[PPT] - DSRIP Projec ect A t Advisory Committee ee ( (PAC) M ) Mee PowerPoint Presentation

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DSRIP Projec ect A t Advisory Committee ee ( (PAC) M ) Mee eeting

March 29, 2017

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Welcome!

AM AMY L L. . WHITE TE-STORFER ER

DIRECTOR, PROJECT MANAGEMENT OFFICE

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Project & Workstream Updates

Our newsletter is available today! With detailed project updates. http://wnycommunitypartners.org/resources/

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Current ent P Projec ect Up Updates a s always o s on-lin line!

http://wnycommunitypartners.org/partners/

DSRIP reporting link on right hand navigation (password protected)

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Funds Flow Update

Spending Update
By provider category
By project

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CPWNY Cumulative Distributed Revenue by PPS Program Category* DY1 to DY2 Q3

*Program category may be different from NYS provider category on MAPP. Total DY2 Budget is $11,020,366. PPS Program Category Sum of DY1-DY2Q3 Expense Percentage Case Management 1,804,146 $ 18.99% Clinical Transformation 87,550 $ 0.92% Community Based Organizations 2,470,973 $ 26.00% Hospice 754,994 $ 7.95% Hospital 1,666,523 $ 17.54% Local Government Unit 270,127 $ 2.84% Mental / Behavioral Health 289,068 $ 3.04% Physician - Primary Care 2,155,605 $ 22.69% Substance Abuse 3,214 $ 0.03% Grand Total 9,502,201 $ 100.00%

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CPWNY Cumulative Distributed Revenue by PPS ProgramCategory DY1 to DY2 Q3

Partners Receiving Funds PPS Program Category Sum of DY1-DY2Q3 Expense % CHS Care Management Case Management 1,208,569 $ 12.72% CHS ED Triage Case Management 471,750 $ 4.96% CMP Care Management DY1-DY2 Case Management 123,828 $ 1.30% Clinical Transformation Team Clinical Transformation 87,550 $ 0.92% Catholic Health System Community Based Organizations 396,669 $ 4.17% Catholic Medical Partners (PMO) Community Based Organizations 1,872,120 $ 19.70% Chautauqua County Health Network Community Based Organizations 42,098 $ 0.44% Compeer Community Based Organizations 13,907 $ 0.15% P2WNY Community Based Organizations 9,290 $ 0.10% Rural AHEC Community Based Organizations 82,484 $ 0.87% Community Health Worker Network Community Based Organizations 22,969 $ 0.24% ECCPASA Community Based Organizations 31,436 $ 0.33% Chautauqua County Hospice Hospice 35,599 $ 0.37% Hospice Buffalo Hospice 717,689 $ 7.55% Niagara Hospice Hospice 1,707 $ 0.02% Hospital Revenue Loss DY1 Hospital 982,378 $ 10.34% Roswell Park Hospital 274,711 $ 2.89% WCA Hospital 409,434 $ 4.31% Chautauqua County DOH Local Government Unit 270,127 $ 2.84% Mental Health Assoc of Erie Cty Mental / Behavioral Health 244,615 $ 2.57% Northpointe Council Mental / Behavioral Health 6,590 $ 0.07% Spectrum Human Services Mental / Behavioral Health 26,359 $ 0.28% Mental / BH Providers P4R Mental / Behavioral Health 6,500 $ 0.07% Horizon Health Mental / Behavioral Health 5,004 $ 0.05% Provider Payment DY1 Physician - Primary Care 1,100,000 $ 11.58% Provider Payment DY2 Physician - Primary Care 1,055,605 $ 11.11% Chautauqua Alcohol & Sub Abuse Substance Abuse 3,214 $ 0.03% Grand Total 9,502,201 $ 100.00%

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CPWNY Cumulative Distributed Revenue by PPS Project Category DY1 to DY2 Q3

Project Sum of DY1-DY2Q3 Expense Percentage 2.a.i Integrated Delivery Systems 2,801,394 $ 29.48% 2.b.iii Emergency Department Triage 972,911 $ 10.24% 2.b.iv Care Transitions 1,778,600 $ 18.72% 2.c.ii Telemedicine 485,224 $ 5.11% 3.a.i Behavorial Health 473,677 $ 4.98% 3.b.i Cardiovascular Health 418,018 $ 4.40% 3.f.i Nurse Family Partnership 620,593 $ 6.53% 3.g.i Palliative Care 1,022,455 $ 10.76% 4.a.i Mental, Emotional, Behaviorial Well being 457,693 $ 4.82% 4.b.i Tobacco Use Cessation 471,636 $ 4.96% Grand Total 9,502,201 $ 100.00%

