project advisory committee (pac) - suffolk care · 6/14/2018 · administrative manager, community...

PROJECT ADVISORY COMMITTEE (PAC)

Thursday, June 14, 2018

9:00am-11:30am

Hyatt Regency Long Island

Hosted by the Office of Population Health at Stony Brook Medicine

WELCOME REMARKS

Presented by

Linda S. Efferen, MD, MBA

Executive Director & VP, Medical Director

Suffolk Care Collaborative

MEETING AGENDA

NEW YORK STATE

PATIENT CENTERED MEDICAL HOME

(NYS PCMH)

Presented by

Althea Williams, MBA, PCMH-CCE

Director, Community and Practice Transformation


OVERVIEW

• Background

• DSRIP Deliverable

• NYS PCMH

• PT Technical Assistance (TA)

• Involves the Primary care team & patient (and

family, when appropriate) managing the full

spectrum of health care needs

• Emphasizes care coordination, population health,

evidence-based guidelines, Health Information

Technology (HIT)

• Ensures patient receives the necessary care

when and where they need and want it in a

culturally and linguistically appropriate manner

www.ncqa.org

WHAT IS PATIENT CENTERED MEDICAL

HOME (PCMH)?

• Since 2008 nationally acclaimed PCMH

recognition program.

• Most widely adopted PCMH model.

• More than 63,561 providers.

• More than 14,077 practice sites.

PCMH Recognition Program

NATIONAL COMMITTEE FOR QUALITY

ASSURANCE (NCQA)

PCMH ACHIEVEMENT - MARCH 2018

New York State

Recognized Primary Care Providers

8,711* (PCMH 2014 Level 3 – 8,455)

(NYS PCMH 2017 – 20)

Recognized PCMH Sites

2,293*(PCMH 2014 Level 3 – 2,181)

(NYS PCMH 2017 – 15)

*Includes PCMH 2011 – Levels 1,2,3; PCMH 2104 – Levels 1,2

NYSDOH ADVANCED PRIMARY

CARE (APC)

https://www.health.ny.gov/technology/innovation_plan_initiative/sim.htm

• APC was supported through New York State

Innovation Model (SIM) Grant

• The overarching goals of the APC model are

consistent with the Triple Aim

• Model of care delivery that focuses on patient

centeredness and medical homes, providing

optimal care, and payment innovation [i.e., Value

Based Payment (VBP) preparation]

DSRIP DELIVERABLE

• PCMH 2014 Recognition or APC Gate 2 Approval

• Across 3 Hubs:o Catholic Health Systems (CHS)

o Northwell Health (NWH)

o Stony Brook University (SBU)

SCC Target Commitment

by March 31, 2018

511 Primary Care Providers

SCC PRACTICE TRANSFORMATION

ACHIEVEMENT

CHS – NWH – SBU

As of March 31st 2018

669 Providers 172 Practice Sites

Data submitted on April 30th 2018

The National Committee for Quality Assurance

(NCQA)

+New York State Department of Health

(NYSDOH)

=

NYS PCMH

NYS PCMH

AS OF APRIL 1ST 2018 NYS PCMH

NYS PCMH

SIM/APC PCMH 2014

PCMH 2011PCMH 2017

New Primary Care Practice Sites

• Alignment with DSRIP initiatives and performance

improvement

• NYS priority - accelerated transition to VBP

• Take advantage of transformation fees paid by State

Innovation Model (SIM) grant

• NCQA Recognition Fees covered 1st year

• Avoid gaps in PCMH recognition by sustaining your

current PCMH 2014 Recognition

• Eligibility for NYS Medicaid PCMH incentive program

WHY SHOULD PCP’S DO THIS?

