PROJECT ADVISORY COMMITTEE (PAC) Tuesday, June 30, 2015 - - PowerPoint PPT Presentation

PROJECT ADVISORY COMMITTEE (PAC)

Tuesday, June 30, 2015 9:00am-12:00pm Islandia Marriott Long Island Hosted by the Office of Population Health at Stony Brook Medicine 1

AGENDA 2

9:00 a.m. – 9:30 a.m.

Welcome Remarks & Program Updates Joseph Lamantia, Chief of Operations for Population Health Stony Brook Medicine

9:30 a.m. – 9:40 a.m.

Community Based Organization (CBO) Engagements Joseph Lamantia, Chief of Operations for Population Health Stony Brook Medicine

9:40 a.m. - 10:10 a.m.

CBO Panel Discussion Gwen O’Shea, President/CEO Health & Welfare Council

• f Long Island

10:10 a.m. – 10:20 a.m.

BREAK

10:20 a.m. – 10:40 a.m.

Patient Centered Medical Home (PCMH) Model Stacey Mallin, MPA, CPHQ, PCMH CCE, CLSSBB Patient Centered Medical Home Advisor HANYS Solutions

10:40 a.m. – 11:10 a.m.

PCMH Panel Discussion James Sinkoff, EVP, Financial, Information and Business Services & CFO Hudson River HealthCare, Inc.

11:10 a.m. – 11:30 a.m.

Project 2di: The 11th Project Amy Solar-Doherty, Project Manager Office of Population Health Stony Brook Medicine

11:30 a.m. – 12:00 p.m.

Closing Remarks Question & Answers Joseph Lamantia, Chief of Operations for Population Health Stony Brook Medicine

PROGRAM UPDATES

Presented by Joseph Lamantia Chief of Operations for Population Health Stony Brook Medicine Alyssa Correale, MHA, PMP Director, Project Management Office Office of Population Health

3

MEETING OBJECTIVES

 NYS DSRIP Milestones  DSRIP Funding & Award Letter Overview  DSRIP Implementation Plan Submission on June 1st  Introduction to Achievement Values & Key Reporting & Payment Timelines  PMO Work Plan Highlights for June, July & August  Key elements of the SCC Communication Plan  Community Based Organization Engagement & Panel Discussion  The Patient Centered Medical Home (PCMH) Model & Panel Discussion  Project Highlight: The 11th Project Pilot Program and Developments

4

NYS DSRIP PROGRAM KEY MILESTONES

Q2-Q3 2015

6/1/2015: Initial Implementation Plan Submitted 7/1/2015: IA provides feedback to PPS on Implementation Plan Early-July: First Claims Extract 7/17/2015 All-PPS Meeting, Albany, NY 7/30/2015: Final Approval of Implementation Plan 7/31/2015: First Quarterly Report Due 8/31/2015: IA provide feedback to PPS on Quarterly Report 9/29/2015: Final Approval of Quarterly Report

Q4 2015

October: NYS CRFP Announcements 10/1/2015: Final Implementation Plan posted to DOH DSRIP website 10/31/2015: Second Quarterly Report Due from PPS

5

SUFFOLK PPS AWARD 6 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 Project Valuation 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

SUFFOLK PPS AWARD DEFINED 7

• Net High Performance Fund: PPS that achieve 20% gap-to-goal or the 90th percentile of the

statewide performance for 10 high performance metrics are eligible for additional payment from this program.

• Example: Project 3ai: Follow-up for Hospitalization for Mental Illness at 7 and 30 days
• Additional High Performance Fund: The Additional High Performance Program is

appropriated from state funds. This will provide supplemental high performance funding against the same DSRIP measures already identified for high performance payments

• Public Equity Guarantee: Award pool available to public leads that are sole PPS in a given

county.

• Public Equity Performance: Award pool available to public leads that are sole PPS in a given

county.

