1 2201 Hempstead Turnpike, East Meadow, NY 11554 516.572.5518 www.nassauqueenspps.org

Project Advisory Committee (PAC) Meeting

December 9, 2015

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• Welcome David Nemiroff

• NQP Updates – DY1Q2 Report & Progress Updates David Nemiroff – Cultural Competency Liz McCulloch – Governance David Nemiroff – Workforce David Nemiroff – Finance John Maher – Information Technology Farooq Ajmal – IT Gap Analysis KPMG – Hub Activities Rob Ginsberg, Ariel Hayes, Mike Gatto

• Clinical Oversight and Quality Updates Dr. Laurie Ward – Committee and Project Overviews – Recommended Clinical Protocols

• 2di Patient Activation Measure Request for Proposal Jessica Byrne & Ariel Hayes • DSRIP Project Approval and Oversight Panel Guest Speaker Patrick Coonan • Questions and Answers

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• DY1Q2 Report was submitted October 31, 2015

• 67 Tasks completed

• Remediation process is underway – Received minimal

comments

– Revisions will be completed and report resubmitted by December 15th

Organizations and Projects # of Tasks in DY1Q2

Cultural Competency 1

Financial Sustainability 4

Governance 16

IT 1

Performance Reporting 5

Practitioner Engagement 2

2ai Integrated Delivery System 2

2bii ED Colocation 3

2biv Care Transitions 6

2bvii INTERACT 5

2di Patient Activation Measure 2

3ai Behavioral Health 1

3aii Crisis Stabilization 7

3bi Disease Mgmt: Cardiovascular 8

3ci Disease Mgmt: Diabetes 4

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Cultural Competency and Health

Literacy Strategy

Medical Providers

Non-Clinical

Staff

Community

Leadership

/Administration

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• PCMH Approach: – Agency for Healthcare Research & Quality (AHRQ) Universal Precautions

Toolkit embedded in Patient Centered Medical Home (PCMH)/Advanced Primary Care (APC) • Provides evidence-based guidance to adult and pediatric practices to ensure that

systems are in place to promote better understanding by all patients, not just those you think need extra assistance.

• 21 Tools (3-5 pages each) that address improving: Spoken communication.

Written communication.

Self-management and empowerment.

Supportive systems.

– Practice Health Literacy Assessment • Identify weaknesses and utilize specific tools within toolkit to problem solve.

– Utilize a combination of Toolkit and on-line resources for in-services

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• Clinical Providers Strategy: – Onboarding CC/HL education

– Electronic Patient Engagement Tool

– Training PCMH/APC AHRQ Toolkit • EMR prompts/documentation

• CareNotes/Krames/Culture Vision (other resources?)

– On-line Case Based Learning • Health literacy, cultural competency, unconscious bias

– Interactive, adult learning principles, evidence based

– Part of Practice Incentive Agreement/CME Credit

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• Non-Clinical Staff Strategy:

– Onboarding CC/HL education curriculum

• REL data, Health Literacy and Cultural Competency tools (Ask Me 3, interpretation services).

– Existing Health Literacy Online Educational Tool

– Electronic Patient Engagement Tool

– PCMH/APC in-services

• AHRQ Universal Precautions Toolkit: Practice CCHL Point Person: Train the trainer education

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• Community Strategy:

– CBO/Community Members:

• CC/HL Curriculum – including video with local community members/staff. – REL data, Ask Me 3, Teach-back, interpretation services, web-

based patient/provider discharge tool

• Train the Trainer Model with CBOs. – CBOs deliver education to community members.

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• Brief overview of: – The impact of social and cultural factors on health

beliefs and behaviors.

– The link between culture, language and patient safety outcomes, quality of care and health disparities.

– The tools and skills needed to manage these factors appropriately, including interpretation services, teach-back, and health-literate patient education materials.

– The importance of empowering patients to be more of an active partner in their healthcare.

– The importance of unconscious bias in patient and family centered care.