As of May 1st 2018

https://www.health.ny.gov/health_care/medicaid/program/update/2018/2018-04.htm#pcmh

NYS DOH PCMH MEDICAID INCENTIVE

PAYMENT

Provider 2014 PCMH Level 2 2014 PCMH Level 3; 2017 PCMH; NYS PCMH

Previous May 1 PreviousMay 1-

June 30, 2018

July 1, 2018-

March 31, 2019

Managed Care

PMPM$3.00 Eliminated $7.50 $5.75 $6.00

FFS Add-on Per

Visit: Article 28$23.25 Eliminated $23.25 $23.25 $23.25

FFS Add-on Per

Visit: Professional$20.50 Eliminated $20.50 $20.50 $20.50

Greater New York Hospital Association

NYS PCMH VS NCQA PCMH 2017

Additionally,

providers

would then

complete 6-9

elective

credits

NYS PCMH 12 NEW “CORE” CRITERIA*

www.ncqa.org

*Formerly NCQA 2017 elective criteria

PATHS TO NYS PCMH RECOGNITION

• Timelineo Renewal – 9 months; New – 15 months

• Core Criteriao QI 10/VBP: ACO, MIPS, PQRS etc. is in negotiation

o CC 21/Health Information Exchange: RHIO, Immunization

Registries, CCD file transfer (signed contracts up until 9/30/18)

-Annual Renewal surveys are eligible for this alternative

documentation

-Full submission sites must have the RHIO and/or exchange

operational

RECENT UPDATES FROM DOH

The New Platform developed by NCQA,

Q-PASS - Quality Performance

Assessment Support System

• Q-PASS Enrollment

• Create an account in Q-PASS

Q-PASS ENROLLMENT

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/get-started/pcmh-enrollment-in-q-pass

NCQA CHECK-IN NYS PCMH

*Practices with NCQA PCMH 2014 Level 3 status subject to renewal or an accelerated path may not require 3 Check-Ins;

others subject to Annual Reporting will be required to meet NYS PCMH Core requirements in addition to NCQA specification.

• Technical Assistance Agentso Previous/Current

• Internal Resourceo PCMH Practice Champion

o DSRIP Practice Champion

o PCMH-CCE

• SCC Technical Assistance support

TRANSFORMING TO NYS PCMH

ON YOUR OWN

• TAs in Region 8o https://www.health.ny.gov/technology/innovation_plan_initiative/ta_contact_info.htm#region_8

• NCQA websiteo http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/new-

york-state-pcmh

o http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-

recognized/get-started/pcmh-enrollment-in-q-pass

• NYS DOH websiteo https://www.health.ny.gov/

o https://www.health.ny.gov/technology/innovation_plan_initiative/nys_pcmh.htm

• Updates specific to NYS PCMH will be made on the

Medicaid website and the NYS SIM/SHIP pages shortly

ADDITIONAL RESOURCES

https://www.health.ny.gov/technology/innovation_plan_initiative/ta_contact_info.htm#region_8

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/get-started/pcmh-enrollment-in-q-pass

https://www.health.ny.gov/

https://www.health.ny.gov/technology/innovation_plan_initiative/nys_pcmh.htm

Shanna Williams, MBA, PCMH-CCEProject Manager, Practice Transformation

Desk: (631) 638-1371

Email: [email protected]

Althea Williams, MBA, PCMH-CCEDirector, Community and Practice Transformation

Desk: (631) 638-1392

Email: [email protected]

PRACTICE TRANSFORMATION

CONTACT INFORMATION

mailto:[email protected]


Questions

NYS PCMH RECOGNITION

visit us at www.suffolkcare.org

COMMUNITY ENGAGEMENT AND RESOURCE UPDATES

Lyndsey Clark, MS

Community Engagement Liaison


Sofia Gondal, MA



Presented by

SCC COMMUNITY ENGAGEMENT WEBPAGE

OVERVIEW & DEMO

SCC Community Engagement Webpage:

www.suffolkcare.org/community

• Health Education Materials

• LIHC Community Calendar

• Bulletin Board

• Health Resources

• HITE Resource Directory

http://www.suffolkcare.org/community

SCC COMMUNITY ENGAGEMENT WEBPAGE

OVERVIEW & DEMO

YOUR CARE, EVERYWHERE BROCHURE

• Brochures are available to educate the community about

Regional Health Information Organizations (RHIOs) and

how to complete the RHIO Client Consent Process.

• Created in collaboration with the SCC Cultural

Competency and Health Literacy IT Subgroup and

partners.

• The brochure was reviewed and endorsed by the SCC

Cultural Competency and Health Literacy Advisory

Workgroup.

