westchester medical center pps project advisory committee · project requirements (2 of 11) : •...
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Westchester Medical Center PPS Project Advisory Committee
February 23, 2015 Via Webinar: 10:00 am – 11:30 am
US TOLL FREE: +1-855-749-4750 Access code: 572 936 751
Confidential – Not for Distribution
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Agenda
Confidential – Not for Distribution
Discussion Topic Time
Welcome & Status Update 10:00 – 10:10 am
Implementation Plan Overview • Four Key Elements • Strategy for Population Health Management • Project plans • Roles by provider “type”
10:10 – 10:40 am
Assessment of PPS readiness 10:40 – 10:50 am
Upcoming Meetings & Opportunities to Participate 10:50 – 11:00 am
Questions 11:00 – 11:30 am
Status: Where We Are
November 2014 December 2014 March 2015
November 14 • Updated Project Plan Application released • Project Plan Application Prototype released • Capital Restructuring Financing application
released (delayed) • 3rd round of initial attribution results
published
April 2015
November 20 Financial Stability Test results
made available
January 2015
November 24 • Scope and Speed of Application
template released • Leads to submit final partner lists
in Network Tool
December 22 Project Plan
Application due April 1 DSRIP Year 1 begins
February 20 Capital Restructuring
Financing Program Application due
April 1 Implementation Plan Due
March 1 Draft Implementation Plan Due
Four Key Elements
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Four Key Elements
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Governance Financial Sustainability Workforce Cultural
Competency
Four Key Elements
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Governance
How our PPS will advance from a group of affiliated providers to a high performing IDS will be influenced by our governance process. We recognize the need for both central governance, clinical and administrative, to insure standards and efficiency and also the need for regional (Hub) governance to ensure local stakeholder input and decision-making. Key issues and areas of measurement include:
• Community Engagement • Workforce communication and
engagement • CBO partnership agreements • Agency Coordination Plans • PPS Quality Committee
Four Key Elements
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Financial Stability
Success for our PPS beyond service delivery integration requires the ability to implement financial practices that will ensure financial sustainability of the PPS. Key issues and areas of measurement include:
• Initial survey of provider’s financial health
• Impact assessment of DSRIP projects on financial health of participating providers
• Establishment of collaborative provider shared-accountability models including value-based contracts
• Local contracting arrangements with MCOs
Four Key Elements
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Workforce
The primary DSRIP goal is a 25% reduction in avoidable hospital use, involving over 40,000 of us and our employees. Our success at transformation includes appropriately preparing our PPS workforce. Key issues and areas of measurement include:
• Gap analysis of current state workforce assessment and projected future state
• Workforce policy, training and redeployment efforts involving 1199 SEIU and other educational and community partners
• Evaluation of salary bands that align with skill mix change required of the workforce
Four Key Elements
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Cultural Competency
Our ability to develop solutions to overcome cultural and health literacy challenges is key to addressing healthcare disparities within our region. Key issues and areas of measurement include:
• Identifying known challenges and priority groups based on the CNA
• Engaging community members and groups in identifying challenges
• Providing assessments and tools for patient self-management
• Training the health care workforce regarding specific population needs
Common Elements Across Projects
Component IDS
Health Home at
Risk
30 day Readmission
BH – Primary
Care
BH Crisis Stabilization Diabetes Asthma Tobacco
Cessation Cancer
2.a.i 2.a.iii 2.b.iv 3.a.i 3.a.ii 3.c.i 3.d.iii 4.b.i 4.b.ii
Protocols/ Evidence-based Care
X X X X X X X X X
Contracts/ DEAA/BAA X X X X X X X X X
EHRs/HIE X X X X X X X X X
Health Home/ Care Management
X X X X X X X X X
Coordination of Care X X X X X X X X X
Performance Reporting X X X X X X X X X
Health Information Exchange (HIE)
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• A Qualified Health IT Entity (QE) manages the Health Information exchange in NY (formerly: a RHIO)
• All providers can access the HIE via the HealthlinkNY Web Portal. This secure, web-based tool allows health care providers to access their patients’ HIE records. A username and password are required.