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DY3 Budget

Starting April 1, 2017

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DY3 Budgeted Expenses

2.a.i IDS, 5,903,116 2.b.iii ED Triage, 1,547,024 2.b.iv Care Tran, 1,159,740 2.c.ii Telemed, 797,511 3.a.i PC Behav, 2,175,072 3.b.i Cardio Hlth, 146,006 3.f.i NFP, 834,245 3.g.i Pall Care, 1,035,739 4.a.i MEB, 321,353 4.b.i Tabacco, 566,436 2.a.i IDS 2.b.iii ED Triage 2.b.iv Care Tran 2.c.ii Telemed 3.a.i PC Behav 3.b.i Cardio Hlth 3.f.i NFP 3.g.i Pall Care 4.a.i MEB 4.b.i Tabacco

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CPWNY DY3 Budget

2.a.i 2.b.iii 2.b.iv 2.c.ii 3.a.i 3.b.i 3.f.i 3.g.i 4.a.i 4.b.i IDS ED Triage Care Transitions Telemedicine PC & Behavioral Health Cardiovascular Health Maternal & Child (NFP) Palliative Care Promote MEB Tobacco Cessation Total Revenue $1,709,221 $1,364,273 $1,309,740 $1,067,181 $2,507,002 $2,168,706 $2,254,605 $654,692 $659,043 $791,779 $14,486,241 Expense Admin & Implementation $2,511,575 $1,547,024 $1,159,740 $797,511 $2,175,072 $146,006 $834,245 $1,035,739 $321,353 $566,436 $11,094,700 Provider Engagement Payments $1,200,000 $0 $0 $0 $0 $0 $0 $0 $0 $0 $1,200,000 Revenue Loss $982,500 $0 $0 $0 $0 $0 $0 $0 $0 $0 $982,500 Contingency $1,209,041 $0 $0 $0 $0 $0 $0 $0 $0 $0 $1,209,041 Total Expense $5,903,116 $1,547,024 $1,159,740 $797,511 $2,175,072 $146,006 $834,245 $1,035,739 $321,353 $566,436 $14,486,241

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Value Based Payment (VBP)

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CPWNY Value Based Payment Activity

In DY2, CPWNY formed a Valued Based Payment (VBP) Work Group

The work group will provide guidance and education around VBP

Initial VBP survey sent to partners in DY2 Q3:

Assess partner’s familiarity with VBP/Contracting for VBP
Assess participation (if any) in pay for performance arrangements

VBP Education performed at Project Advisory Committee (PAC) meeting Partners encouraged to participate in NYS VBP webinars/seminars VBP Information posted on CPWNY website

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Second VBP survey sent in DY2 Q4 with more detailed questions on:

Care Coordination
Are partners providing onsite Care Coordinators, sharing information with partners, collaborating with non-clinical

community based organizations, etc. ?

Technology and Data Analytics of Partners
Determining the use and investment in electronic medical records, telemedicine, clinical decision support, etc.
Additional Education needed on VBP
Whether partners have completed any recent VBP education or do they require additional education sessions? What

issues around VBP are more concerning to the partners?

CPWNY Value Based Payment Activity

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CPWNY VBP Follow-up Actions

CPWNY will utilize the information collected from both surveys to create a more refined VBP plan for providing education and guidance to include:

Education/training sessions to meet identified needs from provider survey, such as contracting/risk

sharing arrangements, VBP data and analytics and performance measurement, etc.

Assistance with interpreting analytic reports and networking to develop relationships between various

providers/community based organizations who may have the potential to collaborate in delivering higher value care

Collect and provide feedback on emerging trends, challenges and issues with the transition to VBP to

share amongst network providers and community based organizations

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Questions?

