1. NYP Queens PPS PAC Meeting
September 13, 2018

2. Clinical Project Updates
Agenda
Welcome
PPS Updates
MY3 Current Performance
MAPP Reporting (DY4 Q2)
Clinical Project Updates
Clinical Projects
Quality Committees
Just Breathe – Asthma Pilot
Poster
MAX Project Update
Charter
Progress Update
Questions
NYP/Q PPS PAC Meeting

3. NYP Queens PPS PAC Meeting
PPS Updates
NYPQ PPS PAC Meeting

4. Measurement Year 4 Month 6 of 12 (1/2017 - 12/2017) Results
PPS Updates
Scorecard/Dashboard Available
Measurement Year 4 Month 6 of 12 (1/ /2017) Results
The data presented includes measures from Domain 2 (System Transformation) and Domain 3 (Clinical Improvement Projects).  Domain 4 (Population Wide) measures will be reported in a later update.
NYPQ PPS PAC Meeting

5. PPS Updates DY4, Q2 Reporting
On September 30,2018 our DSRIP PMO will coordinate and process the PPS DY4 Q2 MAPP report. The report will consist of P4R deliverables in our HIV project that specify the following:
HIV Milestone 6. Empower people living with HIV/AIDS to help themselves and others around issues related to prevention and care.
Documentation and results of collaborative initiatives with partners Bright Point Health and ACQC on peer-led interventions and service expansion will be submitted.
All HIV and Primary Care Behavioral Health P4R project deliverables are scheduled to be completed by DY4, Q3.
NYPQ PPS PAC Meeting

6. PMO Clinical Project Updates
NYP Queens PPS PAC Meeting
PMO Clinical Project Updates
NYPQ PPS PAC Meeting

7. Current Clinical Projects
Patient Navigation Program
Focused on improving performance across adults and pediatric measures through patient engagement and outreach services.
Objective to achieve 5 star rating across prioritized measures.
Smoking Cessation Project
Implement protocols to assess and manage patients with a tobacco use disorder
Implement a patient referral program
Partner with the ALA to Launch an 8 week Freedom from Smoking group at 182nd clinic.
Group session to be facilitated by DSRIP facilitators
SNF Quarterly Committee
PMO to support MLTC 101 – Managed LTC- Value Based Planning & Education.
The PMO to facilitate sessions to educate Skilled Nursing partners how to calculate readmission rates.
Collaboratively the PMO and the SNF committee developed a Blood Transfusion Protocol aimed at improving patient discharges.
Transfusion Protocol: NYPQ will only administer 1 unit in the ED and return the patient to the nursing home. If the patient has previous received a work up please identify on the patient’s paperwork, to prevent a duplicate workout at the ED.
NYP/Q PPS PAC Meeting

8. PPS Quality Committees
Adult Ambulatory
The current action items for this committee includes the following:
Analyze No Show rates from our clinics
 Replication of Pediatrics Ambulatory scheduling pilot
Committee to focus on data going forward
Integrate Smoking Cessation Initiatives into committee
Pediatric Ambulatory
Theresa Lang piloted an Annual scheduling project to increase scheduled appointments for the clinic . From the start date of March to September 2018 there is a 17% increase of scheduled appointments.
Theresa Lang has published flyers containing timeline information for pediatrics to receive immunization and annual appointments to be dispersed in the clinic and local WIC office .
Pediatric Hospital
NYP Queens Pediatric Asthma Center, Theresa Lang, American Lung Association – Asthma Coalition of Queens and St. Mary’s Home Care are collaborating to launch an asthma medication adherence pilot to incorporate care coordination and smart inhalers into patients daily usage. The “Just Breathe” pilot will begin late-September and the NYP Queen Pediatric Asthma Center is currently recruiting patients to participate. The Theresa Lang Clinic will receive provider education in-service by the American Lung Association - Asthma Coalition of Queens and St Mary's Home Care in mid-September
NYP Queens Pediatric Asthma Center and Total Care Rx are partnering on an additional pilot program to increase communication and pharmacy care management for pediatric asthmatic patients. The pilot will focus to improving medication adherence and will allow for additional services to patients such as medication delivery, pharmacy care management, and direct provider communication regarding medication needs or complications. The pilot began in August 2018 and will be monitored to identify quality and process improvements for the pediatric asthma population at the NYP Queens Pediatric Asthma Center.
Hospital Based
In August 2018 we launched the kick-off for our MAX Goals of Care Project. The focus of the project is on improving Goals of Care (GOC) discussions and documentation throughout the Hospital. Our DSRIP NP is currently in the process of educating our PAs and Hospitalist providers. A Supporting CAPC Marketing campaign is also being promoted through out the hospital.
NYP/Q PPS PAC Meeting

9. “Just Breathe” Asthma Pilot
Partners:
New York-Presbyterian Queens Pediatrics Asthma Center
Ambulatory Care Partner - Primary Care and Specialty Care
New York-Presbyterian Queens-Theresa Lang Children’s Ambulatory Center
Pediatric Ambulatory Clinic
The Asthma Coalition of Queens County
Community Based Organization – Provider Education and Patient Outreach
St. Mary’s Home Care
Home Assessment Agency – Home Assessments & Patient Education
Overview:
Increase medication adherence and lower hospital utilization for pediatric asthma patients utilizing care management strategies and technology.
Pilot Goals
Improve pediatric asthma medication based quality indicators
Reduce hospital utilization
Improve access to Community Based services
NYP/Q PPS PAC Meeting

10. Just Breathe Asthma Pilot Flyer
NYP/Q PPS PAC Meeting

11. Goals Of Care Project Charter
PROBLEM
At NYPQ, a chart review of readmitted patients by our Palliative NP revealed a notable lack of documented Goals of Care (GOC) discussions and advanced directives in the form of a MOLST. This was true regardless of being readmitted from home or SNF, and found to be a major contributor to their readmission. Many of these patients had critical/chronic illness at end-of-life placing them at high risk for readmission. Given that the demand for Palliative Care’s services exceeds available resources, generalist (non-palliative care) providers need to be educated in general palliative care and engage patients and their families in goals of care discussions.
GOALS
Provide education to generalist providers in the Department of Medicine regarding the importance of GOC discussions
Provide family education on GOC
Educate generalists on how to conduct and document GOC conversations
Increased generalist utilization of a structured GOC note and MOLST form to better document goals of care for transitions in care
Escalation, as appropriate, for difficult end- of- life cases (Palliative consults, Ethic Committee referrals)
SCOPE (IN BOUNDS)
Critically/Chronically ill patients, including but not limited to a list specific diagnoses
Patients on the Medicine Service
SCOPE (OUT OF BOUNDS)
Patients who are not critically/chronically ill
Patients already enrolled in hospice
Patients not on the Medicine Service
CUSTOMER’S VOICE:
The end users will be the Providers (MDs and PAs) who will be responsible for completing this documentation.
TEAM MEMBERS
Executive sponsors:
Owners: Robert Crupi, MD & RoxanaElena Lazarescu, MD
Team Members: Hoda Abdelaziz, NP, Marlon Hay, Coleen Dunkley, Cynthia Pan, MD and Calvin Hwang, MD
NYP/Q PPS PAC Meeting

12. MAX Project – Progress Update
The project kicked off late due the technical issues. However, this tracker represents the latest updates on the project tasks.
NYP/Q PPS PAC Meeting

13. Questions
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14. Marlon Hay mah9214@nyp.org (718) 670-2103
Contact Information
Marlon Hay
(718)
NYP/Q PPS PAC Meeting