Connect to the QE
•Providers with EHRs are encouraged to connect directly to the
HealthlinkNY HIE. This requires establishing a technical interface with HealthlinkNY.
Bi-directional communication: alerts and secure messages
• Federal requirements for “meaningful use” of electronic health records include: e-prescribing, computerized provider order entry (CPOE)for labs and imaging; send patient reminder notices, employ clinical decision support (e.g. “5 As” for smoking cessation) etc
“Meaningful Use”
Care Management/Care Coordination
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• Referrals to other providers for labs, imaging, procedures • After Hospital discharge, ensure that follow up appointments are kept
and that “receiving” providers have discharge records
Transitions: close the loop
• Help to collect patient generated data: Patient Activation Measure (PAM), asthma control test (ACT), screenings for tobacco use, depression, substance use
• Help close “gaps in care”, link patients to services –both clinical and non-clinical
Care Navigators
• Federal and state program to provide complex care management for the most complex patients
• Health Homes, hospitals, PCPs, BH, etc. communicate and collaborate with each other and with patients and families
Health Home
Performance Reporting
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•Contracts •Meeting Minutes •Evidence-based Protocols and Workflows
Process Milestones
•Asthma Action Plans •Patient Health Questionnaire (PHQ-9) depression screening •Tobacco Cessation Counseling
Clinical Services Reporting
•Uninsured person referred to food bank •Patient connected to Health Home care manager
Non Clinical Touches Reporting
Strategy for Population Health Management
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The Three-system Approach to Healthcare Transformation
All three of these systems work together, but the deployment system is essential to sustaining quality gains.
Slide adapted with permission
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Content System Overview What should we be doing?
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Map the Process Care improvement map – Includes workflow & clinician's decision-flow across care continuum
Identify Common Problems - Potential Improvements Specific AIM Statements for outcomes and process to measures for focused improvement
Scope the problem – Define Precise Patient Registries Specific clinical inclusion and exclusion criteria for the sub-cohort of patients for the AIM
Adopt Standardization Aids Checklists, order sets, and protocols to make it easy for clinicians to choose the best action
Slide adapted with permission
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Infr
astr
uctu
re: H
ostin
g / H
ardw
are
Analytics System Overview Who should do it? For which patients? Where?
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e.g. EPSi, Peoplesoft,
Lawson
e.g. Lawson, Peoplesoft,
Ultipro
Subject Area Mart Designer
Source Mart Designer
EMR
EMR Financial Patient Sat. HR Administrative Claims
Financial Patient
Sat. HR Administrative Claims
e.g. Epic, Cerner NextGen
e.g. Press Ganey, NRC Picker
e.g. API Time Tracking
e.g. Medicare Private Payers
Shared Frameworks & Tools for improvement
Comorbidity Analyzer, Registry Repository, Attribution Modeler, Common Definition Repository, Hierarchies, CAFE, Atlas, IDEA, Eventalytics, Geospatial, Risk
& Severity Profiling, etc
Metadata Driven ETL Engine
Source Data Integration • DOH & MCO claims; provider
EMRs; Process Milestones; Patient Generated Data
Analyze and Interpret Data
• Identify populations and providers, “hot spots”
• Calculate Measures • Produce scorecards and
dashboards to promote best practices; invite action
Infrastructure
• Security, Privacy, Compliance
Slide adapted with permission
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Deployment System Overview How do we get it done?
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Improvement Capacity Assessment Evaluation of organizational capacity for change, current capabilities, and gaps: HIT, Financial, Workforce
Governance Organizational Governance & Prioritization; Clinical Governance & Alignment with other regional efforts; Data Governance/Data Stewardship
Improvement Methodology Rapid cycle evaluations; Systematic improvement incorporating LEAN / PDSA principles, etc.
Accelerated Practices Training Systematic training built in to every project for every effected level of the health care delivery workforce
Slide adapted with permission
WMC PPS: A Learning Organization
Project Plans
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WMC PPS Projects
Project Description
Domain 2: Systems Transformation Projects
2.a.i Create an Integrated Delivery System Focused on Evidence-Based Medicine and Population Health Management
2.a.iii Health Home At-Risk Intervention Program
2.a.iv Create a Medical Village Using Existing Hospital Infrastructure
2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions
2.d.i Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care (Project 11)
Domain 3: Clinical Improvement Projects
3.a.i Integration of Primary Care and Behavioral Health Services
3.a.ii Behavioral Health Community Crisis Stabilization Services
3.c.i Implementation of Evidence-Based Strategies in the Community to Address Chronic Disease – Diabetes
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2.a.i Create an Integrated Delivery System
ACTIVATED PATIENTS: Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).
