Community Partners of WNY DS RIP Proj ect Advisory Committee (P - - PowerPoint PPT Presentation

Community Partners of WNY DS RIP Proj ect Advisory Committee (P AC) Meeting December 13, 2016

DS RIP Patient Engagement Report, Proj ect & Work S tream Updates

Amy White-S torfer Director, Proj ect Management Office

ED Triage (2.b.iii.)-Patient Engagement

Recap: state released new definition for this proj ect on June 28t h

• Engagement - care manager/ care coordination follow up appointment for health

home engaged population*

• Engagement is PCP appointment demonstrated by scheduled appointment with

PCP

* If t he pat ient has not been engaged in t he HH, we cannot count t hem for t he proj ect

ED Triage (2.b.iii.)-Progress Report



Phase I— Health Connections staff (HCs) contact patients with no PCP; warm transfer to clinics (went live 11/ 28)



Phase II— Patient Navigators (PNs) added to care management team at S isters and Mercy Hospitals; warm transfer to clinics

 First round of interviews held; planned start date after Jan 1  4 positions to be filled—

still recruiting for qualified candidates 

Phase III— Patient Navigators and Health Connections staff schedule directly into CHS clinics via S

• rian scheduling (early 2017)



Crimson Care Management (CCM) module workflow tool will be used by both HCs and PNs for connecting patients to services



Continue to report patient engagement numbers are from our partner, WCA Hospital

Care Transitions (2.b.iv.)



CHS and CMP Care Management teams use Crimson Care Management to log patient communication



Care notifications are sent to primary care offices, allowing for communication between PCP and IP facilities 

WCA continues its reporting and workflows

Telemedicine (2.c.ii.)



S pecialists on Call proj ect at WCA Hospital is the only team reporting patient engagement numbers at this time



Planning in Progress: Maternal Fetal Medicine (MFM)

 WCA Hospital and OB/ GYN practice in Erie County are partners for this sub-proj ect  Up to 700 patients could be seen annually with this proj ect  Credentialing providers in progress  Technical start -up includes image licenses for OB/ GYN in Erie County



Potential: Triage assessment for developmentally disabled population prior to ED visit

 Nursing recruitment remains a challenge to start this proj ect

Behavioral Health Integration (3.a.i.)



By year end: 5 sites will have additional Behavioral Health services, care management support at Primary Care facilities



4 private practices (1 Niagara County, 3 Erie County)



1 CHS health clinic 

Continue to discuss options for Model 2

Cardiovascular Health (3.b.i.)



Once-daily dose formulary list for hypertension medications has been finalized



Communication strategy to practice providers in development

Nurse Family Partnership (3.f.i.)



NFP in Chautauqua County



Currently at capacity; expansion proposed



Per NYS , NFP can now bill for Targeted Case Management 

Erie County



CHWNB/ BUL contracts have been executed



1 CHW hired Nov 2016 – training and shadowing at MCCC



Tentative timeline: 2 additional CHWs to be hired early 2017 – placed at S isters and Mercy

Palliative Care & PCP (3.g.i.)



Continuing to explore alternative methods for capturing palliative care engagements at primary care sites



Team looking to clarify the definition of a palliative care engagement and working with CMP CIS G to develop specific criteria.

Prevention Programs (Domain 4)

Promote Emotional, Mental, and Behavioral Well-Being (4.a.i.)



2016-2017 school-based programs are ramping up



“ Just Tell One” public awareness campaign to begin soon



S eptember 29— CPWNY and MCC hosted a proj ect update meeting to update proj ect partners on program implementation and to reinforce reporting and reimbursement processes

Promote Tobacco Use Cessation (4.b.i.)



Roswell team continues community outreach, including to manufacturing and homeless shelters



NYS S mokers Quit Line will send baseline referral/ call data from the three counties; will be updated annually to track community progress on cessation referrals

Work S tream Updates

IT S ystems & Processes



CPWNY Change Management

 Change Management S

trategy approved by DIGC and EGB

 Posted on the CPNWY website under partners only section  Available to view by request  Outlines the appropriate steps for CPWNY partners to follow when IT system changes are made

and the development of a training plan, if determined necessary



Qualified Entity (QE), HEALTHeLINK

 QE plan approved by DIGC and pending EGB approval

 S

ummary of engagement with the local RHIO, HEALTHeLINK

 Involvement with CPWNY patient consent collection & provider participation with the RHIO

Workstream Updates

Performance Reporting

• Working side by side with Performance Management Partners on the

development rapid cycle evaluation (RCE) training webinar.

• The webinar is based out of a system Articulate. This application allows for

pre and post tests to be in place after each of the four training modules.

• The training was presented to our clinical transformation team in mid-

November for review and suggestive trainings.

• These training will go live in the New Y

ear as the Clinical Transformation and CMA staff will work with practices in Niagara and Erie County who have previously been trained in RCE and CCHN will work with Chautauqua County practices.

Work S tream Updates

Population Health

• Clinical Transformation and Care Management teams working with

practices on high risk patients and office registries of those patients.