To receive the brochure via email or for any questions,

please contact:

Lyndsey Clark, MS


631-638-1779

[email protected]


CBO VALUE BASED PAYMENT

SURVEY REMINDER

Accepting survey responses until June 30th

To receive the survey via email or for any questions, please contact:

Stephanie L. Burke, MS, MHA, CHES

Administrative Manager, Community Engagement

631-638-1768

[email protected]

Upcoming Presentation: Value Based Payment 101 & 102

June 19th 11:30 am – 12:30 pm

Suffolk Care Collaborative, Standard Large Conference Room,

1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11788

The SCC thanks you in advance for your participation.


BREAK

15 minutes

FEDERATION OF ORGANIZATIONS’ MAX-NY PROGRAM:

REDUCING HOSPITAL UTILIZATION OF THE BEHAVIORAL

HEALTH POPULATION

Elizabeth Galati, MA

Director of Strategic Partnerships and

Resources Development

Federation of Organizations

Jason Vandewater

Director of Clinical Services

Federation of Organizations

Presented by

Serving NYC Metro Area and Long Island

Administrative OfficeOne Farmingdale Road

West Babylon, NY 11704631-669-5355

New York City116-06 Myrtle Avenue

Richmond Hill, NY 11418718-850-7099

www.fedoforg.org

As a multi-service, community-based social wellness agency, Federation of Organizations(Federation) is a major provider of health and

wellness, senior and children’s services, housing and support services in Suffolk and Nassau Counties, Queens, Brooklyn, the Bronx and

Manhattan. For nearly 50 years, Federation has developed innovative programs to successfully

meet the needs of vulnerable populations. We work with individuals in recovery, those living with

chronic medical conditions, adult home residents, homeless individuals and families, low-income

seniors and at-risk children.

Agency History

Clinical

• PROS (2)

• 3 ACT Teams/ 1

FACT Team

• Wyandanch

Mental Health

Clinic

• Care Coordination

• Homeless

Outreach

• Supported

Employment

• Senior Support

Services

• Financial

Management

• Respite

• HCBS

Peers

• Supportive

Housing

• Community

Residences

• Intensive

Supportive

Apartments

• CR/SROs

• Nursing Home

Diversion in

Nassau and

Suffolk Counties

• Mobile

Residential

Transitional

Support Teams

• Residential

Transitional

Support Teams

Outreach

Community

Housing

Support

Teams

Residential

Federation employs approximately 550 individuals on Long Island and in NYC

Federation of Organizations’ Clinical Department served 1,351 individuals.

In the past year, Federation of Organizations’ Residential Services has opened several new housing programs and now has the capacity of nearly 880 beds across Suffolk, Nassau, Queens, Brooklyn and the Bronx.

Over 1,100 people who were homeless or at risk of homelessness received housing, employment and peer services through our homeless outreach programs.

In Suffolk County, over 425 mental health consumers were provided representative payee services to ensure their financial wellness and obtain skills needed for future financial independence. 96% of the individuals served maintained housing and avoided homelessness and 85% avoided psychiatric hospitalization.

Peer advocates in Suffolk reached out to over 1,850 people with mental illness, providing the support necessary to remain independent in the community.

Over 90,000 care coordination services were provided to individuals on Long Island and in NYC

143 Foster Grandparent volunteers provided over 112,000 hours of one-to-one service

27 Senior Companion volunteers provided over 28,000 hours of assistance

Our food pantry and soup kitchen in Suffolk County provided 26,479 meals to hungry individuals and families.

The Suffolk Care Collaborative approached Federation to participate in the MAXny Series.

As part of the DSRIP program, the NYS DOH launched the MAX Series to redesign the way care is delivered for New York State’s most vulnerable patients. The MAX Series is an innovative program that provides a collaborative structure to learn and implement evidence-based methodologies to support achieving DSRIP goals, milestones, and requirements.

From that initial proposal, Federation began assembling their Implementation Team. The team consisted of:

Elizabeth Galati, MA, Director of Strategic Partnerships and Resource Development

Jason Vandewater, LCSW, Director of Clinical Programs

Carissa Romano, Physician’s Assistant

Ryan Busuttil, LMSW, CHC Associate Director of Clinical Programs

Susan Jayson, LCSW, Director, Behavioral Health Integration, Stony Brook Medicine Office of Population Health

Kim Tucker, MA, Development Implementation Specialist

The project consisted of 3 workshops where change was implemented and results were driven at the local level.

