NYP/Q DSRIP Executive Committee Meeting … Committee...NYP/Q DSRIP Executive Committee Meeting...
Transcript of NYP/Q DSRIP Executive Committee Meeting … Committee...NYP/Q DSRIP Executive Committee Meeting...
NYP/Q DSRIP Executive Committee Meeting
Thursday July 28, 2016- 4:00p.m.-5:00p.m. – KW Board Room
EXECUTIVE COMMITTEE MEMBERS:
Maureen Buglino (Chair) - NewYork-Presbyterian/Queens
Anthony Somogyi M.D. (Vice-Chair) - NewYork-Presbyterian/Queens
Maria D’Urso - NewYork-Presbyterian/Queens
Chris Caufield - NewYork-Presbyterian/Queens
Mark Greaker - NewYork-Presbyterian/Queens
John Lavin - Mental Health Provider of Western Queens
Daniel Muskin - The Grand Nursing Home
Lorraine Orlando - NewYork-Presbyterian/Queens
Faivish Pewzner - Americare
Ashook Ramsaran - PAC Member
Michael Tretola - Silvercrest Center for Nursing and Rehabilitation
Paul Vitale - Queens Coordinated Care Partners
AGENDA:
I. Welcome M. Buglino
II. Review & Approve Minutes of Previous Meeting – Action Item M. Buglino
III. PPS Network Changes– Action Item M. Buglino
a. Voluntary Removal of Partners
b. Opt-Out Letter
IV. Workforce– Action Item L. Orlando
a. Target State
V. IT Systems– Action Item M. Greaker
a. Plan for Attributed Patients in QE
b. IT Security Plan
VI. Performance Reporting Strategy – Action Item A. Simmons
VII. Mid-Point Assessment M. Buglino
a. Project & Organizational Narratives
VIII. Compliance Update D. Marsden
IX. Questions / Open Discussion
X. Adjourn
NYP/Queens PPS Opt-Out Partners
NYP/Queens PPS Opt-Out Partners
Partner Opt-Out Reason
Bernard Fineson Developmental Disabilities Services Office
As Per Ann Morgan, the Partner has requested to be disenrolled in the NYPQ DSRIP PPS
The Fortune Society As Per Lisa Taylor, The Fortune Society has requested to be disenrolled from the NYPQ DSRIP PPS due to their internal decision to not participate.
Yohan and Jia Park (Private MD and NYP/Q) As Per Maria, Dr. Yohan and Jia Park have requested to be disenrolled from the NYPQ DSRIP PPS.
Mohammad Rahman As Per Dr. Rahman, requested to be disenrolled from the NYPQ DSRIP PPS due to time constraints.
NYPQ DSRIP OPT-OUT LETTER
July 12, 2016
NewYork-Presbyterian/Queens
DSRIP Project Management Office
56-30 Main Street
Flushing NY 11355
To whom this may be concerns,
This letter is regarding an opt-out option from the Delivery System Reform Incentive Program (DSRIP)
within the NewYork-Presbyterian/Queens PPS.
________________________ has requested to opt-out of participating in NYS DSRIP program with the
NewYork-Presbyterian/Queens PPS.(NAME) has confirmed that they are unable or unwilling to continue
to participate in the clinical projects and provide the required data to meet the expectations of the
program. Based on the feedback received by the PPS, (NAME) has indicated the following reasons for
disengaging from the DSRIP program: ☐ Time Constraints
☐ Lack of resources
☐ Too Many Requirements from the PPS
☐ Focus on engagement in a different PPS
☐ Other: _______________________________________
The Project Management Office will submit all required documentation to the NYS DOH to request the
removal of ______________________ from the NYP/Q PPS Network in August 2016.
By signing this opt-out letter it confirms that ________________ will no longer be a member of the
NYP/Q PPS Network.
Thank you for participation and cooperation thus far with the NewYork-Presbyterian/Queens PPS.
Partner Name NYP/Q PPS Executive Lead Name
Partner Signature NYP/Q PPS Executive Lead Signature
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NewYork-Presbyterian/Queens PPS
DSRIP Workforce Target State
PLAN OVERVIEW
Organization: NewYork-Presbyterian/Queens PPS
Name of Analysis: DSRIP Workforce Target State
Approval Required: NYP/Q PPS Executive Committee
Approval Date: TBD
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Table of Contents
BACKGROUND AND PURPOSE ................................................................................................ 3
NewYork-Presbyterian/Queens PPS ........................................................................................... 3
Purpose & Overview ................................................................................................................... 3
WORKFORCE CURRENT STATE .............................................................................................. 3
Labor ........................................................................................................................................... 4
Practitioner Shortages ................................................................................................................. 4
Recruitment Challenges .............................................................................................................. 4
WORKFORCE TARGET STATE ................................................................................................. 5
Recruitment and Redeployment .................................................................................................. 5
Training and Retraining .............................................................................................................. 6
Reduction .................................................................................................................................... 6
CONCLUSION ............................................................................................................................... 6
Workforce Next Steps ................................................................................................................. 7
APPENDIX ..................................................................................................................................... 8
A. FTE Count by Job Title .......................................................................................................... 8
B. Community Needs Assessment Data .................................................................................... 11
C. Training Index ...................................................................................................................... 12
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BACKGROUND AND PURPOSE
NewYork-Presbyterian/Queens PPS
The NYP/Q PPS is one of 25 PPS’s participating in the New York State Delivery System
Incentive Payment (DSRIP) Program. The PPS is located in Queens Borough and covers 33 zip
codes, approximately 60% the population in the borough. The PPS is led by NewYork-
Presbyterian/Queens (NYP/Q) hospital, which is the only hospital in the PPS network; NYP/Q is
subspecialties. The PPS network includes partners from over 100 organizations.
The PPS consists of 1,200 partners, and includes
practitioners, clinics, skilled nursing facilities,
hospices, community based organizations, and a
hospital. Over the course of the 5-year DSRIP
program, the NYP/Q PPS aims to reduce potentially
avoidable inpatient and emergency department visits
by 25% (triple aim) for Medicaid beneficiaries and
uninsured patients. The PPS will work toward this goal
through the implementation of 9 projects aimed at
reducing the health disparities found in the PPS service
area. Through the implementation of the DSRIP
projects and the achievement of the triple aim, the
PPS’s intention is to create a sustainable system
centered on value-based care. 1
Purpose & Overview
The goal of the DSRIP workforce target state is to outline the future of the workforce within the
PPS network. The target workforce state utilizes the current state assessment, compensation &
benefit analysis, DSRIP application for the PPS, and forecasted impact of the projects to create
the future state of the workforce. The target state will enable the PPS to collaborate with partner
organizations to create a transition roadmap to ensure a successful shift to value-based care from
volume based care.
WORKFORCE CURRENT STATE
The NYP/Q PPS engaged BDO to complete the DY1 compensation and benefit analysis for the
PPS to meet the milestone. In alignment with the process for collecting information on
1 Count in PPS Network is based on data provided by DOH in November 2015. The count includes a combination of practitioners
and organizations as well as instances of duplicate counts. The duplicates are a result of some partners being counted in multiple
provider types, i.e. a mental health provider may also be a substance abuse provider.
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compensation & benefit, the PPS also
collected data on the current state of the
workforce at the partner organizations. The
entire PPS network was surveyed and the PPS
received 56 responses from a variety of
partner organizations. The survey responses
included 12,932 employees (headcount) and
10,228 FTEs. Additionally, the survey
collected FTE counts by job titles which align
with the DOH job classifications for DSRIP.
The inventory of job titles and FTE counts is listed in Appendix A.
Labor
The PPS network incudes workforce who are represented by collective bargaining agreements.
The largest union representation is from 1199SIEU and includes several divisions of employees.
Local 30 Operating Engineers
Local 1199SEIU
Local 1199SEIU Registered Nurse Division
The PPS is committed to a partnership with labor to ensure a successful transition of the
workforce through DSRIP. The PPS has included a representative from 1199SIEU on the
workforce committee and the PAC committee to ensure seamless communication and input into
the development of the DSRIP program and execution of the workforce deliverables.
Practitioner Shortages
In addition to the survey data compiled by BDO, the PPS looked to the community needs
assessment, completed in 2014, for historical data on practitioner shortages in the service area.
Based on the data, available in Appendix B, the PPS has a shortage of safety net providers,
specifically primary care / family care practitioners, dentists, and specialty providers including
behavioral health. This information has a direct impact on the PPS target state and transition
roadmap to ensure that Medicaid beneficiaries have access to care within the service area.
Recruitment Challenges
The PPS identified numerous areas of challenge when recruiting both staff and practitioners for
partner organizations. The themes of recruitment challenges included:
Bilingual and diverse staff
RNs with sufficient experience for the role
Behavioral health providers
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Competitive salary & benefits for staff
WORKFORCE TARGET STATE
Recruitment and Redeployment
Based on the CNA data, the NYP/Q PPS service area has a lower inpatient bed ratio that NYS.
Therefore, the PPS does not anticipate DSRIP resulting in a bed reduction for the PPS. Based on
this, the target workforce state will be similar to the current workforce state as there will be
minimal redeployments and likely no reductions. The PPS forecasted needing 68 new hires in
various job categories based on the DSRIP program.2
Position Approximate # of New Hires
Administrative 4
Physician 3
Mental Health Providers / Case Managers 10
Social Workers 1
IT Staff 2
Nurse Practitioners 10
Other 38
The new hires outlined above will include both filling vacancies that currently exist and the
recruitment of new emerging job titles. The PPS DY1 Compensation and Benefit Analysis3
includes a detailed list of requirements by job title including experience required, licensure
requirements, and skills needed. The PPS has identified the following as emerging job titles
across the PPS network and the PPS PMO:
Director, PMO
Medical Director
Population Health Manager
Sr. Data Analyst
Data Analyst
Registered Nurse (RN)
o Population Health
o Rapid Cycle
o Chronic Disease Model
o INTERACT/SNF (Educator, Quality, Rapid Cycle)
Care Manager/Coordinator
Patient or Care Navigator
2 The forecasted new hires was provided by the PPS in the 2014 DSRIP application, section 5.4 3 The Compensation & Benefit Analysis is available to the IA through the DY2, Q1 MAPP submission or you can email the
PMO at [email protected]
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Community Health Worker
Peer Support Worker
In the PPS DSRIP application, the PPS estimated that there would be a shift of 200 RNs from the
inpatient to the outpatient setting due to DSRIP and that redeployment, when identified, would
be mandatory. As the PPS has evolved and better learned the network partners, the PPS no
longer anticipates a large redeployment of RNs but instead there will be a need for new
behavioral health practitioners, primary care practitioners, and staff in various care coordination /
navigation roles.
Training and Retraining
The PPS has completed a robust training plan for the workforce based on project specific
participation and the organizational requirements for a successful transformation. The training
plan4 details the needs and requirements for both meeting the DSRIP deliverables and ensuring
that the workforce is competent in providing care through the transformation process. The
training plan includes information on vendors and platforms that will be utilized by the PPS to
accomplish training across the network as well as learning objectives and measuring
competencies for the various training programs.5 The PPS will update the plan annually based on
feedback from the training sessions, needs identified by the workforce and/or project
committees, and any changes to the DSRIP program.
Additionally, the PPS will be partnering with 1199TEF as the approved workforce vendor. The
partnership will include assistance with completing the workforce milestones but also identifying
and vetting training vendors for the PPS. As the collaboration between the PPS and 1199TEF is
formalized, the PPS will provide additional information and update the appropriate plans.
Reduction
The PPS does not anticipate any workforce reductions due to the DSRIP healthcare
transformation. The PPS will support the partner network to fill vaccanies and new positions
with new hires and/or redeployed personnel as needed.
CONCLUSION
The PPS completed a robust survey process of the entire partner network to determine the
current workforce state and the baseline for the compensation and benefit analysis. Based on this
information, the PPS does not anticipate major shifts in the workforce from the current state. The
4 The PPS Workforce Communication and Training plan was completed and submitted with the DY2, Q1. The training plan is
available on the PPS website. 5 The training plan index is available in Appendix B
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PPS plans to fill current vacancies and emerging job titles with new hires and redeployed
personnel as needed to ensure the success of the integrated system.
Workforce Next Steps
The NYP/Q PPS will utilize the information from the compensation and benefit analysis, current
state, and target state to create a gap analysis and transition roadmap for the PPS workforce.
Through the development of these workforce deliverables, the PPS will continue to update the
workforce-training plan and begun planning for the DY3 compensation and benefit analysis of
the network. With guidance from the NYS DOH and engagement from the partners, the NYP/Q
PPS will aide in supporting a well-trained and prepared workforce as healthcare in NYS moves
from an inpatient and fee for service, to an outpatient value based system.
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APPENDIX
A. FTE Count by Job Title
The 56 survey responses included information on FTE counts by job titles. The total inventory
for the PPS is listed below and includes the number of organizations that reported having FTEs
in that job title.
Job Title Reported
Employees (FTE)
Number of
Organizations* Administrative Staff
Executive Staff 154 41
Financial 125 30
Human Resources 64 26
Other 369 28
Administrative Support
Coders/Billers 165 24
Dietary/Food Service 340 18
Financial Service Representatives 59 6
Housekeeping 353 16
Medical Interpreters 1 1
Office Clerks 376 30
Other 352 19
Patient Service Representatives 12 5
Secretaries and Administrative Assistants 322 43
Transportation 86 6
Allied Health
Nutritionists/Dieticians 102 19
Occupational Therapists 74 14
Occupational Therapy Assistants/Aides 54 9
Other 326 11
Pharmacists 57 4
Pharmacy Technicians 30 4
Physical Therapists 149 17
Physical Therapy Assistants/Aides 65 12
Respiratory Therapists 92 5
Speech Language Pathologists 37 12
Behavioral Health
Licensed Clinical Social Workers 106 12
Other 159 10
Other Mental Health/Substance Abuse Titles
Requiring Certification
69 9
Psychiatric Aides/Techs 0 0
Psychiatric Nurse Practitioners 6 6
Psychiatrists 19 12
Psychologists 9 6
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Social and Human Service Assistants 16 3
Substance Abuse and Behavioral Disorder
Counselors
24 9
Clinical Support
Clinical Laboratory Technologists 152 1
Medical Assistants 78 5
Nurse Aides/Assistants 1,711 16
Other 205 5
Patient Care Techs 32 5
Emerging Titles
Care Manager/Coordinator 257 14
Community Health Worker 15 3
Patient or Care Navigator 71 6
Peer Support Worker 13 4
Health Information Technology
Hardware maintenance 11 4
Health Information Technology Managers 20 16
Other 17 7
Software Programmers 37 7
Technical Support 13 11
Home Health Care
Certified Home Health Aides 180 1
Other 24 2
Personal Care Aides 30 1
Janitors and cleaners
Janitors and cleaners 88 16
Midwifery
Midwives 2 2
Nurse Practitioners
Other Specialties (Except Psychiatric NPs) 6 4
Primary Care 47 8
Nursing
LPNs 439 23
Nurse Managers/Supervisors 253 26
Other 283 8
Other Registered Nurses (Utilization Review,
Staff Development, etc.)
58 14
Staff Registered Nurses 1,441 31
Nursing Care
Managers/Coordinators/Navigators/Coaches
LPN Care Coordinators/Case Managers 2 2
RN Care Coordinators/Case Managers/Care
Transitions
120 15
Patient Education
Certified Asthma Educators 1 1
Certified Diabetes Educators 0 0
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Health Coach 0 0
Health Educators 15 7
Other 28 7
Physician Assistants
Other Specialties 19 5
Primary Care 85 5
Physicians
Other Specialties (Except Psychiatrists) 23 10
Primary Care Physician 76 16
Social Worker Case Management/Care
Management
Bachelor's Social Workers 45 10
Licensed Masters Social Workers 117 26
Other 33 12
Social Worker Care Coordinators/Case
Managers/Care Transitions
15 9
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B. Community Needs Assessment Data
The PPS completed a community needs assessment (CNA) in 2014 as part of the DSRIP
application process. In addition to providing essential information about the population in the
service area, the CNA also included data on physician shortages by specialty for Medicaid
beneficiaries and inpatient bed ratios. The CNA is available on the PPS website:
www.nyp.org/queens/dsrippps
Physician Shortage Data -- In aggregate, the service area has a shortage of approximately 327
safety net providers. The data shows adequate primary care, however, the PCP data is inflated as
internal medicine subspecialties are included in primary care. In reality, there is a significant
shortage of primary care, and a less severe specialty shortage than is shown.
Inpatient Bed Ratio -- 2,369 service area beds is equal to 1.49 beds per 1000 persons. This is
lower than the state average of 3.0 beds per 1000 and lower than the national average of 2.6 beds
per 1000.
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C. Training Index
The below is an index of tools and trainings that will be required for the PPS workforce based on organizational section and/or project.
This inventory is detailed in the PPS Workforce Training and Communication Plan. This plan will be updated annually based on
identified needs from the clinical projects and the requirements for DSRIP.
Org. / Project Name Training Name PPS /
Vendor? Frequency
Cultural
Competency
& Health
Literacy
Milestone #2
Develop a training strategy focused on addressing the
drivers of health disparities (beyond the availability
of language-appropriate material).
Cultural Competency Background &
Benefits
Providing Culturally Competent Care
HealthStream Annual
Cultural Competency GNYHA Bi-Monthly
Health Literacy PPS Partner &
HealthStream Annual
PPS Resource Center NYP PPS As Needed
IT Systems &
Processes
Milestone #2
Develop an IT Change Management Strategy
IT Solutions:
ACD
Cureatur
Performance Logic
RHIO
eMOLST
PPS &
Vendors Once Milestone #3
Develop roadmap to achieving clinical data sharing
and interoperable systems across PPS network
Milestone #5
Develop a data security and confidentiality plan Compliance Training
PPS via
HealthStream Annual
Clinical
Integration
Milestone #2
Develop a Clinical Integration strategy
Project Specific Trainings PPS & Vendor Ongoing
IT Solutions:
ACD
Cureatur
Performance Logic
RHIO
PPS &
Vendors Once
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Org. / Project Name Training Name PPS /
Vendor? Frequency
eMOLST
Performance
Reporting
Milestone #2
Develop training program for organizations and
individuals throughout the network, focused on
clinical quality and performance reporting
Metrics & Quality Improvement PPS Ongoing
Performance Logic Performance
Logic As Needed
2.a.ii –
PCMH
Milestone #7
Ensure that all staff are trained on PCMH or
Advanced Primary Care models, including evidence-
based preventive and chronic disease management.
