DSRIP Project Advisory Committee Meeting June 14, 2017 Welcome! - - PowerPoint PPT Presentation

DSRIP Project Advisory Committee Meeting

June 14, 2017

Welcome!

Amy L. White-Storfer

Director, Project Management Office

Project & Workstream Updates

Spring/Summer newsletter is available today! Detailed Project Updates

Spring-Summer 2017 Newsletter

Project Updates

Amy L. White-Storfer Director, Project Management Office

Care transition, ED Triage*, & Integrated Delivery System (2biv, 2bii, 2ai)

Programs continue within Catholic Health Hospitals and its PPS partners, such as WCA in Jamestown NY Bertrand Chaffee Medical Center will begin reporting for these projects HEALTHeLINK reporting and monitoring continues for key data exchange functions Meaningful use training efforts continue PCMH practices moving towards Level 3 status for March 31, 2018 deadline

Highlights

• Addition of the patient navigators at Mercy and

Sisters (part of Mid-Point Assessment)

• Social Worker support in ED for WCA
• Care management tools tracking tools for ED

patients and booking to primary care centers

• Central out-going follow-up calls and primary

care appointment booking

*received recommendations as part of DOH Mid-Point Assessment

Tele-Medicine* (2cii)

▪ Diabetic Eye Exam review and referral ▪ Maternal Fetal Medicine Ultra-Sound Review ▪ Care Management support for I/DD populations (in group setting/individual home) ▪ Cross-clinic behavioral health crisis consults with MAT (medication assisted treatment) providers ▪ Cardiac specialist support for Rural Hospitals (hospital to hospital) ▪ Continued use of third party specialist in Chautauqua County ▪ Exploring Tele-Psychiatry projects (Erie and Chautauqua)

*received recommendations as part of DOH Mid-Point Assessment

Cardiovascular Health & Evidence Based Interventions (3bi)

Collaborations continue with Chautauqua County CHQ250 and the Chautauqua County Health Network and its members

Includes planned engagements with educational institutions for blood pressure monitoring and education PPS Millennium Care Collaborative PPS engaged with this partnership

Behavioral Health (BH) Integration with PC (3ai)

BH Co-location in Primary Care Projects in progress with a 5 total matches of PC and BH providers

• Private and community based practices with Medicaid volume
• Seek to increase the BH screening metric inside PC
• Support PC efforts in managing BH conditions

Behavioral Health (BH) Integration with PC: BH site innovations (3ai)

Expanded mobile outreach teams for providing BH

• Seeks to increase the adherence to medications
• Sees patients in home and community

Fully integrated site. Permanently co-located BH and PC.

• To go-live in Summer 2017

Supporting the use of Community Health Workers in large BH provider

• CHWs are increasing face-to-face touches in the community
• Goal is to re-engage clients in BH after an In-patient stay and with a PC provider.

Nurse Family Partnership & Maternal/Child Health Outcomes* (3fi)

▪ NFP Program continues in Chautauqua County

▪ Seeking a new nurse to expand enrollment capacity

▪ Community Based Organization providing Community Health Workers

▪ Goal to increase early initiation and frequency of prenatal care as well as timely postpartum care for Niagara and Erie County ▪ exploring efforts to make greater impact on pediatric HEDIS metrics.

▪ Part of Mid-Point Assessment recommendation efforts

*received recommendations as part of DOH Mid-Point Assessment

Palliative Care Integration in PCMH* (3gi)

▪ Three local hospice & palliative care organizations engaged and contracted ▪ Algorithm for identification of palliative care-eligible patients

▪ Initiated in Erie County practices (CMP) ▪ Expanding to Chautauqua County and Niagara County PC practices

▪ Piloting MedEnt EHR tool in CMP practices

▪ Goal is to improve documentation of consults

▪ Evaluation of program continues under state specification

*received recommendations as part of DOH Mid-Point Assessment

Promote projects

Mental Emotional Behavioral Health Project

• 15 partners engaged across this project
• justtellone.org effort continues in web &

social media sphere

• Collaborative with Millennium Collaborative

Care

• Workplace Wellness effort supports mental

health support in professional environments

Tobacco Cessation

• Education continues on the smokers quitline

and opt-to-quit functions

• Effort seeks to impact education on tobacco

cessation drugs and documentation of it

• Tobacco cessation advocacy continues in

public sector and within public housing and related areas of impact for low income populations