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• Clinical governance structure

– Charters developed

– Protocols identified and adopted

• Governance reporting and monitoring process

– Reporting process, reports and frequency identified

– Some completed, others in development

– Educate providers on reports and data collection

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• Sub-Committee charter developed and will be presented to Executive Committee

• Workforce staffing template created for Project Workgroups

• 1199 Training Fund presentation to Sub-Committee

• Current State Analysis – internal review underway of staff resources for completion

• RFP in development for Compensation & Benefit Analysis and PPS Training Strategy

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• Working to complete funds flow, distribution plan, network communication

–Refine funds flow budget and distribution plan

– Illustrative fund distribution models developed and discussed

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• Finance organizational structure – Define roles and responsibilities – Charter developed

• Network financial health

– Methodology to assess providers developed, to be discussed with work group

– Analysis of project impact on providers

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• Finalize Compliance Plan

• Value Based Payment

– Work group developed

– VBP & system transformation education & communication strategy

– Develop MCO strategy and engage them

– VBP baseline assessment completed

– Conduct provider meetings on VBP

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• Develop change management strategy

• Plans to identify workflow redesign

– Communication strategy to facilitate change management

• Other IT Requirements

– Security Workbooks

• 4 out of 18 completed

–High level IT infrastructure assessment

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• Project Workgroups

– PCMH Transformation Team

– Behavioral Health and Primary Care Integration

– Crisis Stabilization

– Care Transitions

– ED Co-Location

– Patient Activation Measure

• Care Management Activities

• Reporting / Performance Measurement

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• Project Workgroups have been reclassified based on implementation needs and membership has been increased accordingly: – PCMH & Chronic Disease – Care Transitions – INTERACT – PAM – Crisis Stabilization – Behavioral Health – Co-Location Primary Care & ED

• Focusing on collection and review of Population Health Data (hot spotting)

• Sub-Committee is responsible for providing feedback to Project Committees based on Deliverables

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• Project committees have completed “kick-off” meetings and continue to meet regularly with a focus on:

– Project Scope

– Expectations

– DSRIP Deliverables

• Charter documents have been drafted for each

• Each committee is responsible for recommendations to the Clinical Oversight Sub-Committee

• Current focus is on DY1Q3 deliverables

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• Project Committees evaluated project requirements and determined that the attached protocols are needed for the effective implementation of projects

• Protocols are considered best-in-class and accepted evidence-based practices in the industry

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Protocol Description

Transitional Care Model (TCM) Addresses the common breakdowns in care when older adults with complex needs transition from acute care settings to their home or other care settings, and prepares patient and family caregivers to more effectively manage changes in health associated with multiple chronic illnesses

Care Transition Intervention (CTI) 4-week post hospitalization program where patients with complex care needs receive specific tools, are supported by a Transition Coach, and learn self-management skills to support their transition to home/SNF

American Medical Directors Association - Transitions of care in

the Long term care continuum - Clinical Practice Guideline

Interventions to Reduce Acute Care Transfers (INTERACT) is a quality improvement program that focuses on the management of acute changes in resident conditions. It includes clinical & educational tools & strategies to use in every day practice in long term care facilities

PAM®

Patient Activation Measure ® (PAM) is a tool utilized to survey patients in order to predict future ER visits, hospital admissions, readmissions, medication adherence, etc. The tool is mapped to consumer health characteristics, motivators, attitudes, behaviors, and outcomes for conditions to focus to activation & improved outcomes

Million Hearts® Campaign Resources to help educate, motivate, and monitor patients with clinical attention to the prevention of heart attack & stroke

American Diabetes Association National Standards for Self-

Management education & support Diabetes self management education (DSME)

