project advisory committee...
TRANSCRIPT
PROJECT ADVISORY COMMITTEE (PAC)
Thursday, March 31, 2016
9:00am-12:00pm
Islandia Marriott Long Island
Hosted by the Office of Population Health at Stony Brook Medicine
1
AGENDA
2
9:00 am – 9:10 am Welcome RemarksJoseph Lamantia,
Chief of Operations for Population HealthStony Brook Medicine
9:10 am – 9:45 amSCC DSRIP Program
Progress Reports
Alyssa Scully,Director Project Management Office,
Ashley Meskill, RN,Clinical Project Manager,
Amy Solar Greco, Project Manager
Susan Jayson, LCSW,BH & PC IC Implementation Specialist
9:45 am – 10:00 am BREAK
10:00 am – 10:40 amIntegrating Behavioral Health Across the Continuum of Care
Kristie Golden, PhDAssociate Director of Operations, Neurosciences
Neurology, Neurosurgery & PsychiatryHospital Administration, Stony Brook Medicine
10:40 am – 11:50 am
Primary Care - Behavioral Health Integrated Care Practices Panel
Discussion
Moderator, Kristie Golden, PhDAssociate Director of Operations, Neurosciences
Neurology, Neurosurgery & PsychiatryHospital Administration, Stony Brook Medicine
11:50 am – 12:00 pmClosing Remarks
Question & Answers
Joseph Lamantia,Chief of Operations for Population Health
Stony Brook Medicine
WELCOME REMARKS
Presented by
Joseph Lamantia
Chief of Operations for Population Health
Stony Brook Medicine
3
4
Five Stages of the DSRIP (Apologies to Kubler-Ross)
Denial –
Anger –
Bargaining –
Depression –
Acceptance –
DY1 IS IN THE BOOKS!
You’re kidding right?
You want us to do what?
How many meetings do I have to go to?
Are the days for fee-for-service really numbered?
Where do I sign!
5
KEY THEMES – “BUILDING A FOUNDATION”
March 2015 IT Interoperability and Care Management
June 2015 CBO’s and PCMH
October 2015 Cultural Competency & Health Literacy and
Value Based Purchasing
December 2015 Partner Onboarding Program (Provider
Contracting)
2015 PAC mtg Key Themes
“These key themes have and will continue to shape and provide
form, function and purpose to the SCC”
STAY INFORMED
• Project Advisory Committee
Membership
o Membership directory just over 1,100
•Communication Strategies:
eNewsletters
o Synergy and DSRIP In Action
•Website at www.suffolkcare.org
guide for partners/providers, community and project stakeholders
Text SUFFOLKCARES to 22828 to join our eNewsletters!
Quarterly PAC Meeting Participation
BEHAVIORAL HEALTH AND PRIMARY
CARE INTEGRATION
The “Burning Platform”
Approximately 23% of our PPS Medicaid members are defined as behavioral health
recipients (member* with 1+ claims with a primary or secondary behavioral health
diagnosis)
Source: CY 2013-2014 Medicaid claims data is the data source
Behavioral health recipients cost, on average, 4.65 times more per recipient and
represent 58%of total Medicaid spending
Behavioral health recipients drive 48% of all ED visits;
Behavioral health recipients represent 58% of admissions to hospital and on average
have a 1.65X longer length of stay in hospital than non-behavioral health recipients
32% of all Primary Care visits are attributed to behavioral health recipients
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BEHAVIORAL HEALTH AND PRIMARY
CARE INTEGRATION PROGRAM
• BH → PC Behavioral Health co-located in Primary Care Practices
Model 1
• PC → BH Primary Care co-located in Behavioral Health Practices
Model 2
• IMPACT Evidence-based Care Coordination Model for Depression Care
Model 3
This program is aimed at developing collaborative integrated care
models between PCPs and behavioral health organizations.
MEETING OBJECTIVES
• The office of population health will highlight current status reports on the NYS DSRIP Program efforts, including project-specific updates and achievements to date.
DSRIP Program Progress Reports
• Dr. Kristie Golden, Associate Director of Operations, Neurosciences, Neurology, Neurosurgery & Psychiatry, Hospital Administration at Stony Brook Medicine and Project Lead of the SCC DSRIP Project 3ai, will be describing current trends in Primary Care – Behavioral Health Integrated Care practices, best practices in screenings, and integrated care implementation strategies.
