citywide project advisory committee meeting...§ by email: [email protected] ... tmts (dfta,...

Citywide PAC Meeting March 8, 2017

CITYWIDE PROJECT ADVISORY COMMITTEE MEETING

March 8, 2017


Today’s Discussion

§  Welcome

§  Networking

§  Follow up from November 2, 2016 PAC Meeting

§  Updates:

•  Status of Project Implementation •  OneCity Health’s Mid-Point Assessment •  Phase II Contracting •  Social Service Integration

§  We Need Your Input

•  Facilitation of Referrals •  Understanding the Needs of Primary Care Partners •  Performance Management •  GSI Development

§  Upcoming Events and Deadlines



§  Welcome

§  Networking


Citywide PAC Meeting March 8, 2017 4

§  At our last PAC meeting, you provided thoughtful feedback on ways we can better support and provide information to partners

§  We heard you and continue to address your feedback

§  The next few slides as well as the Appendix of today’s presentation include status updates on all items raised at our last PAC meeting

§  Please keep the feedback coming!

Thank You for your Feedback at the November PAC Meeting

Please contact the OneCity Health support desk: §  By Email: [email protected] §  By Phone: (646) 694-7090


§  Although the Phase I contracting period ends March 31, 2017, several metrics have due dates continuing into April 2017

§  Reporting for Phase I and Phase II metrics will be clearly distinguished in the Partner Portal

§  We are working to improve and streamline processes for reporting for Phase II contracting

§  More information and updates on the Partner Portal design and reporting processes for Phase II contracting are forthcoming

Feedback from November PAC Meeting

Reporting and invoicing through the Partner Portal


Summary of funds flow to Phase I Comprehensive Schedule B (CSB) contracts to date, through 12/31/2016:

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Feedback from November PAC Meeting (2 of 5)

Many partners are still to submit invoices for one or more approved metrics (see list of partners)

Allocation for CSB (excluding patient

engagement)

Earned by partners through

metric submission

Paid to partners

$28.5M $9.7M $9.5M


WHAT DOES THE DATA INCLUDE?

§  Basic demographic data and reason for attribution to the PPS

§  Medicaid Managed Care Organization (MCO) and fee-for-service individuals

§  MCO PCP and Health Home / Care Management Agency details (if applicable)

§  One year of all paid claims for all services (out/inpatient, pharmacy, long-term care, etc.)

§  Provider-level details including referring and treating provider identification numbers

§  Diagnosis and procedure codes

WHAT CAN WE DO WITH THE DATA?

§  Continue demographic profile and condition prevalence analyses

§  Conduct retrospective analyses of utilization

§  Analyze pharmacy data including prescriber information, dosage, duration, and pharmacy location for all filled prescriptions

§  Explore further utility of the data

WHAT ARE THE LIMITATIONS OF THE DATA?

§  Does not include any payment information

§  At least a 6-month lag on all data provided to us

§  Inconsistent quality and high turnover (25% - 40%) in patient population

§  Not suitable for strategy around patient-level interventions or decision support

§  More work with NYS DOH needed to validate any assumptions we make about the data

§  Due to extremely stringent security requirements, we are unable to share data

Data on Attributed Population



A follow-up call was held on January 25th to hear the perspectives of several partners: AHRC NYC; Cerebral Palsy Association of New York State; Metro Community Healthcare Center; and YAI

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Partner feedback on Cultural Competency/Health Literacy for the Intellectual and Developmentally Disabled (IDD)

To learn more about these partners, please visit their websites: •  AHRC NYC: https://www.ahrcnyc.org/ •  Cerebral Palsy Association of New York State (CPANYS): http://www.cpofnys.org/ •  Metro Community Health Centers: http://www.mchcnyc.org/ •  YAI: https://www.yai.org/

In conjunction with the NYC Health + Hospitals’ Office of Diversity and Inclusion, a listening session with this group is scheduled for March 17th to learn more about better addressing the needs of the IDD population as a PPS



Facilitating referrals across care and social service settings What are the types of questions that help to effectively identify necessary referrals?

Sample questions

§  Have you had 3 or more Emergency Room visits or hospital stays in the last 6 months? (for your own health problems – do not count accompanying a family member or friend, excludes pregnancy)

§  Do you have medical problems, such as: asthma or other breathing problems; diabetes; heart disease; or other long term medical problems?