Total Committed
Primary Care Physicians 609
Non-PCP Practitioners 1878
Hospitals 20 Clinics 50
Health Home / Care Management 27
Behavioral Health 324
Substance Abuse 28
Skilled Nursing Facilities / Nursing Homes 43
Pharmacy 4 Hospice 7
Community Based Organizations 148
All Other 1152
Domain 1 Requirements Completion Date: December 2017
Project Requirements (2 of 11) : • Ensure that all PPS safety net providers are actively
sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of Demonstration Year (DY) 3.
• Achieve 2014 Level 3 PCMH primary care certification for all participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standard
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2.a.iii Health Home At-Risk Intervention Program
Total # providers committed
Primary Care Physicians 524
Non-PCP Practitioners 1000 Clinics 29
Health Home / Care Management 27
Behavioral Health 75 Substance Abuse 9 Pharmacy 4
Community Based Organizations 68
All Other 341
All Committed Providers 2077 ACTIVATED PATIENTS: The number of participating patients who completed a comprehensive care management plan.
EXPECTED ACTIVELY ENGAGED PATIENTS: 20,000/year
Activated Patients by June 2015: 500
Domain 1 Requirements Completion Date: December 2017
Project Requirements (2 of 9) : • Develop a Health Home At-Risk Intervention
Program, utilizing participating HHs as well as PCMH PCPs in care coordination within the program.
• Develop a comprehensive care management plan for each patient to engage him/her in care and to reduce patient risk factors.
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2.a.iv Create a Medical Village Using Existing Hospital Infrastructure
Total # providers committed
Number of Medical Villages meeting all project requirements 2
Number of Committed That Are Safety Net Providers*
Primary Care Physicians 112
Non-PCP Practitioners 192
Hospitals 6 Clinics 7
Health Home / Care Management 2
Behavioral Health 5
Substance Abuse 3
Pharmacy 0 Hospice 0 All Other 228
ACTIVATED PATIENTS: The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village in a year.
Domain 1 Requirements Completion Date: December 2018
EXPECTED ACTIVELY ENGAGED PATIENTS: 12,000/year Activated Patients by June 2015: 600
Project Requirements (2 of 7) : • Convert outdated or unneeded hospital capacity into
an outpatient services center, stand-alone emergency department/urgent care center or other healthcare-related purpose.
• Ensure that all safety net providers participating in Medical Villages are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners
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2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions
Total # providers committed
Primary Care Physicians 524
Non-PCP Practitioners 1000 Hospitals 14
Health Home / Care Management 27
Community Based Organizations 64
All Committed Providers 1629
ACTIVATED PATIENTS: the Number of participating patients with a care transition plan developed prior to discharge who are not readmitted within that 30 day period
EXPECTED ACTIVELY ENGAGED PATIENTS: 5,600/year Activated Patients by June 2015: 250
Domain 1 Requirements Completion Date: December 2017
Project Requirements (2 of 7): • Develop standardized protocols for a Care Transitions
Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency.
• early notification of planned discharges and the ability of the transition case manager to visit the patient while in the hospital to develop the transition of care services.
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2.d.i Implementation of Patient Activation Activities (Project 11)
Total # providers committed
Number of individuals trained in PAM® or other patient activation techniques 275
Number of Committed That Are Safety Net Providers*
Primary Care Physicians 150
Non-PCP Practitioners 105
Hospitals 9 Clinics 9 Pharmacy 0 All Other 177 ACTIVATED PATIENTS: Number of individuals who completed PAM® or other patient
engagement techniques
Domain 1 Requirements Completion Date: December 2017
EXPECTED ACTIVELY ENGAGED PATIENTS: 81,500/year Activated Patients by June 2015: 5000
Project Requirements (2 of 17) : • Train community navigators in patient activation and
education, including how to appropriately assist project beneficiaries using the PAM®.