Integrating Behavioral Health Across the Continuum of Care
• A panel of health care leaders representing primary care and mental health will share thoughts and perspective on the Primary Care – Behavioral Health Integrated Care Model and discuss what can be leveraged for DSRIP PPS.
Behavioral Health & Primary Care Integrated Care Panel Discussion
9
DSRIP PROGRAM PROGRESS REPORTS
Presented by
Alyssa Scully,
Director Project Management Office,
Ashley Meskill, RN,
Clinical Project Manager,
Amy Solar Greco,
Project Manager
Susan Jayson, LCSW,
Implementation Specialist,
Behavioral Health & Primary Care Integrated Care Program
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PATIENT ENGAGEMENT SCORECARD
DY1 Q1 - DY1 Q3 (APRIL 1 - DEC 31, 2015)
2bvi: TOC
Hospital
2bix: OBS
Hospital
2bvii: INTERACT
Nursing Home
2di: PAM
CBO
3ai: PCBH
PCP & BH
3bi: Cardio
PCP
3ci: Diabetes
PCP
3dii: Asthma
PCP
Target 9,531
Actual 22,397
Achievement
Rate 235%
Target 2,216
Actual 2,400
Achievement
Rate 108%
Target 717
Actual 1,294
Achievement
Rate 180%
Target 7,950
Actual 8,471
Achievement
Rate 106%
Target 4,505
Actual 11,473
Achievement
Rate 255%
Target 2,180
Actual 3,609
Achievement
Rate 165%
Target 4,533
Actual 5,246
Achievement
Rate 115%
Target 2,180
Actual 3,081
Achievement
Rate 141%
SCC Project Management Office Report Template
Key: Checkmark means meeting or exceeding target, X=Not on Target
12
BUILDING AN INTEGRATED DELIVERY SYSTEM (2AI)
Approach
• Engage groups of SMEs to direct each of the 11 IDS Project Requirements
• Create an integrated delivery system through clinically integrating network providers aimed at achieving improved population health.
Accomplishments
• Expanded IDS/PHM Workgroup
• Clinical Integration Needs Assessment Complete
• IT Clinical Data Sharing & Interoperable Systems Roadmap Complete
• Initial RHIO Gap Analysis Complete
Next Steps
• Complete Clinical Integration Strategy
• Complete Population Health Management Roadmap
• Continue working with safety-net partners on RHIO enrollments
• Continue technical-on-boarding with partners in building the IDS
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/2ai1
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BUILDING AN INTEGRATED DELIVERY SYSTEM (2AI)
2ai Project Committee
PHM/IDS Project Workgroup
TOC Workgroup PM: Ashley Meskil
IT Task Force PM: Ned Micelli
PCMH Certification Workgroup PM: Althea Williams
Care Management & Care Coordination Workgroup
PM: Kelli Vasquez
Performance Reporting & Management Workgroup
PM: Kevin Bozza
Value Based Payment Team PM: Neil Shah
Community Engagement Workgroup PM: Althea Williams
Community Health Activation Program PM: Amy Solar-Greco
IDS Project Key Themes• Integrated Delivery System • Population Health Management • Transitions of Care • Clinical Integration/Clinical
Interoperable Systems• RHIO/SHIN-NY Connectivity • Meaningful Use • PCMH Certification • PCP access & capacity• Care Coordination & Collaborative care
practices• Care Management • Value Based Payment • Community Navigation/Engagement
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ACCESS TO CHRONIC DISEASE PREVENTIVE CARE
INITIATIVES (4BII)
Approach
• Support promotional activities to increase prevention and awareness efforts for lung cancer, breast cancer and colorectal cancer screening education, obesity prevention and tobacco cessation in clinical and community settings.