Physician Champion https://hanys.adobeconnect.com/twy87da.psev5f/
HANYS
Solutions
Once *Recorded for
future use
Care Coordination GNYHA Once
PCMH Training Curriculum HANYS
Solutions 3 Waves
2.b.vii –
INTERACT
Milestone #4
Educate all staff on care pathways and INTERACT
principles. INTERACT Champion Training
INTERACT
Certified
Vendor
Once Milestone #6
Create coaching program to facilitate and support
implementation.
Milestone #7
Educate patient and family/caretakers, to facilitate
participation in planning of care.
Partner Engagement of
Patient/Family/Caregiver
PPS & PPS
Partner Ongoing
2.b.viii –
Home Care
Milestone #2
Ensure home care staff have knowledge and skills to
identify and respond to patient risks for readmission,
as well as to support evidence-based medicine and
chronic care management. INTERACT-like Tool Champion
Training
INTERACT
Certified
Vendor
Once Milestone #4
Educate all staff on care pathways and INTERACT-
like principles.
Milestone #6
Create coaching program to facilitate and support
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Org. / Project Name Training Name PPS /
Vendor? Frequency
implementation.
Milestone #7
Educate patient and family/caretakers, to facilitate
participation in planning of care.
Partner Engagement of
Patient/Family/Caregiver
PPS & PPS
Partner Ongoing
Milestone #9
Measure outcomes (including quality assessment/root
cause analysis of transfer) in order to identify
additional interventions.
Root Cause Analysis PPS Quarterly
3.a.i – PC/BH
Integration
Milestone #3
Conduct preventive care screenings, including
behavioral health screenings (PHQ-2 or 9 for those
screening positive, SBIRT) implemented for all
patients to identify unmet needs.
Best Practice Training PPS Ongoing
3.b.i – Cardio
Milestone #3
Ensure that EHR systems used by participating safety
net providers meet Meaningful Use and PCMH Level
3 standards and/or APCM by the end of DY 3.
Physician Champion https://hanys.adobeconnect.com/twy87da.psev5f/
HANYS
Solutions
Once *Recorded for
future use
Care Coordination GNYHA Once
Milestone #9
Ensure that all staff involved in measuring and
recording blood pressure are using correct
measurement techniques and equipment.
BP Competency PPS & Partner
Organization Annual
Milestone #18
Adopt strategies from the Million Hearts Campaign. Million Hearts Campaign PPS As Needed
3.d.ii –
Asthma
Milestone #4
Implement training and asthma self-management
education services, including basic facts about
asthma, proper medication use, identification and
avoidance of environmental exposures that worsen
asthma, self-monitoring of asthma symptoms and
asthma control, and using written asthma action
plans.
Asthma Education Program PPS & CBO
Partner Ongoing
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Org. / Project Name Training Name PPS /
Vendor? Frequency
3.g.ii –
Palliative
Care
Milestone #4
Engage staff in trainings to increase role-appropriate
competence in palliative care skills and protocols
developed by the PPS.
Education in Palliative and End-of-
Life Care (EPEC) PPS Bi-Monthly
4.c.ii – HIV
Milestone #2
Increase peer-led interventions around HIV care
navigation, testing, and other services.
NYC HIV Collaborative Education NYC HIV
Collaborative As Needed
Milestone #3
Launch educational campaigns to improve health
literacy and patient participation in healthcare,
especially among high-need populations, including:
Hispanics, lesbian, gay, bisexual, and transgender
(LGBT) groups.
Cultural Competency Background &
Benefits
Providing Culturally Competent Care
HealthStream Annual
Cultural Competency GNYHA Bi-Monthly
Health Literacy PPS Partner &
Healthstream Annual
PPS Resource Center NYP PPS As Needed
Milestone #6
Empower people living with HIV/AIDS to help
themselves and others around issues related to
prevention and care.
NYC HIV Collaborative Education NYC HIV
Collaborative As Needed
Milestone #7
Promote delivery of HIV/STD Partner Services to at
risk individuals and their partners.
NYC HIV Collaborative Education NYC HIV
Collaborative As Needed
1
Document Title: NYP/Q PPS Member Segments Analysis
Purpose:
The purpose of this document is to define member segments and
associated specific engagement needs (e.g., geo-access assessment,
cultural/linguistic needs)
Reviewing
Committee: IT/Performance Reporting Committee & Executive Committee
Date Reviewed: TBD
NYP/Q PPS Service Area
PPS service area consists of 33 of the 52 zip codes in Queens
County
o This represents an urban population of 1.59M
Queens County, specifically the NYP/Q PPS service area, is one
of the most areas of New York
o Geographic and economic disparities:
Percentage of families living in poverty ranges
from 4.6% – 23.8%
o Medicaid Beneficiaries:
692k Medicaid Beneficiaries in the service area
Enrollment ranges from 18% – 69% of
population based on zip code
o Uninsured:
360k people, 19.2% of population, are uninsured
Population demographics in NYP/Q PPS service area:
o Race and Ethnicity:
Whites – 394,481
Blacks – 227,432
Asian – 422,309
Hispanic – 479,486
Other – 70,584
o Disability – 9.3%
o Age 65+ – 36%
o Non-US citizen –22.1%
o Education
19.7% do not have a high school diploma
PPS Member Segments
Population by gender:
o Male Population – 780K
o Female Population – 814K
White colored area represents
the NYP/Q PPS Service Area
2
Median Age – 37.8 years old
o Health service utilization has variable rate by age within the population
The diverse demographics of the population impact health services in the following ways:
o Cultural diversity
o Language and health literacy
o Disease prevalence
o Disease manifestation
Tools needed to engage the population.
Geo-Access: Patient Portals to enable two way communication between the patient and
their providers, Telehealth/Telemedicine gadgets and tool, email, electronic reminders
Ads, and Population Health Tools
Cultural and Linguistics: Population Health Tools, Patient Portal with multiple
language capability and translation services
Summary
The population in the NYP/Q PPS service area is older compared to New York but has fewer
65+ residents; this translates to a large non-Medicare adult population. Providers must prepare as
this pre-Medicare population ages and transitions to a higher utilization of health services.
Queens County is a highly diverse county, inclusive of numerous cultures, spoken languages,
and varied health literacy rates, all of which contribute directly to disease prevalence and
manifestation among the population in the PPS service area. The poverty rate of the service area
is comparable to the New York State rate, but the rate within both the county and service area
varies significantly by geography. To address the health gaps evidenced in the NYP/Q
community needs assessment interventions and resources will be convened at local levels. In the
NYP/Q service area, there are 692k Medicaid beneficiaries, which encompasses 43% of the
population and is significantly higher than the NYS rate for Medicaid. The highest concentration
of Medicaid beneficiaries is located in North Central and North West zip codes; this includes
306k uninsured individuals. Queens County has a relatively low rate of uninsured individuals
with 306k located within the service area.
To address the health disparities seen, the PPS will invest in two main tools for partners,
specifically a population health management software and a patient portal. The population health
tool will enable providers to more effectively identify, manage, and treat patients including
performing risk assessments based on diagnosis, co-morbidities, and utilization of health care
resources. The patient portal tool will provide a platform where patients and providers will be
able to engage in a two-way communication. The patient portal will also provide patients with
the ability to perform open access scheduling, at specific practice sites, along with the capacity to
both send and receive secure messages to providers.
Document Title: Data Security & Confidentiality Plan
Approval Needed: IT Committee & Executive Committee
Approval Date: TBD
Document
Objective/Summary:
IT Chair to develop a data security & confidentiality plan that includes
monitoring and auditing of PPS-wide protocols for protected data
Purpose of the Data Security and Confidentiality Plan
The purpose of the data security and confidentiality plan is to establish standards and
recommendations for the NYP/Q PPS providers and affiliates to prevent or limit the potential
compromise of healthcare data being accessed and shared. The data security and confidentiality
plan establish that all NYP/Q PPS partners will maintain reasonable procedures to prevent
unauthorized access to data, including:
Administrative Safeguards
Assign Security Responsibilities
Information Access Management
Security Awareness and Training
Security Incident Procedures
Contingency Plans
Business Associate Agreements
Arrangements
Physical Safeguards
Facility Access Controls
Workstation Use
Workstation Security
Device and Media Control
Technical Safeguards
Access Control
Audit Controls
Integrity
Person Authentication
Transmission Security
Elements of the Data Security & Confidentiality Plan
The elements of the data security and confidentiality plan are based on the existing NYPQ
security standards, implemented to protect patients’ health information when being accessed or
exchanged. The NYP/Q IT leadership recommends that all PPS partners follow the NYP/Q
security standards matrix to establish their own security policies and protocols. PPS partners will
be monitored and audited to determine if the minimum standards of data security and
confidentiality are being met. It is the recommendation of the PPS that partners follow and
implement policies from the security grid in order to establish Administrative, Physical and
technical Safeguards. In addition or in parallel to the adoption of the adoption of the PPS
standard model, partners can also follow HHS guidelines as well.
Covered DSRIP Data Streams
1. PHI generated within the PPS. This includes demographic data, claims data and clinical
information
2. PHI generated by a managed care organization (MCO). This may include demographic
data, claims and encounters data, and clinical data.
3. PHI managed in a Qualified Entity (QE). The QE may perform at least two different roles
related to PHI management: a) as a provider of analytic services and/or b) as a health
information exchange (HIE). For the latter role, this would include clinical data generated
by providers and shared through interfaces between electronic health records set up by
QEs
New Presbyterian Queens - Security Standards Matrix
ADMINISTRATIVE SAFEGUARDS
Standards Sections Implementation
Specifications
R=Required, A=Addressable
Status Policy
Number
Policy Name
Security
Management
Process
164.308(1)
Risk Analysis R In Sentact 9100-204 Risk Analysis
Risk Management R
In Sentact 9100-032 Security Management
Process
Sanction Policy R
In Sentact 9100-032 Security Management
Process
Activity Review R
In Sentact 9100-032 Security Management
Process
Assigned
Security
Responsibility
164.308(2)
R
In Sentact 9100-033 Assigned Security
Responsibility
Workforce
Security 164.308(3)
Authorization and/or
Supervision A
See: Human
Resources
Policies
On Intranet
9237(100-131
and 700-702)
See: Human Resources
Policies
On Intranet
Workforce Clearance
Procedure A
See: Human
Resources
9237(100-131
and 700-702)
See: Human Resources
Policies
Policies
On Intranet
On Intranet
Termination Procedures
A
See: Human
Resources
Policies
On Intranet
9237(100-131
and 700-702)
See: Human Resources
Policies
On Intranet
Information
Access
Management
164.308(a)(4)
Isolating Health Care
Clearinghouse Functions R
In Sentact 9100-034 Isolating Health Care
Clearinghouse
Functions
Access Authorization A In Sentact 9100-035 Access Authorization
Access Establishment and
Modification A
In Sentact 9100-036 Access Establishment and
Modification
Security
Awareness and
Training
164.308(a)(5)
Security Reminders A In Sentact 9100-037 Security Reminders
Protection from Malicious
Software A
In Sentact 9100-004 Protection from Malicious
Software
Log-in Monitoring A In Sentact 9100-038 Log-in Monitoring
Password Management A In Sentact 9100-205 Password Management
Security
Incident
Procedures
164.308(a)(6)
Response and Reporting
R
In Sentact 9100-039 Response and Reporting
Contingency
Plan 164.308(a)(7)
Data Backup Plan R In Sentact 9100-040 Contingency Plan
Disaster Recovery Plan R In Sentact 9100-040 Contingency Plan
Emergency Mode
Operation Plan R
In Sentact 9100-040 Contingency Plan
Testing and Revision
Procedures A
In Sentact 9100-040 Contingency Plan
Applications and Data
Criticality Analysis A
In Sentact 9100-040 Contingency Plan
Evaluation 164.308(a)(8) R In Sentact 9100-042 Evaluation
Business
Associate
Contracts and
Other
Arrangements
164.308(b)(1)
Written Contract or Other
Arrangement
R
In Sentact 9200-331 Business Associate
Agreements
PHYSICAL SAFEGUARDS
Standards Sections Implementation
Specifications
R=Required, A=Addressable
Status Policy
Number
Policy Name
Facility Access
Controls 164.310(a)(1)
Contingency Operations A In Sentact 9100-044 Contingency Operations
Facility Security Plan A In Sentact 9100-015 Facility Security Plan
Access Control and
Validation Procedures A
In Sentact 9100-030 Access Control and
Validation
Procedures
Maintenance Records A In Sentact 9100-045 Maintenance Records
Workstation
Use 164.310(b)
Acceptable Use Policy R
In S e ntact 9200-385 Acceptable Use Policy
Workstation
Security 164.310(c)
In Sentact 9100-041 Workstation Security
Device and
Media Controls 164.310(d)(1)
Disposal R In Sentact 9100-031 Device and Media Controls
Device and Media Controls
Device and Media Controls
Device and Media Controls
Media Re-use R In Sentact 9100-031
Accountability A In Sentact 9100-031
Data Backup and Storage A In Sentact 9100-031
TECHNICAL SAFEGUARDS
Standards Sections Implementation
Specifications
R=Required, A=Addressable
Status Policy
Number
Policy Name
Access Control 164.312(a)(1)
Unique User
Identification R
In Sentact 9100-043 Unique User Identification
Emergency Access
Procedure R
In Sentact 9100-0047 Emergency Access
Procedure
Automatic Logoff A In Sentact 9100-219 Automatic Logoff
Encryption and
Decryption A
In Sentact 9100-029 Encryption
Audit Controls 164.312(b) R In Sentact 9100-048 Audit Controls
Integrity 164.312(c)(1)
Mechanism to
Authenticate Electronic
Protected
Health Information
A
In Sentact 9100-0046 Mechanism to Authenticate
Electronic Protected Health
Information
Person or
Entity
Authentication
164.312(d)
R
In Sentact 9100-0049 Person or Entity
Authentication
Transmission
Security 164.312(e)(1)
Integrity Controls A In Sentact 9100-0050 Integrity Controls
Encryption A In Sentact 9100-029 Encryption
Page | 1
NewYork-Presbyterian/Queens PPS
PPS Performance Reporting Strategy
PLAN OVERVIEW
Document Title: NYP/Q PPS Performance Reporting Strategy
Version 1.0
Purpose:
This document outlines the PPS performance reporting strategy to include
policies, processes, and procedures to ensure confidential data exchange and
effective communications for quality and operational data between the PPS
and its provider network.
Approving
Committee: IT Committee – Clinical Integration Committee – Executive Committee
Approval Date: TBD
Page | 2
Table of Contents
OVERVIEW ........................................................................................................................................................................... 3
GOVERNING PROCESS....................................................................................................................................................... 3
TARGET AUDIENCE ........................................................................................................................................................... 4
KEY STAKEHOLDERS ........................................................................................................................................................ 4
MILESTONES ........................................................................................................................................................................ 5
REPORTING OF PERFORMANCE ...................................................................................................................................... 5
Data Sharing Process – .............................................................................................................................. 5
Project Engaged Patient Data Collection – ............................................................................................... 5
Project Requirement Status / Achievement Reporting – ......................................................................... 6
Quality Metrics Data Collection – ............................................................................................................. 6
RAPID CYCLE EVALUATION ............................................................................................................................................ 7
ROOT CAUSE ANALYSIS ........................................................................................................................................................... 8
POLICY ALIGNMENT ......................................................................................................................................................... 8
DATA SECURITY ................................................................................................................................................................. 9
DATA WAREHOUSING / TOOL UTILIZATION ............................................................................................................... 9
PPS Secure Network Claims Data ............................................................................................................ 9
MAPP / Salient Tool Utilization ............................................................................................................... 9
Performance Logic .................................................................................................................................. 10
Population Health Management Tool ..................................................................................................... 10
PERFORMANCE DASHBOARDS / SUMMARIES ...................................................................................................................... 11
EXECUTIVE SUMMARY ............................................................................................................................ 11
QUALITY BASED OUTCOMES ................................................................................................................... 12
EXECUTIVE DASHBOARD ......................................................................................................................... 12
COMMUNICATIONS & ROLL-OUT PLAN ..................................................................................................................... 13
ATTACHMENT A: EXECUTIVE SUMMARY ............................................................................................................................. 14
ATTACHMENT B: EXECUTIVE DASHBOARD .......................................................................................................................... 20
ATTACHMENT C: QUALITY BASED OUTCOMES .................................................................................................................... 21
ATTACHMENT D: PATIENT ENGAGEMENT DATA REQUEST ................................................................................................. 22
ATTACHMENT E: QUALITY BASED OUTCOME METRICS ....................................................................................................... 26
Page | 3
OVERVIEW
The NYP/Q PPS includes over 134 network partners covering the service area of Queens County representing
33 of the 52 zip codes in the borough. These partners represent the full healthcare spectrum, including
homecare, post-acute care, hospice, pharmacies, behavioral health and substance abuse, primary care, and
community based organizations. Nine projects including primary care, behavioral health, long term care,
palliative care, asthma, cardiovascular, and HIV were selected based on the needs of the community we serve.
The NYP/Q PPS must ensure a robust performance reporting strategy and policy to ensure the collaboration and
communication among multiple organization and provider types that have individual clinical and operational
strategies to best serve their patient base. The PPS Project Management Office (PMO) will utilize this strategy
to:
Establish reporting expectations of monthly, quarterly, and annual data sets
Outline a governing structure of how the data will be managed, shared, and used for reporting to the
NYS DOH or within the network to perform continuous quality improvement efforts
Create a communication strategy among network partners to ensure actionable data & reports are
generated
Align with the PPS Training Strategy and evolve based on the needs of the network
Establish expectations for IT tools to be used for data sharing, analytics, and reporting (operational)
Create processes that utilize existing tools used by NYS DOH for data gathering and analytics
GOVERNING PROCESS
The IT Committee will govern the approval and implementation of the performance reporting strategy and
policies. Strategy and policy implementation and updates will be brought to the PPS Executive Committee for
review, recommendations, or final approvals. The strategy and policies will be reviewed annual for adjustments
based on PPS performance or network needs.