SBIRT® Comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders

PHQ-2 / PHQ-9

Patient Health Questionnaire (PHQ) incorporates DSM-IV depression criteria with other leading major depressive symptoms into brief self-report instruments that commonly used for screening & diagnosis as well as selecting and monitoring treatment. PHQ-2 inquires as to the degree to which an individual has experienced depression mood & anhedonia over the past two weeks in order to screen for depression. The PHQ-9 provides further evaluation to determine if the patient meets the criteria of a depressive disorder

5 A's Tobacco cessation Five major steps to intervention to identify & document tobaccos use (Ask, Advise, Assess, Assist, Arrange)

AHQR Health Literacy Universal Precautions Toolkit

Helps primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels

AskMe3® Teach back method Method to confirm providers have explained healthcare information in a manner understood by their patients

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Jessica Byrne & Ariel Hayes

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• Project Goal: Engage, educate, and integrate the Uninsured and Low/Non-utilizing Medicaid Population into community-based care

• Core components:

– Coaching for Activation (e.g. medication compliance, self-efficacy, and stress management)

– Navigate to appropriate healthcare resources, focusing on preventive and primary care services

– Annually reassess clients “level” of activation to determine improvements and provide additional services as needed

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• NQP expects to engage the following number of clients throughout the DSRIP program:

# Surveys – Sept 30 # Surveys – March 31

DY 1 18,642 37,284

DY 2 29,828 59,655

DY 3 37,284 74,569

DY 4 37,284 74,569

DY 5 37,284 74,569

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• RFP was distributed on November 23, 2015 to over 300 organizations – RFP and resulting Q&As were posted on NQP’s public website

• Respondents were asked to provide a detailed plan for implementing this project, including: – Engagement projections

– Workforce needs

– Data collection capabilities and needs

– Budget for two years

• Responses are due today, 12/9/15

• CBOs will be selected by 12/21/15 and notified 12/23/15

• There will be additional opportunities for CBOs to apply!

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• Low and Non Utilizing Hotspots

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• Uninsured Hotspots

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• Overall proposal suitability / ability to meet scope and needs

• Organizational Experience with outreach, activation activities, and identified “hot-spot” communities

• Previous work (assessed through client testimonials and references)

• Value and cost

• Ability to begin the engagement once the selection is announced

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• NQP and its partnering CBOs will be assessed based on specific metrics:

– The number of individuals that completed a PAM survey (this must equal quarterly targets that were set by the NQP)

– Interval measure of % of members of total with Level 3 or 4 on PAM (these must improve over the course of DSRIP)

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• For more information, please visit the “Resources” tab of our website: http://www.nassauqueenspps.org/resources

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Patrick Coonan Dean of Adelphi University’s College of Nursing and Public

Health

Member of DSRIP Project Approval and Oversight Panel

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The Delivery System Reform Incentive Payment (DSRIP) Program is an incentive payment model that rewards providers for performance on delivery system transformation projects that improve care for low-income patients • Funded federally via Medicaid 1115 waivers, DSRIPs shift

hospital supplemental payments from paying for coverage to paying for improvement efforts

• There is a large range in DSRIP funding amounts and durations across states, with per state funding as high as $11+ billion and lasting up to 5.5 years (New York =$8 billion and 5 years)

• DSRIP projects and milestones are specific and tend to have an increasing focus on outcomes over time

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• In April 2014, Governor Andrew M. Cuomo announced that New York State and CMS finalized agreement on the MRT Waiver Amendment.

• Allows the state to reinvest $8 billion of the $17.1 billion in federal savings generated by MRT reforms.

• The MRT Waiver Amendment will:

• Transform the state’s Health Care System

• Bend the Medicaid Cost Curve

• Assure Access to Quality Care for all Medicaid members

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Performing Provider Systems (PPS): Entities that are responsible for performing a DSRIP project. DSRIP eligible providers, which include both major public general hospitals and safety net providers, collaborating together, with a designated lead provider for the group. DSRIP Project: Individual method created by a Performing Provider System to transform the delivery of care that support Medicaid beneficiaries and uninsured as well as address the broad needs for the population the performing provider system serves. DSRIP projects will be designed to meet and be responsive to community needs while meeting 3 key elements: appropriate infrastructure, integration across settings and assumes responsibility for a defined population

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DSRIP PROGRAM PRINCIPLES

Patient-Centered • Improving patient care & experience through a more efficient, patient-centered and

coordinated system.