Step 1: Identify High Utilizers

Step 2: Develop real time notification of

healthcare

Step 3: Link with community medical resources

Goal: To reduce unnecessary hospitalizations

and readmissions for high utilizers

Through the use of PSYCKES we identified 12 individuals who had a new QI Flag in March 2017 and were attending our Recovery Concepts at Patchogue PROS program.

All clients identified received the clinical component of the PROS program.

We used internal filters within PSYCKES to identify the high utilizers with a new QI Flag.

The following QI Flags were identified; 2+ Inpt- MH, 2+ Inpt- Medical, 2+ Inpt- BH, 2+ ER-

Medical, 2+ ER MH, 2+ ER BH, No Gluc/HbA1C, HARP No Health Home

2+ ER Medical - 7

2+ Inpt-MH/BH - 3

2+ ER MH/BH- 2

2+ Inpt-Medical - 1

NO Gluc/HbA1c & LDL - 1

HARP no HH 1

58%

25%

17%

We participate in the Healthix RHIO to receive alerts on our consumers.

Consumers are offered a Healthix and PSYCKES consent at intake. Program staff have also been trained in the use of Healthix and PSYCKES.

We developed a contact list including CPEP and area psychiatric units. This allows us to have a point of contact should we be notified of an ER visit or hospital admission.

Our EHR allows for individuals who are identified as high risk to be flagged.

Utilized a Physician Assistant within PROS to assist consumers in obtaining bloodwork to track HbA1c and LDL’s.

The PA also worked with consumers to link to Primary Care to avoid unnecessary ER visits and reduce the use of ER visits to obtain medication.

Linked individuals with Medford Chemist Pharmacy to allow for home delivery of medication. Long acting antipsychotic medication is also delivered directly to the PROS program to assist individuals with medication compliance.

We fostered a relationship with Northwell Health to integrate bloodwork results directly into our EHR.

Developed a partnership with HRHCare to provide integrated care within our clinical programs in Suffolk County.

Of the 12 individuals identified 5 were male and 7 were female. With 58% diagnosed with MDD, 25% Schizoaffective and 17% Bipolar.

7 individuals remained in Federation programs throughout the year March 2017 to 2018.

Of the 5 discharged from Federation programs, 3 graduated to a clinic level of treatment, 1 disengaged, and 1 transferred to drug tx.

100% of individuals identified were linked or received coordination of care with a PCP.

Only 3 visits to the ER/hospital for the same Quality Indicator.

100% of individuals remained out of the ER for medication refills.

50% were linked to home medication delivery.

Elizabeth Galati, MA, Director of Strategic Partnerships and Resource Development [email protected]

Jason Vandewater, LCSW, Director of Clinical Programs, [email protected]



IMPROVING DIABETES CARE AT

EAST HAMPTON FAMILY MEDICINE

Presented by

Douglas Kronenberg

Practice Administrator

East Hampton Family Medicine

IMPROVING DIABETES CARE AT EAST HAMPTON FAMILY

MEDICINE

Caring for the Health and Wellness

of our Community

CARING FOR THE HEALTH AND WELLNESS OF OUR COMMUNITY

• TWO PHYSICIAN PRACTICE

• 1 PA, 4 NPS

• 21 TOTAL EMPLOYEES

• 16,014 PATIENT VISITS IN 2017

• ON PACE FOR 18,500+ PATIENT VISITS IN 2018

MEASURES

• DSRIP (DELIVERY SYSTEM REFORM INCENTIVE PAYMENT)

• HEDIS (HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET)

• MIPS (MERIT BASED INCENTIVE PAYMENT SYSTEM)

• INSURANCE COMPANY INCENTIVES

DIABETES MEASURES

USING LEAN METHODOLOGY

• LEAN IS A PHILOSOPHY THAT USES TOOLS

TO REMOVE WASTE AND ADD VALUE TO A

PROCESS BASED ON CUSTOMER NEEDS

• LEAN USES THOSE THAT ”TOUCH” THE

PROCESS TO IMPROVE THE PROCESS

• WE MAPPED OUR PROCESS (CURRENT

WORK FLOW)