Accomplishments
• Create a first draft community resource directory
• HITE Online Community Resource Directory website partnership formalized
• Patient Education materials reviewed & approved by CC & HL workgroup
Next Steps
• Initiate work on online Community Resource Directory on the SCC website
• Formalize materials for chronic-disease prevention/education programs
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/4bii
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SUBSTANCE ABUSE PREVENTION AND
IDENTIFICATION INITIATIVES (4AII): SBIRT
Approach
• Identify & train SBIRT Hospital-based Facility Champions to implement SBIRT Implementation Plan
• Operationalize PPS-wide SBIRT Training Program for Hospital staff
• Workgroup & Committee engaged to collaborate on best practices, lessons learned and risk mitigation strategies through “Learning Collaboratives”
Accomplishments
• SCC Monthly SBIRT Training Program underway
• Stony Brook Medicine & Brookhaven Hospital go-live complete
• CHS held kick-off for Health System
• Continue learning from Northwell Health Southside’s experiences in SBIRT roll-out
Next Steps
• Continue to host Monthly SBIRT Trainings at all partner hospitals to train staff
• Next Learning Collaborative scheduled to share collaborative practices implemented by Stony Brook Medicine & Brookhaven Hospital
• Begin collecting data to support program development efforts
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/4aii
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TRANSITION OF CARE PROGRAM FOR INPATIENT &
OBSERVATION UNITS (TOC) (2BIV & 2BIX)
Approach
• Engagement of nationally recognized SME to support TOC Model development
• Identify & train TOC Hospital-based Facility Champions to initiate TOC Implementation Plan
• Workgroup & Committee engaged to collaborate on best practices, lessons learned and risk mitigation strategies through “Learning Collaboratives”
Accomplishments
• TOC Model designed by the Project Committee has been approved by the Clinical Governance Committee & Board of Directors
• Partnered with two Preventive Medicine Residents from the Stony Brook Medicine School of Preventive Medicine to support Hospital’s during Implementation
Next Steps
• TOC Implementation Plan for each Hospital will be initiated
• Training Curriculum will be designed using the contents of the TOC Model Approved
• First Learning Collaborative will be scheduled to begin collaboration amongst project stakeholders
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/2biv
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INTERVENTIONS TO REDUCE ACUTE CARE TRANSFER
PROGRAM (INTERACT) (2BVII)
Approach
• SNF Facility Champion & Co-Champions obtain INTERACT Training Certification
• INTERACT Workgroup representative of all SNF DNS engaged in designing content and deploying a SCC INTERACT Implementation Toolkit
• SNF Facility Champions will be using Performance Logic to report progress against the SNF INTERACT Implementation Plan
Accomplishments
• SNF Facility Champions & co-champions trained & certified
• SNF INTERACT Implementation Toolkit Complete and adopted by Project Committee
• SNFs oriented to Technical On-boarding processes to support IDS
• SCC Project Manager presented our INTERACT Implementation approach at a GNYHA Post-Acute Care Workgroup Meeting
Next Steps
• SNF Facility Champions will initiate INTERACT Implementation Toolkit. First steps include building SNF-based Implementation Teams & Hosting Kick-Off Meetings
• SCC PMO begins to support development of INTERACT program patient, family and caregiver communication pamphlets
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/2bvii
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CLINICAL IMPROVEMENT PROGRAMS (3BI) & (3CI)
Approach
• Adopt evidence-based guidelines to support training and implementation of clinical improvement practices in medical settings.
• Operationalize a Stanford Peer Training Program in partnership with our existing community based programs.
• On-board Provider Relations Managers to monitor Practice Site Implementation Plans and training requirements.
Accomplishments
• Evidence-based guideline summaries are complete.
• PCP and Non-PCP practice site implementation plan complete.
• Clinical improvement program materials are in development for the Diabetes and Cardiology in concert with program SMEs.
Next Steps
• Initiate practice site Implementation Plan with our contracted/engaged practice Sites
• Continue to develop Training Curriculum and program materials to support implementation.
• Hot-spotting strategies to support implementation in development.
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/3bi &
https://suffolkcare.org/aboutDSRIP/projects/3ci
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PROMOTING ASTHMA SELF-MANAGEMENT PROGRAM
(PASP) (3DII)
Approach
• Through community partnerships initiate an Asthma-Home Environmental Trigger Assessment Program deployed by CHWs in our communities for high risk patients.
• Promotion of Program to PPS medical practice sites and promote use of Asthma Action Plans at medical practices.
Accomplishments
• Home Environmental Trigger Assessment Program procedures and workflows created.
Next Steps
• Formalize partnerships to operationalize Home Environmental Trigger Assessment Program.
• Engage workgroups to create communication materials and pamphlets for program for our network of providers.
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/3dii
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COMMUNITY HEALTH ACTIVATION PROGRAM
(CHAP) (2DI)
Approach
•Support a CBO-led in-reach and outreach program to identify, engage, educate and integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care.
• Identify hot-spot locations across the County to identify individuals.
•Build community navigation resources and partnerships to connect individuals to primary care, BH, access to health care/enrollment, health home or social service agencies resources.