§  Do you have 5 or more different medications that you take every day?

§  Do you feel you are less able to care for yourself this year than last year (cook, clean, shop, or get to a doctor’s office)?

§  Do you have problems with your mood or feelings, do you feel sad or anxious?

§  Do you currently have a problem with alcohol and drug use?

§  Are you homeless, or do you worry that you could become homeless soon?

§  Do you worry that you will run out of food?

§  Do you feel safe at home?

§  Were you in jail or prison anytime in the last year?

§  Is it hard for you to take your medications or to do what your doctor asks?

§  Do you miss some of your doctors’ appointments?

§  Do you have trouble remembering what people told you?

§  Do you have trouble reading instructions from your doctor?

§  Do you need help finding work?

§  Do you need help finding childcare?

§  Do you need help with enrolling in school or a training program?


§  Welcome

§  Networking


§  Updates:

•  Status of Project Implementation

•  OneCity Health’s Mid-Point Assessment

•  Phase II Contracting

•  Social Service Integration



OneCity Health DSRIP Project Implementation Update (as of January 2017)

DSRIP PROJECT

DY2/3 RISK

PERFORMANCE RISK DESCRIPTION IMPLEMENTATION DESCRIPTION

ED Care Triage CM staff consolidation

Phase 1 underway in 3 NYC H+H facilities (Metropolitan, NCB, Woodhull), kick-off meetings for remaining sites scheduled in early 2017; model for care management staffing was approved--selecting pilot site for Phase 2 in early 2017 and closely aligning with CMMI program to plan for transition

Health Home At-Risk

Partner capacity/staffing;

contracting delay

Contracted with 3 health home leads (NYCH+H, CCMP, CHN) to provide care coordination services; matching HH leads/care coordinators to community primary care partners + NYC H+H facilities

Care Transitions

Partner capacity/staffing

Pilot underway in one medical (Bellevue) and one psychiatric (Kings) setting; contracted with 5 partners to provide TMTs (DFTA, Brightpoint, VillageCare, ArchCare, NYCH+H), matching underway for PPS-wide scale-up in early 2017; 3 teams from VillageCare trained and ready for placement

Palliative Care in PCMH

Network capacity in primary care/social worker shortage

17 NYC H+H facilities performing Phase 1; training resources from Center to Advance Palliative Care (CAPC) made available to entire PPS network. Plan to pilot more intensive training initiative at 12 primary care sites.

Asthma

CHW shortage + training capacity; conversion rate (acceptance of offered services)

Contracted with 11 community partners* to provide CHW services; CHW partners matched to all NYC H+H facilities and 10 community clinical providers**-- two facilities (Elmhurst + Lincoln) generating referrals, PPS-wide scale up in Jan/Feb 2017

PC/BH Integration

BH staffing shortage;

building sustainable colocation model

Consultant contracted to support co-location has begun detailed implementation planning with 10 pilot sites (5 H+H, 5 community partners***), includes both co-location and reverse co-location, depending on the site; preparing to develop additional supports for IMPACT with community clinical providers in 2017

*Asthma CHW VillageCare, a.i.r. NYC, St. Mary’s Healthcare System for Children, CABS Home Attendants Services, Make the Road NY, LSA Family Health Service, Asian Community Care Management, Queens Village Committee for Mental Health, Union Settlement Association, The NY Foundling, NYC H+H

**Asthma Clinical REST Medical, Center for Comprehensive Health Practice, Dr. Sheldon Lippman, SUNY Downstate, Dr. Henry Sardar, Urban Health Plan, Community Healthcare Network, Dr. Joseph Andrade, Boriken Neighborhood Health Center, Gentle Touch Medical

***PCBH Pilot Sites

SUNY Downstate (Family Health Services at Lefferts), SUNY Downstate (Amb. Site), TSINY, Fedcap Rehab Services Inc., Riverdale Mental Health Association, Lincoln, Elmhurst, Bellevue, Kings, Cumberland

High failure risk for speed/scale or sustainability On track for commitments; significant addressable risk On track to meet commitments


DSRIP PROJECT

DY2/3 RISK

PERFORMANCE RISK DESCRIPTION

IMPLEMENTATION DESCRIPTION

CVD

No currently unmanageable risk

Integration with NYC H+H population health programming to strengthen existing efforts; exploring training and technical assistance options for community clinical partners for 2017