Source: NYS DOH Presentation Presented June 2015 – Final DSRIP Valuation Overview

IMPLEMENTATION PLAN SUBMITTED JUNE 1ST Key Submission Requirements:

• Organizational Work stream work plans
• Workforce, Governance, Cultural Competency & Health Literacy, Financial Sustainability, IT Systems, Practitioner

Engagement, Performance Reporting, Funds Flow, Budget, Population Health Management, Clinical Integration

• Risk & Risk Mitigation Strategies by Organizational Work stream
• Project Dependencies
• Key Project Stakeholders, Internal & External Stakeholders
• Project 2ai: Creating an Integrated Delivery System Project work plan
• Domain 1 Patient Engagement Quarterly Metrics

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Visit our website www.suffolkCare.org for the full SCC DSRIP Implementation Application

EARNING ACHIEVEMENT VALUES “AVS” What is an Achievement Value (AV)?

• AVs are the points given for achieving milestones in a given reporting

period for Domains 1-4.

• Pay-for-Performance AVs are AVs earned through improving quality

performance (by 10%) for individual measures based on PPS-specific baseline results for each measure and the state performance targets for each measure.

• Pay-for-Reporting AVs are AVs earned for measures regardless of

performance; some measures require PPS cooperation in reporting.

• AVs are typically calculated as either a 1 or 0, which correlates to

either “meeting” or “not meeting” a milestone. 9

Source: NYS DOH Presentation Presented June 18th 2015 – DSRIP Incentive Payment Domain 2-4 Achievement Values

PAY FOR PERFORMANCE FUNDING SCHEDULE

• Over the life of the waiver, funding shifts from process milestones

(Domain 1) and reporting (P4R) to performance (P4P): 10

Domain

Payment

Annual Funding Percentages DY 1 DY 2 DY 3 DY 4 DY 5 Domain 1 Project 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, 2015 July 2016 DY 1, Q4 1/1/16 – 3/31/16 April 30, 2016 DY 2, Q1 4/1/16 – 6/30/16 July 31, 2016 January 2017 DY 2, Q2 7/1/16 – 9/30/16 October 31, 2016 DY 2, Q3 10/1/16 – 12/31/16 January 31, 2017 July 2017 DY 2, Q4 1/1/17- 3/31/17 April 30, 2017

11

Source: Department of Health presentation on April 21, 2015 entitled “DSRIP Domain 1 Achievement Values “

The SCC PMO is currently preparing for the first DSRIP Quarterly Report Due July 31, 2015

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

12

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

PMO WORK PLAN Ongoing Program Design

 Use aggregated baseline assessment results to determine SCC Partner Scope of Work  Continue to identify &/or brainstorm risks and complimentary risk mitigation strategies  Sustain high partner engagement via communication strategies  Initiate SCC Primary Care Practice Baseline Assessment & Initiate Gap Analysis  Identification of linkages across 11 DSRIP projects  Refine project design, budget and schedule

Project Implementation

 Initiate Project Management Plans in Performance Logic PM Software  Lessons Learned & Change Control

13

June July August

PMO JULY CALENDAR 14

Date Time Upcoming Project Stakeholder Meeting

7/1/2015 9:00am – 10:00am Project 2di PAM Workgroup Meeting 7/15/2015 9:00am - 10:30am Project 3ai BH&PC Committee Meeting 7/16/2015 9:00am – 10:00am Project 4aii SBIRT Workgroup Meeting 7/16/2015 10:30am-11:30am Project 4bii Colorectal Cancer Screening Education Workgroup Meeting Week of 7/20th TBA Project 2biv & 2bix Hospital Partner Workgroup 7/21/2015 TBA Project 2bvii INTERACT Committee 7/22/2015 9:00am-10:00am Project 4bii Breast Cancer Screening Workgroup Meeting 7/27/2015 10:00am – 11:00am Performance Evaluation & Management Workgroup 7/28/2015 8:00am-9:00am Project 4bii Lung Cancer Screening Workgroup Meeting 7/30/2015 11:00am-12:00ppm Project 4bii Obesity Prevention Workgroup Meeting 8/7/2015 1:00pm – 2:00pm Project 3bi CVD Committee Meeting Please visit our website www.suffolkCare.org for the full compliment of Project Meetings

SCC COMMUNICATION PLAN

The SCC PAC Communications will include:

• Bi-Monthly “DSRIP in Action” eNewsletter
• Monthly “Synergy” eNewsletter
• www.suffolkCare.org
• Quarterly PAC Meetings
• Bi-Annual DSRIP Project Webinar Series
• SCC Partner Portal

Stakeholder Communication Requirements

• Engaged/Contracted Partners
• Provider Community
• Patients/Family
• Workforce

15

Key features of SCC Communication Plan:

• Communications Management Approach
• Change Control
• Stakeholder Communication Requirements
• Roles
• Project Team Directory
• Communications Matrix
• Communication Flow Chart
• Guidelines for Meetings
• Standardization for Communication
• Communication Escalation Process

CBO

Presented by Joseph Lamantia Chief of Operations for Population Health Stony Brook Medicine

16

COMMUNITY BASED ORGANIZATION (CBO) 17

A community based organization, is an

• rganization which is representative of a

community or a significant segment of a community, and is engaged in meeting human, educational, environmental, or public safety community needs.

CBOs:

• Provide numerous, often highly valued, targeted population programs and

services to the members of their community

• Provide services and support to the most marginalized, disadvantaged

and stigmatized sections of society

• Provide essential primary healthcare (especially for the very poor, women

and children) in low- and middle-income countries

Source: http://www.health-policy-systems.com/content/10/1/36

THE CBO ROLE “Because they understand their local communities and are connected to the groups they serve” Chillag et al. (2002) 18

Our objective is the collaboration with CBOs via workgroups, obtaining advisory feedback in planning and development project phases, leverage CBO communication strengths, on-going monitoring and building ongoing growth strategies of our programs. SCC has partnered with over 50 CBO’s representing a variety of areas including:

• Food Banks
• Behavioral Health Organizations
• Social Support Service Organizations
• Developmentally Disabled
• Vocational Programs
• Civic Centers
• Faith Based Organizations
• Family and Children’s Support Services

…and many more.

19

SCC AND CBOS

All DSRIP projects selected by the SCC include CBO engagement.

CBO ENGAGEMENT HIGHLIGHTS

Engagement Description DSRIP Project

Grass-roots communication strategies to include engagement with patients, families, communities All DSRIP Projects Provide workforce who offer the experience in working with our populations, who can offer a hands-on relationship building approach to foster long term relationships Project 2di: PAM Project Contracted with to help support community, provider and patient engagement requirements, including workforce allocations Project 3ai: Behavioral Health & Primary Care Integration Project Offer advisory guidance in building the Care Transitions Model for SCC and engaged/contracted for patient population. Collaborative care efforts include warm handoffs and follow up care. Project 2biv: Transitions of Care Project Cultural and Health Literacy Guidance All DSRIP Projects

20 20

Moderator

Gwen O’Shea, President/CEO Health & Welfare Council of Long Island

Panelists

Karen Boorshtein, LCSW, President & CEO, Family Service League John O’Neil, Commissioner, Suffolk County Department of Social Services Sister Margaret Rose Smyth, OP, Founder and Executive Director, North Fork Spanish Apostolate, St. John the Evangelist’s Parish Outreach Michael Stoltz, LCSW, Chief Executive Officer, Association for Mental Health & Wellness

CBO PANEL

21

THE PATIENT CENTERED MEDICAL HOME (PCMH) MODEL

Presented by Stacey Mallin, MPA, CPHQ, PCMH CCE, CLSSBB Patient Centered Medical Home Advisor HANYS Solutions

22

Moderator

James Sinkoff, Executive Vice President of Financial, Information and Business Services & CFO, Hudson River HealthCare, Inc.