Accomplishments
•Met 100% DY1 patient engagement survey-targets 1 month early.
• Identified beneficiaries to attend Project Workgroup discussions to support strategies to further enhance program operations.
Next Steps
•Continue working with partner CBO’s and identifying new CBO partnerships for program.
•Formalize the Coaching for Activation program for surveyed individuals.
•Baseline and evaluate year 1 survey data to support strategies in year 2.
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/2di
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PRIMARY & BEHAVIORAL HEALTH INTEGRATED CARE
PROGRAM (3AI)
Approach
• Partner with Nationally recognized SME to support development of evidence-based program materials and training curriculum for Integrated Care.
• Design and deploy a Program Toolkit to support implementation of Integrated Care at practice sites.
• Engage practices sites in a phased approach which includes: current state assessment, model selection, implementation and monitoring.
• Practice sites will be invited to participate in “Learning Collaboratives” led by our SMEs.
Accomplishments
• Program Toolkit drafted for Integrated Care (IC) practice sites.
• Phase 1 practices sites have selected the model they will implement.
Next Steps
• Initiate implementation of IC at Phase 1 practice sites.
• Partnering with Community Based Organizations for embedded staff resources.
• Phase 2 practice sites will initiate in July 2016.
Visit our program page: https://suffolkcare.org/aboutDSRIP/projects/3ai
BREAK
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INTEGRATING BEHAVIORAL HEALTH
ACROSS THE CONTINUUM OF CARE
Presented by:
Kristie Golden, PhD
Associate Director of Operations, Neurosciences
Neurology, Neurosurgery & Psychiatry
Hospital Administration
Stony Brook Medicine
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INTRODUCTION
• Primary Care-Behavioral Health Integration, also referred to as physical-mental health integration, is an evidence-based approach that supports collaboration between physical health and behavioral health providers to improve the identification and triage of those in need of mental health and/or substance abuse services.
• Promotes the collaboration between primary care providers, behavioral health specialists and other disciplines
• Various models of how to integrate services being implemented nationwide
GLOBALLY - WHY INTEGRATE?
• Individuals/families that are closely connected with a PCP have a trusting relationship with that doctor
• Individuals/families are more likely to follow up with appointments either in their PCP’s familiar location or coordinated by their PCP rather than traveling to a new doctor or initiating an appointment on their own
• Better communication among all parties, screenings for early intervention and treatment, better individual health and family outcomes, lower healthcare costs, improved work and school performance
• Opportunity to identify behavioral health conditions and address them when the patient is in the office.
WHY IDENTIFY BEHAVIORAL
HEALTH DISORDERS?
• Research evidence supports that screening for potential medical problems
(cancer, diabetes, hypertension, tuberculosis, vitamin deficiencies, renal
function) provides preventative services prior to the onset of acute
symptoms and delays or precludes the development of chronic conditions
• Depression is linked to numerous medical conditions such as diabetes and
cardiac disease
• Risky levels of substance use and any level of smoking are also directly
linked to numerous medical conditions and chronic disease
• Co-occurring tobacco use is a significant contributor to the increase in
mortality among individuals with psychiatric disorders
• Screening for depression and substance use has been proven to help
identify those individuals at risk who have not previously sought services
Source: Barbara E. Warren, Psy. D. LMHC, CASAC, CPP: Stony Brook Presentation 8/20-8/21
SCREENING BENEFITS
• Primary focus on depression and substance use
• Does not require a behavioral health specialist to complete the
screening
• Provides approach and language to address issues using motivational
interviewing
• Approach is non-confrontational and puts the responsibility for change
on the patient
• Provides an active systematic way to screen and provide a brief
intervention or a referral for more services
Source: Barbara E. Warren, Psy. D. LMHC, CASAC, CPP: Stony Brook Presentation 8/20-8/21
HOW DOES THIS RELATE TO DSRIP?
• Population health efforts seek opportunities for education and
intervention at the point of care (i.e. emergency department, hospital
unit or PCP/GYN office)
• Studies indicate that screening, education and brief intervention for
substance use reduced future use of substances.
• Studies indicate that screening and intervention for depression has a
positive impact on the management of chronic medical conditions.
