1. The Affordable Care Act is Transforming Health Care in our Community: The Washington Heights-Inwood Regional Health Collaborative 18th Annual NHMA Conference J. Emilio Carrillo MD, MPH March 29, 2014

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3. NYP Regional Health Collaborative Goals  Provide Better Care  Measurably Improve Health  Contain and Reduce Costs Health Reform is transforming the care we provide patients in the Washington Heights-Inwood Community DRAFT

4. 4 WHI Regional Health Collaborative WHI Regional Health Collaborative NYP Outcomes Evaluation ISABELLA VNSNY Community Health Needs Assessment HEBREW HOME ColumbiaDoctors Columbia NYSPI (WH) NYSPI (WH) Community MDs

5. Setting the Framework: Washington Heights-Inwood Demographics Population: 205,000 Foreign Born: >50% born outside US Poverty Level: 31% Education: Residents aged 25 and older have completed fewer years of education than NYC overall Race / Ethnicity: 71% Hispanic 14% Black 11% White 2% Asian 2% Other

6. Setting the Framework: Insurance Gaps in NYC Map represents children in NYC community districts who are “EPHINE”: “Eligible for Public Health Insurance but NOT Enrolled Washington Heights / Inwood is among the worst according to this measure Nov 24 2009

7. Setting the Framework: Detailed Health Needs Assessment of our Community  Overall Health: 1/3 adults consider themselves to be in poor health  PCP: 1/3 adults have no PCP  Insurance: 1 in 3 adults is uninsured or had no insurance year before  Heart Disease: hospitalization rate has increased  Obesity: 1 in 5 adults is obese  Diabetes: 11% of adults have diabetes  Mental Health: more than 1 in 20 adults suffer from depression  Asthma: hospitalization rates higher than NYC overall

8. Pediatric Asthma  National prevalence 8%  Local prevalence 18%-22%  Leading chronic illness in children  Health disparities in minority populations  NHLBI 2007 Guidelines – –Control and risk

9. The NYP Patient Centered Medical Home: The Centerpiece of the Washington Heights Regional Health Collaborative Targeted Care Management Team Based Care IT Tools for Patient Care and Population Health Cultural Competency and Community Health Workers Diabetes, Asthma, Heart Failure, Depression, COPD, Children Special Health Needs

10. Care Management and Redesign Before – SilosAfter – Care Team

11. Patient Supporting the Patients after they leave the Hospital Transitions of Care Initiative Comprehensive Discharge Planning and Education Beginning on Day of Admission Ambulatory Care begins Engagement of the Patient with a Medical Home Disease Registries Care Management IT Enabled Cultural Competency Management of Transitions of Care Emergency Department-to-Home Hospital-to-Home

12. PFA (Patient Financial Analyst– NYP Title) - Front desk Registrar; greets and signs- out all patients. - Provides visit tallies ahead of time to Nurses and Providers -Participate in Pre-Visit Planning Process and discussion. Medical Assistant (MA) - Participates in Pre-Visit Planning Process and discussion -Document Pre-Visit Planning on Flowsheet -Execute traditional MA clinical functions Community Health Worker (CHW) - Peer to peer outreach, education and support that includes home visits - Focused on Diabetes and Pediatric Asthma - Subcontracted position from collaborating Community Based Organizations. Diabetes Educators - AADE based curriculum, certification - Dietitians, nurses, or pharmacists - 1:1 Assessments and follow up visits - Group classes - Refer patients to PCMH supporting program s Physician Primary Nurse RN Care Manager The Team Weekly Interdisciplinary Meeting, Daily Huddles

13. PCMH October 2010 Cohort: 2-Year Results Reduced Emergency Department Utilization by 23.8% Reduced Inpatient Admissions by 18.0% Reduced 30-Day Readmission by 23.3% Length of Stay reduced by 13.6% Lowered Hemoglobin A1C Levels ( 0.32; 3.96%) n= 2,795 14 n = 5,857

14. Outcome Measures 20092012Percent Change Patients with asthma 20003539+77% MS-CHONY Admissions 7052- 57% MS-CHONY ED visits 200156-60%

15. Targeted Care Intervention - TCI Study is based on 580 patients (TCI=290; Control=290) who have been in care management for at least 3 months. (all payers) Admissions reduced by 63% ED utilization reduced by 35% 20

16. NYS Medicaid “Health Home” Care management service model across a continuum of medical, behavioral care and social services. Health Home services are provided through a network of organizations – providers, health plans and CBOs. (26 Collaborators with MOUs) The care manager oversees and coordinates access to the services and promotes communication among providers. Health records are shared among providers so that services are not duplicated or neglected. Aim to reduce ED, Admissions and improve health outcomes and patient experience

17. NYP Health Home Network * Care Management Agencies for Health Home Provider Contract

18. Hospital-Medical Home Demonstration Transform outpatient continuity training sites to high quality Patient Centered Medical Homes Improve the level of integrated, coordinated, and culturally appropriate care in the participating outpatient settings Extend/expand the continuity training experience for their primary care residents Implement inpatient safety improvements 2

19. The Patient Centered Medical Home and Medical Village 21,000 120,000 240,000 PCMH Patients in Registries (Diabetes, Asthma, CHF, Depression, Complex and High Risk) NYP Ambulatory Care population All Washington Heights & Inwood Community Targeted Care Intervention

20. 30 NYP Regional Health Collaborative Population Health Infrastructure / Capability Patient Centered Medical Homes Transitions of Care Initiative (TCI) Integration & Coordination of Community-based Programs and Services Health Information and Exchange Medical Village Transitions of Care Initiative (TCI) Integration & Coordination of Community-based Programs and Services Health Information Exchange Medical Village Patient Centered Medical Homes Targeted Care Management – Care Transitions Collaboration Care Providers in the Region J. Emilio Carrillo MD, MPH