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Workforce Update

Valerie Putney Director of Programming WNY Rural AHEC

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Milestone Update

1. Target Workforce State: baseline report submitted to State
2. Transition Roadmap: baseline report submitted to State
3. Gap Analysis: baseline report submitted to State

Workforce Shortages

Nursing staff (RN, LPN, Nurse Managers, etc)
Mid-levels (PA/NP)
CNAs and Direct Care Staff
PCP
Psychiatrists and Psychologists
4. Compensation and Benefit: First survey result submitted to State
5. Training Strategy: baseline report submitted to State

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Community Partners of Western NY

Metrics of Key Job Titles and Relevant Reported Data

Non-Licensed Emerging Job Titles 8%+ Vacancy Rate Job Title # Responding Organizations Response Rate # Employees # Vacancies Vacancy Rate Primary Care Physician 24 25% 75 9 12.00% Primary Care Nurse Practitioner 18 19% 40 4 10.00% Psychiatric Nurse Practitioner 9 9% 30 3 10.00% Staff Registered Nurse 47 48% 3,275 128 3.91% Licensed Practical Nurse 52 54% 743 93 12.52% RN Care Coordinators/Case Managers/Care Transitions 22 23% 277 23 8.30% Psychiatrist 11 11% 50 0.00% Psychologist 9 9% 43 0.00% Medical Assistant 21 22% 208 14 6.73% Social and Human Service Assistants 11 11% 557 40 7.18% Substance Abuse and Behavioral Disorder Counselors 11 11% 309 9 2.91% Nursing Aide/Assistant 20 21% 1,744 224 12.84% Certified Home Health Aide 8 8% 730 45 6.16% Personal Care Aide 8 8% 1,104 188 17.03% Licensed Clinical Social Worker 18 19% 92 12 13.04% Bachelor's Social Worker 20 21% 120 1 0.83% Licensed Master’s Social Worker 22 23% 254 25 9.84% Social Worker Care Coordinator/Case Manager/Care Transition 16 16% 144 3 2.08% Care Manager / Coordinator 23 24% 335 15 4.48% Care or Patient Navigator 9 9% 53 11 20.75% Community Health Worker 14 14% 219 13 5.94% Peer Support Worker 7 7% 55 8 14.55% Most Common Reported Degree Requirement for Non-Licensed Care Coordination Positions: Unreported 53 January 2017

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Summary Snapshot: High Vacancy Rates by Job Title

Number of PPSs with 8%+ Vacancy Rates, by Job Title

Fewest PPSs Most PPSs

Note: Only 23 PPSs submitted vacancy rate data Job Title # of PPSs with 8%+ Vacancy Rate Primary Care Physician 12 Primary Care Nurse Practitioner 16 Psychiatric Nurse Practitioner 17 Staff Registered Nurse 8 Licensed Practical Nurse 8 RN Care Coordinators/Case Managers/Care Transitions 11 Psychiatrist 13 Psychologist 4 Medical Assistant 8 Social and Human Service Assistants 5 Substance Abuse and Behavioral Disorder Counselors 7 Job Title # of PPSs with 8%+ Vacancy Rate Nursing Aide/Assistant 9 Certified Home Health Aide 5 Personal Care Aide 6 Licensed Clinical Social Worker 14 Bachelor's Social Worker 3 Licensed Master’s Social Worker 9 Social Worker Care Coordinator/Case Manager/Care Transition 6 Care Manager / Coordinator 8 Care or Patient Navigator 12 Community Health Worker 9 Peer Support Worker 16 54 January 2017

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Happening now…

Collecting DSRIP Year 2, Quarters 3 and 4 spending data
Collection of Compliance Attestations: used to acknowledge rules,

polices, and procedures included in the Community Partners of Western NY Compliance Program

Tracking training data to update Training Strategy report
Communication Plan for the Governance Milestone 9: will be

approved and ready for submission by end of DSRIP Year 2 (March 31, 2017)

Year 3 Compensation and Benefit Survey: Projected roll out is late

summer (August/September)

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Ques estions ns?

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DSRIP Project Advisory Committee Meeting March 29th, 2017

HEALTHeLINK Update

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Agenda

HEALTHeLINK Overview
Consent overview
HEALTHeLINK Services
CPWNY Engagement
Partner Organizations
CBO

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Who is HEALTHeLINK?