• IDENTIFIED ISSUES (WASTE) WITHIN OUR

PROCESS

• THEN IMPLEMENTED IMPROVEMENTS TO

THE PROCESS (FUTURE WORK FLOW)

ORIGINAL WORK FLOW (AT START OF PROJECT)

PREVIOUS ISSUES

INTERVENTIONS

CURRENT WORK FLOW

During pre-visit planning, Chart alerts are created

Same day appointments are checked for any gaps in care by RN, regardless of why they are coming in

Medical assistants are updating the chart and obtaining names and

phone numbers of other specialists the patient may

be seeing

Discharge desk helps to make and assist patients in obtaining appointments and creates referrals for

the eye appointment

RESOLVED ISSUES

Patients are being referred to

ophthalmologist that can accommodate our patient either same day or next

day

Consult notes are received within 24 hours of the

consultation

Patients that have Medicaid and

transportation issues are referred to our nurse care

manager

SUCCESS

PERFORMANCE UPDATES

Presented by:

Kevin Bozza, MPA, FACHE, CPHQ, RHIT

Chief of Operations, VP, Population Health Management Services

More than 50% of performance measures are improving or

meeting performance goals

More than 50% of project measures met

Total inpatient and emergency room Medicaid spend is under

target

Minimum of 10% of Managed Care expenditures are in a level

1 or higher Value Based Payment arrangement

DY3 STATEWIDE PPS PERFORMANCE GOALS

© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.

SCC PERFORMANCE


0%

20%

40%

60%

MY1 MY2 MY3 MY4

35.5% (11/31)

45.2%(14/31)

47.1%(16/34)

*55.9%(19/34)

Measurement Year Results (Claims Based Measures)

MY1 MY2 MY3 MY4* Preliminary – Month 3 of 12

% M

easure

s M

et

Met High Performance Targets (20% improvement) for 5 measures

Met the Additional High Performance Program Target (10% improvement for 5 of 9 measures)

- Follow-up after hospitalization for Mental Illness – within 7 days

- Follow-up after hospitalization for Mental Illness – within 30 days

- Potentially preventable Emergency Room Visits (for persons with BH Diagnosis)