The PMO IT and Data Analytics resources will work with partners monthly to ensure compliance of the
strategy and will report compliance issues to the IT Committee based on findings. All partner compliance
issues will be reported to the Executive Committee quarterly, or more frequently as needed, with an action plan
to remedy the issues identified.
Page | 4
TARGET AUDIENCE
All network providers of the PPS will be educated on this strategy and all policies that are aligned. The
audience will include the clinical providers, organizations, as well as the operational support staff that are
identified for data collection, analytics, or DSRIP project management/implementation.
The strategy has been written for a general network audience while each training will be customized based on
the needs of the individuals being trained.
KEY STAKEHOLDERS
The following key stakeholders and responsibilities align with the performance reporting strategy:
ROLE RESPONSIBILITY
Lead Entity (NYP/Q) Oversight of PPS to ensure confidentiality of data, adherence to policies,
and compliance with state and federal regulatory requirements
PPS Project Management
Office
Establishing reporting policies & expectations
Gathering data elements & reporting to NYS and partners
Monitoring use & compliance of partners with policies
Data warehousing of partner performance data
Ongoing reporting to Executive Committee
PPS Executive Committee Oversight of the PMO processes
Chair accountable to the Lead Entity for ongoing updates
PPS Network Partners Fulfill project requirements, engaged patient reporting, and outlined quality
outcome data gathering as outlined in the performance reporting strategy
Identify risks or concerns regarding the PPS process
Directly communicate with the PMO regarding data & reporting processes
Page | 5
MILESTONES
This strategy & accompanying policies will address the following milestone:
Performance Reporting – Milestone #1 – Establish a reporting structure for PPS-wide performance
reporting and communication
This document will address all steps associated with the milestone and will meet the minimum standards
expectations of the DSRIP program.
PPS Training Strategy addresses the following milestone:
Performance Reporting – Milestone #2 – Develop a training program for organization and individuals
throughout the network, focused on quality and performance reporting
REPORTING OF PERFORMANCE
Performance reporting will be managed monthly by the Project Management Office Data Analytics team and
will include the following processes:
Data Sharing Process – o The PMO Data Analytics team will receive patient-level data on a monthly basis from the NYS
DOH via a secure sFTP server. Only two team members of the PMO staff will have access to
analyze the claims-based files, which are required to remain on the secure sFTP server. The
claims-based files can be compared with the quality-based outcomes data located on the
Medicaid Analytics Performance Portal (MAPP). From MAPP, the summary-level data can be
exported and shared with clinical workgroups for process improvement analysis and planning. In
addition, the PMO Executive Team, Clinical Integration Committee, and Executive Committee
will be provided with the summary-level data of the actively engaged patient count compilation.
The data will then be used to determine whether the speed and scale commitments targets are
met for each reporting quarter.
Project Engaged Patient Data Collection – o Committed partners will report actively engaged patient detail monthly to meet the definition as
set by the NYS DOH. The PMO utilizes a secure intake process in order to compile PPS partner
data for forecasting of performance as well as quarterly MAPP reporting of performance. The
data collection process consists of the PMO sending project-specific data request templates to the
participating partners. The template is an excel workbook with four separate tabs, see
Attachment D. The first tab provides instructions to partners for completion of the request. The
following three tabs contain a data dictionary, an attestation form, and a data worksheet, all to be
Page | 6
returned by the partner prior to a scheduled deadline. The data is collected monthly and entered
into an aggregate file, where the data is validated to ensure that it is accurate and contains no
duplications.
o The standard tool that the PPS is recommending to partners, for the secure exchange of the
patient count data is the Cureatr Messaging App. All NYP/Q partners who are participating in
the engaged patient data collection will be provided with a user account and access to send and
receive related data files. On a monthly basis, partner will receive the patient engagement
template for the NYP/Q PPS data analyst. The file will be sent via the Cureatr App and partners
will be expected to complete the template and communicate the data files using the App. NYP/Q
will maintain administration of the Cureatr application to include auditing and user support.
Additionally, training for appropriate use of the application will be provided courtesy of a user
guide and screenshots. These resources will be provided vendor and distributed by the NYP/Q
team.
o Upon receipt of the monthly patient level information, the PMO team compiles and analyzes the
engaged patient information to ensure no duplication of engaged patient count and to ensure a
complete representation of patient information to include CINs, NPIs, etc. Any missing,
incorrect, or duplicated information is communicated to the originating partner to ensure strong
communication regarding the process.
Project Requirement Status / Achievement Reporting – o PPS partner agreements outline project requirements for all partner types based on the project
commitments made by individual or group partners. The PMO will work with each partner
monthly / quarterly / annually to outline progress towards project requirements to ensure
completion by designated project dates. The PMO Performance Logic tool will be utilized for
tracking of the project requirements as there are no PHI elements associated with this
expectation.
Quality Metrics Data Collection – o Majority of the data elements for the quality based outcome metrics will be provided by the NYS
DOH utilizing tools such as 3M, AHRQ 4.4, HEDIS 2015, and CAHPS Audits. The NYS DOH
will provide reports to the PPS in order to fulfill the requirement of pay-for-reporting or pay-for-
performance. Attachment E provides an overview of the quality metrics.
o Additional metrics will be completed by an annual chart audit. The audit will be managed by a
NYS DOH vendor in order to identify random partners for quality outcome sampling. The PPS
will be engaged in the process of chart audits and will receive feedback and results upon
completion of the audit.
Page | 7
Project Measure Description Measure Type
3.a.i Screening for
Clinical
Depression and
Follow-up
Percentage of Medicaid enrollees age 18
and older who were screened for clinical
depression using a standardized depression
screening tool, and if positive screen,
received appropriate follow-up care
Hybrid – G Codes &
Chart Review
Information
3.b.i Controlling High
Blood Pressure
Percentage of Medicaid members 18-85
years of age who had a diagnosis of
hypertension (HTN) and BP effectively
controlled during the MY.
HEDIS
o The PPS PMO Rapid Cycle Evaluation Unit will identify additional processes for data reporting
& tool utilization for more timely data collection in order to influence process improvement
efforts. The performance reporting strategy will be updated based on the development and
outcomes of the Rapid Cycle Evaluation Unit.
The timing of performance metrics will be based on the implementation plan or the NYS designated
measurement years. Timelines include:
Description From To
Implementation Plan –
Distribution Year (DY)
April 1st March 31
st
Quality Metrics – Measurement
Year (MY)
July 1st June 30
th
RAPID CYCLE EVALUATION
The tools and processes outlined in this strategy will establish partner expectations for data reporting to ensure
ongoing quality improvement efforts are made for the PPS. A Rapid Cycle Evaluation (RCE) Unit will be
established in DSRIP DY2 to utilize performance data reported by partners as well as data available in MAPP
(Salient) and other tools for quality improvement efforts. A CQI (Continuous Quality Improvement) technique
will be established with expectations that align with PPS performance of metrics as well as the timing
associated with such metrics.
Upon recruitment of the Rapid Cycle Unit team, a focused strategy will be developed to outline the processes
associated with the unit. This strategy will outline partners, data sources, process improvement strategies,
follow-up methods for improvements, and risks associated by quality based outcomes. National best practices
will be utilized to build the strategy & processes for the PPS.
Page | 8
ROOT CAUSE ANALYSIS
The long term care project workgroups have established a process of analyzing an actual patient encounter
recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency
department utilization. The patient information and facility information is blinded and the encounter from
beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause
Analysis (“RCA”) is completed in a workgroup where the team reviews items such as pre-condition/admission
indicators, clinical indications, facility processes, communication among facility partners, access to electronic
health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons
learned to make local performance improvement changes to clinical operations in order to avoid ED utilization,
admissions, and re-admissions. The RCA will become an integral part of the Rapid Cycle Evaluation Unit to
allow team input for process improvement efforts.
POLICY ALIGNMENT
As recommended by DOH, the New York Presbyterian of Queens PPS has established a specific strategy to
address Privacy and Data Sharing within the PPS. Our strategy will be based around a Data Security and
Confidentiality plan. Within the Data Security and Confidentiality Plan, the PPS will establish and outline
appropriate policies to address Administrative, Physical and Technical Safeguards. Additionally the policies
outlined in the Data Security and Confidentiality Plan, are aligned with the existing policies implemented at
NYP/Q to address Privacy and security of protected health information. These policies and standards will be
available for review and guidance on the NYP/Q, PPS website.
The following are the NYP/Q PPS data sharing and security policies and procedures:
o Acceptable Use
o Access Authorization
o Access Control and Validations
o Access Control Procedure
o Access Establishment and Modification
o Account Management
o Audit Controls
o Automatic Logoff
o Configuration Management
o Data Use and Sharing
o Encryption
o Facility Security Plan
o Identification and Authentication
o Integrity Controls
o Log-In Monitoring
Page | 9
o Person or Entity Authentication
o Protection from Malicious Software
o Remote Access
o Secure Access To Electronic Protected Health Information
o Security Management Process
o System and Communications Protection
o Two Factor Authentication
o Unique User Identification
o Vulnerability Scanning
DATA SECURITY
The NYP/Q PPS will apply and maintain quarterly audits to ensure that recommended data security policies and
standards are being met by all participating DSRIP partner. These audits will be performed using surveys and
individual reviews of partner’s policies and methods of data to sharing. The objectives of the audits will be to
determine if partners are using recommended standards and policies to maintain the Privacy and Security of
data being shared.
DATA WAREHOUSING / TOOL UTILIZATION
PPS Secure Network Claims Data
NYS DOH provides claims based data to the PPS, which is housed on a secure server, to allow each PPS the
ability to analyze data depending on the need of the analysis. The claims based data will be a tool that allows
the PMO Data Analyst to complete in-depth analysis including disease profiling by facility or partner, trending
of patient activity by network partner, and much more.
MAPP / Salient Tool Utilization
The MAPP tool, managed by the NYS DOH, will be a data gathering source for the PPS. The tool provides a
dashboard approach to quality and network data that is drillable. The tool is fed by Salient, an additional NYS
data warehouse. Both the MAPP and Salient tools will be limited to the PMO staff and will be used to provide
network analysis to project committees and executive leaders for quality outcomes and network attributions.
Page | 10
Performance Logic
The Performance Logic project management tool will be utilized as the primary warehouse for non-patient
related data such as the implementation plan steps & milestones, project requirements, meeting documents,
strategy & policy documents, etc. This tool will be used as the primary operational connection tool between the
PMO and network partners in order to establish expectations of deliverables, outline timing of tasks and project
requirements, and maintain a database of PPS reference documents for the partners.
The operational functions of the PL tool will be managed by the PPS Project Management Office while the
security related maintenance will be managed the PMO IT staff. The collaboration of operations and IT will
allow for a comprehensive tool with appropriate security levels in order to be compliant with all PPS policies.
Population Health Management Tool In support of Population Health requirements, the NYP/Q PPS will implement the Allscripts Care Director
(ACD) application. As specified by the DOH, the PPS is required to “perform population health management by
actively using EHRs and other IT platforms to track attributed lives by creating registries”. Allscripts Care
Director will support population health and performance reporting, through the use of a standardize care plan,
Event Notifications, Attribution Plans, Patient Registries, Risk Stratification and Care Coordination. Once fully
implemented the Allscripts Care Director System will provide a central location for the management and
tracking of all engaged patients. The system will also support performance reporting thorough its Ad hoc
reporting capabilities. All actively engaged attributed patient will be enrolled into the population health system,
where they will be able to be managed and tracked through the various tools such as Event Notifications, Care
Plan and Assessment. Implementation of the Population Health System will follow a two phase roll-out plan.
Phase 1 will provision system design to include; Interface builds, Assessments, Care Plans, Patient/Provider
Upload, Attribution Plans and Security configuration. Additionally, phase 1 will also include the creation of
user accounts for the designated care coordinators within the lead PPS. Phase-II, of the implementation plan
will include the design and configuration of the tool to accommodate identified safety net providers who are not
currently using a population health tool. Also within phase II of the implementation plan, PPS partners will also
be trained how to leverage the tool efficiently, in order to meet population health management and reporting
requirements. All Participating safety net partners, will be expected to manage their PPS attributed lives in the
Allscripts Care Director application using the designated attribution plan/registries, assigned by the lead PPS,
NYP/Q.
Page | 11
PERFORMANCE DASHBOARDS / SUMMARIES
The PPS PMO team will produce the following performance dashboards:
EXECUTIVE SUMMARY The PMO will generate a monthly Executive Summary that will encompass all functions of the PPS to include
organization and project expectations and performance. The summary is based on a ‘stoplight’ approach and
will identify risks by category associated with the PPS roll-out or transition to a sustainable model. Details of
functions or projects will be reflected in the document to ensure progress along with risks & mitigation
strategies, next steps & focus, and questions identified for NYS regarding implementation of the DSRIP
program. This tool will be distributed to the Executive Committee and the NYS/IA monthly as a driving
communication tool. Attachment A provides an example of the summary.
Page | 12
QUALITY BASED OUTCOMES Quarterly quality based outcome dashboards will be produced for all project workgroups. The dashboards will
encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure
server. Each dashboard will be unique to the clinical project and will be shared with the project workgroups for
further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle
Evaluation Unit team to identify trends & risks associated with quality based outcomes.
Scoring methodology of the quality based outcomes will align with the NYS DOH metric target & high
performance goals produced annually (MY) for the PPS. The baseline year (MY) and goals will be
communicated to the network through clinical project committees, PAC, Clinical Integration Committee, and
the IT Committee to ensure improvements. The Rapid Cycle Evaluation Unit will utilize metric goals as
performance baselines to do continuous quality improvement efforts. The MY2 baseline and goal information
can be found in Attachment E.
Quality Indicator Dashboards have been created by project grouping to monitor progress and work internally
with the project workgroups to identify process improvement efforts for all partners involved. An example of
the dashboard can be found in Attachment C.
EXECUTIVE DASHBOARD A quarterly executive dashboard will be created and shared with the Executive Committee. The dashboard
(Attachment B) provides a high level view of the following indicators:
Overall Performance
Financials
Workforce
Operations
Clinical Integration & Quality
Risks & Mitigations
The dashboard will be a guiding tool for the Executive Committee to inform and drive change based on
quarterly performance.
Page | 13
COMMUNICATIONS & ROLL-OUT PLAN
The PMO and the DSRIP IT Project Manager will take a proactive role in ensuring effective communications
on this strategy. The PPS will focus to utilize existing communication sources, sited in the Communications &
Engagement Plan, to maximize efforts currently in place. If project information is communicated via secure
means or through internal company resources, all stakeholders, internal and external, must have the necessary
access to receive project communications.
The Project Management Office will partner with the network to continue the roll-out of the performance
reporting strategy. The roll-out of this strategy began in DY2 beginning with dashboard development and use,
Performance Logic builds, and NYS data compilation and warehousing. The network partners will have
multiple access points for roll-out to include:
Access to Performance Logic
Access to Population Health Management Tool
Engagement in committee meetings & workgroups
PMO partner meetings regarding performance of attributed lives (Rapid Cycle Evaluation Unit)
It is critical that communications and roll-out for our network is efficient and effective to ensure partner
engagement and use of products developed. The PMO management team will perform continuous outreach to
partners for feedback on the process, tools, reports, and data for ongoing updates.
Page | 14
ATTACHMENT A: EXECUTIVE SUMMARY NewYork-Presbyterian/Queens PPS – DSRIP
Executive Update
This memo will serve as an Executive Summary of the development of the NYP/Q PPS to include accomplishments and
upcoming focus and deliverables in order to ensure strong communication and effectiveness of PPS implementation.
Memo Date Range: May 27, 2016 – June 20, 2016
Organizational Milestones & Focus
Org Function Status Indicator
Red/Yellow/Green
Status / Notes
Governance Green 45 contracts executed to date
In process of finalizing CBO addendums for contractual
engagement expectations (Asthma Coalition, etc.)