HEALTHeLINK is the Western New York Clinical Information Exchange. HEALTHeLINK was created to enable the exchange of clinical information in secure and meaningful ways to improve both efficiency and quality, while also helping to control health care costs. HEALTHeLINK allows doctors, with patient consent, to access a patient's clinical data electronically, this allowing the data to follow the patient to whatever health care setting he/she goes to within the eight-counties of Western New York and now across New York State. Because of this, physicians have the ability to query data on patients regardless of where they were treated previously.

Better Health Better Care Lower Costs

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Health Information Exchange (HIE) – “The Noun”

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What is the SHIN-NY?

SHIN-NY is the Statewide Health Information Network for New York.

The network of network for Health Information

Exchange (HIE) in NY

HEALTHeLINK is the certified Qualified Entity (QE)

and the western most node of the SHIN-NY supporting 8 counties

A collaboration between the QE’s, New York

eHealth Collaborative (NYeC), and NYS DOH that establishes the governance, policy, technology standards and framework for HIE in the state

Statewide Patient Record Lookup now enabled

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HEALTHeLINK Data Sources

Hospital Systems

Bertrand Chaffee
Brooks Memorial†
Catholic Health System *
Eastern Niagara Hospital †
ECMC * * †
Jones Memorial Hospital †
Kaleida Health System *testing images
Lakeshore Hospital †
Medina Memorial *testing images
Mount St. Mary’s Hospital
Niagara Falls Memorial * *
Roswell Park Cancer Institute
UMMC/Batavia
Upper Allegheny Health System/Olean †
WCA of Jamestown †
Westfield Hospital
Wyoming County Community Hospital

Home Health Agencies

Advantage Home TeleHealth
Catholic Health/McAuley Seton Home Care
Visiting Nursing Association
Willcare

* Radiology images NOT available * * EKGs ARE available † Can deliver images to connected EMRs Regional Radiology Providers

Buffalo MRI
Dent Neurologic
Diagnostic Imaging Associates†
Great Lakes Imaging
Seton Imaging†
Southtowns Imaging†
Spectrum Radiology Associates†
Windsong Radiology Group †

†

WNY Imaging †

Regional Reference Labs

ACM
Genetic Diagnostic Laboratories
Quest Diagnostics
X-Cell Laboratories

Long T erm Care Facilities

Beechwood Continuing Care
Briody Health Care Facility, LLC
Brothers of Mercy
Heritage Ministries

Medication History Resources

Surescripts

(rolling 13 months)

Buffalo Pharmacy

Physician Practice Data

Refer to www.wnyhealthelink.com for list

6/22/16

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Consents by Age Group

6/22/16

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Cultural Diversification

Availability of Consent forms

English
Spanish
Arabic
Russian
Polish
Burmese
Nepali
Bengali
Somali
Karen

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HEALTHeLINK Services

Patient Record Look-Up

Clinical records from local data sources
Practice data collected via CCDs
Radiology images
Medication History via Surescripts
Additional data from statewide (SHIN-NY) and national (VA)

patient record look-ups

Interoperability

Results Delivery (Including IERD)
CCD at the close of an encounter
Secure Messaging

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Alert Notifications

Subscribe to patients
Configure event profile
Receive event notification

Data Repository / Analytics

Community data aggregation
Data standardization / content validation
Specific data extracts (ACO, PPS)
Population analytics and metric reporting

Consent required No Consent required

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Patient Record Look-up

Medication History Laboratories SHIN-NY Hospitals Radiology Centers Physician

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Real time alerts to providers when a patient is admitted to or discharged from a hospital

Facility Admission

r Discharge

ADT

Admit
Discharge
Transfer

HEALTHeLINK Alerts (Notify) Care Coordination Systems, Health Homes, ACOs, Practice Care Coordinators Establish Patient Relationship (Subscribe) 67

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Results Delivery

Order Test Upload Clinical Results Results Delivered to EMR Eliminates the need for faxes, manual scanning, and attaching clinical records to the patient’s electronic chart.

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Patient Data at the close of an encounter

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C-CDA Upload

EMR

C-CDA Upload

Query EMR Query of data- future

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Participation Status- CPWNY Partners

Partner Class Total Partners HEALTHeLINK Participants % Patient Attribution % Tier 1 135 125 92.6 83.2 Tier 2 91 67 73.6 14.4 Tier 3 316 165 52.2 2.4

Tier 1: All PCP with > 0 Attribution, All other groups with >200 attribution Tier 2: All remaining groups with > 20 Attribution Tier 3: All remaining groups

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Tier 1 Partner Engagement

0.00% 20.00% 40.00% 60.00% 80.00% 100.00% HEALTHeLINK Service Percent of Tier 1 Partners Engaged

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Partner Engagement with HEALTHeLINK (125 Tier 1 Participants)

4+ Services 3 Services 2 Services 1 Service 0 Services 10 20 30 40 50 60 Number of Participants

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Questions?

