1. NYP Queens PPS PAC Meeting
December 12, 2017

2. Clinical Project Updates 5. Questions
Agenda
Welcome
DSRIP Updates
Key Upcoming Dates
PPS Updates
PMO Staffing
Medical Record Review
Rapid Cycle
MY3 Performance
HU ED Project
Clinical Project Updates
5. Questions
NYP/Q PPS PAC Meeting

3. DSRIP Updates Key Dates
12/13: Clinical Integration and Quality Meeting
12/14: Executive Committee Meeting
12/15: DY3, Q2 Remediation Due
12/31: DY3, Q3 Ends
December
1/1: DY3, Q4 Begins
1/10: PPS Executive meeting NYC
1/31: DY3, Q3 MAPP Reports Due
January
NYP/Q PPS PAC Meeting

4. DSRIP Performance Statewide Performance
DSRIP program is at risk for funding reductions if the statewide goals are not met
Statewide Goals:
Statewide Metrics Performance – more measures are increasing than decreasing
Success of projects – More metrics targets are met than missed
Medicaid Spending – growth in spending is at or below the target rate
Managed care plans – VBP roadmap goals achieved
Funding Risks (Allocated proportionally to PPSs):
DY3: $74.1M
DY4: $131.7M
DY5: $175.6M
NYPQ PPS PAC Meeting

5. NYP Queens PPS PAC Meeting
DSRIP Updates
NYPQ PPS PAC Meeting

6. PPS Updates PMO Staffing
PPS PMO is continuing recruitment to fill vacant positons
New Team Members/Roles:
Nurse Practitioner– Hoda Abdelaziz
Patient Navigator - Andres Duran
Currently Recruiting:
Patient Navigators
Population Health Manager
Project Coordinator
Data Analyst
Care Coordinators
NYPQ PPS PAC Meeting

7. PPS Updates Medical Record Review
DOH Medical Record Collection and data abstraction is in progress
The goal is to collect MY3 sample data from the PPS to measure annual improvement targets
PPS Reported Measures:
Screening for Clinical Depression and Follow Up Plan
Controlling High Blood Pressure
2017 Sample Report
NYPQ PPS PAC Meeting

8. Current Performance data MY3 Month 10 of 12 (March 2016)
PPS Updates
Scorecard/Dashboard Available
Current Performance data MY3 Month 10 of 12 (March 2016)
NYPQ PPS PAC Meeting

9. PPS Updates Rapid Cycle
Rapid Cycle Team is meeting with project committees on an ongoing basis to present quality data; next steps include:
Next Steps:
Import and analyze data from multiple sources including claims, hospital EHR and ambulatory EHR
Restructure PPS committees in 2018 to align with focus to quality and implementing performance improvement plans plan
Develop interventions and solutions based partner feedback
PPS is currently meeting 52% of quality measures*
Currently meeting 4 of 9 high performance measures
*based on available data though MY3 Month 9 of 12 (March 2017)
NYPQ PPS PAC Meeting

10. PPS Updates VBP
PPS will be launching a VBP education series beginning January 2018 (co-hosting with NYP PPS) and will kick-off with 2 sessions – VBP 101 & NYS VBP Roadmap
VBP University -
Provides helpful guides and videos to breakdown VBP
NYPQ PPS PAC Meeting

11. Clinical Project Updates
NYP Queens PPS PAC Meeting
Clinical Project Updates
NYPQ PPS PAC Meeting

12. PPS Updates High Utilizers ED Project
In continuation of the NYS DOH collaboration program MAX, the PPS launched its own high utilization program in September 2017
Goal of the program is to reduce high utilization of the Emergency Department by addressing patient’s social drivers
Criteria: High Utilizers (HU) are defined as having 9+ ED visits within 12months
Action plans and Interventions for HUs include:
Case Conferencing
Patient Interviews
Provider Education
Data management
Outpatient Root Cause Analysis
Provide Patient referral information
After final workshop on final outcomes will be measured and shared with DOH
NYPQ PPS PAC Meeting

13. PPS Updates 2.a.ii (PCMH)
The PMO has been focusing efforts to complete all the required DY3,Q4 milestones / deliverables that are due in March 2018
Key requirements for March 2018
All partner EHRs meets RHIO’s HIE and SHIN-NY requirements
PPS uses alerts and secure messaging functionality
Implement open access scheduling in all primary care practices
Currently all project partners have been connected to the RHIO and have MU stage 2 requirements
The PMO is currently collaborating with specific CBOs, including QCCP and Elmcor, to increase patients referrals to health homes and provide practitioner trainings on substance abuse
NYP/Q PPS PAC Meeting

14. PPS Updates 2.b.v, 2.b.v.ii, 2.b.v.ii 3.g.ii (LTC Projects)
2.b.v – SNF
Silvercrest and NYPQ successfully implemented a warm handoff policy to improve care transition between hospital and the SNF
Warm Hand off compliance rate increased from 36.36% in Sept. to 40.91% in Nov. 2017
Project due DY3, Q4 (March, 31, 2018)
2.b.vii – INTERACT
Through the implementation of INTERACT, the hospital has been able improve PPR rate
2.b.viii – Home Care
The PPS is in the process of engaging all the partners to collect milestones documentation including provider lists, telemedicine, medication reconciliation and MOLST information.
3.g.ii – Palliative Care
PPS will be rolling out EMOLST and an updated Integrated Palliative Care Outcome Scale (IPOS) form in Jan. 2018
NYP/Q PPS PAC Meeting

15. PPS Updates 3. a. i (PC/BH), 3. b. i (Cardio), 3. d. ii (Asthma), 4. c
PPS Updates 3.a.i (PC/BH), 3.b.i (Cardio), 3.d.ii (Asthma), 4.c.ii (HIV)
3.a.i – PC/BH Integration
The PMO is currently working with our partners to recruit providers, develop policies, and screening to support our co-location by DY3, Q4 (March 2018)
3.b.i – Cardiovascular
NYPQ has created a patient stratification system to identify patients who have repeated elevated blood pressure but no diagnosis has been created
Roll-out is tentatively scheduled for January 2018
3.d.ii – Asthma
Hot spotting data for this project has been collected and shared with the project committee
Next steps include engaging the schools and provider in the high risk areas for collaboration and process improvement pilots
4.c.ii – HIV
The PMO is working with partners to launch and maintain peer-led programs that will help to impact patient support and education
NYP/Q PPS PAC Meeting

16. Questions
NYP/Q PPS PAC Meeting