa Cole, NAI Coordinator, from New Americans Welcome Center under YMCA talked about the health literacy workshops for new immigrants that provide access to doctors, health insurance, emergency Medicaid, and shared referral information for additional resources.
NYPQ PPS PAC Meeting

8. PPS Updates Rapid Cycle Evaluation Updates
Rapid Cycle Evaluation work is well in progress
Charter has been finalized
First kickoff meeting - April 20, 2017
Next step: Present performance metrics to the Clinical Integration Quality committee and to each project committee meeting; work on the intervention strategies
NYPQ PPS PAC Meeting

9. PPS Updates MAX Updates
On October 2016, NYP Queens signed up for the MAX Series which is a Rapid Cycle Continuous Improvement program that focused on “Targeting Avoidable Hospital Readmissions for High Utilizers” with the goal of reducing 30-day readmissions and overall hospital utilization
High Utilizers are defined as any patient that has 4+ Inpatient Admissions in a 12-month timeframe
MAX Action team members included ambulatory care
Medical Director, case manager, social worker, nursing rep
and attending ED physician from NYP Queens and the
PI staff from Silvercrest SNF
The action team suggested and implemented various action
plans, some of which include warm handoff from the
hospital to SNF, collection of capabilities list from all SNF
partners, Health Home on site, etc.
MAX session ended on April 25, 2017
Two Train the Trainers from PMO certified
Ongoing QI efforts
NYPQ PPS PAC Meeting

10. PPS Updates Finance WOW!!!
Total disbursement of Payment #4 will be: $1,806,689.27
Expected release towards the end of May 2017
Additional funding not included in this number is for our RHIO participants:
$25,000 has been allocated
(10) sites can be paid in this current distribution, but some will be delayed
As they are made available, we will release funding and deduct from this
pre-approved balance
NYPQ PPS PAC Meeting

11. PPS Updates Bed Utilization Summary & Plan
NYP Queens PPS has finalized document that summarizes hospital bed utilization statistics
for the NYP Queens hospital, which is the lead hospital of the PPS, and outlines a plan
for future changes anticipated as a result from the improvements made by the DSRIP program
Submitted to NYSDOH for DY2Q4 reporting
The average bed utilization rate for the hospitals listed in Queens County is 79.16% as
compared to the New York State average of 61.80% of staffed beds
The only hospital within the PPS network maintains a bed utilization rate of 93% of staffed beds
which is 14% above the local Queens average and 31% above the state average
Along with high utilization rates of staffed beds, the Definitive Healthcare information system
reports a 4.64% Medicaid utilization of inpatient days for the NewYork-Presbyterian Queens
hospital as compared to the community average of 11.41%
As per the Community Needs Assessment, Queens County has a bed rate per 1,000 persons of
1.49 as compared to the overall NY State average of 3.0 and the national average of 2.6 beds
per 1,000. This is 1.51 beds less that the state average and 1.11 beds less than the national
average.
NYPQ PPS PAC Meeting

12. PPS Updates Bed Utilization Summary & Plan, cont’d RECOMMENDATIONS:
Engage critical network partners to implement 9 DSRIP projects meeting project requirements,
scale and speed expectations.
Align project implementation to quality process improvement efforts of the Rapid Cycle
Evaluation Unit utilizing care coordination efforts, best practice utilization, technology connectivity
and integration, and other population health strategies.
Forecast impact to hospital inpatient indicators monitored by the RCE and partner with the
Hospital Quality Team to plan action items associated with direct impact.
Implement connectivity tools such as RHIO (Healthix) and population health management tools
(Allscripts & Cureatr) to streamline network communication and ensure access of patient record
activity in order to reduce utilization and improve outcome quality.
Complete analytics utilizing the Rapid Cycle Evaluation Unit to identify high-risk patient
populations for inpatient and emergency department utilization in order to establish action plans
by MCO designated provider to create outreach or educational opportunities for access or
connectivity to care coordination.
Incentivize network partners utilizing the PPS funds flow model to reward quality improvements
and high-risk care coordination activities that align with the RCE findings of inpatient &
emergency department utilization.
Partner with the hospital Quality Team to partner quality based process improvement efforts to
maximize efforts & network impact
NYPQ PPS PAC Meeting

13. PPS Updates IT Updates Allscripts Care Director (ACD) Updates
NYP Queens PPS Population Health Management Tool- ACD roll out is expected to happen sometime in summer.
Trainings on basic navigation have been completed in March 2017
Next step is to finalize the utilization strategy
Performance Logic Training & Rollout
PPS Project Management Tool, Performance Logic, has been rolled out.
Webforms with deliverables have been pushed out to all partners
Several training sessions were completed in March
NYP/Q PPS PAC Meeting

14. PPS Updates Workforce Training Updates
INTERACT Train-the-Trainer sessions and trainings in SNF partner sites
Performance Logic Training
Allscripts Care Director Training
Cardiovascular best practices and protocols refresher webinar
eMOLST Webinar
NYPQ PPS PAC Meeting

15. PPS Updates Website & Newsletter
NYP Queens PPS restructured website
More updates posted. Please continue to visit our website
First quarterly newsletter released in January 2017
Next newsletter release- anticipated mid-May
Highlights on
PPS achievements
Partner Interview
Community events
Best practices
Educational opportunities
Job opportunities
In order to add any recipient to the newsletter distribution, please contact Coleen or Sadia in PMO
NYP/Q PPS PAC Meeting

16. PPS Updates Patient Centered Medical Home Project
Initially, NYP Queens PPS committed to 35 PCPS getting certified under Level PCMH
To date, PPS has 45 PCPs in this project
25 PCPs already Certified Level PCMH – 56%
20 PCPs in process of transformation
WOW!!!
NYP/Q PPS PAC Meeting

17. PPS Updates SNF Care Transition, INTERACT and Home Care Projects
All 27 SNFs implemented INTERACT
All home care partners we committed in the project implemented INTERACT
Silvercrest successfully implemented warm handoff protocol in their facility
Next step is to roll out to all other SNF partners
All 27 SNFs signed RHIO participation agreements.
Next step is to start data sharing
WOW!!!
WOW!!!
NYP/Q PPS PAC Meeting

18. PPS Updates Palliative Care Project
WOW!!!
EPEC first round will be completed on May 10, 2017
Tremendous success and turnout rate in all sessions so far
Partners were surveyed and requested to make up for following modules
Plenary 1 & 2: Gaps in End -of-Life Care & Legal Issues
Modules 1 & 2 : Advance Care Planning & Communicating Bad News
Modules 3 & 4 : Whole Patient Assessment & Pain Management
Next step: Explore to bring guest speakers for Pediatric Palliative Care
NYP/Q PPS PAC Meeting

19. PPS Updates Cardiovascular Project
Standardized protocols in place for network; Training Completed
Home Blood Pressure monitoring
Blood Pressure Measure Competency
Medication Management
Tobacco Cessation Protocols, 5A’s
Care Coordination
Health Home Trainings completed with more than half of the cardio project partners
ED Health Home Training- April 12, 2017
15 ED staff trained
WOW!!!
NYP/Q PPS PAC Meeting

20. PPS Updates Pediatric Asthma Project
Pediatric Asthma Center was one of the few centers who received award from NYP for best Patient Experience
Asthma Coalition of Queens trained 5 staff in ED who will be
getting certified as Asthma Educators this summer
WOW!!!
NYP/Q PPS PAC Meeting

21. Questions
NYP/Q PPS PAC Meeting