• When depression, alcohol and other drug screening becomes more
routine, you typically find:
o Greater patient & family satisfaction
o Better patient management & follow-up Source: Barbara E. Warren, Psy. D. LMHC, CASAC, CPP: Stony Brook Presentation 8/20-8/21
OTHER BENEFITS
• Reduces ED visits
• Reduces readmission rates
• Improves public health over time
• Addresses/Treats the “whole” person
• Improves family outcomes
• Improves patient/family satisfaction
• Reimbursable services in hospitals and doctors offices
• Promotes a proactive/wellness approach
WHAT HAS HELD UP WIDESPREAD
ROLL-OUT IN THE PAST?
• Fear and a lack of understanding between PCPs and BH Providers often paralyzes forward movement when considering collaborationo Work culture differences
o Differences in knowledge-base and/or approach to care
• PCP’s struggle with the many psychosocial needs of their patients and the needs of their families and appreciate the BH supporto Older adult-specific issues
o Youth-specific issues
o Family situation-specific issues
o Addiction concerns
• Screening/Assessment opens the door to a myriad of psychosocial issues which cannot be ignored (collaboration is imperative here)
o Case management needs: adequate housing or in home support, safety, nutrition, social isolation, health insurance, medications, managing chronic conditions, etc.
YEARS PAST
• Problem Identified
• Go to Doctor
• Get Treatment
• All is Well
2016
• Problem Identified
• Go to Doctor (in Your Insurance Network)
• Get Treatment (Maybe from a Specialist through a Referral from
your PCP)
• Find Out Ideal Treatment is Limited or Not Authorized
• Doctor Makes Case for Treatment
• Make Calls to Specialists
• Find out There are no Appointments for 6 Weeks
• Go to Appointment
• Get Prescription
• Find Out Prescription is not Covered Under Your Plan
• Call Doctor Back……
DSRIP Concepts
Promote Solutions
HOW TO SET-UP WITHIN A PCP PRACTICE
What discipline(s) is needed?
Is more than one person necessary?
Social Workers/Mental Health Counselors
Psychologists/Neuropsychologists
Health Coaches/Peer Specialist
Alcohol & Substance Abuse Counselors
Psychiatrists/Nurses
Care/Case Managers
Who is affordable/sustainable?
o Define the collaborative agreement between the PCP/BH Employed? Shared space? Lease agreement? etc.)
o Work through issues and set a target start date**
o Identify PCP needs:o What does their PCP patient caseload look like?
o How many people does the PCP see daily?
o Does the PCP have BH experience? Prescribing experience?
o Are they comfortable identifying those in need through screening?
o What is the insurance mix of his/her patient load?
o How will the office staff be involved in the planning?
**(2 people collaborating requires time to work through a lot of detail)
DEVELOP COLLABORATIVE RELATIONSHIPS SET-UP CONTINUED…
Review Potential Arrangements & Work Flow
o Identify local BH resources for back-up and other urgent care or specialty care needs (i.e. inpatient units, long-term treatment)
o Discuss screening tools, i.e. PHQ9, PSC, AUDIT, DAST other screenings, and how this will define when a hand-off is made to the BH Specialist
o Develop practice specific protocols
o Screening completed during annual office visit?
o Paper or EMR? - Who will do it/review it?
o Who will refer patient for services?
o Where will services take place?
o Who does scheduling?
o How will the services be billed?
o What coding needs to be considered and understood?
The “Warm” Hand-off
COMMUNICATION BETWEEN DIVERSE DISCIPLINES
Communication Process
• Establish plan to share records, preferably electronically
o Who uses what documentation “language”? Abbreviations?
Strength-based or “weakness-based” notes?
• Plan communication protocols for ongoing dialogue
o How and when will cases get reviewed?
o How will treatment plan be updated and whose input will be
included?
o How will progress be monitored/measured?
o How will crisis/emergencies be handled?
• Plan for use of other communication technology, i.e. smart phones,
• Consideration of HIPAA compliance
COMMUNICATION CONTINUED…
Monitor Outcomes
• DSRIP Metrics - Design how you will measure health outcomes, i.e. reduced symptoms, better patient engagement, fewer ER visits
• Design how to measure “life” outcomes, i.e. living independently, socializing, improved school outcomes, relationship development, etc.
• Design how, where and by whom data will be collected and analyzed and reported to PPS
• Utilize EMR to communicate and measure progress
• Conduct satisfaction surveys- both patient and referral source
LESSONS LEARNED
• Collaboration does work
• Patients gain access to services more quickly
• Symptoms improve
• PCPs offer more comprehensive treatment to their patients
• PCPs have a more consistent patient flow
• People get healthier
• Creates possibility of “high reliability” organization
HAPPIER PATIENTS = HAPPIER PROVIDERS
Integration
improves patient
satisfaction.
