agenda i.our dsrip: acp / aw medical what it means for community providers like us? ii.the physician...
TRANSCRIPT
AGENDA
I. Our DSRIP: ACP / AW Medical
What it means for community providers like us?
II. The Physician and DSRIP:
Pay for performance
III. Patient engagement:
Simple steps to higher payment
• Asian American ACO• Chinese American IPA• Chinese Community ACO• Eastern Chinese American Physicians IPA• Korean American Physicians IPA• CBW Community Health Center
Community Provider Network (CPN)
• Balance Medical ACO• Balance Medical IPA• Breukelen Community Network IPA• Corinthian Medical IPA• Excelsior Medical IPA• Queens County IPA
Renaissance Collaborative (RC)
• Dr. George Liu, Co-Chairman• Dr. Ramon Tallaj, Co-Chairman• Dr. Henry Chen, Treasurer • Dr. Emilio Villegas - Secretary• Dr. Bing Lu, Board of Manager• Dr. Hanbin Zheng, Board of Manager• Dr. Jonathan Chang, Board of Manager• Dr. Michael Li, Board of Manager• Dr. Sunhoo Foo, Board of Manager• Dr. Vincent Wang, Board of Manager• Dr. Hal Sadowy, Co-Chief Operating Officer• Ms. Peggy Sheng, Co-Chief Operating Officer
NYCPP Leadership Team
Non-physician partners
AW Medical PPS is not just made up of Physicians
Behavior Health and
other important providers
Physicians
Hospitals
• ACMH, Inc.• Affinity Health Plan• Alpine Home Health Care• Amazing Home Care• Amber Court At Home• Amber Court Of Pelham Gardens• Arms Acres, Inc• Best Choice Home Health Care, Inc.• Beth Abraham Health Services• Boris Dubrovsky, Phd• Bronx Center For Rehabilitation &
Health Care• Bronx Lebanon Hospital Center• Bronx Park Rehab & Nursing Center• Bronx Supported Housing • Bronx-Lebanon Hospital Center• Center for Urban Community Services• Centerlight Healthcare Inc.• Centerlight Healthcare Diagnostic & Tr
eatment Center• CL Healthcare Inc• Community Access Inc• Daughters Of Jacob Nursing Home
Company Inc.• Doshi Diagnostic Imaging Services,
P.C.• Eli Leiter, Phd• Friends And Family• Hebrew Home At Riverdale• Jewish Association For Services For
The Aged (Jasa) • Jewish Board Of Family And Children'S
Services• Kings Harbor Multicare Ctr.• Kingsbridge Hieghts Rehab And Care
Center• Mvp Housing Development Fund
Company Inc.• Narco Freedom, Inc• New York Dialysis Services, Inc.
• New York Psychotherapy And Counseling Center
• Palisade Nursing Home Company, Inc.• Park Housing Development Fund
Company Inc.• Phoenix Houses Of New York, Inc.• Postgraduate Center For Mental Health • Project Renewal• Rain (Regional Aid For Interim Needs)• Riverdale Mental Health Association• Rosselle Estrella, Pt• Scheuer Gardens Limited Partnership• Scheuer Plaza Limited Partnership• Schnurmacher Center For
Rehabilitation And Nursing• Seniorcare Emergency Medical
Services• Seniorride• Sheryll Garcia, Pt• St Barnabas Hospital Health System• St Joseph's Hospital• Steinway Child And Family Services,
Inc• Success Counseling Services, Inc• Sus-Mental Health Programs, Inc.• Terrace Health Care Center, Inc• The Bridge• The Pac Program Of The Bronx, Inc• University Consultation & Treatment
Center For Mental Hygiene, Inc.• University Nursing Home• VIP Community Services• Westchester Family Health Center• Weston United Community Renewal,