Update: Critical Workstream Efforts

Workforce

▪ Data collection continues ▪ Tracking all DSRIP training ▪ Compensation & Benefit Survey expected in September 2017

Cultural Competency & Health Literacy

▪ Large provider training scheduled for late June ▪ Flexible training options are key to provider engagement with materials ▪ Engagement of Medicaid patients in focus group evaluation of self management tools

Funding Update

CPWNY Cumulative Distributed Revenue by PPS Program Category DY1 to DY2 Q4

Provider Category Sum DY1 - DY2 Q4 Amount Percentage Substance Abuse 272,735 $ 2.08% Local Government Unit 321,071 $ 2.44% Community Based Organizations 3,051,281 $ 23.22% Hospice 963,249 $ 7.33% ED Triage 480,618 $ 3.66% Practioner-Primary Care Provider 2,468,225 $ 18.78% Care Transitions 1,542,819 $ 11.74% Hospital 3,834,529 $ 29.17% Clinical Transformation 107,573 $ 0.82% Case Management / Health Home 96,864 $ 0.74% All Other 4,480 $ 0.03% 13,143,443 $ 100.00%

CPWNY Cumulative Distributed Revenue by PPS Project Category DY1 to DY2 Q4

Project Sum of DY1-DY2Q4 Expense Percentage 2.a.i Integrated Delivery Systems 5,546,714 $ 42.20% 2.b.iii Emergency Department Triage 1,020,527 $ 7.76% 2.b.iv Care Transitions 2,013,794 $ 15.32% 2.c.ii Telemedicine 534,151 $ 4.06% 3.a.i Behavorial Health 568,981 $ 4.33% 3.b.i Cardiovascular Health 442,194 $ 3.36% 3.f.i Nurse Family Partnership 716,636 $ 5.45% 3.g.i Palliative Care 1,237,845 $ 9.42% 4.a.i Mental, Emotional, Behaviorial Well being 492,789 $ 3.75% 4.b.i Tobacco Use Cessation 569,811 $ 4.34% Grand Total 13,143,444 $ 100.00%

Total Revenue Received YTD DY2 Q4 from all sources: $13,506,447

CPWNY Cumulative Distributed Revenue by PPS Program Payments by Category DY1 to DY2 Q4

Partners Receiving Funds Provider Category Sum of DY1-DY2 Q4 Expense Percentage

Prevention Focus All Other 4,480 $ 0.03% CHS Care Management Care Transitions 1,392,446 $ 10.59% CMP Care Management DY1-DY2 Care Transitions 150,373 $ 1.14% Catholic Charities Case Management / Health Home 49,035 $ 0.37% Horizon Health Case Management / Health Home 10,103 $ 0.08% Spectrum Human Services Case Management / Health Home 37,726 $ 0.29% CMP Clinical Transformation Team Clinical Transformation 107,573 $ 0.82% Buffalo Urban League Community Based Organizations 27,053 $ 0.21% CASA Chautauqua Community Based Organizations 6,417 $ 0.05% Chautauqua County Health Network Community Based Organizations 58,280 $ 0.44% Catholic Health System Community Based Organizations 446,737 $ 3.40% Catholic Medical Partners (PMO) Community Based Organizations 2,325,413 $ 17.69% Rural AHEC Community Based Organizations 92,238 $ 0.70% P2 WNY Community Based Organizations 11,790 $ 0.09% Community Hlth Worker Network Community Based Organizations 32,127 $ 0.24% ECCPASA Community Based Organizations 45,199 $ 0.34% WNY United Against Drug & Alcohol Abuse Community Based Organizations 6,028 $ 0.05% CHS ED Triage ED Triage 480,618 $ 3.66% Chautauqua County Hospice Hospice 56,487 $ 0.43% Hospice Buffalo Hospice 902,955 $ 6.87% Niagara Hospice Hospice 3,806 $ 0.03% Hospital Revenue Loss DY1 Hospital 982,378 $ 7.47% Hospital Revenue Loss DY2 Hospital 1,983,666 $ 15.09% Roswell Park Hospital 372,886 $ 2.84% WCA Hospital 495,599 $ 3.77% Chautauqua County DOH Local Government Unit 321,071 $ 2.44% Provider Payment DY1 Practioner-Primary Care Provider 1,100,000 $ 8.37% Provider Payment DY2 Practioner-Primary Care Provider 1,368,225 $ 10.41% Chautauqua Alcohol & Sub Abuse Substance Abuse 7,623 $ 0.06% Compeer Substance Abuse 13,907 $ 0.11% Mental Health Assoc of Erie Cty Substance Abuse 244,615 $ 1.86% Northpointe Council Substance Abuse 6,590 $ 0.05% Grand Total 13,143,443 $ 100.00%