Warm hand-off
should reduce patient
wait time.
FUTURE FRAMEWORK
• Establishing PCP and BH collaboration at the start of a practice
o Seeing integrated model as routine in areas where it is not yet standard
o Teach integration in medical schools and other clinical degree programs
o Learn and measure value of routine screening and prevention
o Change reimbursement methods to support wellness approach
o Population-level change
• PCPs developing trusting relationship with BH peers
o Co-located/Integrated Specialist
o Telepsychiatry and Telephone “Curb-side Consultations”
o Project TEACH in NY
• Reimbursement Models for Sustainability
o Short-run…Utilizing appropriate billing codes
o Long-run…….Value-based reimbursement
o Reduced or eliminated fee-for-service models
Contact InformationKristie Golden, PhD, CRC, LMHC
Associate Director of Operations
Stony Brook Medicine
(631) 444 - 2032
Moderator
Kristie Golden, PhD, Associate Director of Operations, Neurosciences, Neurology,
Neurosurgery & Psychiatry, Hospital Administration, Stony Brook Medicine
Panelists
Luigi Buono, D.O.
Board Certified-American Board Family Practice
Prime Care Medical of Long Island d/b/a North Fork Family Medicine
Martha A Carlin, Psy.D.
Director, Long Island Field Office
New York State Office of Mental Health
Jeff Steigman, Psy.D.
Chief Administrative Officer
Family Service League
Rajvee Vora MD, MS
Director, Ambulatory Behavioral Health for DSRIP Implementation
Northwell Health 43
PRIMARY CARE - BEHAVIORAL HEALTH
INTEGRATED CARE PRACTICES PANEL DISCUSSION
QUESTION & ANSWER
www.suffolkcare.org
44
Appendix
45
PAY FOR PERFORMANCE FUNDING SCHEDULE
• Over the life of the waiver, funding shifts from process milestones
(Domain 1) and reporting (P4R) to performance (P4P):
46
Domain PaymentAnnual Funding Percentages
DY 1 DY 2 DY 3 DY 4 DY 5
Domain 1Project Process Milestones
P4R 80% 60% 40% 20% 0%
Domain 2 System Transformation & Financial Stability Milestones
P4P 0% 0% 20% 35% 50%
P4R 10% 10% 5% 5% 5%
Domain 3: Clinical Improvement Milestones
P4P 0% 15% 25% 30% 35%
P4R 5% 10% 5% 5% 5%
Domain 4: Population Health Outcomes P4R 5% 5% 5% 5% 5%
Source: NYS DOH Presentation Presented June 18th 2015 – DSRIP Incentive Payment Domain 2-4 Achievement Values
DOH DSRIP DEMONSTRATION YEAR
TIMELINE & PAYMENT SCHEDULE
Demonstration
Year & Quarter*Reporting Period Quarterly Report Due Payment Due
DY 1, Q1 4/1/15 – 6/30/15 July 31, 2015 January 2016
DY 1, Q2 7/1/15 - 9/30/15 October 31, 2015
DY 1, Q3 10/1/15 – 12/31/15 January 31, 2015July 2016
DY 1, Q4 1/1/16 – 3/31/16 April 30, 2016
DY 2, Q1 4/1/16 – 6/30/16 July 31, 2016January 2017
DY 2, Q2 7/1/16 – 9/30/16 October 31, 2016
DY 2, Q3 10/1/16 – 12/31/16 January 31, 2017July 2017
DY 2, Q4 1/1/17- 3/31/17 April 30, 2017
47
Source: Department of Health presentation on April 21, 2015 entitled “DSRIP Domain 1 Achievement Values “
Table continues through DY 5*
Domain 1 AVs are tied to semi-annual payment based on
completing all Domain 1 requirements
Demonstration
Year*DSRIP Year Date Range Payments
Measurement Period
Used for Domain 2-3
AVs
DY 1 4/1/2015- 3/31/2016 Payment 1: Q2
(9/30/2015)
N/A
Payment 2: Q4
(3/31/2016)
Measurement Year 1
7/1/2014 – 6/30/2015
DY 2 4/1/2016 – 3/31/2017 Payment 1: Q2
(9/30/2016)
Measurement Year 1