Public agency coordination plan blended into the
Communications & Engagement Plan to ensure alignment with
engagement strategies and communications – Due DY2Q2
Remediation feedback completed & returned to IA
DY1Q4 reporting expectations completed - AV driving quarter –
Payment anticipated in July 2016
Finance Green Payment #2 final payments in process – pending
BAA’s/agreements
Expenses & Revenue reconciled for 2016 YTD May
Partnering with NYP on VBP MCO contracting strategy,
negotiations, and baseline assessment process
VBP Baseline Survey beginning June 2016
Workforce Yellow BDO Compensation & Benefit Analysis Draft received &
pending review / approval by Executive Committee
Pending meeting with 1199 TEF to review revised scope based
on need of PPS and available workforce budget
Healthstream training tool contract signed – Kick off call
scheduled for PMO July 7th
Training & communications strategy in draft form & pending
review / approval by Executive Committee (June 2016)
Workforce Impact analysis underway with project committees
Workforce expense analysis ongoing for quarterly reporting –
YTD spending expectations met by PPS
Page | 15
Cultural Competency &
Health Literacy
Green CCHL Strategy implementation in process
Aligning with Communications Committee to align with
communications & engagement processes
Poverty Simulator tool not being utilized by PPS due to down-
state tool not developed (only upstate developed). We are
reviewing the purchase of the curriculum but it is on backorder
IT Systems Yellow Phase II RHIO Pilot partners identified – 20 Partners in process
TOM project completed – EIP Measure
Security workbooks in progress for July 2016 submission
Performance Reporting Strategy & Policy in development for
June 2016 Executive Committee approval
Clinical Integration Green Metric Review & Planning Day – June 22, 2016 – review,
educate, and begin process improvement for metrics overall &
those out of compliance with goals
Clinical Integration Strategy in development – June 2016
Executive Committee review/approval
Ongoing best practice recommendations for review & approvals
PMO Green PMO Director – Hired – Welcome Sadia
Financial Analyst – Hired – Begins June 27th
Active Recruitment –
o Population Health Manager
o Data Analyst
Page | 16
Project Milestones & Focus
Org Function Status Indicator
Red/Yellow/Green
Status / Notes
ALL PROJECTS Green DY2 Q1 Actively Engaged Patient Counts
o All projects on track for achieving goals set
MAPP Dashboards – Data Analyst presenting at all project
workgroups
Mid-Point Assessment Narratives in development – Due July 31,
2016
2.a.ii – PCMH Green On track to meet requirement – 36 PCPs
Care Coordinator training held 6/15/16
Primary Care Plan in development – due August 31, 2016
2.b.v; 2.vii; 2.b.viii; 3.g.ii
– LTC Projects
Green Facility Champions are in the process of being identified at sites
2nd
Root Cause Analysis September 9, 2016
INTERACT training scheduling in progress
3.a.i – PC / BH Yellow Evaluating how to move forward based on co-location limitations
(regulations) with the lack of capital funding
Site visits under way to outline potential placement of PC’s in
BH site(s). (Brightpoint, MHPWQ)
3.b.i – Cardio Green Working with internal million hearts campaign team member to
roll out requirements for the project
3.d.ii – Asthma Green Training of school based staffing continues
Action plan in development for bigger plan of school based
education of staff
IT Tools (Population Health) under review for connectivity and
engaged patient tracking
2 Partners attending NYS Asthma Home Based Services
Conference – June 24, 2016
4.c.ii – HIV Green Continued engagement in the NYS HIV Collaborative
Peer led intervention strategy completed
Discussions underway for expanding existing activities
Page | 17
Next Steps / Focus:
Focus / Strategy Description
Performance Reporting Strategy & Policy Development of a robust performance reporting strategy
& policies
Quarter Close – DY2Q1 – Workplan review Workplan review of all deliverables to identify risks /
completion / next steps
Preparation for July 2016 reporting
PPS Partner Agreements Identifying critical partners for additional contracting
needs
Aligning commitment provider counts with scale &
speed goals
Mid-Point Assessment Understanding NYS expectations
Completing project & organizational narratives
Educate partners of 360 review potentials
Identifying risks & mitigation strategies
Workforce 1199 Training & Education Fund contracting
Healthstream Roll-out
Training & Communication Plan Roll-Out
Clinical Clinical Integration of projects
Utilization of MAPP Dashboard data in project
committees
Rapid Cycle Evaluation Unit Development Continued recruitment of a Population Health Nurse
NYS Workforce meeting Lean concepts – to be discussed
internally by team for potential identification of
initiatives
EIP/EPP Contracting Partnering with NYP on MCO contracting
Page | 18
Risks & Challenges
Risk Project/Function Description Mitigation /
Accountability
Owner
EPP & EIP
Payments
Overall Unsure how the collaborating contracting PPS
model will apply to the new DOH expectations for
EPP & EIP payments
M. Buglino
Primary Care :
Behavioral Health
Co-location Billing
PC : BH Co-location primary care & behavioral health
billing practices create complexity within
organizations sharing locations
M. D’Urso
Limited Revenue to
Create Robust
Incentive Plan
Overall Need to ensure a robust incentive structure for
partners to allow for buy in of requirements
A. Simmons
Value Based
Payment Model
Financial
Sustainability
The ability to move to a VBP process with multi-
organizations while being compliant with state &
federal regulations within the limited amount of
time allotted for DSRIP
M. Buglino
Improvement of
Non-Compliant
Metrics
Metric Outcomes Timing of project implementation with the
MY/DY spread of metrics is a challenge to ensure
process improvement that will result in quality
outcomes
Team
Page | 19
Questions & Clarification
Topic Questions
Pending from 11/13/15 Meeting
Non-Safety Net Provider
Status
Spreadsheet provided 10/14/15 to KPMG/PCG includes a list of
providers that only render services at the Article 28 extension clinics
of NewYork-Presbyterian/Queens but are listed by DOH as non-
safety net
New Questions
MAPP Data When will the MAPP system be updated to fix the provider level
detail of attribution / quality outcomes by provider? Currently we
have numerous metrics that have over 90% in No PCP Assigned by
MCO and all other provider counts seem severely. We were told
that the June 2016 update caused this issue.
Salient Training We have brought on new staff and will continue to as we grow the
PMO and we were informed that there will be no Salient training
until further notice; therefore, we cannot get our new Director and
data analyst access to the system. Can you tell us when they plan to
have additional trainings or to assign our users access?
Page | 20
ATTACHMENT B: EXECUTIVE DASHBOARD
Actual Spend Application $ Discount $Variance to
Discount
Amount Rolled
to next DY
128,455$ $ 188,702 $ 113,221 $ 15,234 $ 60,247
YTD Actual Pending Payouts
Expense
Budget % of Rev Notes On Target for Deliverables
AOH 518,866$ -$ 35.30%
COI 156,652$ -$ 10.66% Caution or Risk of Not Meeting Expectations
Non-Cov 26,775$ 45,150$ 4.89%
Rev Loss 96,468$ 50,521$ 10.00%
Contingency 73,499$ -$ 5.00% Not Meeting Expectations
Incentives 42,500$ 252,181$ 20.05%
Proj Rqmt Incentives -$ 285,383$ 19.41%
Totals 914,760$ 633,235$
Spend
Grand Total
Includes
Grant
Funded
Items
%'s will not
balance to
application
as revenue
does not
include
EIP/EPP $s
367,497$
Pending DY1 Q4 IA Review
1,469,988$
Legend
Payment 3
Payment 2
PPS Expense to Budget
NYP/Q PPS Executive Performance Dashboard
Quarter Date Range: January 1, 2016 - March 31, 2016
Delivery System Reform Incentive Payment (DSRIP)
Executive Operations Workforce
DY1 Q4 - DY1 Year End
Q3 = Non Revenue
producing quarterNetwork Development / Partner Engagement
39 Partner contracts completed to date
Continued signatures based on partner engagement
CBO Contracts signed = Asthma Coalition & Elmcor
Payment Cycle #1 & #2 Completed - Next cycle = September 2016
March 31, 2016 ends the DY1 of the NYP/Q DSRIP Program. The PPS has met all
expectations to maximize revenue to the network. Nine projects are currently in the
implementation phase with vast partner engagement ranging from primary care
physicians to pharmacies. Partners are engaged with all committees and contracts
allow the PPS to flow funds based on engagement, non-covered service, revenue
loss, and actively engaged patient reporting.
Milestone / Task Status
Clinical Integration & Quality Financial
DY1 Q4 Reporting submitted April 27, 2016. Pending NYS Independent Assessor review &
feedback for final AV values.
PPS Revenue
Project Committees meet monthly - full partner engagement
CBO Contracting continued with refinements to scope of agreements
See Monthly Executive Summary for specific project updates
Payment 1 1,102,491$
Project Implementation
Mitigation / Action Plan - Not Meeting Expectation KPI's
Meeting with legal council to identify regulatory issues related to BH : PC co-location.
Partnering with NYP, who is responsible for the NYP/Q PPS managed care contracting, to complete the EIP/EPP contracts for the paired payers as well as to outline a VBP plan.
Comp & Benefit Analysis
- BDO hired to complete the Compensation & Benefit Analysis
- Survey process underway. 58 surveys completed from 35+ organizations
- On target to meet milestone by DY2 Q1
Target Workforce State & Roadmap
- Current State Analysis completed
- Target State under development to include the development of the roadmap
- On target to meet milestone by DY2 Q1
Impact Analysis
- Utilizing existing budget work completed which outlines workforce needs to define impact
analysis
- Working with each project committee to outline impact
- On target for DY2Q1 completion
Training Strategy
- Training strategy in development across all functions & projects to align need with workforce
budget
- On target for DY2 Q2
1199 TEF Contract
- Working to develop scope & budget for training contract
Overall Performance Scorecard
Total Avs Avs Awarded Notes
150 150
Quarter Reporting Status
Project Management Office
Project Coordinator & Data Analyst - Staffed
Director - Hired - June 2016 start date
Financial Analyst - Offer pending
Data Analyst - Interviews underway
Population Health Manager (RN) - Applicants under review
Risks Identified
Quality Metrics
The Population Health Manager is in recruitment to establish a Rapid Cycle
Evaluation Unit (RCE)
The newly recruited PMO Director has a vast quality background
Project Committees will begin to focus to operational improvements focused to
quality metrics
Long term care committee to begin a Root Cause Analysis with multiple partners
on an actual blinded patient case
Primary Care & Behavioral Health co-location regulatory issues identified
EPP / EIP Contracting for a Collaborative Model PPS with NYP partnership
Value Based Payment contracting in a collaborative model PPS
Page | 21
ATTACHMENT C: QUALITY BASED OUTCOMES
Page | 22
ATTACHMENT D: PATIENT ENGAGEMENT DATA REQUEST
An Excel document is utilized with all committed partners by project to outline expectations and ensure data integrity and
security of patient level information. The following tabs are included in the monthly collection process from partners.
Tab 1- Instructions for Completion of the Request
Page | 23
Tab 2- Data Dictionary
Page | 24
Tab 3- Partner Attestation Form
Page | 25
Tab 4- Data Worksheet to be completed by partners
Page | 26
ATTACHMENT E: QUALITY BASED OUTCOME METRICS
Page | 27
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
2.a.ii
Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP))
Adult Access to Preventive or Ambulatory Care - 20 to 44 years 83.44983553 ▲ 84.21332151
0.763485987 91.0846954
Adult Access to Preventive or Ambulatory Care - 45 to 64 years 91.32996633 ▲ 91.63213279
0.302166457 94.3516309
Adult Access to Preventive or Ambulatory Care - 65 and older 94.16058394 ▲ 94.18896999
0.028386046 94.4444444
CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers 86.35595281 ▲ 86.91135753
0.555404719 91.91
Children's Access to Primary Care - 12 to 19 years 95.38281707 ▲ 95.72791629
0.345099223 98.8338093
Children's Access to Primary Care - 12 to 24 Months 96.31053036 ▲ 96.67947733
0.368946964 100
Children's Access to Primary Care - 25 months to 6 years 95.42124542 ▲ 95.72122614
0.299980718 98.4210526
Children's Access to Primary Care - 7 to 11 years 97.8314746 ▲ 98.04832714
0.21685254 100
Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) 90.65300129 ▲ 90.83970116
0.186699871 92.52
H-CAHPS - Care Transition Metrics (Q23, 24, and 25) 93 ▲ 93.4
0.4 97
Helpful, Courteous, and Respectful Office Staff (Q24 and 25) 92.66679517 ▲ 92.99811565
0.331320483 95.98
Medicaid Spending on ER and Inpatient Services +/- 300.89391
Page | 28
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Medicaid spending on Primary Care and community based behavioral health care 50.75988688
PDI 90 - Composite of all measures +/- 655.2525893
593.8638304
-61.38875893 41.365
Percent of eligible providers meeting Meaningful Use criteria who conduct bidirectional exchange with qualified entities (RHIOs) 45.28301887 ▲
Percent of eligible providers meeting Meaningful Use criteria who have participating agreements with qualified entities (RHIOs) 48.42767296 ▲
Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards 28.73134328 ▲
Potentially Avoidable Emergency Room Visits +/- 39.2739968
35.95649712 32.63899744 -3.31749968 6.099
Potentially Avoidable Readmissions +/- 1352.948368
1235.719131 1118.489894 -117.2292368 180.656
PQI 90 - Composite of all measures +/- 2454.780362
2241.407726
-213.3726362 321.054
Primary Care - Length of Relationship - Q3 83.16443129 ▲ 83.50198817
0.337556871 86.54
Primary Care - Usual Source of Care - Q2 86.38296794 ▲ 86.99167115
0.608703206 92.47
2.b.v
Care transitions intervention for skilled nursing facility (SNF) residents
Adult Access to Preventive or Ambulatory Care - 20 to 44 years 83.44983553 ▲ 84.21332151
0.763485987 91.0846954
Adult Access to Preventive or Ambulatory Care - 45 to 64 years 91.32996633 ▲ 91.63213279
0.302166457 94.3516309
Adult Access to Preventive or Ambulatory Care - 65 and older 94.16058394 ▲ 94.18896999
0.028386046 94.4444444
CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers 86.35595281 ▲ 86.91135753
0.555404719 91.91
Page | 29
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Children's Access to Primary Care - 12 to 19 years 95.38281707 ▲ 95.72791629
0.345099223 98.8338093
Children's Access to Primary Care - 12 to 24 Months 96.31053036 ▲ 96.67947733
0.368946964 100
Children's Access to Primary Care - 25 months to 6 years 95.42124542 ▲ 95.72122614
0.299980718 98.4210526
Children's Access to Primary Care - 7 to 11 years 97.8314746 ▲ 98.04832714
0.21685254 100
Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) 90.65300129 ▲ 90.83970116
0.186699871 92.52
H-CAHPS - Care Transition Metrics (Q23, 24, and 25) 93 ▲ 93.4
0.4 97
Helpful, Courteous, and Respectful Office Staff (Q24 and 25) 92.66679517 ▲ 92.99811565
0.331320483 95.98
Medicaid Spending on ER and Inpatient Services +/- 300.89391
Medicaid spending on Primary Care and community based behavioral health care 50.75988688
PDI 90 - Composite of all measures +/- 655.2525893
593.8638304
-61.38875893 41.365
Percent of eligible providers meeting Meaningful Use criteria who conduct bidirectional exchange with qualified entities (RHIOs) 45.28301887 ▲
Percent of eligible providers meeting Meaningful Use criteria who have participating agreements with qualified entities (RHIOs) 48.42767296 ▲
Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards 28.73134328 ▲
Potentially Avoidable Emergency Room Visits +/- 39.2739968
35.95649712 32.63899744 -3.31749968 6.099
Potentially Avoidable Readmissions +/- 1352.948368
1235.719131 1118.489894 -117.2292368 180.656
Page | 30
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
PQI 90 - Composite of all measures +/- 2454.780362
2241.407726
-213.3726362 321.054
Primary Care - Length of Relationship - Q3 83.16443129 ▲ 83.50198817
0.337556871 86.54
Primary Care - Usual Source of Care - Q2 86.38296794 ▲ 86.99167115
0.608703206 92.47
2.b.vii
Implementing the INTERACT project (inpatient transfer avoidance program for SNF)
Adult Access to Preventive or Ambulatory Care - 20 to 44 years 83.44983553 ▲ 84.21332151
0.763485987 91.0846954
Adult Access to Preventive or Ambulatory Care - 45 to 64 years 91.32996633 ▲ 91.63213279
0.302166457 94.3516309
Adult Access to Preventive or Ambulatory Care - 65 and older 94.16058394 ▲ 94.18896999
0.028386046 94.4444444
CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers 86.35595281 ▲ 86.91135753
0.555404719 91.91
Children's Access to Primary Care - 12 to 19 years 95.38281707 ▲ 95.72791629
0.345099223 98.8338093
Children's Access to Primary Care - 12 to 24 Months 96.31053036 ▲ 96.67947733
0.368946964 100
Children's Access to Primary Care - 25 months to 6 years 95.42124542 ▲ 95.72122614
0.299980718 98.4210526
Children's Access to Primary Care - 7 to 11 years 97.8314746 ▲ 98.04832714
0.21685254 100
Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) 90.65300129 ▲ 90.83970116
0.186699871 92.52
H-CAHPS - Care Transition Metrics (Q23, 24, and 25) 93 ▲ 93.4
0.4 97
Helpful, Courteous, and Respectful Office Staff (Q24 and 25) 92.66679517 ▲ 92.99811565
0.331320483 95.98
Medicaid Spending on ER and Inpatient 300.89391
Page | 31
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Services +/-
Medicaid spending on Primary Care and community based behavioral health care 50.75988688
PDI 90 - Composite of all measures +/- 655.2525893
593.8638304
-61.38875893 41.365
Percent of eligible providers meeting Meaningful Use criteria who conduct bidirectional exchange with qualified entities (RHIOs) 45.28301887 ▲
Percent of eligible providers meeting Meaningful Use criteria who have participating agreements with qualified entities (RHIOs) 48.42767296 ▲
Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards 28.73134328 ▲
Potentially Avoidable Emergency Room Visits +/- 39.2739968
35.95649712 32.63899744 -3.31749968 6.099
Potentially Avoidable Readmissions +/- 1352.948368
1235.719131 1118.489894 -117.2292368 180.656
PQI 90 - Composite of all measures +/- 2454.780362
2241.407726
-213.3726362 321.054
Primary Care - Length of Relationship - Q3 83.16443129 ▲ 83.50198817
0.337556871 86.54
Primary Care - Usual Source of Care - Q2 86.38296794 ▲ 86.99167115
0.608703206 92.47
2.b.viii
Hospital-Home Care Collaboration Solutions Adult Access to Preventive or Ambulatory Care
- 20 to 44 years 83.44983553 ▲ 84.21332151
0.763485987 91.0846954
Adult Access to Preventive or Ambulatory Care - 45 to 64 years 91.32996633 ▲ 91.63213279
0.302166457 94.3516309
Adult Access to Preventive or Ambulatory Care - 65 and older 94.16058394 ▲ 94.18896999
0.028386046 94.4444444
CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers 86.35595281 ▲ 86.91135753
0.555404719 91.91
Page | 32
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Children's Access to Primary Care - 12 to 19 years 95.38281707 ▲ 95.72791629
0.345099223 98.8338093
Children's Access to Primary Care - 12 to 24 Months 96.31053036 ▲ 96.67947733
0.368946964 100
Children's Access to Primary Care - 25 months to 6 years 95.42124542 ▲ 95.72122614
0.299980718 98.4210526
Children's Access to Primary Care - 7 to 11 years 97.8314746 ▲ 98.04832714
0.21685254 100
Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) 90.65300129 ▲ 90.83970116
0.186699871 92.52
H-CAHPS - Care Transition Metrics (Q23, 24, and 25) 93 ▲ 93.4
0.4 97
Helpful, Courteous, and Respectful Office Staff (Q24 and 25) 92.66679517 ▲ 92.99811565
0.331320483 95.98
Medicaid Spending on ER and Inpatient Services +/- 300.89391
Medicaid spending on Primary Care and community based behavioral health care 50.75988688
PDI 90 - Composite of all measures +/- 655.2525893
593.8638304
-61.38875893 41.365
Percent of eligible providers meeting Meaningful Use criteria who conduct bidirectional exchange with qualified entities (RHIOs) 45.28301887 ▲
Percent of eligible providers meeting Meaningful Use criteria who have participating agreements with qualified entities (RHIOs) 48.42767296 ▲
Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards 28.73134328 ▲
Potentially Avoidable Emergency Room Visits +/- 39.2739968
35.95649712 32.63899744 -3.31749968 6.099
Potentially Avoidable Readmissions +/- 1352.948368