Inc.• Williamsbridge Manor Nursing Home
Bronx
• MJHS License Home Care Service Agency
• AlphaCare• Amber Court at Home• Amber Court of Brooklyn• Americare Certified
Specialty Services, Inc.• Anna Sidorkina, LAC• Best Choice Home Health
Care, Inc.• BETH ISRAEL MEDICAL CTR• BGR Services, Inc.• Boro Park Center for
Rehabilitation & Health Care• Breukelen Community
Network IPA• Bridge Back to Life Center,
Inc.• Bridger• BRIDGING ACCESS TO
CARE• Brooklyn Center for
Rehabilitation and Residential Health Care
• Brooklyn Community Services
• Bushwick Brooklyn ACT• Bushwick Center for
Rehabilitation and Health Care
• CAIPA Social Day Care Center
• Catholic Charities• Center for Nursing and
Rehabilitation• Center for Urban Community
Services• CenterLight Certified Home
Health Agency• Central Brooklyn ACT• CL Healthcare Inc• Cobble Hill Health Center,
Inc.• Community Access Inc./
Warren Street• Community Radiology of NY• Doshi Diagnostic Imaging
Services, P.C.• East Brooklyn ACT Team• Elderplan• Emerson TAP• Empire City Laboratories• Federation of Organizations
for NYS Mentally Disabled• Fresenius• God's Love We Deliver, Inc• Guidance Center of
Brooklyn• Health Homes
• Homecrest Community Services, Inc
• ICL• ICM Brooklyn• Jewish Board of Family and
Children's Services• John J. Pershing
Intermediate School 220• Lawton Street Community
Residence• Linden House Community
Residence• Livonia Avenue • LUTHERAN MEDICAL
CENTER• Marizza Dulfo, PT• Menorah Center for
Rehabilitation and Nursing Care
• MJHS Long Term Care• New York Congregational
Nursing Center• New York Psychotherapy
and Counseling Center• NEW YORK THERAPEUTIC
COMMUNITIES, INC• Ohel Childrens Home and
Family Services • Phoenix House Foundation,
Inc.
• Phoenix Houses of New York, Inc.
• Postgraduate Center for Mental Health
• Preventive Diagnostics• Rockaway Park Center• Shiel Medical Laboratory• St. Joseph's Hospital• St. Mark's MICA Supported
Housing• St. Mark's Scattersite
Supported Housing• Steinway Child and Family
Services, Inc.• Steppingstone Congregate
Treatment• Summit Home Health Care• Supported Housing for
Women with HIV/AIDS• SUS• Tillary Street Women's
Shelter• Williamsburg Physical
Therapy
Brooklyn
• 181 Street Medical PC• 3rd Street Men's Shelter• ACMH, Inc• Alberto De Castro, PT• Aleksey Kleyman, LAC• Americhoice• Amerigroup MLTC• Amerigroup/Healthplus• Asian American Accountable Care
Organization, LLC• Balance Medical ACO• Balance Medical IPA, Inc• Beacon of Hope House• BETH ISRAEL MEDICAL CTR• Bridge Back to Life Center, Inc.• CareNext• Center for Alternative Sentencing
and Employment Services• Center for Urban Community
Servcies• Charles B. Wang Community
Health Center• Chinese American IPA, Inc.
• Chinese Community Accountable Care Organization
• CL Healthcare Inc• Community Access Inc.• Community Association of
Progressive Dominicans (ACDP)• Comunilife Inc• Coordinated Behavioral Care, Inc
Pathways to Wellness HH• Corinthian Medical IPA, Inc• Diana Badillo• Doshi Diagnostic Imaging
Services, P.C.• Elizabeth Uzor• Elmont Open MRI• Empire State Dental• Geffner House• Good Sheperd Services• Gouverneur Healthcare Services -
Skilled Nursing Facility• Gramercy Park Digestive Disease
Center, LLC• Greenwich House, Inc.