Project 11 No currently

unmanageable risk

Contracted with 38 community partners* to utilize the PAM tool with uninsured patients and track the connection of patients to insurance/HHC Options/FQHC + primary care services

MH/SA

No currently unmanageable risk “100 Schools” effort launched via JBFCS and PPS collaborative

HIV (Discrete Projects)

No currently unmanageable risk

First-phase (2016) care model approved and focused on introduction of Pre-Exposure Prophylaxis; 2017 focus is on linkage and navigation

IDS Data access and consents

Community PCMH certification, CCHL self-assessment, and RHIO connectivity pilot all underway; exploring closed loop feedback platform to enable integration of healthcare and social services

*Project 11

Academy of Medical & Public Health Services, * African Services Committee, * APICHA Community Health Center, * Arthur Ashe Institute for Urban Health, Inc, * Bedford Stuyvesant Restoration Corporation, * BOOM!Health, * Bronxworks, * Carribeann Women's Health Association, * Community Service Society of New York, *Council of Peoples Organization, *First MedCare, Inc, * Gentle Touch Medical, PC, * Haitian Centers Council, Inc, * Harlem United/Upper Room AIDS Ministry, * Iris House, Inc, * Jamaica Family Practice & Osteopathic Medicine, * Joseph P. Addabbo Family Health Center, Inc, *Make the Road New York, * MedCare LLC, Medical Arts Sanitarium d/b/a Cornerstone Medical Arts, *Northern Manhattan Perinatal Partnership, * Queens Village Committee for Mental Health for J-CAP, Inc, * Puerto Rican Family Institute, R.A.I.N. Inc, * Rest Medical Care, PC, *Ridgewood Bushwick Senior Citizen Council , * SCO Family of Services, * South Asian Council for Social Services, * Sunnyside Community Services, * SUNY Downstate Medical Center, * Sutphin Drugs Inc, * The Fortune Society , * Upper Manhattan Mental Health Center, Inc. , * Uptown Health Care Management, * Urban Health Plan, * William F. Ryan Community Health Center, Inc, * Xincon Home Health Care Services, Inc.,* Public Health Solutions

High failure risk for speed/scale or sustainability On track for commitments; significant addressable risk On track to meet commitments

OneCity Health DSRIP Project Implementation Update (as of January 2017)


§  Official review of each of the 25 PPSs in New York

§  Assessment was led by New York State’s Independent Assessor (IA)

§  Assessment was comprised of three sources: •  An in-person, half day visit by the IA •  “360 survey” sent to a sample of PPS

partners selected by the IA •  Mid-point assessment narratives

submitted by OneCity Health §  OneCity Health ranked 7th in overall

performance §  Mid-Point Assessment culminated in a

presentation by all PPSs to the Project Approval and Oversight Panel (PAOP)

OneCity Health’s Mid-Point Assessment


§  Two main recommendations from the IA: •  Develop an action plan to increase

partner engagement across projects •  Accelerate its contracting strategy to

distribute funding to promote more engagement

§  IA review of OneCity Health highlighted PPS Risks:

•  Seven of nine projects received a low risk score of two

•  Two projects (Asthma, Integrated Delivery System) received a score of three

§  Partner engagement in implementation efforts

§  Plan to address IA recommendations was developed and submitted for review and approval

•  Includes partner engagement strategy

OneCity Health’s Mid-Point Assessment (2 of 2)


§  Increase in allocation from $55 million in Phase I to $85 million in Phase II

§  What will remain the same from Phase I? •  CSB structure is a single schedule for

partners with identified projects •  Metrics to earn eligible funds •  Use of DocuSign to execute CSB •  Submitting metrics and invoicing through

the Partner Portal

Refinements in Phase II will include: •  Metrics more targeted to partners’

services, including non-Medicaid billing organizations

•  Introduction of outcomes-based measures (subset of NYS identified measures)

•  9-month contract term: April 1, 2017 – December 31, 2017

•  Partners receive 10% of their total eligible allocation upon signing the CSB

•  Most projects that were “carved out” in Phase I are now included in the CSB

•  Level of partner engagement will be a consideration in offering Phase III CSB

•  CSB must be signed by May 15th in order to participate in Phase II contracting period