1235.719131 1118.489894 -117.2292368 180.656
Page | 33
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
PQI 90 - Composite of all measures +/- 2454.780362
2241.407726
-213.3726362 321.054
Primary Care - Length of Relationship - Q3 83.16443129 ▲ 83.50198817
0.337556871 86.54
Primary Care - Usual Source of Care - Q2 86.38296794 ▲ 86.99167115
0.608703206 92.47
3.a.i
Integration of primary care and behavioral health services
Adherence to Antipsychotic Medications for People with Schizophrenia 61.79775281 ▲ 63.26503635
1.467283539 76.4705882
Antidepressant Medication Management - Effective Acute Phase Treatment 57.46606335 ▲ 57.71945701 57.97285068 0.253393665 60
Antidepressant Medication Management - Effective Continuation Phase Treatment 39.36651584 ▲ 39.77769034 40.18886485 0.411174506 43.4782609
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia 72.72727273 ▲ 74.67754545 76.62781818 1.950272727 92.23
Diabetes Monitoring for People with Diabetes and Schizophrenia 58.33333333 ▲ 61.47959184 64.62585035 3.146258507 89.7959184
Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication 80.17241379 ▲ 81.05425498
0.881841191 88.9908257
Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) 25.56390977 ▲ 25.8345188
0.270609023 28.27
Follow-up after hospitalization for Mental Illness - within 30 days 60 ▲ 62.82352941 65.64705882 2.82352941 88.2352941
Follow-up after hospitalization for Mental Illness - within 7 days 50 ▲ 52.41935484 54.83870968 2.41935484 74.1935484
Follow-up care for Children Prescribed ADHD Medications - Continuation Phase 85.71428571 ▲ 85.71428571
0 78.65
Follow-up care for Children Prescribed ADHD Medications - Initiation Phase 70.21276596 ▲ 70.41838012
0.205614164 72.2689076
Page | 34
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) 56.14035088 ▲ 56.24031579
0.099964912 57.14
Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) +/- 93.49881797
87.67753617 81.85625437 -5.821281797 35.286
Screening for Clinical Depression and Follow-Up Plan 13.07189542 ▲ 17.38770588
4.315810458 56.23
3.b.i
Evidence-based strategies for disease management in high risk/affected populations (adult only)
Aspirin Use 40 ▲ 42.286
2.286 62.86
Discussion of Risks and Benefits of Aspirin Use 55.68 ▲ 56.839
1.159 67.27
Flu Shots for Adults Ages 18 - 64 38.4 ▲ 40.905
2.505 63.45
Health Literacy - Describing How to Follow Instructions 87.12729487 ▲ 87.38456539
0.257270513 89.7
Health Literacy - Explained What To Do If Illness Got Worse 89.30038121 ▲ 89.78034309
0.479961879 94.1
Health Literacy - Instructions Easy to Understand 97.21571584 ▲ 97.37614426
0.160428416 98.82
Medical Assistance with Smoking and Tobacco Use Cessation - Advised to Quit 89.29 ▲ 89.919
0.629 95.58
Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Medication 68.52 ▲ 70.056
1.536 83.88
Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Strategies 55.36 ▲ 57.351 59.342 1.991 75.27
Prevention Quality Indicator # 13 (Angina without procedure) +/- 33.999728
30.8748552
-3.1248728 2.751
Prevention Quality Indicator # 7 (HTN) +/- 122.3990208
111.3911187
-11.00790208 12.32
3.d.ii
Page | 35
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Expansion of asthma home-based self-management program
Asthma Medication Ratio (5 - 64 Years) 52.98245614 ▲ 55.2883772
2.305921056 76.0416667
Medication Management for People with Asthma (5 - 64 Years) - 50% of Treatment Days Covered 51.41509434 ▲ 53.13072777
1.715633426 68.5714286
Medication Management for People with Asthma (5 - 64 Years) - 75% of Treatment Days Covered 31.13207547 ▲ 32.51324994
1.381174473 44.9438202
Pediatric Quality Indicator # 14 Pediatric Asthma +/- 507.3500715
460.8699644
-46.48010715 42.549
Prevention Quality Indicator # 15 Younger Adult Asthma +/- 52.52790545
48.6315149
-3.896390545 13.564
4.c.ii
Increase early access to, and retention in, HIV care
Age-adjusted percentage of adults who have a regular health care provider - Aged 18+ years 76.8 ▲
Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years 109.1
Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years - Ratio of Black non-Hispanics to White non-Hispanics 1.67
Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years - Ratio of Hispanics to White non-Hispanics 0.97
Chlamydia case rate per 100,000 women - Aged 15-44 years 1432.9
Newly diagnosed HIV case rate per 100,000 22.6
Page | 36
Measure Baseline for MY2 Increase Flag
MY2 Annual Improvement Target
MY2 High Performance Target
Change needed to meet MY 2 Target
Statewide Performance Goal
Newly diagnosed HIV case rate per 100,000 - Difference in rates (Black and White) of new HIV diagnoses 27.6
Newly diagnosed HIV case rate per 100,000 - Difference in rates (Hispanic and White) of new HIV diagnoses 23.8
Percentage of adults with health insurance - Aged 18-64 years 76.4 ▲
Percentage of premature death (before age 65 years) 23.9
Percentage of premature death (before age 65 years) - Ratio of Black non-Hispanics to White non-Hispanics 2.04
Percentage of premature death (before age 65 years) - Ratio of Hispanics to White non-Hispanics 2.15
Primary and secondary syphilis case rate per 100,000 females 0.5
Primary and secondary syphilis case rate per 100,000 males 15.7
Domain 1 Measure
Health Home assigned/referred members in outreach or engagement 69.30966469 ▲
Health Home engaged members with a care plan during the measurement year 52.25225225 ▲
Health Home members who were in outreach/engagement who were engaged during the measurement year 18.95276039 ▲
NYP/Q PPS Governance
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Governance Successes to Date: The NYP/Q PPS created a successful collaborative contracting model for the PPS governance structure. The PPS Executive Committee is comprised of members from the PPS lead, NYP/Q, as well as partners from LTC, Behavioral health, Home Care, and a community member. The executive committee oversees the progress and partner engagement for the PPS. Additionally, the PPS has built a PMO team which includes a Director, Program Coordinator, Data Analyst, Financial Analyst, and IT staff. The PMO is continuing to recruit for clinical staff (rapid cycle, chronic disease, and behavioral health) and an additional data analyst. The PMO team works with the NYP PPS PMO to ensure collaboration and consistency across some areas of DSRIP such as VBP and IT resources. This collaborative relationship between the PPSs ensures the appropriate leveraging of resources and tools across both PPSs when available and knowledge sharing for the successes and challenges of DSRIP. The PPS has created an organizational structure for the projects to be grouped based on deliverables and partner engagement for each. The projects are bucketed into 5 groups – Asthma (3.d.ii), HIV (4.c.ii), Primary Care/Behavioral Health (3.a.i), Long Term Care (2.b.v, 2.b.vii, 2.b.viii, 3.g.ii), PCMH & Cardiovascular (2.a.ii, 3.b.i). The clinical workgroups report into the Clinical Integration and Population Health Management Committee, which is comprised of the chairs from the clinical projects, IT committee chair, and a representative from the RHIO Healthix. The grouping of these projects ensures efficiency for partners by grouping the deliverables to make the scope of the projects more manageable where possible. The PPS holds bi-annual town hall meetings to promote staff and community engagement and provide a forum for educational sessions and communication on the DSRIP initiatives. Previous town hall meetings have included presentations on DSRIP 101, DSRIP funds flow, pediatric asthma and PCMH. The PPS has been featured in local media from the town hall meetings.
DRAFT
NYP/Q PPS Governance
The China Press 03
14 16.pdf The PPS has executed 45 contracts to date and flowed funds to 49 partner sites1. A robust communication and engagement plan has been approved by the PPS and outlines the communication process for partners, CBOs, and public agencies for the PPS. Challenges: The PPS has identified
95%/5% Funding Rule – Per the STCs of the DSRIP waiver, the PPS is only permitted to flow 5% of fund to non-safety net providers. As the PPS engages non-safety net partners, specifically CBOs, in the DSRIP projects, the ability to incentivize these organizations is limited by this requirement.
Value Based Payment – The NYP/Q PPS is a collaborative model approach which has no accountability of MCO contracting for engaged partners. Along with no direct-accountability, the PPS is also limited to assisting with negotiation and planning due to federal regulatory compliance limitations.
Mitigations:
95%/5% Funding Rule – The PPS is working on engaging CBO partners through project participation and educational opportunities for the PPS. The PPS is also working with partners to identify potential sub-contracting opportunities for CBOs and external revenue sources, such as grant funding. DOH is currently in the process of requesting an extension of the safety net definition to any provider who sees a minimum of 25 Medicaid patients. If this is approved, the PPS will have more flexibility with incentive funding as additional providers in the PPS will be eligible for the 95%.
Value Based Payment – The PMO team is partnering with the NYP PPS to build an educational program focused to value based payment conversion. The models will provide educational materials as well as financial modeling tools for partners in order to internally prepare for MCO negotiations and contracting.
1 Partners are contracted at an organizational level and funds are flowed by DOH categorization, therefore the PPS may contract
with an FQHC that has 3 sites. This results in 1 contract but 3 funds flow to each of the sites within the FQHC.
DRAFT
NYP/Q PPS – Financial Sustainability, Funds Flow, Budget
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Funds Flow / Financial Sustainability / Budget Successes to Date: The PPS continues to meet the expectations associated to the financial aspects of the PPS. This mid-point assessment narrative will address (1) Funds Flow, (2) Financial Sustainability, and (3) Budget.
o Overall – o A Financial Analyst was recruited to the PMO and currently is focused to developing monthly
financial tools to include budget, actual spend, forecasting, and variance explanations. This team member will work in partnership with the Finance Committee and executive leadership to consistently track and trend financials as well as complete finance deliverables.
o Additional recruitment is underway for numerous positions to include both clinical & non-clinical positions to support operations as well as clinical integration.
o Funds Flow –
o Quarterly partner distributions continue with a schedule of March & September to align with the NYS DSRIP payments to include payments for incentives, cost of implementation, and revenue loss.
o PIT Updates in MAPP include payments made to partners based on actual checks cut in quarter being reported.
o CBO payments are included in the incentive funding and will be reviewed monthly to ensure compliance with the 95% / 5% safety-net provider ruling.
o The NYP/Q PPS Executive Leadership is working with the NYP Managed Care team to complete the contracting for the EIP/ EPP funding. One contract has been signed and a second contract is in final phases of signatures.
o Financial Sustainability – o The financial sustainability partner analysis was completed and two partners were identified
as potential risks within the network. The Financial Analyst is working to complete the follow-up action items that are identified in the PPS Financial Sustainability plan.
o The PPS Executive Leadership is partnering with the NYP PPS to align strategies of Value Based Payment transition of the lead hospital as well as partners.
DRAFT
NYP/Q PPS – Financial Sustainability, Funds Flow, Budget
o Budget –
o Actual spend has met expectations outlined with the DSRIP application to include: 5% Contingency, 2% Workforce, 30% Administrative Overhead, 5% Non-Covered Services, 10% Revenue Loss, 18% Cost of Implementation, and 30% Incentives.
o Expense forecasting is underway to ensure availability of funds pending the EIP/EPP Contracting.
Challenges: The PPS has identified the following challenges related to performance reporting:
Funds Flow: 95% / 5% Safety Net Limitation – A number of the clinical programs require a direct connection to CBO’s for engagement and education and the organizations are not safety-net providers.
Financial Sustainability: Value Based Payment Adoption – The NYP/Q PPS is a collaborative model approach which has no accountability of MCO contracting for engaged partners. Along with no direct-accountability, the PPS is also limited to assisting with negotiation and planning due to federal regulatory compliance limitations.
Funds Flow: Delayed EIP / EPP Contracting – The NYP/Q organization depends on the NYP organization to complete all MCO negotiations and contracting. The leadership at NYP is working on behalf of both NYP & NYP/Q PPS in order to complete the EIP/EPP contracting as a system strategy.
Transition of the Funds Flow Model to Performance Based – The existing PPS funds flow model was built to encourage engagement, project requirements, and engaged patient volume. In order to meet the quality based outcomes for performance the model will need to evolve into a true pay-for-performance model blended with other indictors which will ensure engagement, productivity, and quality.
Mitigations: The PPS has identified mitigation strategies to the challenges:
Funds Flow: 95% / 5% Safety Net Limitation – The PPS is working with partnering organizations in order to identify potential sub-contractor relationships with CBO’s in order to ensure engagement for education and engagement.
Financial Sustainability: Value Based Payment Adoption – The PMO team is partnering with the NYP PPS to build an educational program focused to value based payment conversion. The models will provide educational materials as well as financial modeling tools for partners in order to internally prepare for MCO negotiations and contracting.
Funds Flow: Delayed EIP / EPP Contracting – Both NYP & NYP/Q PPS’s are working closely with the NYP managed care operations executives to complete the contracting in a timely manner. The PMO teams are providing financial analytics and input into the negotiating processes to ensure full understanding of drafted contracts.
DRAFT
NYP/Q PPS – Financial Sustainability, Funds Flow, Budget
Transition of the Funds Flow Model to Performance Based – The Financial Analyst and PMO leadership are working on modeling additional phases of the funds flow models focused to engagement as well as outcomes. It is anticipated to have models presented to the Finance Committee late 2016.
DRAFT
NYP/Q PPS – Financial Sustainability, Funds Flow, Budget
DRAFT
NYP/Q PPS Cultural Competency & Health Literacy
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Cultural Competency & Health Literacy Successes to Date: The NYP/Q PPS successfully completed both the Cultural Competency and Health Literacy strategy and training strategy. The PPS has built both the organizational structure and clinical projects with CCHL as the foundational principle. The PPS has built the strategies on national best practices including the NQF CLAS standards, Teach Back, and AskMe3. The PPS is leveraging the expertise of partners who has historically done trainings for the community on health literacy to determine the best ways to educate the community. Challenges: The PPS has identified three primary challenges to ensuring the success of the CCHL work.
CC/HL Leadership – The PPS currently does not have an expert within the PPS to lead the CC/HL committee. The committee is currently being run by the PMO and leveraging experience within the partner network but lacks a true subject matter expert in this area.
Training Competencies – The PPS has created a comprehensive training plan which includes the CCHL trainings. The PPS will be using an e-learning platform for the majority of the trainings. There are currently no national standards for competencies for CCHL. The PPS will include pre- and post- tests in the training to ensure that participates are going through the modules and can track the change in the results. The PPS would like to include additional competencies to ensure that the trainings are comprehended as opposed to being another item that staff click through but do not make any changes to their processes.
Cultural Shift for the Workforce – The PPS will be providing training to the partner network workforce through both in person trainings and e-learning platforms. The PPS will monitor training and the embedded tests to track the changes in competency for the CCHL trainings. The PPS is aware that completing training does not necessarily result in a paradigm shift for the workforce in how they interact with the patients and present information about healthcare and self-management.
Mitigations: The PPS has identified mitigation strategies to the challenges to the success of the workforce work stream.
DRAFT
NYP/Q PPS Cultural Competency & Health Literacy
CC/HL Leadership – The PPS is hoping to engage 1199TEF to act as an expert in CCHL and help lead the committee. The committee has successfully created a strategy and training strategy but is looking to engage an expert for the execution and engagement of these plans. The PPS is in the process of contracting with 1199TEF and aims to have this included within the scope of work.
Training Competencies – The PPS will include embedded pre- and post-tests for staff in the eLearning platform and provide questionnaires for in person trainings to monitor the success of the training. The PPS will continue to monitor updates from NQF on competencies on CCHL to incorporate into the trainings and evaluation processes.
Cultural Shift for the Workforce – The PPS will provide training for the workforce and track the progress of the embedded competencies. The PPS will continue to work with partners to ensure that CCHL is embedded as a philosophy within the organization beginning at the leadership level. The PPS will strive to engage partners and partner leadership to incorporate the NQF principles in the workflows of the organization and begin to encourage the cultural shift that accompanies this workstream.
DRAFT
NYP/Q PPS Performance Reporting
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Performance Reporting Successes to Date: The PPS has drafted a performance reporting strategy that includes the partners and processes associated with performance outcomes. The strategy includes the plan for existing data sources as well as planned tools and data sources focused to partner engagement and performance improvement. The strategy aligns IT with clinical operations in order to maximize partner engagement and ensure positive improvements to quality metrics. The PMO team recruited staff which includes a data analyst and financial analyst. The role of the data analyst is to manage the monthly intake of engaged patient information, development of dashboards specific to need of the projects or leaders, and to partner with the Rapid Cycle Evaluation Unit to complete forecasting and risk assessments as outlined in the Population Health Management strategy. The financial analyst will partner with the data analyst on maintaining databases which allow for complete analysis of partners based on outcome data. The PMO Director will manage the overall performance reporting process and brings a vast amount of quality experience. The PPS dashboards have been rolled out and each project committee began utilizing the quality based dashboards to educate partners and began the conversations of process improvement focused to quality based outcomes. The claims based data will be utilized to deepen the analysis of patients, partners, and processes. The long-term care project lead began a root-cause analysis (RCA) exercise with the committee members focused to actual patient outcomes. The blinded patient process is discussed from beginning to end in order to identify areas that the network could have changed processes, tools, or communication channels to avoid an emergency department visit, admission, or re-admission. The exercise is not intended to place blame but to identify process improvement opportunities or gaps in care in order for the long-term care network to improve quality outcomes. The RCA will continue and will be a tool that is utilized in the Rapid Cycle Evaluation Unit.