Transparent • Decision making process takes place in the public eye and that processes are clear and

aligned across providers.

Collaborative • Collaborative process reflects the needs of the communities and inputs of stakeholders.

Accountable • Providers are held to common performance standards, deliverables and timelines.

Value Driven • Focus on increasing value to patients, community, payers and other stakeholders.

• Better care, less cost

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NYS DSRIP PLAN: KEY COMPONENTS

• Key focus on reducing avoidable hospitalizations by 25% over five years.

• Statewide initiative open to large public hospital systems and a wide array of safety-net providers.

• Payments are based on performance on process and outcome milestones.

• Providers must develop projects based upon a selection of CMS approved projects from each of three domains.

• Key theme is collaboration! Communities of eligible providers will be required to work together to develop DSRIP project proposals.

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• The Project Approval and Oversight Panel (PAOP) has three main responsibilities – Conduct reviews and make recommendation on the scores

of the subjective components of DSRIP Project Plans • Secondary review panel to the scoring performed and

recommended by the Independent Assessor

– Assist New York State with ongoing oversight of DSRIP Projects • Act as continued advisor to DOH; make recommendations on

changes to PPS networks and DSRIP projects

– Conduct reviews and make recommendations pertaining to the $1.2B in state funding approved for capital projects to fund DSRIP projects and related efforts • Secondary check to the scoring performed and funding

recommendations made by New York State agency staff and the IA

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DSRIP PAOP Member List Members • Co-Chair: Ann F. Monroe, President, Health Foundation for Western & Central New York

• Co-Chair: William Toby Jr., Former Administrator of the Centers Medicare and Medicaid Services (CMS), MRT Brooklyn Work Group member

• Steven Acquario, Executive Director, NYS Association of Counties

• John August, Associate Director of the Healthcare Transformation Project within Cornell University´s School of Industrial and Labor Relations

• Stephen Berger, Former Chair of the Commission on Health Care Facilities in the 21st Century; MRT

• Kate Breslin, President & CEO, Schuyler Center for Analysis & Advocacy

• Patrick R. Coonan, EdD, RN, Dean, Adelphi University, College of Nursing and Public Health

• William Ebenstein, Ph.D., Senior Fellow, John F. Kennedy, Jr. Institute for Worker Education, City University of New York

• Lara Kassel, Coordinator, Medicaid Matters New York (MMNY)

• Mary McKay, Ph.D., McSilver Professor of Poverty Studies; Director, McSilver Institute for Poverty Policy and Research at New York University Silver School of Social Work

• Philip Nasca, Ph.D., Dean, University at Albany, School of Public Health

• Marilyn Pinsky, Immediate Past President, NYS AARP

• Sherry Sutler, Consumer Representative

• Chau Trinh-Shevrin, DrPH, Director of the NYU Center for the Study of Asian American Health and Assistant Professor at the NYU School of Medicine

• Jaime R. Torres, DPM, MS, Former Regional Director, US Department of Health & Human Services, New York Regional Office, 2010-2014

• Judith B. Wessler, MPH, Former Director of Commission on the Public's Health System, Community Health Policy Advocate

• Mary Louise Mallick, Former Policy Advisor to the State Comptroller

• William Owens, Former Congressman, New York´s 21st Congressional District

• Cesar Perales, Secretary of State of New York, appointed March 2011, former Regional Director, US Department of Health and Human Services, Region II-New York