Panelists

Jacqueline Delmont, MD, Chief Medical Officer, Beacon Healthcare Deborah Johnson Ingram, Health Care Quality Improvement Specialist & Director of Compliance and Patient Centered Services, Primary Care Development Corporation Janet Zolli, MD, Site Director, North Shore-LIJ Health System Imrana Ahmed, DO, Practicing Family Medicine Practitioner, Brookhaven Hospital’s Bellport Primary Care Center

PCMH PANEL

23

PROJECT 2DI “THE 11TH PROJECT”

Presented by Joseph Lamantia Chief of Operations for Population Health Stony Brook Medicine Amy Solar-Doherty, MPA, MA Project Manager Office for Population Health

24

1) 2di Project Overview & Requirements 2) Patient Activation Measures (PAM) 3) Coaching for Activation

25

OBJECTIVES

The Suffolk Care Collaborative has initiated the 11th project: To be eligible for this project:  The SCC had to already be pursuing 10 projects  Demonstrate its network capacity to handle an 11th project  Evaluate that the network is in a position to serve the target populations, as

• nly the uninsured, non-utilizing, low-utilizing Medicaid member populations

will be attributed to this project. Based on the Attribution for Performance received in March of 2015 from NYS DOH, total attribution for Project 2di includes:  93,694 Non-Utilizing and Low-Utilizing Medicaid Enrollees  168,618 Uninsured  A total combined population of 262,312

26

PROJECT OVERVIEW

PROJECT OVERVIEW

• Implementation of Patient Activation Activities to

Engage, Educate and Integrate the Uninsured and Low/Non-Utilizing Medicaid Populations into Community Based Care

Project Goal

• This project is focused on individuals not utilizing the

health care system and works to engage and activate those individuals to utilize primary and preventive care services.

Project Objective

• We will formally train workforce on the PAM tool and

post-PAM coaching

• We will engage our population in the community with

the PAM tool and regularly update assessments in the communities to monitor

Engagement Requirements

PROJECT ORGANIZATIONAL STRUCTURE 28

Project Manager & Project Lead Contracted/Engaged SCC Partners (CBOs) Patients & Our Community Vendor Agreement Insignia (PAM Tool) Project 2di Workgroup Project 2di Committee

PROJECT IMPLEMENTATION WORK STREAMS

29

Initiation of Project 2Di

• Engaged three CBO Partners
• Implementation plan for July-September organized

Wellness Coaching Implementation

• Building the Patient Activation Activities
• Engaging additional PPS partners in Wellness Coaching

Measurement & Monitoring Procedures

• Using Insignia Flourish Tool to monitor Survey Counts & Results
• Organized roles within CBO partners to monitor progress towards

achieving measurable project objectives

OVERVIEW OF THE PROJECT 2DI PATIENT ACTIVATION MEASURE

• The Patient Activation Measure (PAM) is a product developed by Judith

Hibbard and colleagues at the University of Oregon which assesses an individual’s knowledge, skill, and confidence for managing one’s health and healthcare.

• Individuals who measure high on this assessment typically understand the

importance of taking a pro-active role in managing their health and have the skills and confidence to do so.

• The PAM survey measures patients on a 0-100 scale and can segment

patients into one of four activation levels along an empirically derived continuum.

• Each activation level reveals insight into an array of health-related

characteristics, including attitudes, motivators, behaviors, and outcomes.

• PAM reliably predicts future ER visits, hospital admissions and

readmissions, medication adherence and more.

Source: http://www.insigniahealth.com/

GLOBALLY VALIDATED IN 190+ PUBLISHED, PEER-REVIEWED STUDIES

• Disease Prevention
• Diabetes
• Hypertension
• CAD
• CHF
• Metabolic Syndrome
• High Cholesterol
• COPD
• Asthma
• HIV
• Cancer (various)
• Back Pain/Spinal Surgery
• Mental Health (various)
• Multiple Sclerosis
• Parkinson's
• Sleep Apnea
• Chronic Pain
• Digestive Disorders
• Multiple Comorbidities

PAM is grounded by more than a decade of rigorous, peer-reviewed research conducted by hundreds of researchers across the globe.