DRAFT
NYP/Q PPS Performance Reporting
Challenges: The PPS has identified the following challenges related to performance reporting:
Salient Access – The new PMO team members currently do not have access to the Salient tool and we have been informed that the team will not be given access until training occurs and the state has no future training dates set.
Timeliness of Quality Data – The quality data provided in the MAPP tool is dated due to the process of utilizing claims based data sources.
Ability to Receive Real Time Quality Data – The PMO is working with a partner PPS to identify potential opportunities for data analytics tools to utilize for the Rapid Cycle Evaluation Unit and Performance Improvement. The analytics tool will provide the ability to load real-time quality data from partners, but the PMO will have challenges obtaining the data from partners with so many other requirements and commitments in daily operations.
MAPP “No Assigned PCP” – The current amount of patient activity in MAPP that has no ability to trend based on a provider due to “No Assigned PCP” is substantial and severely limits the team’s ability to complete provider based analytics.
Mitigations: The PPS has identified mitigation strategies to the challenges:
Salient Access – The PMO has brought the training & access issue to the attention of PCG//IA and will continue to maximize other tools such as MAPP and the claims based data until the team receives training.
Timeliness of Quality Data /Ability to Receive Real Time Quality Data – The PMO team is working with NYP PPS to identify possible analytical tools & processes to build a process of tools & analytics in a more timely fashion. Questions regarding data security have been posed to PCG and the team will continue the planning based on the response.
MAPP “No Assigned PCP” – The PPS continues to communicate this issue to the PCG/IA teams and will utilize the claims based information to build provider level analytics in order to prioritize partners to align with process improvement techniques.
DRAFT
NYP/Q PPS – Population Health Management
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Population Health Management Successes to Date: The PPS has initiated conversations with project workgroups to outline a roadmap strategy for population health management. The roadmap will align with the nine projects and will select a focused patient base to manage with the existing tools to be implemented by the IT team to include Allscripts Care Director, Cureator, and an analytical tool to be announced. The following steps will be the focus of the PMO & clinical leads to outline this strategy:
o Recruitment of a Population Health Manager (RN preferred) – The PMO leadership currently has a vacant position for a PH Manager and will continue to interview to fill as soon as possible. This position will be accountable for building the Rapid Cycle Evaluation Unit while partnering with the clinical leads to implement the PHM strategy.
o Population Analytics – The PHM strategy will identify a select patient set to manage as the PPS funding limits the ability to manage the entire population. NYP/Q chose project 2.a.ii versus 2.a.i and will not create an integrated delivery system to align with a PHM strategy. The focused PMH strategy will align with the selected projects such as the PCMH integration in order to address gaps in care, care coordination, patient tracking, provider identification & engagement, etc. The PMO data analytics team will work with the existing data elements to identify a select population to maximize the benefit of implementing a PHM strategy. The data will be categorized and prioritized to include utilization, chronic conditions, access, and gaps in care and will be presented to the Clinical Integration Committee for final prioritizations and decisions.
o Alignment of Focused Patient Base to Projects – The analytics completed above will then be aligned with complimenting projects to outline process workflows, plans to ensure proper provider engagement, and address any gaps in care focused to care coordination & quality improvements.
o Completion of the PHM Strategy – Upon final analytics and vetting among partners and clinical leads, the PMO team will finalize a strategy roadmap to outline the PPS strategy to include processes, partners, and IT tools for the focused patient base.
o Clinical Workgroup, Clinical Integration & PAC Presentation – A complete PHM strategy roadmap will be reviewed by multiple partner outlets to include clinical workgroups and PAC. The final PHM strategy will be reviewed & approved by the Clinical Integration and Executive Committees.
DRAFT
NYP/Q PPS – Population Health Management
Challenges: The PPS has identified the following challenges related to population health management:
Limited Funding for a Complete PHM Strategy – The available funding for the NYP/Q PPS is limited and will be consumed by the clinical integration of the nine projects. A strategy of population health for the entire attributed network would require more funding to ensure complete processes and tools are implemented (ex: Care coordination, data analytics, etc.)
Manual Processes for IT Tool Registration – The PMO IT team has identified tools needed to implement the PHM strategy which requires a large amount of workforce time to manually register patients for tracking.
Mitigations: The PPS has identified mitigation strategies to the challenges:
Limited Funding for a Complete PHM Strategy – The PMO team is working to identify a select group of patients to build a PHM strategy focused to quality improvements. The population that will be identified during the ‘population analytics’ process on page one of this document will focus to the most relevant patient population based on need and opportunities for improvements in order to maximize the return of investment for processes and tools.
Manual Processes for IT Tool Registration – The PMO IT team is working with the IT vendors in order to identify additional batch methods for the registration of the attributed lives for the NYP/Q PPS. The complexity of this task is to ensure no duplication of records when we receive a monthly performance attributed patient registry from NYS.
DRAFT
NYP/Q PPS - Clinical Integration
DSRIP Mid-Point Assessment
Clinical Integration
Organizational Narrative
PPS Name:NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
The NYP/Queens PPS has been working towards the creation of an integrated clinical network through the DSRIP program. The PPS, through its organizational committees, project committees, and partner engagement and outreach initiatives, has determined the fundamental needs of a sustainable integrated network. The robust and effective structure of the Clinical Integration committee, which is responsible for the Clinical Integration and Population Health workflows in addition to ensuring clinical quality and oversight of the project committees, engaged both internal stakeholders and PPS partners in the identification of gaps in integration. As the oversight committee for clinical quality, the Clinical Integration Committee in NYP/Queens PPS is also responsible for approving best practices, evidence based standards, and protocols that have been recommended by the project committees and/or are deemed necessary by the Clinical Integration Committee. To date, the Clinical Integration Committee has reviewed and approved over 15 best practices for the PPS. NYP/Queens PPS continues to work with partners in vetting out evidence based best practices for various clinical processes. It is necessary to analyze gaps in clinical and operational workflows at the same time as the PPS practices the ongoing approval of best practices. Therefore, NYP/Queens PPS is continuing their search for recruitment for population health nurse who in collaboration with PMO team will work extensively on PDSA (Plan, Do, Study, Act) cycles. The NYP/Queens PPS will also establish a Rapid Cycle Evaluation (RCE) unit in DSRIP DY 2 to utilize performance data reported by partners as well as data available in MAPP (Salient) and other tools for quality improvement efforts. In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in project committees. In June 2016, a metrics review and planning day was organized as well within the group, the objective of which was to review, educate and begin process improvement for metrics overall and those out of compliance with goals. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for all project workgroups. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. Each dashboard will be unique to the clinical projects and will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes. Another big highlight of the NYP/Queens PPS in the Clinical Integration organizational project is the establishment of Root Cause Analysis (RCA) workgroup. The long term care project workgroups have
DRAFT
NYP/Q PPS - Clinical Integration
established a process of analyzing an actual patient encounter recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency department utilization. The patient information and facility information is blinded and the encounter form beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause Analysis is completed in a workgroup where the team reviews items such as pre-condition/admission indicators, clinical indications, facility processes, communication among facility partners, access to electronic health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons learned to make local performance improvement changes to clinical operations in order to avoid ED utilization, admissions and re-admissions. The RCA will also become an integral part of the Rapid Cycle Evaluation Unit to allow team input for process improvement efforts. Furthermore, as learned in the June 21, 2016 DOH Conference in Albany, the PPS also plans to utilize Lean concepts and create effective workflows with minimal waste in the process. The PPS leadership and PMO team are in discussion for potential identification of such initiatives. But all these successes and efforts happened after overcoming multiple challenges, some of which the PPS still continues to face. The next few bullet points outline some of many challenges NYP/Queens has been facing and how we tried to resolve them. Challenge 1: Non-current data and limited tools and resources for data analytics Timing of project implementation with the MY/DY spread of metrics is a challenge to ensure process improvement that will result in quality outcomes. The PPS has received several DSRIP data feeds, including the member roster and the MAPP performance dashboards. While this information is a necessary start to the quality data process, there continues to be limited availability of data to the PPS and at the partner level. The member roster contains minimal information while the MAPP dashboards have limited access. This data is necessary both as claim based feeds from DOH, but also has real time information to enable rapid cycle improvement in the PPS. Moreover, due to some movement of employees in the PMO team since the beginning of DSRIP project, the new staff members who are responsible for data analysis and trending do not have access to Salient as they were never present when the initial training was first offered to all PPSs. No upcoming Salient trainings are offered as well. Despite the PPS' interest to be active participant in the Salient Interact Miner workgroup and utilize the data efficiently and meaningfully, the limited tools, staff, and available data for this continues to pose a risk to integration. Mitigation strategy by NYP/Queens PPS: The PPS is continuing their efforts in working with DOH and Salient contacts who can possibly manage to offer additional Salient training to the new staff in PMO office. In addition, the PPS is working best to use the data that is currently made available to us and create dashboards and summary to be presented to project committees and possibly utilize for further analysis by RCE unit. Challenge 2: Partners are engaged with more than 1 PPS and are asked to implement multiple best practices Two thirds of the NYP/Queens PPS partner network is participating in more than 1 PPS for DSRIP. These
DRAFT
NYP/Q PPS - Clinical Integration
partners are asked to participate in data reporting, implementation of clinical projects, and adoption of best practices by multiple PPSs. This creates conflict when PPSs are doing the same project, 3.b.i Cardiovascular project for example, and are requesting difference best practices to be implemented. As the PPS needs to report out quarterly on partner participation and completion of requirements based on the speed and scale commitments, this poses a risk for partners who are asked to implement multiple best practices. Due to the large overlap of network providers in the PPS, there is an inherent risk in how these practices will be adopted by partners and their capacity to continue to partner with multiple PPSs based on the volume of requests and requirements. Mitigation strategy by NYP/Queens PPS: The PPS is working with committees and sub-committees to engage partners in the implementation process for the projects. The goal is to ensure that robust partner participation can reduce the burden of having numerous parallel but separate requests from PPSs surrounding the implementation process. In addition, the PPS is continuing to reach out to neighboring PPSs and look for collaboration opportunities to ensure that these requests are streamlined whenever possible to partners. The NYP/Queens PPS will continue to post the approved best practices to the PPS website to ensure transparency and seamless communication with the public, including community members, other PPSs, and network partners. Challenge 3: Limited revenue to create robust incentive plan It is important to ensure a robust incentive structure for partners to allow for buy in of requirements. As a small PPS, NYP/Queens PPS receive very small funding which make it very difficult to create an attractive funds flow model. Mitigation strategy by NYP/Queens PPS: The PPS is trying to be creative as always and is in the process of formulating an updated incentive plan which will revolve around partners meeting the quality outcome based measures. This will not only make effective use of the limited funding and create a robust incentive plan, but will also serve as a good buy-in strategy for partners to comply with requirements and adopt best practices as needed.
DRAFT
NYP/Q PPS – Practitioner Engagement
DSRIP Mid-Point Assessment
Practitioner Engagement
Organizational Narrative
PPS Name:NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
The NYP/Queens PPS has made enormous efforts to date to build a sense of efficiency and community among PPS practitioners, partners, and leaders by sharing regular, organized communications. We also continue to encourage transparency among practitioners and partners in order to instill public trust in the changes being proposed and community belief in the potential for successful outcomes. The NYP/Queens PPS is organized as a collaborative contracting model. It is made up of dozens of healthcare, mental health and community service providers in the region. These community partners, agencies, patients, and providers participate in 15 subcommittees that function under an Executive Committee that reports in to New York-Presbyterian/Queens and its Board of Trustees. One of these sub-committees is a Communications Committee. Community partners also participate in a Project Advisory Council (PAC) that oversees development of the NYP/Queens DSRIP’s nine (9) approved community projects as well as a bi-annual Town Hall meeting that focuses on PPS function and project updates to the community at large. To date, the internal NYP/Queens internal practitioners participate in the project workgroups, executive committee and professional group meetings. The monthly / quarterly project workgroups are focused to (1) Primary Care & Behavioral Health, (2) Cardiovascular, (3) Long Term Care, (4) Palliative Care, (5) Asthma, and (6) HIV. Executive committee meetings occur monthly which are focused to PPS development, approvals, risks, and financials. The numerous Professional Group meetings occur based on the scheduling of each organization. Agenda items include general topics, DSRIP specific items, and related professional topics. Additionally, the PPS is working on rolling out multiple IT tools for project management, population health management, event notifications etc. With that, the PPS also recognizes that it is critical that communications and roll-out for our network is efficient and effective to ensure partner and practitioner engagement and use of products developed. The PMO management team will continue to perform continuous outreach to partners for feedback on the process, tools, reports, and data for ongoing updates. In order to ensure active and meaningful practitioner engagement, the NYP/Queens PPS has arranged several trainings which encourage the practitioner to be subject matter expert or champion and educate others at their respective sites. Examples include trainings to recruit Physician champions for PCMH, Palliative Care champions and INTERACT champions for the long term projects. For the sites who are undergoing the PCMH transformation and for those that have completed the transformation, the PPS is appointing a physician champion at each site. Physician champion training is provided to selected practitioners. The training is focused on NCQA's 2014 PCMH standards, True practice
DRAFT
NYP/Q PPS – Practitioner Engagement
transformation, role of change management, role of HIT, and lessons learned. Then, the physician champion is expected to be engaged in various ways. They will partner with HANYS PCMH Advisory Services to ensure buy-in from the team and effective roll out of processes. They will serve as the liaison between CMO and other physicians. In addition, they will be the go to person for escalations and reinforcement with other providers. They will partner with Project Manager and PCMH team to educate clinicians and staff on goals and standards. Moreover, they will also report monthly updates to appropriate parties. Besides PCMH training, the PPS will provide training to the long-term care providers participating in the INTERACT and home care project. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. In collaboration with GNYHA, the NYP/Queens PPS has hosted an all-day training session on June 15, 2016 for care coordinators in the PPS. Care coordinators are those who would play a coordination role in the continuum of care for patient. The PPS observed very good attendance record for this training. The assigned care coordinators from each partner site were very engaged. This specific training was intended to specifically educate the coordinators about the fundamental, evidence-based concepts for building an effective care coordination process to achieve improved outcomes and understands roles, responsibilities and best practices within their individual sites. Another way of encouraging practitioner engagement that the PPS has adopted is through building training modules and requiring partners/ practitioners to comply by watching the modules and testing their knowledge in it. The NYP/Queens PPS aims to train the PPS partner's workforce on DSRIP through DSRIP 101 training, which includes what DSRIP is, the goals of the program, the specifics of the NYP/Queens PPS, how to participate, and the funds flow incentive model. Similar to the DSRIP 101 training, the PPS has also undertaken training specific to each of the projects for the partners participating in each. These project specific trainings are aimed at providing baseline knowledge of the goals and requirements of each project and provide a platform for in depth project specific training. These baseline trainings have taken place at committee meetings with participating providers/partners and at town hall meetings for the PPS. The PPS will continue to engage partners in these forums and through individual encounters to ensure any new participants/practitioners in DSRIP have a thorough understanding of the projects that have been selected. The PPS also educates partners/practitioners on various policies, procedures and approved documents and best practices. For instance, Performance Reporting Strategy is an approved document crafted by the PPS that includes policies, processes, and procedures to ensure confidential data exchange and effective communications for quality and operational data between the PPS and its provider network. Partners/Practitioners will be educated on the Performance Reporting Strategy as well. Given the hundreds of partners that the NYP/Queens PPS has, the liaison role that partners play is a critical one to ensure success, overall and in specific projects. The goal is to have partner organizations take ownership of PPS projects by developing knowledge and enthusiasm. Below are a variety of communications vehicles and engagement methods that are already implemented or will be in near future to stimulate partners’ active participation, helping them to lead and manage potential issues: Web site: A microsite has already been created for use by all stakeholders, including PPS partners. This is a common work environment that provides plans, schedules, materials, and links to other content and engagement tools of various types. The website will be continually updated based on the development of
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NYP/Q PPS – Practitioner Engagement
the PPS.
Message track: This outlines key messages to be used in discussing programs. It includes citations for data used to support those programs, as well as messaging around the Community Needs Assessment that details the needs around which those programs were created.
Elevator speech: A one-page document that describes DSRIP, what the PPS is doing and the route to success. Partner leaders and team members should customize this speech and use it to talk about DSRIP with external stakeholders and their own staff.
Frequently Asked Questions (FAQs): Responses to commonly asked questions collected from leaders, employees and physicians. It provides answers directly from the DSRIP project team.
Glossary of Terms: A common list of terms that people may hear during the DSRIP rollout – terms they may not be familiar with or understand.
Master deck: A collection of slides that tells the story of DSRIP. It will include a healthy dose of visuals and infographics suitable for varying audiences. The deck is not meant to be used in its entirety; partner leaders will be encouraged to pull out necessary slides and graphics to suite their purposes.
Community Needs Assessment 101: A brief on the highlights of fall 2014 findings and what they mean to the community.
Templates for Milestone Announcements: Models of ads, press releases, media advisories and letters will be provided for partner use in communicating with their external stakeholders. Other items will be developed if needed as programs roll out.
Link to possible Introductory Video: If feasible from budget perspective, a video will be produced to introduce Partner leadership, their employees and physicians to the DSRIP project. It will include description of DSRIP projects, why the projects are being developed and what it means for individual stakeholder organizations.
Project List, Descriptions, Timeline and Site-Specific Involvement: Timeline of when major project milestones will occur and what it means for partners. The timeline will change as projects progress.
Archive and Links: Relevant content, as well as tools on other web sites, including NY State Department of Health.