• Harlem East life Plan• Healthfirst• Heritage Health Home Network• Heritage Healthcare Network• ICL Broadway Community
Residence• Isabella Nursing Home• Jason Waterman• Jewish Board of Family and
Children's Services• Kenneth Ged• Kenton Hall Men's Shelter• L&L Orthotics, LLC• Manhattan Supportive Housing• Mary Claire Arbilo, PT• MARY MANNING WALSH• Melida Knibbs• Metroplus Health Plan• Metropolitan Center for Mental
Health• Metropolitan Jewish Home Care
Inc. d/b/a MJHS Home Care
Manhattan
• MIH Experience LTD• Mitzy Baldovino, PT• MJHS Hospice and Palliative Care• National Association on Drug
Abuse Problems, Inc.• New York Dialysis Services, Inc.• New York eHealth Collaborative
(NYeC)• NEW YORK EYE & EAR
INFIRMARY• Ninel Platsman, PT• Palladia, Inc.• Phoenix House Foundation, Inc.• Postgraduate Center for Mental
Health• Project Renewal• Rapid Care Solutions• Rowell Arguelles, PT• Salcare Home Health Services,
Inc• SCAN New York• Senior Health Partners
• Senior Whole Health• Seong Chul Ha, LAC• Service Program for Older People,
Inc.• Shiel Holdings, LLC • Shiel Medical Laboratory• ST LUKES ROOSEVELT HOSP-
ROOSEVELT HOSP• ST LUKES ROOSEVELT HOSP-
ST LUKES HOSP• St. Nicholas House• SUS- Mental Health Programs,
Inc. • TERENCE CARDINAL COOKE• The Bridge• The Fifth Avenue Counseling
Center, Inc.• The First Chinese Presbyterian
Community Affairs Home Attendant Corp.
• THE MOUNT SINAI HOSPITAL• The National Alliance for the
Mentally Ill of New York City, Inc.• The PAC Program of The Bronx,
Inc• United Rx Buying Group LLC• University Settlement Early
Intervention Program• Vidyasagar Pamulapati, PT• Vijayalakshmi P. Davuluri, PT• Visiting Nurse Service of New
York Home Care• VNS Choice• VNSNY• VNSNY Behavioral Health• VNSNY Hospice and Palliative
Care• Washington Heights Imaging• WellCare Health Plan• WellCare MLTC• Weston United Community
Renewal, Inc.• Women In Need
Manhattan (continued)
• ACMH, Inc.• Alvin Orodio, Pt• Amber Court Of Westbury• Arms Acres, Inc• Bleuler Psychotherapy Center,
Inc.• Bridge Back To Life Center, Inc.• Catholic Charities• Center For Urban Community
Services/Rikers Island Single Stop• CL Healthcare Inc• Conifer Park, Inc• Cornerstone Medical Arts Center
Hospital• Cuatro Llc Dba Access Medicare
Ny• Doshi Diagnostic Imaging
Services, P.C.• Dr. William O. Benenson Rehab
Pavilion• Eastern Chinese American
Physicians Ipa• Excelsior Medical IPA• Fed Of Org For Nys Mentally
Disabled• Fidelis Care
• Fishman Center Total Eye Care• Flushing Manor Care Center• Flushing Manor Dialysis Center• Flushing Manor Nursing Home• Goodwill Industries• Holliswood Center For
Rehabilitation And Healthcare• Jewish Board Of Family And
Children'S Services• Liberty Physical Medicine &
Rehab• Long Island Care Center• Long Island Consultation Center• Margaret Tietz Nursing And
Rehabilitation Center• Michael K.T. Mangubat, Pt• Milestone Supportive Housing• New Horizon Counseling Center• New York Psychotherapy And
Counseling Center• Ohel Childrens Home And Family
Services • Parker Jewish Institute For
Healthcare & Rehabilitation• Phoenix House Foundation, Inc.• Phoenix Houses Of New York, Inc.
• Postgraduate Center For Mental Health
• Qsa Services, Inc.• Queens Center For Rehabilitation
& Residential Health Care• Queens County Ipa• Queens Treatment Apartment
Program• Samaritan Village • Samuel Field YM/YWCA• Shiel Medical Laboratory• South Shore Physician Group• St Joseph's Hospital• Steinway Child And Family
Services, Inc.• Supportive Services For Veteran
Families• Sus- Mental Health Programs, Inc. • The Mount Sinai Hospital Of
Queens• Union Plaza Nursing Home Dba
Union Plaza Care Center• Venture House• Xeron Labs
Queens
ABOUT DSRIP
• Delivery System Reform Incentive Payment
• Incentive payments are performance based
• Patient engagement is KEY for incentive payment
calculation which starts 01/01/2015
• Goals are to achieve transformation of the health care safety
net provider system, improving healthcare quality, improving
population health, reducing avoidable hospital and ED use,
and lowering healthcare cost.