7/1/2014 – 6/30/2015
Payment 2: Q4
(3/31/2017)
Measurement Year 2
7/1/2015 - 6/30/2016
DY 3 4/1/2017 – 3/31/2018 Payment 1: Q2
(9/30/2017)
Measurement Year 2
7/1/2015 - 6/30/2016
Payment 2: Q4
(3/31/2018)
Measurement Year 3
7/1/2016 - 6/30/2017
48
Domain 2-4 AVs are tied to semi-annual payment based primarily on
measures calculated annually
Source: NYS DOH Presentation Presented June 18th 2015 – DSRIP Incentive Payment Domain 2-4 Achievement Values
Table continues through DY 5*
DOH DSRIP DEMONSTRATION YEAR
TIMELINE & PAYMENT SCHEDULE
QUANTIFYING ACHIEVEMENT OF DSRIP GOAL OF 25% REDUCTION IN AVOIDABLE
HOSPITAL READMISSIONS OVER 5 YEARS
49
DSRIP OVERALL GOALS
GOAL OF 90% PAY FOR PERFORMANCE BY DY 5
Reduction BucketPotentiallyAvoidable
25% Reduction
Denominator Denominator Definition
Prevention Quality Indicators (PQIs)
3,651 913 35,540 Suffolk County Medicaid admissions age greater than 18
Pediatric Quality Indicators (PDIs) 432 108 3,837 Suffolk County Medicaid admissions age less than 18; excluding newborns
Reduction BucketPotentially Avoidable
25% Reduction Denominator
Denominator Definition
Avoidable ED (PPV) 86,435 21,609 112,902 Emergency department volume by Suffolk County Medicaid members
Avoidable Readmissions (PPR) 1,612 403 26,714 At risk admissions defined by 3M at Suffolk County hospitals
Source
PQIs and PDIs are computed from the 2013 limited SPARCS data
All other measures are based on CY 2012 data
SUFFOLK PPS AWARD
50
Period of Agreement: April 1, 2015 To: December 31, 2020
Suffolk PPS Award of funds is contingent on our ability to meet DOH
deliverables and performance measure targets.
Net ProjectValuation
Net High Performance
Fund
Additional High
Performance Fund
Public Equity Guarantee
Public Equity Performance
Total Valuation
$ 181,115,320 $ 4,200,998 $10,045,427 $58,971,622 $44,228,717 $298,562,084
NYS Total Valuation
Grand Total $ 7,385,825,815
PROJECT IMPLEMENTATION SPEED
51
DY Timeline DY 0 (2014) DY 1 (2015) DY 2 (2016) DY 3 (2017) DY 4 (2018) DY 5 (2019)
Projects Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4 Q1/Q2 Q3/Q4
2A1 - IDS X
2B4 - TOC X
2B9 - OBS X
3A1 - BH-PC X
3B1 - CV X
3C1 - DIABETES X
3D2 - ASTHMA X
2D1 - UNINSURED X
2B7 - INTERACT X
Suffolk PPS Speed Requirements by Project
Domain 4 Projects do not have Project Speed & Scale Commitments
We are here
SPEED & SCALE OVERVIEW
52
ProjectProject
Description
Providers to be Engaged
(Revised 9/30/15)
# of Actively Engaged
% of Attributed Population
Actively Engaged DefinitionBy
Year:
2.a.i IDS 3,702 N/A N/A N/A N/A
2.b.ivTransitions
of Care3,278 25,326 17% Care Transition plan developed 2
2.b.vii INTERACT 38 SNFs 1,914 1.3%Avoided hospital transfer due to INTERACT
2
2.b.ixObservation
Units1,079 8,866 6% Utilizing Observation services 3
2.d.iPAM/
Uninsured350 trained in PAM 45,426 N/A Individuals who completed PAM survey 4
3.a.iPC & BH
Integration3,432 45,059 30%
1) PHQ/SBIRT screening at PCMH site 2) Primary care services at BH site3) PHQ/SBIRT screening at IMPACT site
4
3.b.i Cardio 3,538 14,556 10%Documented Self-Management goals in Medical records
4
3.c.i Diabetes 3,538 12,094 8%Received a hemoglobin a1c test in previous DSRIP year
3
3.d.ii Asthma 3,382 6,751 4.5%Registered in home assessment log, patient registry, or other IT platform.
2