• Utilizing health plan claims data and office registries for

population health

• DOH Medicaid claims are forthcoming as part of DS

RIP data available to PPS

Work S tream Updates

Practitioner Engagement

• Continue engagement with:
• Newsletters
• practitioner meetings
• P

AC meetings

• governance meetings
• One-on-one visits at practices conducted by the Clinical

Transformation and Care Management Advisor teams

Work S tream Updates

Cultural Competency and Health Literacy

• Continue to hold Medicaid focus groups in each county, 1-2 times a year.

Purpose is to engage the Medicaid beneficiary in self management and improvement in cancer and blood pressure screenings

• Also working with the P2 Collaborative of WNY (PHIPS

) to engage businesses to allow employees time from j ob to achieve their health screenings

• S

elf management programs in each county which are related to the community needs assessments performed by PPS .

• CCHL required training is being delivered to partners, to high volume

practices first. Offices are being contacted by email for scheduling in person training.

• Interested in CCHL training, please contact bbolden@

chsbuffalo.org

Work S tream Updates

Clinical Integration (CI) 2016-2017

The integration of clinical information and healthcare delivery services from related and or separate entities. Using data to help drive healthcare quality, cost improvement and improved patient satisfaction.

• CI plan in place and work is on-going
• Clinical Transformation and Care Management teams

working with practices to improve quality and utilization metrics

Work S tream Updates

Workforce

• R-AHEC/ CPWNY continues to finalize documents for the upcoming

DY2Q3 milestones deliverables (e.g. target workforce state, transition roadmap, and training strategy).

• These documents will be presented at the upcoming Workforce

Workgroup meeting on Dec 15, 2016 for approval.

• Once approved by Workforce Workgroup, the documents will go to the

Executive Governing Body for final sign off before submission.

Budget Updates

Dapeng Cao, PhD Manager, Healthcare Analytics Catholic Medical Partners

Expense review

 Total of $7.8 million spent to date  Proj ect costs spread among 10 proj ects and proj ect

management office expenses (included in 2ai proj ect expenses)

Project Name Sum of Expense DY1-DY2Q2 % 2ai IDS - PMO & Workstreams Expense 1,440,584 $ 18.45% 2ai IDS - Provider Engagement Expense 662,838 $ 8.49% 2biii Emergency Department Triage 942,810 $ 12.07% 2biv Care Transitions 1,539,792 $ 19.72% 2cii Telemedicine 433,577 $ 5.55% 3ai Behavioral Health 428,405 $ 5.49% 3bi Cardiovascular Health 389,196 $ 4.98% 3fi Nurse Family Partnership 545,361 $ 6.98% 3gi Palliative Care 791,035 $ 10.13% 4ai Mental, Emotional, Behavioral Well being 322,096 $ 4.12% 4bi Tobacco Use Cessation 313,540 $ 4.01% 7,809,235 $ 100.00%

CPWNY Cumulative Distributed Revenue by Project DY1 to DY2 Q2

CPWNY Cumulative Distributed Revenue by Project DY1 to DY2 Q2

PPS Program Category Sum of DY1-DY2Q2 Expense Percentage Case Management 1,591,288 $ 20.38% Clinical Transformation 66,881 $ 0.86% Community Based Organizations 1,937,690 $ 24.81% Hospice 615,331 $ 7.88% Hospital 1,341,019 $ 17.17% Local Government Unit 217,774 $ 2.79% Mental / Behavioral Health 173,995 $ 2.23% Physician - Primary Care 1,862,838 $ 23.85% Substance Abuse 2,420 $ 0.03% Grand Total 7,809,236 $ 100.00%

CPWNY Cumulative Distributed Revenue by PPS Program Category* DY1 to DY2 Q2

May be different from NYS provider category on MAPP.

Partners Receiving Funds PPS Program Category Sum of DY1-DY2Q2 Expense % CHS Care Management Case Management 1,022,780 $ 13.10% CHS ED Triage Case Management 471,750 $ 6.04% CMP Care Management DY1-DY2 Case Management 96,758 $ 1.24% Clinical Transformation Team Clinical Transformation 66,881 $ 0.86% Catholic Health System Community Based Organizations 339,518 $ 4.35% Catholic Medical Partners (PMO) Community Based Organizations 1,519,332 $ 19.46% Compeer Community Based Organizations 13,907 $ 0.18% P2WNY Community Based Organizations 4,290 $ 0.05% Rural AHEC Community Based Organizations 60,643 $ 0.78% Chautauqua County Hospice Hospice 19,176 $ 0.25% Hospice Buffalo Hospice 595,207 $ 7.62% Niagara Hospice Hospice 948 $ 0.01% Hospital Revenue Loss DY1 Hospital 982,378 $ 12.58% Roswell Park Hospital 116,614 $ 1.49% WCA Hospital 242,027 $ 3.10% Chautauqua County DOH Local Government Unit 217,774 $ 2.79% Mental Health Assoc of Erie Cty Mental / Behavioral Health 141,248 $ 1.81% Northpointe Council Mental / Behavioral Health 6,590 $ 0.08% Spectrum Human Services Mental / Behavioral Health 19,657 $ 0.25% Mental / BH Providers P4R Mental / Behavioral Health 6,500 $ 0.08% Provider Payment DY1 Physician - Primary Care 1,200,000 $ 15.37% Provider Payment DY2 Physician - Primary Care 662,838 $ 8.49% Chautauqua Alcohol & Sub Abuse Substance Abuse 2,420 $ 0.03% Grand Total 7,809,236 $ 100.00%

CPWNY Cumulative Distributed Revenue by PPS Program Category DY1 to DY2 Q2

May be different from NYS provider category on MAPP.