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Transportation Panel Discussion

KELLY LY D DIXON, PRINCIPAL PLANNER

GREATER BUFFALO NIAGARA REGIONAL TRANSPORTATION COUNCIL

MARY K. COMTOIS, DIRECTOR OF HEALTH INITIATIVES,

UNITED WAY OF BUFFALO & ERIE COUNTY

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Interagency transportation group which

establishes transportation plans, policies and program for the region.

Provides a regional decision-making

forum for the development of a multi- modal, integrated transportation system.

Greater Buffalo Niagara Regional Transportation Council

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CHALLENGES

Graphic via: Streetsblog, P. Fleisher, Empire State Futures, Joe the Planner

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5 Focus Areas

Land Use and Development Transportation and Mobility Housing and Neighborhoods Food Access and Justice Climate Change Action

A plan that makes Buffalo Niagara competitive and sustainable

Collaboration and Coordination

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Growing Partnerships

Steering Committee Working Teams Greater Buffalo-Niagara Regional Transportation Council (GBNRTC) Niagara Frontier Transportation Authority (NFTA) New York State Department of Transportation (NYSDOT) Erie County Niagara County City of Buffalo City of Niagara Falls Association of Erie County Governments Niagara County Supervisors Association University at Buffalo Regional Institute and Urban Design Project (UBRI/UDP) Daemen College Center for Sustainable Communities and Civic Engagement VOICE Buffalo Local Initiatives Support Corporation Buffalo The John R. Oishei Foundation Buffalo Niagara Medical Campus Belmont Housing Resources for WNY, Inc. Buffalo Niagara Partnership Empire State Development Niagara County Department of Social Services Niagara Falls Housing Authority Engaging the private sector, local government officials and members of the community Clean Air Coalition Uniland Development USA Niagara Erie County Water Authority Buffalo Niagara Builders Association University District Community Development Association PUSH Buffalo Niagara Falls Office of Community Development ReNU Niagara NYSERDA Town of Amherst Planning Department Cornell Cooperative Extension Alden Chamber of Commerce Erie County Department of Environment and Planning Singer Farms Coalition for Economic Justice Buffalo CarShare Southtowns Rural Transit Corporation Inc. Hearts and Hands: Faith in Action Western New York Land Conservancy Jaeckle Fleischmann & Mugel, LLP Village of Williamsville City of North Tonawanda Community Development Department Food for All Buffalo Niagara RiverKeeper WNY Environmental Alliance Niagara Wind & Solar Buffalo Urban Development Corporation Community Development Manager - KeyBank

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Since 1970, our region has “sprawled without growth,” with implications to our built environment, tax burden, economy, and infrastructure.

We are developing our land at a staggering rate while losing population in our region.

WHAT THE DATA TELLS US

Source: US Census, 1970, 2010 Population loss, 1970 - 2010 Urbanized Area growth, 1970 - 2010

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WHAT THE DATA TELLS US

Source: US Census, 1990, 2010; NYS Comptroller’s Office

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WHAT THE DATA TELLS US Source: US Census, 1970, 2010

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WHAT THE DATA TELLS US Source: GBNRTC, 2011

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Provides the framework for improving

transportation services for persons with disabilities, older adults, individuals with lower incomes.

Strives for communities to coordinate

transportation resources provided through multiple sources.

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Identifies geographic and non-

geographic gaps in transportation service based on a demographic assessment profile of the two- County area.

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Categories -

Geographic Gaps
Service Time Gaps
Information/ Awareness Gaps
Capacity/ Resource Gaps

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Serves as a mechanism for Section

5310 – Enhanced Mobility for Seniors and Individuals w/ Disabilities Grant Program.

NYSDOT Public Transit Division in

Albany administers this program

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Funding to support vehicle

acquisition and provide operating assistance for non-profit

rganizations
Grant distributed annually with at

least 55% of funding directed to vehicle (capital) projects.