- Potentially preventable Emergency Room Visits

- Potentially preventable Readmissions

SCC PERFORMANCE

MY3 FINAL RESULTS


MY3 STATEWIDE RESULTS – CLAIMS BASED MEASURES

MY3 (July 2016- June 2017) Statewide Results

Rank PPS Name

# Of Domain 2&3

Performance Targets

Met

Total # of Domain 2&3

Performance TargetsPercent Met

1 Refuah Community Health Collaborative 14 24 58%

2 Staten Island Performing Provider System 14 25 56%

3 Bronx-Lebanon Hospital Center 17 32 53%

4 The New York and Presbyterian Hospital 15 29 52%

5 NYC Health and Hospitals Corporation 16 33 48%

6 SUNY at Stony Brook University Hospital 16 34 47%

7 Samaritan Medical Center 13 29 45%

8 Westchester Medical Center 13 30 43%

8 Central New York Care Collaborative, Inc 12 28 43%

10 NewYork-Presbyterian/Queens 14 33 42%

11 Bassett Medical Center 12 29 41%

11 Mount Sinai PPS, LLC 12 29 41%

13 NYU Lutheran Medical Center 12 30 40%

14 Montefiore Medical Center 13 33 39%

15 Advocate Community Providers, Inc. 13 34 38%

15 Nassau Queens Performing Provider System 11 29 38%

17 Care Compass Network 10 28 36%

18 SBH Health System 12 34 35%

19 Maimonides Medical Center 11 33 33%

20 Alliance for Better Health Care, LLC 9 29 31%

21 Adirondack Health Institute, Inc. 7 24 29%

22 Better Health for Northeast New York Inc 9 33 27%

23 Sisters of Charity Hospital of Buffalo 7 30 23%

23 Millennium Collaborative Care 7 30 23%

25 Finger Lakes Performing Provider System 4 26 15%


BEHAVIORAL HEALTH PROGRAM

Measurement Year 3 Final Results

Behavioral Health Program

PPS Target

10% Gap-to-Goal

High Performance Target

20% Gap-to-Goal

NYS Performance

GoalAdherence to Antipsychotic Medications for People

with Schizophrenia x

Antidepressant Medication Management - Effective

Acute Phase Treatment x x

Antidepressant Medication Management - Effective

Continuation Phase Treatment x x

Cardiovascular Monitoring for People with

Cardiovascular Disease and Schizophrenia x x

Diabetes Monitoring for People with Diabetes and

Schizophrenia x x

Diabetes Screening for People with Schizophrenia or

Bipolar Disease who are Using Antipsychotic

Medication ✅Initiation of Alcohol and Other Drug Dependence

Treatment (1 visit within 14 days) x

Engagement of Alcohol and Other Drug Dependence

Treatment (Initiation and 2 visits within 44 days) ✅ ✅Follow-up after hospitalization for Mental Illness -

within 30 days ✅ ✅Follow-up after hospitalization for Mental Illness -

within 7 days ✅ ✅Follow-up care for Children Prescribed ADHD

Medications - Continuation Phase x

Follow-up care for Children Prescribed ADHD

Medications - Initiation Phase x

Screening for Clinical Depression and Follow-up ✅Potentially Preventable Emergency Department

Visits (for persons with BH diagnosis) +/- (per 100) ✅ ✅© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or

its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.

MY4 Preliminary Results

PPS Target – 10% Gap-to-Goal

✅

✅

✅

x

✅

x

✅

✅

✅

✅

x

x

✅

CHRONIC DISEASE PROGRAM

Chronic Disease Program


PPS Target

10% Gap-to-Goal


20% Gap-to-Goal

NYS

Performance

Goal

Asthma Medication Ratio (5 - 64 Years) ✅Medication Management for People with Asthma (5 - 64 Years) - 50% of Treatment Days Covered ✅Medication Management for People with Asthma (5 - 64 Years) - 75% of Treatment Days Covered x

Pediatric Quality Indicator # 14 Pediatric Asthma +/- (per 100,000) ✅Prevention Quality Indicator # 15 Younger Adult Asthma +/-(per 100,000) ✅Controlling High Blood Pressure ✅Prevention Quality Indicator # 7 (HTN) +/- (per 100,000) ✅Prevention Quality Indicator # 8 (Heart Failure) +/- (per 100,000) ✅Statin Therapy for Patients with Cardiovascular Disease –Received Statin Therapy x

Statin Therapy for Patients with Cardiovascular Disease –Statin Adherence 80% x

Comprehensive Diabetes Care- Hemoglobin A1c (HbA1c) Poor Control (>9.0%) +/- ✅Comprehensive Diabetes screening - All Three Tests (HbA1c, dilated eye exam, nephropathy monitor) ✅Prevention Quality Indicator # 1 (DM Short term complication) +/- (per 100,000) ✅




x

x

x

✅

x

✅

✅

x

✅

✅

CARE TRANSITIONS PROGRAM

Care Transitions Program


PPS Target

10% Gap-to-Goal


20% Gap-to-Goal NYS Performance Goal

Adult Access to Preventive or Ambulatory Care - 20 to 44 years x

Adult Access to Preventive or Ambulatory Care - 45 to 64 years x

Adult Access to Preventive or Ambulatory Care - 65 and older x

Children's Access to Primary Care - 12 to 19 years x

Children's Access to Primary Care - 12 to 24 Monthsx

Children's Access to Primary Care - 25 months to 6 years x

Children's Access to Primary Care - 7 to 11 yearsx

PDI 90 - Composite of all measures +/- (per 100,000) ✅

PQI 90 - Composite of all measures +/- (per 100,000)✅

Potentially Preventable Emergency Room Visits +/-(per 100) ✅ ✅Potentially Preventable Readmissions +/- (per 100,000) ✅ ✅




x

x

x

x

✅

x

x

✅

✅

✅

✅

CG CAHPS

MY3 PERFORMANCE

Measures


PPS Target

10%

Gap-to-Goal

High Performance

Target

20% Gap-to-Goal

NYS

Performance

Goal

Aspirin Use x

CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers x

Discussion of Risks and Benefits of Aspirin Usex

Flu Shots for Adults Ages 18 - 64x

Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) x

Health Literacy - Describing How to Follow Instructions x

Health Literacy - Explained What To Do If Illness Got Worse ✅Health Literacy - Instructions Easy to Understand

x

Medical Assistance with Smoking and Tobacco Use Cessation - Advised to Quit ✅Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Medication ✅Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Strategies ✅Primary Care - Length of Relationship - Q3 ✅Primary Care - Usual Source of Care - Q2 ✅© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or

its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.