ACHIEVING THE GOAL
• Implementing collaborative models of patient care
• Enhanced care coordination and care management
models
• Monitoring specific performance measures
• Adherence to evidence-based protocols
• Adherence to standardized processes across the PPS
• EDI and PCMH level 3 certification
2.a.i Integrated Delivery System
2.a.iii Health Home At-Risk Intervention Program
2.b.iii ED care triage for at-risk populations
2.b.iv Care Transition
3.a.1 Integration of Primary Care & Behavioral Health
3.b.1 Cardiovascular Disease Management
3.c.1 Diabetes Disease Management
3.d.iii Asthma Management
4.b.i Tobacco Use Cessation
4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and
Management in Both Clinical and Community Settings
Projects Selection
• 2.a.i Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management
• Target: All patients and Providers
• Engagement: Every patient has a sign RHIO consent form.
PCMH (2014 Version) Level 3 by 2017
2014 2015 3/31/2015 2016 3/31/2016 2017 3/31/2017
Action Attest Data Action Attest Data Action Attest Data
EHR
Adopt, Implement, Upgrade (AIU) to 2014 Certified EHR
AIU to Certified EHR
AIU any 90-day period from 2014
Use Certified EHR
MU Stage 1-Y1any 90-day period from 2015
Use Certified EHR
MU Stage1-Y2 & meet MU Stage 2 criteria
full yr. 2016
MU Stage 1-Y1 any 90-day period from 2014 MU Stage 1-Y2 full yr. 2015 MU Stage 2-Y1 full yr. 2016
MU Stage 1-Y2 any 90-day period from 2014 MU Stage 2-Y1 full yr. 2015 MU Stage 2-Y2 full yr. 2016
MU Stage 2-Y1 any 90-day period from 2014 MU Stage 2-Y2 full yr. 2015 MU Stage 3-Y1 full yr. 2016
PCMHUpgrade to PCMH 2014 version
Prepare PCMH Level 3 Submit PCMH Level 3 Achieve PCMH Level 3 by 6/2017
2.a.iii Health Home At-Risk Intervention Program
Target: Patients with one progressive chronic disease, serious mental Illness or traumatic brain Injury Engagement: Every patient that has a documented comprehensive care plan in place
2.b.iii ED care triage for at-risk populations
Target: Every patient seen in the EDEngagement: Every patient is given an appointment with their PCP or Health Home
2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions
Target: Every patient with a Hospital admission or ER visitEngagement: Every patient in with pre-discharge planning and transitional care visit
3.a.i Integration of primary care and behavioral health services
Target: Every patient seen in the Primary Care or Behavioral Health settingEngagement: Every patient must have PHQ9 screening performed and documented
3.b.i Evidence based strategies for disease management in high risk/affected populations (adult only) (Cardiovascular Health)
Target: Every adult patient with Cardiovascular disease or Hyperlipidemia Engagement: Every patient must have life style change counseling documented
3.c.i Evidence based strategies for disease management in high risk/affected populations (adults only) (Diabetes Care)
Target: Every adult patient with DiabetesEngagement: Every patient must have a documented HgbA1C
3.d.iii Evidence based medicine strategies for asthma management (Asthma)
Target: Every patient with AsthmaEngagement: Every patient must have a documented Asthma action plan in place
4.b.i Tobacco Use Cessation
Target: All smokersEngagement: Every patient must be screened for tobacco use and smokers counseled on cessation and referral to NY QUITS documented
4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings
Target: All patients Engagement: Document and Prescribe Colonoscopy, Mammogram, Pap Smear, Prostate exam, HPV Vaccination, Safe Sex Education
Support Team
• Lidia Virgil [email protected]
• John Dionisio [email protected]
• Susan Lau [email protected]
• Liz Webb [email protected]