Source: http://www.insigniahealth.com/

• Arabic
• Australia
• Canada
• China
• Creole
• Czech

Republic

• Denmark
• Filipino
• France
• French Canadian
• Germany
• Greece
• Hebrew
• Japan
• Mexico
• Netherlands
• New Zealand
• Norway
• Portugal
• Russia
• Slovakia
• Somali
• Spain
• Sweden
• United

Kingdom

• United States
• Vietnamese

ACTIVATION = KNOWLEDGE, SKILLS, CONFIDENCE

An activated consumer…

• Has the knowledge, skill and confidence to

take on the role of managing their health and health care

– Informed choices – Partner in care – Self management/prevention

• Activation varies within age, income,

education groups, even among people with low literacy skill

• Demographics tend to account for 5% to 6%
• f PAM score variation

Source: http://www.insigniahealth.com/

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ACTIVATION BEGINS WITH MEASUREMENT: PAM-10

Source: http://www.insigniahealth.com/

• 33

PATIENT ACTIVATION MEASURES

Source: http://www.insigniahealth.com/

• 34

PAM ACCURATELY PREDICTS…

Lower patient activation is associated with higher rates of hospitalization / ER visits A PAM score is predictive of future utilization and costs Lower patient activation is associated with poor disease self- management, including medication taking & self-monitoring

Higher patient activation is associated with stronger lifestyle behaviors and increased use of preventive care services Higher patient activation is associated with increased use of decision support resources Higher patient activation associates with more productive encounters with healthcare providers

Source: http://www.insigniahealth.com/

35

LOW ACTIVATION SIGNALS PROBLEMS (AND OPPORTUNITIES)

Source: http://www.insigniahealth.com/

• 36

PAM LEVELS PREDICT SELF-MANAGEMENT BEHAVIORS

Achieving best practice self-care is developmental

Source: http://www.insigniahealth.com/

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COACHING FOR ACTIVATION: KEY ROLES

Understanding a patient’s level of activation Active and reflective listening (listen for barriers) Spending more time asking than telling Understanding & focusing on the patient’s agenda Guiding patient’s choices toward level appropriate and attainable goals & action steps

Source: http://www.insigniahealth.com/

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COACHING FOR ACTIVATION

Know activation level Watch and listen Ask, don’t tell Check in (reflections) Guide toward level appropriate goals & steps Active listening

Source: http://www.insigniahealth.com/

• 39

MATCH GOALS TO CAPABILITY

Source: http://www.insigniahealth.com/

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QUESTION & ANSWER

www.suffolkCare.org 41

Appendix

CRFP UPDATE 43

• Capital Restructuring Financing Program is a DOH, multi-year, $1.2 billion capital pool
• A total of 34 CRFP Applications we’re submitted to NYS DOH on March 6th with a total ask of

just over $90 Million.

• The Suffolk PPS was last advised on Friday, June 18th that CRFP application results would

be released by the DOH in October 2015. Once awards are made, the State will contact each applicant directly.

QUANTIFYING ACHIEVEMENT OF DSRIP GOAL OF 25% REDUCTION IN AVOIDABLE HOSPITAL READMISSIONS OVER 5 YEARS

44 DSRIP OVERALL GOALS

GOAL OF 90% PAY FOR PERFORMANCE BY DY 5

Reduction Bucket Potentially Avoidable 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 Bucket Potentially 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

PROJECT IMPLEMENTATION SPEED 45

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 46

Project Project Description Providers to be Engaged # of Actively Engaged % of Attributed Population Actively Engaged Definition By Year: 2.a.i IDS 3,935 N/A N/A

N/A

N/A 2.b.iv Transitions of Care 3,489 25,326 17%

Care Transition plan developed

2 2.b.vii INTERACT 46 SNFs 1,914 1.3%

Avoided hospital transfer due to INTERACT

2 2.b.ix Observation Units 1,820 8,866 6%

Utilizing Observation services

3 2.d.i PAM/ Uninsured 350 trained in PAM 45,426 N/A

Individuals who completed PAM survey

4 3.a.i PC & BH Integration 3,651 45,059 30%

1) PHQ/SBIRT screening at PCMH site 2) Primary care services at BH site 3) PHQ/SBIRT screening at IMPACT site

4 3.b.i Cardio 3,763 14,556 10%

Documented Self-Management goals in Medical records

4 3.c.i Diabetes 3,763 12,094 8%

Received a hemoglobin a1c test in previous DSRIP year

3 3.d.ii Asthma 3,598 6,751 4.5%

Registered in home assessment log, patient registry, or other IT platform.

2