Mini-White paper, “What does Transformation look like”? This will be provided to PPS partners for use within their organization and with external stakeholders.
Performance Logic: A project management software, will be rolled out to all engaged partners to track project progress and action items for proper PPS quarterly reporting.
Function and Project Committees and Sub-Committees: All partners were surveyed as to their interest in all function and project committees and sub-committees, based on the projects committed or subject matter expertise. Committee rosters are maintained and partners are encouraged to add additional members based on the evolution of each group. (All meetings allow in person and call in options with occasional webinars)
Project Advisory Council (PAC): All external partners hold a seat on the PAC and are invited to engage quarterly.
Town Hall: Meetings allow external stakeholders to participate and / or present as a subject matter expert to the community, based on the topic being covered.
MAX Series: Identified engaged partners that align with the NYS MAX series topics are given the
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NYP/Q PPS – Practitioner Engagement
opportunity to participate and receive additional funds flow based on the approved PPS funds flow model.
TOM Series: IT focused committee that allows for partner engagement to collaborate on information technology scenarios and how they relate to a project to anticipate the PPS need for operational changes to improve IT and patient care. This is an additional item that links to the funds flow model approved.
NYS All PPS Meetings: The PPS leadership reviews all PPS meeting agendas to identify partner attendance to allow access to all state PPS meetings. As PPS project implementation accelerates, regularly scheduled Partner/team conference calls will be instituted to provide updates, identify issues as they develop, answer questions, and share ongoing communications guidance
DRAFT
NYP/Q PPS - Workforce
DSRIP Mid-Point Assessment - Organizational Narratives
PPS must submit a narrative highlighting
the overall organizational efforts to date.
PPS Name: NewYork-Presbyterian/Queens
Highlights and successes of the efforts:
Organizational Section: Workforce Successes to Date: The NYP/Q PPS has completed 2 workforce milestones, target state and compensation & benefits analysis; in addition the PPS has successfully achieved the DY1 committed workforce spend and anticipates meeting the commitments for DY2-DY5. Additionally, the PPS completed a workforce communication and training plan that details the workforce needs for each DSRIP organizational work stream and clinical project. Challenges: The PPS has identified two primary challenges for completing the workforce milestones.
Tracking and Reporting of Staff Impact – The PPS currently has limited infrastructure across the partner network to track and report on staff impact for all of the required categories. This information is currently housed by some HR systems but is not tracked by workforce category (recruitment, redeployment, retraining, and reduction) nor by job title and organization type.
Limited Funding – The PPS has limited revenue to support the partner network including providing vendor and/or in person training sessions, providing IT solutions for tracking and reporting the workforce staff impact, and recruitment of new practitioners needed to address the safety net gap identified in the CNA.
Mitigations: The PPS has identified mitigation strategies to the challenges to the success of the workforce work stream.
Tracking and Reporting of Staff Impact – The PPS is in the process of creating a manual process to collect data from partners on staff impact by organization type, job title, and workforce impact category. The PPS will continue to look for IT solutions to provide to the partner network to ensure that the staff impact process can be streamlined if possible.
Limited Funding – The PPS is contracting with a vendor to provide an e-platform for training across the partner network. This will enable the PPS to provide training required for the organizational work streams and clinical projects to the partner network; this includes the ability to complete training from the office and for the PPS to track the training that has been completed at the PPS
DRAFT
NYP/Q PPS - Workforce
level across partner organizations for reporting. Additionally, the PPS is connecting partners to outside resources to assist with funding for recruitment such as the Mental Health Service Corps.
DRAFT
NYP/Q PPS – Project 2.a.ii
DSRIP Mid-Point Assessment - Project Narratives
PPS must submit a narrative in each
Section for every project the PPS is implementing
PPS Name: NewYork-Presbyterian/Queens
Project: 2.a.ii
Challenges the PPS has encountered in project implementation:
The PPS has identified several challenges specific to the implementation of the PCMH project. These challenges include
Care Coordination Resources – Approximately 1/3 of partners that are undergoing PCMH transformation are small practices, which may only include a physician and a medical assistant. The PCMH practices, especially these small sites, have limited resources to provide care coordination and generally do not have the capacity to hire a new employee specific to care coordination.
EHR/IT Requirements – NYP/Q is currently undergoing a change in EHR systems for the ambulatory clinics from eCW to Athena Health. The PCMH transformation and application process requires that clinics have reports, population health management, and an EHR. In order to provide this information, the sites are required to have an EHR system that is utilized. The transition from eCW to Athena Health has required a delay for the NYP/Q sites to complete the application and certification process.
Transformation Process – The transformation process for PCMH is a both a time consuming and resource intensive process. Many practitioners have identified this as the largest hurdle to participating in this project.
Efforts to mitigate challenges identified above:
Based on the identified challenges for the project, the PPS has identified the following mitigation strategies:
Care Coordination Resources – The PPS has partnered with GNYHA to provide care coordination training to PPS partners. The PPS hosted the 1st session in June 2016 and had 27 attendees from across the partner network. The PPS aims to continue supporting these in person sessions and will consider including a refresher course on the eLearning platform.
EHR/IT Requirements – NYP/Q sites completed the transition to Athena Health in July 2016. The HANYS Solutions team is in the process of reengaging the NYP/Q sites to complete the application process. NYP/Q sites are on schedule to submit the PCMH 2014 Level 3 application in the fall/winter of 2016.
DRAFT
NYP/Q PPS – Project 2.a.ii
Transformation Process – The PPS has engaged HANYS Solutions to assist practices with the transformation process across the partner network. As of DY2, Q2 4 practices (21 practitioners) have completed the PCMH process and received their 2014 Level 3 certification. The PPS is continuing to work with an additional 7 practices (22 practitioners) to complete the certification process by the end of DY3 per the project requirement. Currently, all practices are on track to meet the requirements for certification.
Site Name # of Practitioners PCMH Transformation Status
Brightpoint Health 3 Certified 2014 Level 3
Community Health Network 14 Certified 2014 Level 3
Advanced Pediatrics 3 Certified 2014 Level 3
Ma Jesus Calagos, M.D. 1 Certified 2014 Level 3
Jackson Heights 4 In Progress
TLCC 6 In Progress
ACC 4 In Progress
Jose Quiwa, M.D. 1 In Progress
Rego Park Medical Associates 3 In Progress
Rest Medical Care PC 3 In Progress
Arkhady Takhalov, M.D. 1 In Progress
TOTAL 43
Implementation approaches that the PPS considers a best practice:
The PPS has approved several best practices for the PCMH project:
Roles & Responsibilities – Care Coordination & Physician – The project committee has created an outline of the roles and responsibilities for care coordinators and physician champions in the PCMH project.
Care Coordinator
Role and Responsibilities 01 13 16.pdf
Physician Champion
Role and Responsibilities 01 13 16.pdf
PCMH Roadmap – The PPS, in collaboration with HANYS Solutions, created a roadmap for completing the PCMH process and built a training outline including a timeline and protocols.
PCMH Roadmap 11
30 15.pdf
PCMH Training
Protocols & Timeline 03 22 16.pdf
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasted to be met based on those partners committed to the project.
DRAFT
NYP/Q PPS – Project 2.a.ii
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served by the patient centered medical home project.
DRAFT
DSRIP Mid-Point Assessment SNF Care Transition Project Narrative
PPS Name:NewYork-Presbyterian/Queens
Project:2.b.v
Challenges the PPS has encountered in project implementation:
The NYP/Queens PPS selected this project and bundled it with two other projects INTERACT and Hospital Home care as the objectives and deliverables align well together. One of the main objectives of this specific project is to ensure SNF staffs have access to hospital patient records and hospital staff prior to patient discharge; therefore, Information Technology is an integral key to success. The NYP/Queens PPS IT survey revealed that most partner nursing homes have EHR systems. However, there is a lack of interoperability among partners. Currently, SNFs are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below). Also, in implementing several milestones for this project, the PPS has been encountering numerous challenges. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS.
Efforts to mitigate challenges identified above:
To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO. In order to make sure the SNFs and home care facilities can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites.
DRAFT
The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016.
Implementation approaches that the PPS considers a best practice:
The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that.
Development of Advance Care Planning Tools The PPS is encouraging partners to utilize the eMOLST tool for participation in the long-term care bundled projects. eMOLST optimizes the clinicians workflows and helps them to determine the level of appropriate care for terminally Ill, patients. The PPS has engaged Dr. Patricia Bomba, MD, FACP with Excellus BlueCross BlueShield to provide training to PPS partners on how to utilize the tool most efficiently. This training will be provided based on demand by the PPS partners.
INTERACT Implementation checklist shared with the partner facilities This checklist is intended to assist organizations in determining the degree to which the INTERACT Quality Improvement Program is being implemented. INTERACT implementation requires all the key components in the checklist, not just using selected INTERACT tools.
Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.
Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started
DRAFT
utilization of MAPP dashboard data in the SNF/INTERACT project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our Care Transitions Intervention for Skilled Nursing Facility (SNF) residents’ project, as our clinical integration of the project align with the needs outlined in our community needs assessment.
DRAFT
DSRIP Mid-Point Assessment
INTERACT Project Narrative
PPS Name:NewYork-Presbyterian/Queens
Project:2.b.vii
Challenges the PPS has encountered in project implementation:
The NYP/Queens PPS has selected the INTERACT program as one of the 9 clinical projects as we think this is a best practice for reducing avoidable readmissions from nursing facilities. The PPS intends to support partner sites implementing this program and utilize lessons learned from partners that have already adopted the program to ensure a successful implementation across participating sites. However, in implementing several milestones for this project, the PPS has been encountering numerous challenges. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS. Moreover, in order to build better coordination system and meet the multiple project requirements, the partner organizations needs to have eMR and be connected to RHIO. Currently, SNFs are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below).
Efforts to mitigate challenges identified above:
The NYP/Queens PPS conducted a survey of participating nursing homes to assess if the INTERACT program had been adopted and the degree of adoption. One facility reported the adoption of seven of the tools designed for nursing homes and was advanced in its practice of INTERACT principles. This entity proved to be a great resource for the quality improvement collaborative. During the assessment, nursing homes were also asked to complete the Interact Version 3.0 Nursing Home Capabilities List to strengthen the match between SNF selection and patient needs at hospital discharge. This is a first step towards the adoption of the INTERACT program and therefore the implementation has begun. In order to make sure the SNFs and home care facilities can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then
DRAFT
having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016. To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO.
Implementation approaches that the PPS considers a best practice:
The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that.
Development of Advance Care Planning Tools The PPS is encouraging partners to utilize the eMOLST tool for participation in the long-term care bundled projects. eMOLST optimizes the clinicians workflows and helps them to determine the level of appropriate care for terminally Ill, patients. The PPS has engaged Dr. Patricia Bomba, MD, FACP with Excellus BlueCross BlueShield to provide training to PPS partners on how to utilize the tool most efficiently. This training will be provided based on demand by the PPS partners.
INTERACT Implementation checklist shared with the partner facilities This checklist is intended to assist organizations in determining the degree to which the INTERACT Quality Improvement Program is being implemented. INTERACT implementation requires all the key components in the checklist, not just using selected INTERACT tools.
Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management
DRAFT
care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.
Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in the SNF/INTERACT project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our INTERACT project as our clinical integration of the project align with the needs outlined in our community needs assessment.
DRAFT
DSRIP Mid-Point Assessment
Hospital Home Care Project Narrative
PPS Name:NewYork-Presbyterian/Queens
Project:2.b.viii
Challenges the PPS has encountered in project implementation:
The NYP/Queens PPS has identified Hospital Home Care project, alongside Care Transitions in SNF and INTERACT project, as a vital project to make impact to its community based on the community needs assessment. For patients identified as high risk for readmission, transitions from hospital to home are expected to be managed using an interdisciplinary, multi-agency discharge team including patient and family, hospital, PCMH, home care, DME, social services and specialty services as needed. A transition care coordinator is expected to ensure timely patient follow-up with their PCP, that the plan of care is communicated to all involved, and that guidelines and criteria are in place for early identification and treatment of worsening patient conditions. As one of the resources and tools that can be used by home care agencies, the PPS chose the INTERACT Program as it offers a comprehensive implementation package which is compatible with EHR and paper based systems. The NYP/Queens PPS is supporting the adoption and implementation of the INTERACT tools by the home care agencies. This project is well suited to using a quality improvement collaborative model (“learning system that brings together teams to seek improvement in a focused topic area”) to implement the INTERACT program and are used by the NYP/Queens PPS. Since the INTERACT processes and materials are already developed and available, the home health agencies can focus collectively on the systematic implementation of the tools while learning from each other, leveraging common resources such as physician and staff training, and support each other throughout the process. The early adopter in the group can share lessons learned with others just starting. However, in implementing that came some barriers as well. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS. As stated in DSRIP application for this project, partner home care agencies will adopt Healthix (RHIO) for real-time exchange of information and the PPS will provide technology guidance through this process. Currently, home care agencies are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below).
DRAFT
Efforts to mitigate challenges identified above:
In order to make sure home care facilities and SNFs can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016. To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO.
Implementation approaches that the PPS considers a best practice:
The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that:
Root Cause Analysis Workgroups: The long term care project workgroups have established a process of analyzing an actual patient encounter recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency department utilization. The patient information and facility information is blinded and the encounter form beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause Analysis is completed in a workgroup where the team reviews items such as pre-condition/admission indicators, clinical indications, facility processes, communication among facility partners, access to electronic health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons learned to make local performance improvement changes to clinical operations in order to avoid ED utilization, admissions and re-admissions. The RCA will also become an integral part of the Rapid Cycle Evaluation Unit to allow team input for process improvement efforts.
Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting
DRAFT
process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.
Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in the Hospital Home Care project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project. The PPS is actively exploring different options for telehealth and mobile health technology. Options will be evaluated and best tools will be implemented to best meet the needs of the beneficiary population.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our Hospital Home Care project as our clinical integration of the project align with the needs outlined in our community needs assessment.
DRAFT
NYP/Q PPS – Project 3.a.i
DSRIP Mid-Point Assessment - Project Narratives
PPS must submit a narrative in each
Section for every project the PPS is implementing
PPS Name: NewYork-Presbyterian/Queens
Project: 3.a.i
Challenges the PPS has encountered in project implementation:
The PPS has identified challenges specific to the integration of primary care and behavioral health and the implementation of the requirements for the project.
Behavioral Health Workforce Recruitment – NYS has a shortage of behavioral health practitioners, including NPs, Case Managers, and physicians. The PPS has also identified a shortage of behavioral health providers, which has been compounded by the closing of several behavioral health clinics in the past several years.
EHR Interoperability – The project requires EHR interoperability between the primary care and behavioral health providers as a requirement of both Models 1 and 2. Based on this, the PPS will need to navigate the regulatory limits of sharing data related to behavioral health between the practitioners to ensure continued compliance.
Capital Funding – The PPS committed to integrating care at 3 sites within PPS; additionally, the PPS committed to purchasing a population health management tool for use by the entire partner network. Both of these are commitments that require capital funding. The PPS applied for CRFP funds from the state but was not awarded any of the submitted application. The PPS therefore has to ensure the success of these commitments on a limited DSRIP valuation and without CRFP funding.
Cultural Stigma – Through the PPS CNA qualitative data compilation, many stakeholders identified significant cultural and/or religious barriers to seeking behavioral health care. The sites that will be integrating services will have a challenge engaging patients in care due to this cultural barrier.
Efforts to mitigate challenges identified above:
DRAFT
NYP/Q PPS – Project 3.a.i
The PPS has identified several strategies for mitigating the identified challenges for the PPS.
Behavioral Health Workforce Recruitment – The PPS is committed to connecting partners to resources to assist with the recruitment of behavioral health providers, such as Mental Health Corps. The PPS will continue to work to identify opportunities for partners to assist in recruiting behavioral health providers and connecting with resources within the partner network.
EHR Interoperability – The project committee is collaborating with the IT committee, legal counsel, and Healthix to ensure that all regulations are met in the course of implementing the co-location process.
Capital Funding – One PPS partner, Brightpoint Health, was awarded CRFP funding for the integration of primary care and behavioral health project. Brightpoint Health is one of the partners in the network that will be integrating services. The other partners that will be integrating services are Child Center of NY, Mental Health Providers of Western Queens (MHPWQ), and NYP/Q. These partners who did not receive CRFP funding are looking at their internal budgets to ensure that they can fund the requirements for integration.
Cultural Stigma – The PPS is working with partner organizations to provide education and information on behavioral health. The PPS will utilize platforms such as the e-learning to provide training to practitioners and staff, and the bi-annual town hall meeting for community members. Additionally, the PPS will leverage community engagement events that are held by partner organizations.
Implementation approaches that the PPS considers a best practice:
The PPS has approved best practices related to preventative health screenings, including the PHQ-2/9, SBIRT, lipid screenings, and others.
Preventative Care
Screenings 11 30 15.pdf Additionally, the PPS is in the process of determining tools that can be provided to partners on administering primary screenings at the behavioral health sites and behavioral health at the primary care sites.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasted to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
DRAFT
NYP/Q PPS – Project 3.a.i
There are no current proposals for changes to the populations served by the integration of primary care and behavioral health.
DRAFT
NYP/Q PPS – Project 3.b.i
DSRIP Mid-Point Assessment
Cardio Project Narrative
PPS Name:NewYork-Presbyterian/Queens
Project:3.b.i
Challenges the PPS has encountered in project implementation:
Cardiovascular disease has the highest prevalence and utilization rates of any disease state in the NYP/Queens PPS community. Improving the health status of persons with cardiovascular disease, and thereby decreasing preventable utilization for cardiovascular disease, will inherently decrease overall preventable utilization. This project was selected as one of the clinical projects with the intention that the PPS would work with high risk patients to address any barriers to managing their cardiovascular disease. However, as the PPS approached in implementing different strategies to meet milestones for the project, we encountered multiple challenges, some of which are outlined below:
Partners are engaged with more than 1 PPS and are asked to implement multiple best practices Two thirds of the NYP/Queens PPS partner network is participating in more than 1 PPS for DSRIP. These partners are asked to participate in data reporting, implementation of clinical projects, and adoption of best practices by multiple PPSs. This creates conflict when PPSs are doing the same project, 3.b.i Cardiovascular project for example, and are requesting difference best practices to be implemented. As the PPS needs to report out quarterly on partner participation and completion of requirements based on the speed and scale commitments, this poses a risk for partners who are asked to implement multiple best practices. Due to the large overlap of network providers in the PPS, there is an inherent risk in how these practices will be adopted by partners and their capacity to continue to partner with multiple PPSs based on the volume of requests and requirements.