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Phase II Comprehensive Schedule B (CSB) Contracts - Summary


§  If your organization’s signatory has changed, let us know so we ensure the CSB is sent to the correct signatory

§  Confirm that your organization has a primary and one backup account user for the Partner Portal

§  A template example of the Phase II CSB language and metrics are posted on the OneCity Health website (view the “News” post from February 14) •  Begin reviewing the language in the contract so you

know what to expect when you receive your organization’s CSB

§  If your organization does not receive its CSB by March 31, 2017, please notify the OneCity Health support desk immediately

§  Important dates: •  ~ March 20, 2017: CSB released to signatory through

DocuSign •  March 31, 2017: Contact our Support Desk if your

signatory has not received your CSB •  May 15, 2017: Last day to sign CSB in order to

participate in Phase II contracting period (no extensions will be granted)

Phase II CSB Contracts – Next 30 days

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Define Target Population (for Phased

Roll-Out)

Define Key Social Service Interventions

Develop Screening & Referral Approach

& Tools, and Engage Workforce

Refine Network of Partners

Implement & Evaluate

LEVERAGE EXISTING ASSETS IN PPS

CAPITALIZE ON NEAR-TERM IMPLEMENTATION OPPORTUNITIES

ENGAGE STAKEHOLDERS REGULARLY

Social Services Integration

Overall Framework for Planning & Implementation


Landscape Scan: Developing inventory of current screening tools & methods used for screening and referral at facility & PPS level; reviewing key social service needs of patient population Alignment: Collaborate with key workforce (care management, social work staff, key CBO partners) Launching Near-Term Opportunities: Initiating on-site services where opportunities exist §  NY Legal Assistance Group (NYLAG): Staff

attorneys at 11 acute care sites and 2 post-acute care sites; additional immigration attorneys starting March / April; enhanced training to spur referrals

§  SNAP Enrollers: Recent grants to deploy 3 additional SNAP enrollers for benefits enrollment; looking at opportunities to cross-train existing staff at other facilities to serve as SNAP enroller

§  Health Leads: Health Leads advocates at 3 pediatrics clinics connecting parents to community resources; current evaluation underway

§  Benefits Enrollment: Exploring partnership to expand SNAP enrollment and WIC outreach

§  Enablers: Exploring expansion of access to City’s “Worker Connect” to facilitate discharges and applications and reviewing other data matching initiatives

Referral Management and Tracking: Exploring referral management software options §  Timeline for launch anticipated ~ Fall 2017

Social Services Integration: Status Update



§  Welcome

§  Networking


§  Updates:


§  We Need Your Input •  Facilitation of Referrals •  Understanding the Needs of Primary Care Partners •  Performance Management •  GSI Development


§  Facilitating referrals •  What questions are missing from the list? •  Should any of these questions be clarified?

§  Understanding the needs of primary care partners •  What technical assistance and support

services do these partners need? (See Appendix slide 31 on OneCity Health community primary care network)

§  Performance management •  Request for partners interested in being

part of a workgroup to improve PPS approach to performance monitoring

§  GSI development •  Request for partners to nominate staff

for participation in GSI user acceptance testing

We need your input!

If you have any feedback or are interested in providing additional input identified above, please contact the OneCity Health support desk: §  By Email: [email protected] §  By Phone: (646) 694-7090



§  Welcome

§  Networking


§  Updates:


§  We Need Your Input

•  Facilitation of Referrals •  Understanding the Needs of Primary Care Partners •  Performance Management •  GSI Development

§  Upcoming Events and Deadlines


March 9, 2017 Workforce Impact Survey Office Hours from 10:00 a.m. – 11:00 a.m. Login details on website

March 14, 2017 Monthly partner webinar from 2:00 p.m. – 3:30 p.m. (login details on website)

March 20, 2017 Start release of Phase II CSB to signatories

March 31, 2017 Contact Support Desk if your organization does not receive a Phase II CSB

March 31, 2017 Deadline for submitting several Phase I CSB metrics, including the contract-signing metric (P_1)

April 1 - 20, 2017 Email your completed Workforce Impact Survey to the OneCity Health Support Desk ([email protected])

May 15, 2017 Last day to sign Phase II CSB (Phase II: April 1, 2017 – December 2017)

June 14, 2017 Citywide PAC Meeting (location forthcoming)

Upcoming Dates and Events

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PLEASE TAKE A BRIEF ANONYMOUS SURVEY TO HELP US BETTER SERVE YOU

https://www.surveymonkey.com/r/JNVKCKN

We Work In Service To You: How Are We Doing?