• Increase the volume of non-emergent (primary, behavioral, dental) care provided to Uninsured, Non- utilizing and Low-utilizing persons.
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3.a.i Integration of Primary Care and Behavioral Health Services
Total # providers committed
Primary Care Physicians 100
Non-PCP Practitioners 100 Clinics 25 Behavioral Health 115 Substance Abuse 11
Community Based Organizations 20
All Other 200
All Committed Providers 571
ACTIVATED PATIENTS: Number of patients (age 12 and older) screened for mental health and substance use: (PHQ-9 / SBIRT)
EXPECTED ACTIVELY ENGAGED PATIENTS: 31,000/year
Activated Patients by June 2015: 2000
Domain 1 Requirements Completion Date: December 2017
Project Requirements: (Model 1, BH services at primary care site) • All practices meet NCQA Level 3 PCMH and/or APCM
standards by the end of DY#3. • Conduct preventive care screenings, including
behavioral health screenings (PHQ-9, SBIRT) implemented for all patients to identify unmet needs.
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3.a.ii Behavioral Health Community Crisis Stabilization Services
Total # providers committed
Number of Crisis Intervention Programs meeting all project requirements 7 Number of Committed That
Are Safety Net Providers*
Primary Care Physicians 272
Non-PCP Practitioners 100
Hospitals 13 Clinics 40
Health Home / Care Management 11
Behavioral Health 60
Substance Abuse 27
All Other 300 ACTIVATED PATIENTS: Participating patients receiving crisis stabilization services from
participating sites, as determined in the project requirements.
Domain 1 Requirements Completion Date: December 2017
EXPECTED ACTIVELY ENGAGED PATIENTS: 3,150/year Activated Patients by June 2015: 150
Project Requirements (3 of 11) : • Deploy mobile crisis team(s) to provide crisis
stabilization services using evidence-based protocols developed by medical staff.
• Establish central triage service with agreements among participating psychiatrists, mental health, behavioral health, and substance abuse providers.
• Expand access to observation unit within hospital outpatient or at an off campus crisis residence for stabilization monitoring services
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3.c.i Implementation of Evidence-Based Strategies– Adult Diabetes
Total # providers committed
Primary Care Physicians 524 Non-PCP Practitioners 800 Clinics 13
Health Home / Care Management 27
Behavioral Health 109 Substance Abuse 11 Pharmacy 4
Community Based Organizations 65
All Other 478
All Committed Providers 2031 ACTIVATED PATIENTS: The number of participating patients with at least one
hemoglobin A1c test within previous Demonstration Year (DY).
Domain 1 Requirements Completion Date: December 2016
EXPECTED ACTIVELY ENGAGED PATIENTS: 8,039/year Activated Patients by June 2015: 500
Project Requirements (2 of 7): • Engage at least 80% of primary care providers within
the PPS in the implementation of disease management evidence-based best practices.
• Develop care coordination teams (including diabetes educators, nursing staff, behavioral health providers, pharmacy, community health workers, and Health Home care managers) to improve health literacy, patient self-efficacy, and patient self-management.
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3.d.iii Implementation of Evidence-Based Guidelines for Asthma
Total # providers committed (as per
project plan application)
Primary Care Physicians 524
Non-PCP Practitioners 800
Clinics 15
Health Home / Care Management 27
Pharmacy 4
Community Based Organizations 35
All Other 455
All Committed Providers 1860 ACTIVATED PATIENTS: The number of participating patients with asthma action plan.
Domain 1 Requirements Completion Date: December 2016
EXPECTED ACTIVELY ENGAGED PATIENTS: 6,800/year Activated Patients by June 2015: 500
Project Requirements (2 of 5): • Establish agreements to adhere to national
guidelines for asthma management and protocols for access to asthma specialists, including EHR-HIE connectivity and telemedicine.
• Deliver educational activities addressing asthma management to participating primary care providers.