Defining true care coordination team As one of the requirements for this project, the PPS needs to develop care coordination teams including use of RN staff, pharmacists, dieticians & community health workers to address lifestyle changes, medication adherence, health literacy issues, & patient self-efficacy and confidence in self-management. Currently the definition for care coordination team is very vague and does not specify if the members in the care coordination team have to be located in same site or can work together remotely, etc. Without a clear description and concept of care coordination tea, it is difficult to build the appropriate team that will meet the patient’s needs and at the same time be operationally feasible.
Non-current data available to the PPS Timing of project implementation with the MY/DY spread of metrics is a challenge to ensure process improvement that will result in quality outcomes. The PPS has received several DSRIP data feeds, including the member roster and the MAPP performance dashboards. While this information is a necessary start to the quality data process, there continues to be limited availability of data to the PPS and at the partner
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NYP/Q PPS – Project 3.b.i
level. The member roster contains minimal information while the MAPP dashboards have limited access. This data is necessary both as claim based feeds from DOH, but also has real time information to enable rapid cycle improvement in the PPS.
Efforts to mitigate challenges identified above:
In order to mitigate the challenges identified above, the NYP/Queens PPS have undertaken multiple efforts and implemented some effective strategies, all of which are briefly summarized below:
For this 3bi project, the PPS has formed a Cardio committee that meet monthly to discuss deliverables, workflows, best practices and partner feedback. The committee also reports out to Clinical Integration Committee. As the oversight committee for clinical quality, the Clinical Integration Committee in NYP/Queens PPS is responsible for approving best practices, evidence based standards, and protocols that have been recommended by the project committees and/or are deemed necessary by the Clinical Integration Committee. To date, the Cardio Committee and the Clinical Integration Committee have reviewed and approved over several best practices for the PPS. NYP/Queens PPS continues to work with partners in vetting out evidence based best practices for various clinical processes.
The PPS is also working with committees and sub-committees to engage partners in the implementation process for the projects. The goal is to ensure that robust partner participation can reduce the burden of having numerous parallel but separate requests from PPSs surrounding the implementation process. In addition, the PPS is continuing to reach out to neighboring PPSs and look for collaboration opportunities to ensure that these requests are streamlined whenever possible to partners. The NYP/Queens PPS will continue to post the approved best practices to the PPS website to ensure transparency and seamless communication with the public, including community members, other PPSs, and network partners.
In collaboration with GNYHA, the NYP/Queens PPS has hosted an all-day training session on June 15,
2016 for care coordinators in the PPS. Care coordinators are those who would play a coordination role in the continuum of care for patient. The PPS observed very good attendance record for this training. The assigned care coordinators from each partner site were very engaged. This specific training was intended to specifically educate the coordinators about the fundamental, evidence-based concepts for building an effective care coordination process to achieve improved outcomes and understands roles, responsibilities and best practices within their individual sites.
Also, to target the medication management piece for care coordination team development concept,
the NYP/Queens PPS is currently in discussion to work with a partner. The given partner has best practices in medication management and the PPS plans to roll that out for whole network as part of developing care coordination interdisciplinary team.
The PPS is continuing their efforts in working with DOH and Salient contacts who can possibly
manage to offer additional Salient training to the new staff in PMO office. In addition, the PPS is working best to use the data that is currently made available to us and create dashboards and summary to be presented to project committees and possibly utilize for further analysis by RCE unit.
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Implementation approaches that the PPS considers a best practice:
The NYP/Queens PPS has implemented several best practices and undertaken approaches that we consider to be best practices and also highlight our successes to date. The PPS is providing materials related to the Million Hearts Campaign, hypertension diagnosis and medication management, blood pressure check and tobacco cessation referrals for partners. Million Hearts Campaign
The Million Hearts Campaign, http://millionhearts.hhs.gov/, provides resources and protocols on hypertension and tobacco-smoking cessation. These protocols have been provided to participating sites for implementation by the clinical director. The PPS will offer an in service, as needed, with partners and participating sites on how to use the tools and protocols for improving patient care. Blood Pressure Competency
The PPS has approved the competency checklist for both the manual and automatic blood pressure check. Partners will ensure that the BP competency is incorporated into their annual competency check process and provide copies of the completed certification of competency to the PPS.
The PPS will request random audits and documentation of the partner blood pressure competency and utilization of the million hearts campaign. The PPS will use these samples as part of the documentation submission process for the IA quarterly reports. NYS Smokers Quit line Provider Education Resources
In order to make sure providers are comfortable speaking with patients, who are identified as smokers, about the smoking quitting referral, the PPS has provided the partners/providers with education resources from NYS Smokers Quit line program.
Collaborative call- Sep 7, 2016 http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=7050
Continuing Medical Education- online module http://nysmokefree.com/cme/
More tools and resources for Provider & Partners http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=70280
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NYP/Q PPS – Project 3.b.i
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our cardio project as our clinical integration of the project align with the needs outlined in our community needs assessment.
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NYP/Q PPS – Project 3.d.ii
DSRIP Mid-Point Assessment - Project Narratives
PPS must submit a narrative in each
Section for every project the PPS is implementing
PPS Name: NewYork-Presbyterian/Queens
Project: 3.d.ii
Challenges the PPS has encountered in project implementation:
Challenges related to the Asthma Home Based Care project relate directly to funding availability, the ability to influence socio-economic factors within the patient’s home, and the ability to directly improve quality based indictors that cover a broader range of patient outside of a pediatric population. Challenges are detailed below with mitigation strategies outlined in the second section of this file:
Asthma Resource Center (ARC) – The application process originating before the financial valuation created a misalignment of funding and the plans for clinical integration of new service line offerings. Initially in the application, the team planned to develop an Asthma Resource Center (ARC) that would provide care coordination, provider education, and other resources for the provider and patient community.
95% / 5% STC Funding Rule – Understanding that the DSRIP program is focused to maximize efforts and utilization at our safety-net partners, the asthma program has benefits to expanding our relationships with CBO’s and non-clinical providers in order to increase education & access points to the pediatric population. The current 95%/5% rule within the STC limits our ability to incentivize our non-clinical/non-safety net partners to expand the program services.
Home Access & Change – Home access to asthmatic pediatric population has been identified as a challenge as the socio-economic factors of each patient is unique along with the family structure and support system. Gaining access to the home is the initial struggle while influencing changes in the home setting to include behavioral changes of family members is an additional challenge that our program will face.
NYS Assigned Non-Pediatric Quality Metrics – The focus of the Asthma partner network within our PPS is to improve quality outcomes in order to maximize the improvement to our community and partners. The clinical workgroup aligns clinical integration planning with metrics as best as possible but the metrics outlined by the NYS DOH for this project have a wider range of patients that our specific pediatric project. Our application was submitted to serve those 18 years and younger while only two of the five metrics focus to pediatrics (PQI #14 & PQI #15). Three quality indicators cover ages 5-64 (medication management ratio, 50% treatment days covered, and 75% of treatment days covered).
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NYP/Q PPS – Project 3.d.ii
Efforts to mitigate challenges identified above:
The process of risk identification & mitigation planning is an ongoing process of the clinical teams. The clinical workgroup structure allow for proper identification and planning of risks as clinical integration tasks are completed at all partner types. The above risks have been vetted utilizing the clinical workgroup structure and include the following mitigation strategies:
Asthma Resource Center (ARC) – The clinical workgroup has identified an alternative to the Asthma Resource Center (ARC) and has created a plan to develop a CBO based process that will focus to provider education based on the access points of patient activity (ED, Inpatient Hospitalizations, School Based Clinics, Clinical & Non-Clinical providers). The CBO based program will also include a patient navigation / coordination effort to ensure connectivity to home-based care. The program dynamic will ensure education of patients and providers based on the access points and the connectivity to home-based care providers based on the need of the patient or family. The CBO contract with The Asthma Coalition of Western Queens has been executed and the PMO team is working to outline a full scope of the agreement to align incentives based on clinical integration and quality based outcomes for a partner that is non-billable.
95% / 5% STC Funding Rule – The above contract with the Asthma Coalition is being forecasted to maintain the 95%/5% ruling, but the team is finding the incentive funding potential limiting as the NYP/Q PPS has limited revenue potential and 5% is limited. The clinical teams are working internally with safety-net partners to identify additional contracting strategies with CBO’s and other safety net providers in order to maximize incentives to critical non-safety net or non-clinical providers. Such contracting strategies include third-party contracting with safety net providers based on existing relationships.
Home Access & Change – The clinical workgroup, which includes community based organizations, clinical partners, behavioral health partners, and non-clinical partners, understands the dynamics associated with such a challenging process of behavior changes for those surrounding the pediatric asthmatic patient and is building an education based model with multiple access points to help influence change. An example of educational opportunities include school based clinic trainings. The partnership with the Asthma Coalition and Mental Health Providers of Western Queens has provided opportunities for education of the staff within the clinic to identify triggers of asthma patients, refer patients to home-based care, and to help educate family members on the processes available to manage this chronic condition.
NYS Assigned Non-Pediatric Quality Metrics – Understanding that we have no ability to change the indicators for our project, our team is aligning our pediatric asthma project with our PCMH project to increase access and care coordination for this chronic condition. Along with project coordination, the PPS will align the Rapid Cycle Evaluation (RCE) Unit to include provider quality analytics in order to outline process improvement opportunities which will include asthma patient populations up to the age of 65. The expertise in the clinical workgroup will be leveraged during the process improvement processes in an effort to increase awareness, communication, and education to our provider network.
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NYP/Q PPS – Project 3.d.ii
Implementation approaches that the PPS considers a best practice:
The Asthma clinical workgroup has adopted numerous national best practices for this patient population and are being used as a clinical integration tool with all partners committed to this project. Along with the national best practices, our PPS has identified the following as internal PPS best practices to date:
School Based Clinic Education Program – The clinical team outlined an education program for school based clinic staff that focus to asthma basics, environmental triggers, home-based care opportunities, referrals for home-based care and clinical providers, and other items. This education is an amazing opportunity to access pediatrics patients where they spend most of their time, in school, and helps the clinical staff to decrease absenteeism and potentially reduce emergency department utilization and hospital admissions through multiple access points for education & coordination.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our pediatric asthma project as our clinical integration of the project align with the needs outlined in our community needs assessment.
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NYP/Q PPS – Project 3.g.ii
DSRIP Mid-Point Assessment - Project Narratives
PPS must submit a narrative in each
Section for every project the PPS is implementing
PPS Name: NewYork-Presbyterian/Queens
Project: 3.g.ii
Challenges the PPS has encountered in project implementation:
The PPS has identified challenges specific to the implementation of the Palliative Care in Skilled Nursing Facilities (SNF) project. These challenges include the cultural/religious stigma of palliative care, MOLST/eMOLST tools, and Funding/MCO reimbursement rates for services. Challenges are detailed below with mitigation strategies outlined in the second section of this file:
Cultural/Religious Stigma – Queens County Medicaid Beneficiaries are inclusive of a diverse group of people from various ethnic, racial, religious, and cultural backgrounds. Patients/care givers/ family members in the past have been reluctant to participate in end of life and/or palliative care discussions. The PPS has a large lift to engage the community in these efforts and provide information and education on the importance of the integration of palliative care.
MOLST/eMOLST Tools – The PPS has committed to utilizing the MOLST/eMOLST tool for the project. The PPS is encouraging partners to adopt the eMOLST tool but there is resistance amongst clinicians as the tool takes a significant amount of time to complete compared to the paper version (approximately 45 minutes).
MCO Reimbursement/Project Funding – The project partners has indicated that the MCO reimbursements for palliative care services are insufficient or nonexistent specific to consultations and education for the patient/family/care giver. Additionally, as the smallest PPS in the DSRIP program, NYP/Q PPS has very limited resources to commit to the project and provide as incentive funding for partners.
Efforts to mitigate challenges identified above:
Based on the identified challenges, the PPS has formulated mitigation strategies to ensure the success of the project. These strategies are detailed below:
Cultural/Religious Stigma – The PPS has begun a training program for practitioners on palliative care from the EPEC (Education in Palliative and End-of-Life Care) program. The training program includes modules on communication and how to address patients/families/care givers on this topic. Additionally, the practitioners will be provided education from the CC/Hl workgroup on cultural competency and health literacy. The PPS also aims to inform patients and the community on palliative and end-of-life care and will use the biannual town hall meeting as a forum for
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NYP/Q PPS – Project 3.g.ii
presentations and discussion on the topic.
MOLST/eMOLST Tools – The PPS is providing support to partners as they adopt the MOLST or eMOLST forms. The PPS is partnering with Dr. Bomba from Excellus BCBS to provide training on the eMOLST tool to help providers better understand how to navigate and document in the tool and provide tips on how to reduce the time burden for completing the eMOLST.
MCO Reimbursement/Project Funding – The PPS is committed to providing partners with aggregate data on partner survey responses for uncovered services and patient outcome data to use when partners begin the VBP process with MCOs. Additionally, the PPS is providing incentives to partners outside of DSRIP funding, such as EPEC certification and CME credits for participation in training.
Implementation approaches that the PPS considers a best practice:
The Palliative Care committee has adopted several best practices which have been presented to and approved by the Clinical Integration Committee.
EPEC – The training program has been adopted as a best practice for the PPS. The trainings are held bi-monthly and cover two modules per session. The trainings rotate between partner sites and practitioners that attend are eligible to receive CME credits. Additionally, practitioners that attend all of the sessions can receive their certification in EPEC.
EPEC Training
Schedule v3.pdf CAPC— The PPS is engaged with CAPC (Center for Advanced Palliative Care) as an educational
resource for partners. Membership with CAPC has been made available to the partner network at a discounted DSRIP rate. In addition to educational opportunities, CAPC offers information on policy, clinical quality data, networking, and news updates.
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
All scale & speed expectations for this project are forecasted to be met based on those partners committed to the project.
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
There are no current proposals for changes to the populations served with our palliative care project.
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NYP/Q PPS – Project 4.c.ii
DSRIP Mid-Point Assessment - Project Narratives
PPS must submit a narrative in each
section for every project the PPS is implementing
PPS Name: NewYork-Presbyterian/Queens
Project: 4.c.ii
Challenges the PPS has encountered in project implementation:
Challenges related to the project focused to increasing early access, and retention in, HIV care have been discussed in detail with the project workgroup and are described as follows:
Lack of Dedicated Funding for Non-Covered Medicaid Services – Outreach and education are critical elements of this program and the project workgroup has identified an outreach strategy that will require additional contractual relationships with non-clinical (CBO) partners to expand existing programs & service areas that focus to outreach & education based on the needs of the patient base.
Connectivity of Medical Records for Partner Use – The PPS is focused to RHIO connectivity with a rigorous processes and training for the patient consent process, but the HIV population is a select group of patients, similar to behavioral health and pediatrics that has limitations on access.
95%/5% Safety Net Funding NYS DOH Ruling – The HIV project will rely heavily on relationships/contracts with CBO’s in order to expand access to outreach and educational opportunities. The CBO partners identified are not considered safety net providers due to the fact that they are not billable Medicaid providers yet our project will depend on funding to this partner base.
Lack of Quality Based Outcome Data / Partner Specific – The workgroup is currently focused to hot-spotting patient activity in order to identify unmet patient needs for outreach, HIV testing, education, and access to care. The current data compilation is being derived from public data that is dated and the team would benefit from actual PPS partner data to have more timely data specific to the need of the population we serve.
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NYP/Q PPS – Project 4.c.ii
Efforts to mitigate challenges identified above:
Lack of Dedicated Funding for Non-Covered Medicaid Services – The NYP/Q PPS has built a funds flow model that is a group practice method where all projects are considered priority and receive the same formula for an overall resource of revenue received from performance. The HIV project has incentives outlined focused to performance of project requirements, engagement in state level activity, etc. and has educated all partners on the potential to maximize incentives based on their engagement in the project.
Connectivity of Medical Records for Partner Use – The NYP/Q PMO IT team is working with Healthix to identify potential processes for patient consent for this patient population. The team is also working with all partners on the RHIO Connectivity pilot project which is aligned with incentive funding to ensure connectivity.
95%/5% Safety Net Funding NYS DOH Ruling – Partner relationships are being established or expanded for safety-net providers in order to sub-contract with non-safety net providers who are critical to the success of the project. The sub-contractor model is not ideal to ensure timeliness of implementation but will allow partners to maximize return & build on existing relationships with CBO’s.
Lack of Quality Based Outcome Data / Partner Specific – The PPS has been informed that there will eventually be access to this patient level information and the workgroup will complete the hot-spotting activity at that time to continue to identify needs of the community based on geography or partner activity.
Implementation approaches that the PPS considers a best practice:
The PPS partners to include clinical providers, pharmacies, CBO’s, etc. have identified an outreach strategy that aligns with the patient need based on unconventional access points for outreach, education, and testing. The outreach strategy is attached to outline the current approach and will be used to continue to evolve based on the need of the patients and partners.
NYPQ HIV Outreach
Strategy Final.pdf
Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:
The PPS continues to engage in NYS HIV collaboration workgroups to maximize efforts of 6 PPS’s and ensure consistency among partners involved. The collaborative recently identified additional sub-committees focused to topics and the NYP/Q PPS is working with engaged partners to assign members to each workgroup and will work with executive leaders to include in the funds flow method in order to provide incentives to partners for engaging.
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NYP/Q PPS – Project 4.c.ii
Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:
At this time, there has been no changes to populations of patients or network partners that affect the clinical implementation of the HIV project. The PMO team will continue to monitor the patient base and partner network to identify additional changes or trends.
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