Value Based Payment (VBP)

Barry Stelmach Catholic Medical Partners, Chief Financial Officer

CPWNY Value Based Payment Activity

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 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 analyzing performance 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

VBP Education Program

▪ Key constituent education program coming for DY3, 4, and 5

▪ Primary care providers/practices ▪ Behavioral Health providers – Mental Health and Substance Use Disorder ▪ CBOs focused on Social Determinants

▪ Potential Education venue options

▪ In-person sessions ▪ Webinars ▪ E-learning sessions

VBP Next Steps

▪ CPWNY to develop schedule of Educational/Informational Events ▪ Perform ongoing Annual VBP Surveys

▪ To assess current VBP understanding ▪ To assist in educational event curriculum development

VBP Training and Tools

Check out our “Partners Only” Section

http://wnycommunitypartners.org/partners/training-and-tools/vbp-education/

Additional Information

▪ Opportunities to learn from state-wide resources

▪ For all providers

▪ DOH resources ▪ State landscape: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm ▪ Educational videos: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/webinars_presentations.htm ▪ FREE!

▪ For Behavioral Health Care community---CTA/MTAC at http://www.ctacny.org/

▪ Great resources for measuring value in community based health care ▪ FREE!

▪ Look for updates in our CPWNY newsletters for updates on state-wide resource availability!

Questions?

Gardenin ing Communit itie ies s sin ince 1994 1994

So, what does “GGWNY” do?

Grassroots Gardens WNY is a determined group of activists who educate and lead committed neighborhood gardeners. We collaboratively cultivate and manage more than 300,000 square feet (and growing!) of green space in Buffalo and Niagara Falls. Our work is rooted in the belief that a garden has the power to transform an urban neighborhood. Gardens deliver beauty and escape and produce healthy food in unexpected places that previously had little value. A garden creates a shared sense of purpose that empowers a community, creates environmental awareness and improves public health. 1 PEOPLE 2 LAND 3 INSURANCE 4 MATERIALS 5 SKILLS

What does GGWNY really do?

ENGAGE EMPOWER TRANSFORM

WE GARDEN COMMUNITIES.

Community Conservation

Community Conservation is an approach to land conservation that includes more people. Community conservation begins by listening to many different voices in the community — then responding. Community conservation uses the strengths of the land trust (GGWNY) to meet needs expressed by people in the community.

• Respond to a community need
• Connect people with place
• Connect people with people
• Create opportunities for people to get involved
• Energize the community
• Provide some form of public access
• Provide lasting and meaningful impact

Let the Community Call the Shots

100% Community Driven

Cleaning up Chaos

Rea eapin ing t the B Benef efit its: C Communit ity G Garden I Impact

• Food Access: 30,000 lbs. of vegetables and fruits grown

annually – 23,000 in food insecure neighborhoods

• 86% have tried a new fruit or vegetable due to their

garden participation

• 72% have increased overall consumption of fresh produce
• 80% preserve their harvest beyond the growing season
• Cross cultural pollination
• Healing spaces

Environmental

• Fostering a new generation of stewards
• Creating critical pollinator habitats
• Supporting local food systems
• Reduced emissions by 31755kg

(761,096 miles driven by passenger cars )

Reaping the Benefits: Community Garden Impact

Strategic Program Delivery

SAFE ROOTS: Engaging Across Cultures

COMMUNITY O ORGANIZER SERIES: B : Build ildin ing S Socia cial l Capacit city

Strategic Program Delivery

Quest stions? ns?

Contact Us/Get Involved/Donate: www.grassrootsgardens.org director@grassrootsgardens.org (716) 783-9653

Heart Smart for Life

Mercy Comprehensive Care Center (MCCC)

Jeanne O'Hara, Office Manager

For more information on Heart Smart for Life

Mercy Comprehensive Care (MCCC) 397 Louisiana Street Buffalo, NY 14204 Phone: (716) 923-6152

Questions?

THANK YOU