Useful Link for Providers and Professionals
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Useful NYSDOH website that includes links to Project Plan Applications and Independent Assessor PPS Project Scores as well as information on the Implementation Plan, Workforce and related webinars: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/providers_professionals.htm
Roles by Provider “Type”
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Roles & Tasks vary by provider type and project
Primary Role
• Asthma – Primary Care , Hospitals,
Pulmonologists and Allergists
• BH Crisis Stabilization – BH, CBOs, Hospitals
• Patient Activation – CBOs, FQHCs
• Transitional Care-30 day – Hospitals, HH, Primary Care
• Tobacco Cessation – PCPs , Specialists, BH
Supporting Role
• Asthma – Other Non-PCP, Behavioral
Health, Health Homes
• BH Crisis Stabilization – Primary Care
• Patient Activation – Specialists, Hospitals
• Transitional Care-30 day – CBOs, All Others
• Tobacco Cessation – All Others 33
Assessment of PPS Readiness
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Assessment of PPS Readiness
• Information critical to the Four Key Elements • In-depth IT readiness survey by site • Financial and employment data by organization • Workforce strategy and future needs • Populations served, number of Medicaid patients, and services provided by site
to aid CRHI in determining how each organization will participate – Provider Contracts, Funds Flow, VBC
• Preliminary Survey in Process (all Primary Care)
• Contact names and numbers for DSRIP work • Number of sites; hours of PCPs at each site • EHR used? PCMH status • Some particulars on treatment of asthma, diabetes, behavioral health • Marcie Colon: [email protected]; Melissa Thomas-Belmar: [email protected]
Upcoming Meetings
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Upcoming Meetings
37 Confidential – Not for Distribution
• Integration of Primary Care and Behavioral Health • March 12, 2015
• Primary Care Physician Webinar: same content, two
opportunities to participate • March 10, 2015, 5:30-6:30 PM • March 11, 2015, 8:00-9:00 AM
• Workforce Workgroup
• March 10, 2015 • PAC Executive
• March 10, 2015 • Hudson Valley Health Regional Officers Meeting
• March 6, 2015, 12:00-2:00 PM
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Additional Registration Information
Primary Care Physician Webinar: • Tuesday, March 10, 5:30 – 6:30 p.m.
– Register: http://tiny.cc/march-10-pcp-webinar – You will receive dial-in details after registering
• Wednesday, March 11, 8:00- 9:00 a.m. – Register: http://tiny.cc/march-11-pcp-webinar – You will receive dial-in details after registering
Opportunities to Participate
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Participation Opportunities
40 Confidential – Not for Distribution
• WHAT’S YOUR PASSION? • We are committed to being a learning
organization! • We will be forming groups within our PPS and
with the other PPSs in our region to discuss and share information about our projects. Look for announcements in our newsletter and on our website: www.crhi-ny.org
• We will be mixing it up on the MIX to share information within our groups.
JOIN THE MRT Innovation eXchange - MIX https://www.ny-mix.org/login
MIX Participation
41 Confidential – Not for Distribution
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Please send your questions or thoughts!
• Questions, comments, thoughts may be shared with us anytime by email: [email protected]
• Please check our website for meeting updates and registration information: http://www.crhi-ny.org/
November 2014 December 2014 March 2015 April 2015 January 2015
April 1 DSRIP Year 1 begins
April 1 Implementation Plan Due
March 1 Draft Implementation Plan Due
THANK YOU!
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Contact Information
Tony Mahler Chair, DSRIP PAC Executive Committee Senior Vice President, Strategic Planning Westchester Medical Center P: (914) 493-5086 E: [email protected] Janet (Jessie) Sullivan, MD Vice President Medical Director Center for Regional Healthcare Innovation P: (914) 326-4202 E: [email protected] Peg Moran Vice President of Operations Center for Regional Healthcare Innovation P: (914) 326-4210 E: [email protected]
June Keenan Senior Vice President, Delivery System Transformation Executive Director Center for Regional Healthcare Innovation P: (914) 326-4201 E: [email protected] Deborah Viola, PhD Vice President Director, Health Services Research and Data Analytics Center for Regional Healthcare Innovation P: (914) 326-4203 E: [email protected] Helene Kopal Senior Director of Integrated Delivery Systems Center for Regional Healthcare Innovation P: (914) 326-4209 E: [email protected]