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Smart Growth and investment in existing

communities when it comes to how we use our land and where development

ccurs
Promotion and education on

transportation options (public transit, ridesharing, bikesharing, etc.)

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gobuffaloniagara.org

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gobuffaloniagara.org

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Go Buffalo Mom

DSHRIP Community Partners of WNY Buffalo, NY March 29, 2017

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Goal

Helping low income pregnant moms get to medical and other appointments will help them meet their goal of a healthy baby.

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USING DATA & RESEARCH LISTENING TO CUSTOMERS

Preterm Birth Rate

New York, 8.9% Yonkers, 9.0% Syracuse, 9.0% Rochester, 10.2%

Buffalo, 11.4%

Women Lacking Prenatal Care in 1st Trimester 28.2%

Transportation is a key barrier

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Buffalo & Erie County City of Buffalo population is 258,959 More than one in two residents lack financial stability:

over 30% (75,830) live in poverty
136,574 indicate they are struggling

financially

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Collect, analyze, and share program data Assessing costs and needs for the program

A Unique Cross-Sector Partnership

Health Systems Private Insurance Plans Medicare/Medicaid

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Designing for Growth: a design thinking tool kit for managers (2011)

Human Centered Design Thinking …a systematic approach to problem

solving. It starts with customers and the

ability to create a better future for them. It acknowledges that we probably won’t get that right the first time…. Design ‘insists’ that we prepare ourselves to iterate our way to a solution.”

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Early Research

Interviewed 47 pregnant mothers and

mothers with young children in clinic waiting rooms and non-profit agencies.

Typical transportation issues of bus

unreliability, trip length, and affordability are further complicated by pregnancy and growing families.

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Savings Behavior

The goal is to use existing voucher savings

programs to enable young families to afford unlimited monthly transportation passes.

Eligible families establish a bank account,

review their financial status, attend financial education, and agree to a savings structure.

The program will also help build

relationships with mainstream financial institutions willing to incentivize financial stability at the prospect of holding future mortgages or loans for clients.

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Go Buffalo Mom

Customer Desirability Assumptions

Outcomes are valued enough by customers

to attract participation in savings program.

Program requirements match customer

commitment level.

The savings matching structure is attractive

to customers.

The incentives appeal to customers
Transportation passes are affordable.

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Go Buffalo Mom

Determining Prototype

Existing savings program in place.
Feedback required on current transportation

expenditures and savings behavior was fairly specific.

Based on these factors, a more traditional

survey questionnaire was determined to be the best instrument approach.

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Transportation Options

Personalized trip planning and education

program to provide low income, pregnant women with information on access to alternative transportation options.

Features a transportation navigator to meet

with pregnant women to initially assess their trip needs to develop an individualized trip options plan.

Navigators will build the capacity of families

to plan trips that are the least expensive, most reliable, and shortest route.

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Go Buffalo Mom

Customer Desirability Assumptions

Low-income Buffalo mothers will be

interested in participating in the program

Patients will feel the program is needed.
The user will be willing to participate in an

initial assessment.

The first meeting will take place in a

comfortable setting for the patient.

The navigator will provide an initial plan and

follow up.

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Go Buffalo Mom

Determining Prototype

Navigator and personal trip plans key

components of program.

Storyboard approach was workable for this

concept.

Cover major points of the program through

pictures.

Different choices in how customers want to

interact with the navigator, receive information, etc. makes this approach very person-centered.

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Go Buffalo Mom

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GO Buffalo Mom Connect via: with Navigator Create personalized transportation plan Learn and save

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Go Buffalo Mom

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Go Buffalo Mom

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Each premature baby costs employers an additional $49,760 in newborn health care costs. When maternal costs are added, employers and their employees pay $58,917 more. In Buffalo and Erie County, over 1,150 infants are delivered pre-term annually.

Cost Savings Over 1 Year ~$59,000

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18 Month Pilot Program ~$610,000

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BABIES

TEN

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Questions

Kelly Dixon, Principal Planner Greater Buffalo Niagara Regional Transportation Council kdixon@gbnrtc.org Mary K. Comtois, Director of Health Initiatives, United Way of Buffalo & Erie County mary_k.comtois@uwbec.org

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Wrap Up

RFP Link and Questions

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THANK YOU!