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DSRIP Workforce

PPS Redeploy Retrain

New

Hire Admin Physician

MHP-

CM SW IT Staff NP Other*

Adirondack Health 1 5 5 39 19 109 73 18 53 559

Advocate Community Partners 10 10 5 220 30 510 90 30 45 880

Albany Med 2.4 7 5 337 80 165 112 93 109 87

Bronx-Lebanon 20 20 25 200 500 300 500 70 1000 2750

Catholic Medical Partnbers- Accountable Care

IPA 10 40 5 21 12 17 24 4 4 76

CNY DSRIP PPS 1 55 1 10 4 0 21 1 21 219

ECMC 25 20 55 25 3 3 74 25 33 88

Finger Lakes PPS 3 12 1 150 46 291 100 120 46 184

Ellis Hospital 1 1 2 5 22 38 29 11 19 100

Lutheran Medical Center 1.5 20 5 30 15 35 0 35 35 53

Maimonides 1 27 3 30 10 1315 40 10 30 65

Mohawk Valley Mary Imogene Bassett 10 55 10 32 5 175 19 9 20 0

Montefiore 49 35 76 0 55 250 52 33 28 0

Mount Sinai 20 20 25 200 500 600 500 70 1000 2350

NUMC- Nassau Queens 5 30 6 180 22 33 300 14 365 1086NYC HHC 5 20 1 50 75 90 100 10 70 205