CAHPS Clinician and Group Adult 3.0 core survey

o Expanded to include 18 supplemental

questions

Distributed by: NYS DOH

13 measures:

o 2 Primary Care Items

o Getting Timely Appointments, Care, and

Information Composite

o Providers' Use of Information to Coordinate

Patient Care Composite

o 3 Health Literacy Items

o HEDIS Items (2 Aspirin Use, 1 Flu Shots, 3

Medical Assistance with Smoking and

Tobacco Use Cessation)

Sampling Frame:

o Adults ages 18-64

o Current Medicaid members, enrolled

continuously for six months

o Patients who have had at least one qualifying

outpatient visit in the last six months as of July

Administration Period: September – December

PPV/PPR THREE YEAR TREND


Potentially Preventable ED Visits (PPV)

(Per 100 People)

32.17% reduction

Potentially Avoidable Readmissions (PPR)

(Per 100,000 People)

41.78% reduction

MY1 • Project planning initiated• MAX program – Brookhaven (Multi Visit Utilizers)

MY2 • Certified Interact Champion Training Program Held• Engaged SNFs in Action Planning Process focused

on reducing PPRs• TOC Model Workgroup established• Engaged Dr. Amy Boutwell to facilitate the

development of TOC program• TOC Model and Protocols developed (includes high

risk assessment)• Social Needs Screen Built• TOC Model Approved• Max Program – Southside Hospital (Multi Visit

Utilizers)

MY3 • TOC Care Management Support• Care Transitions Learning Collaboratives and

Regional Care Workgroups established• 10 Hospitals submit all requirements for

implementation of TOC Project • Max Program - Good Samaritan (Multi Visit

Utilizers)• PCP performance workbooks operationalized - QI

planning begins

CHILD ACCESS – 3 YEAR TREND


1% Decrease

0.35% Increase

0.1% Decrease

0.54% Increase

Missed MY3 target by 70

membersMissed MY3 target by 77

members


members


members

ADULT ACCESS – 3 YEAR TREND


2.57% Decrease1.76% Decrease

0.23% Decrease

Missed MY3 target by 1,277

members


members


members

DSRIP TIMELINE

DSRIP is Currently in Demonstration Year 4 Quarter One

(DY4 Qtr. 1) and Closing-out Measurement Year 4 (MY4)

June 2018

FINANCIAL OVERVIEW – REMAINING AT RISK DOLLARS

MEASURE TYPE (MY3 – MY5)


MY4 SPRINT TO THE FINISH!!!

June 30, 2018 MY4 Closes

Measure(s) Activities

Access (7) • Prioritized partners and outreach efforts based on opportunity across HUBS

• Utilized EHRs and MCO Payor Panels to identify members in need of annual wellness visit and initiated outreach and tracking of gap closure

• Pilot project initiated with 2 CBO partners to assist 4 SCC contracted PCP practices (1,056 patients) engage attributed patients unknown to them

• Working with partners to escalate attributed members to MCOs following multiple failed attempts to reach members

Cardiovascular & Diabetes Monitoring/Diabetes Screening (4)

• Utilized DOH claims data and identified members in need of test

• Collaborated with partners to engage members• Tracking gap closure


MY5 PI INITIATIVES

July 1, 2018 MY5 Begins


Prioritized measures for focus based on valuation and

performance

HUBS have developed a structured approach to impact

performance

Refresh SCC Action Plans with Primary Care Providers

Engage Behavioral Health Providers and Hospitals in the SCC

Action Planning Process

Transition to sustainable processes and systems

Focus on supporting Value Based Payment arrangements

CLOSING REMARKS

Presented by

Linda S. Efferen, MD, MBA

Executive Director & VP, Medical Director


project advisory committee (pac) - suffolk care · 6/14/2018 · administrative manager, community...

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