CPWNY Cumulative Distributed Revenue by PPS Program Category* DY1 to DY2 Q2

<1%

Revenue Proj ection & Expenditure

Revenue Received in DY1: $5.46M Total Revenue Expected in DY2: $8.94M Total Revenue Expected in DY3: $13.73M

Expected revenue is calculated based on anticipated payment timing from multiple payment sources (e.g. NYS Department of Health, MCOs via the Equity and Additional High Performance Funds S upplemental program, etc.)

Cumulative Revenue Received DY1Q1-DY2Q2: $11.56M Cumulative Expenses DY1Q1-DY2Q2: $7.81M

Budget Planning DY3

 Proj ect budget planning starting for April 1, 2017  All proj ect budgets will be reviewed  Please submit formal budget change requests to your

proj ect leadership or proj ect coordinators by no later than January 31, 2017.

 Budget questions can be directed to

awhitestorfer@ chsbuffalo.org or pgunning@ chsbuffalo.org

Measurement Y ear 1 (MY1) Additional Highlights

Phyllis G.M. Gunning, MPH Director, Clinical Programs

Measurement Y ear 1 Additional Highlights: Potentially Preventable ED Visits

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Measurement Y ear 1 Additional Highlights: Potentially Preventable ED Visits

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Measurement Y ear 1 Additional Highlights: Child Access – Primary Care (12 to 24 Months)

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Measurement Y ear 1 Additional Highlights: Follow Up after MH Inpatient (7 Days)

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Measurement Y ear 1 Additional Highlights: Potential Preventable ED Visits (BH)

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Measurement Y ear 1 Additional Highlights: Antipsychotic Medication Adherence

http:/ / wnycommunitypartners.org/ Partners Only tab -> Performance Reporting

Mid-Point Assessment

Phyllis G.M. Gunning, MPH Director, Clinical Programs

Mid-Point Assessment (MP A)



The Mid-Point Assessment is a required component of the New Y

• rk Delivery

S ystem Reform Incentive Payment (DS RIP) Program



Goal: Assess each PPS for overall compliance and each proj ect for likelihood of proj ect success



Informing the report:



CPWNY report s submit t ed t hrough DY2Q2 (9/ 30/ 16)



Proj ect and organizat ional narrat ives submit t ed August 2016



S it e Visit s



PPS member surveys 

Final deliverable: Formal report to the federal government (CMS )



All updates and documents can be found here:

 https:/ / www.health.ny.gov/ health_care/ medicaid/ redesign/ dsrip/ 2016/ mid-

pt_assessment.htm

MP A Visits-Completed

October 12: On-site Independent Assessor (IA) Visit



Proj ect s reviewed:

 Behavioral Health & Primary Care Integration (3ai)  ED Triage (2biii)



Key organizat ional effort s reviewed:

 Governance S

tructure

 Cultural Competency/ Health Literacy Planning & S

trategy

 Financial S

ustainability Efforts

 PPS

Funds Flow

 Primary Care Plan/ Working with PCP providers

December 2: On-site Proj ect Approval and Oversight Panel (P AOP) Visit



Areas of focus:



Overview of DS RIP program at CPWNY



Community engagement; NYS Wellness Agenda Proj ect (Domain 4)



Communit y part nership spot light



Buffalo Urban League



Mental Health Association



Chautauqua County Dept of Health



Millennium Collaborative Care

MP A Report and Recommendations

 Received November 29. Overall, no maj or DS

RIP systematic changes.

 CPWNY Recommendations

 Ten recommendations for improvement, all with risk score of 2 (Very Likely to

be on Track) or 3 (Likely to be on Track).

 Recommendations were proj ect and provider based.  CPWNY immediately requested corrections to discrepancies and will include in

formal comments submission

 Full report can be found at:

• http:/ / www.health.ny.gov/ health_care/ medicaid/ redesign/ dsrip/ pps_map/ m

idpoint/ assm_rpt/ sisters.pdf

Mid-Point Assessment-Next S teps



December 21: CPWNY submit formal response to IA ’s initial MP A Report and Recommendations

 Partner input welcome and appreciated! S

end to awhitestorfer@ chsbuffalo.org or pgunning@ chsbuffalo.org by 12/ 16. 

January 3, 2017: Final IA Report and Recommendations released



January 3-23, 2017: S econd comment period



January 31-February 3, 2016: P AOP convenes, approves final set of MP A recommendations to be submitted to Commissioner of Health



Final recommendations will require the PPS to submit action plans to NYS by March 3, 2017



Action plans to be implemented in DY3