Refuah 0 85 2 9 0 14 3 1 1 14Staten Island 3 43 3 21 30 45 12 10 0 282

Samaritan Medical Center 0 50 1 4 8 4 0 6 2 12

St. Barnabas Hospital 1 30 1.5 50 20 550 50 10 20 50

Stony Brook 4 40 1 39 45 87 12 11 37 135

The NY and Presbyterian 10 10 80 23 8 22 4 17 14 66

The NY Hosp MC of Queens 20 50 30 4 3 10 1 2 10 38

United Health Services Hospitals 34 58 8 0 0 6 30 7 24 92

Westchester Medical Center 3.9 72.8 15.6 27 12 75 38 25 30 146

Total 9.63 32.63 14.88 1706 1524 4744 2184 642 3016 9537 23353

*Other=multiple types of postions across PPS

Listed Spearately

Workforce Implication Positions and Approximate Number of New

Percent of Employees

Impacted

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Region PPS Name Total

Employees Retrained Redeployed New Hire

Full Placement

Partial Placement

Total Budget Reductions

NYC ACP 10% 10% 50% 90% 10% 53,221,054

45,000 4500 4500 1800

NYC Bronx

Lebanon 20% 20% 25% 40% 20% 13,865,000 20 beds

8,000

NYC Bronx

Partners 30% 1% 2% 95% 5% 12,020,000 18-20 beds

30,000 10,000 150 750

NYC HHC 20% 5% 1% 95% 5% 65,000,000 Can't predict bed reductions now

60,000 12,000 3,000 650

NYC Lutheran 20% 2% 5% 55% 12%

3,621,189 40 NH beds

4,060 203

NYC Maimonides 27% 1% 3% 55% 25% 10,746,000 500 workers; 104 beds 1500

NYC Mt. Sinai 20% 20% 25% 40% 20% 10,000,000 NH and Hospital bed reductions; no

specific number 12000 600 5220

NYC NYHQ 50% 20% 30% 90% 10% 517,124 Not expected 200 38

NYC NY

Presbyterian 10% 10% 80% 852,000 154

NYC RUMC 13,000 43% 3% 3% 75% 25% 20,302,125

410 400

LI Nassau 30% 1% 6% 85% 15% NH and Hospital bed reductions; no

specific number 9,900 165 2000 56,946,446

LI Suffolk 40% 0% 1% 98% 1% 150 hospital FTEs, satisfied primarily

through attrition; 50 NH beds 847 22,981,250

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Region PPS Name Total

Employees Retrained Redeployed

New Hire

Full Placement

Partial Placement

Total Budget Reductions

HV Albany Med

15,000 7% 2% 5% 95% 5% Conversion of 200 SNF beds

983 5,358,506

HV Ellis

Hospital

1% 1% 2% 100% 10-100 hospital beds; 82 NH beds

80,435,170 30 FTEs in ERs

HV Montefiore

0% 0% 1% 82% 18% Minimal net job loss

350 490 10,152,810

HV Refuah

85% 0% 2% No reductions or redeployments

42 1,334,904

HV Westcheste

r Med

43,749 73% 4% 16% 45% 25% 125 beds

7,875,000

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Region PPS Name Total

Employees Retrained Redeployed New Hire

Full Placement

Partial Placement

Total Budget Reductions

Upstate Adirondack

5% 1% 5% 75% 25% Potential reductions projected to be minimal 16,500 750 150 850 3,627,325

Upstae Catholic Med

40% 10% 5% 98% 2%

Work to decertify unused, unstaffed beds. Does not anticipate significant workforce impact. 154 3,050,000

Upstate Central NY

55% 1% 1% 70% 30% Reductions will be managed by attrition and reductions in temporary staff 275 59,502,500

Upstate Erie County

1% 1% 90% 10% Decertify up to 511 hospital (390 unstaffed). Impact: 117 FTEs. 32 FTEs impacted by ER reductions. Decertify 275 NH beds (200 unstaffed). Impact: 62 FTEs 12,644 105 106 251 13,745,100

Upstate Finger Lakes

12% 3% 22% 5% Less than 1% reductions (1,760)

176,000 21120 4900 230 24,000,000

Upstate Bassett

55% 10% 10% Few excess resources; do not expect reductions

Upstate Samaritan

50% 0% 1% 100% 0% 7,000,000 Any reductions will be covered by attrition

1800 36

Upstate UHHS

58% 34% 8% 37% 63% Reduction of 135 in acute care; 160 increase at CBOs 30,000 160

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November 20, 2015 38

Detailed Steps for Care Coordination

Category

Patient registry/

A Member

identification

Activities

1. Select data feeds

2. Data warehousing (structured database)

3. Data hosting (server capacity)

4. Select data feed and methodology

5. Perform data analysis

6. Identify individuals for enrollment in programs

1. Define enrollment protocoltemplate/script and skill

requirements 8 Enrollment

Risk

C stratification/

Assessment

2. Contact patients (house call center)

3. Input enrolled patients into system

1. Define assessment template/script and skill requirements

2. Schedule assessment with individual patients

3. Perform assessments in person

4. Perform assessments telephonically

5. Submit assessment output into system

Care Plan 0

development

1. Select relevant care planning template

2. Gather clinical input on proposed care plan

3. Share proposed care plan with patient,finalize, and enter

into system

1. Assemble directory of service providers

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Current State

• Siloed care delivery model: Inconsistent collaboration across different professional types; physicians are individually accountable for patients

• Inconsistent care coordination: small percentage of patients with chronic conditions receive care coordination; poor execution of coordination/communication between different patient caregivers

• Frequent use of high-cost, acute care settings: Many individuals use acute care settings as primary source of care and may not see PCP regularly

Future State

• Team-based care delivery model: Physician leads multi- disciplinary team jointly accountable for patients

• Appropriate care coordination: patients with complex chronic conditions have dedicated care coordination; patients with minor conditions receive necessary coordination; care coordinators facilitate all necessary communication between all patient caregivers

• Reduced ER usage: PCPs act as primary source of care; improved primary care and management of complex chronic conditions reduces ER usage

Implications

• More engagement with the primary care system, fewer encounters with high- resource acute care settings

• Physicians tailor the amount of time and resources spent per patient to patient need; shift in tasks from physicians to other care team members

• More care coordinators required; some burden of care shifts from other care professionals to care coordinators

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https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_applications/ A nice overview program can be found at: www.chcs.org/media/CHCS-DSRIP-Presentation-Slides.pdf

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• Materials from today’s presentation will be available on NQP’s website: http://www.nassauqueenspps.org/

• Look out for emails from NQP regarding updates and opportunities to provide feedback and input