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APPENDIX


# ACTION ITEM STATUS

1 Consider adding a networking component to the PAC Meeting

Networking component added effective March 6, 2017 PAC Meeting. We will continue to encourage networking and welcome any additional feedback

2 OneCity Health to distribute a DSRIP/acronym glossary to group

Update on resources for partners (including a glossary) posted to the OneCity Health website on February 27: http://www.onecityhealth.org/wp-content/uploads/nys-dsrip_glossary.pdf

If there are other terms you would like to see added to the glossary, let us know!

3 OneCity Health to educate practices and partners (of all types) about HIPAA policies, procedures, and practices

We addressed DSRIP compliance requirements and deadlines during January and February 2017 monthly webinars. We are exploring how we can best support partners in understanding HIPAA, more updates to come on this topic

4 OneCity Health to digest the Medicaid claims data Full update provided on slide 7

5 Clarify wording around metric notification window: “validation,” “submitted,” “accepted,” “rejected”

See Appendix slide 30

6 Partners would like to receive automatic email notification of metric status changes

Due to NYC Health + Hospitals’ policy, automatic emails (“push notifications”) are not possible. Follow-up emails are sent by the support desk when a metric is rejected, as well as monthly reminders (via email or phone) when metric invoices are available for submission


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# ACTION ITEM STATUS

7 OneCity Health to develop further clarity on vision for IT/single platform for communicating and collaborating across all partner types

While the PPS will never be able to adopt one unified IT platform across all sites, we are working on getting all our partners connected to the Regional Health Information Organization (RHIO) which will serve as the standard platform for data exchange and retrieval in the PPS.

Many partners have been contacted by Digital Edge, our IT assessment vendor, and we thank you for your cooperation! Using that data, we are launching the next phase of this effort by reaching out to partners who do NOT have a connection to the RHIO and are offering technical assistance in connecting them.

Although OneCity Health will not be offering monetary compensation, we will be partnering with NYC Health + Hospitals IT staff to do much of the technical heavy lifting. Be on the lookout for further communications from the PPS around this.

8 Support Desk does not always have full knowledge to address partner questions about why metrics were rejected and cannot see what the partner sees while troubleshooting specific issues

For audit reasons, OneCity Health cannot enter a partner’s account to see exactly what they see; however, we are identifying ways to better support partners including:

•  Support Desk has been asking partners for screen shots to view exactly what they are seeing when certain problems arise

•  We are educating our internal team on how to better understand what a partner should see and how to troubleshoot partner challenges

As we move into Phase II contracting, we are working to redesign the Partner Portal to streamline/eliminate areas of confusion


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Submitting Metrics: Main Notifications Window On the Schedule B landing page, the Notifications Window in the upper left corner of the screen shows all activity for all submitted metrics.


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To view the history of a particular metric: §  Scroll down webpage to the relevant project §  Click the arrow to expand the project to see all metrics related to that project §  Select “View Report” to see the status

Submitting Metrics: Main Notifications Window


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The Notifications Window in the upper left corner of the screen shows all activity for that specific metric.

Submitting Metrics: Main Notifications Window – Statuses & Definitions


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STATUS DEFINITION

“Report received” Confirmation that partner has submitted a metric

“Pending validation approval”

Pending first level of approval, which reviews bare minimum requirements were met: e.g., attachment was included, correct reporting template used, etc.

“Validation approved” First level of approval completed

“Pending Content Review” After first level of approval, the metric goes for in-depth content review which involves reviewing all content provided by the partner to see if it meets criteria for payment

“Content Approved” Content review is completed

“Submit Invoice” Invoice has been generated and is ready to be submitted by partner

“Invoice Received” Confirmation that partner has submitted an invoice

“Pending Invoice Approval” Invoice is pending first level of approval

“Invoice Approved” Submitted invoice has been approved for payment

“Processing Payment” Payment to the partner is being processed

Submitting Metrics: Main Notifications Window – Statuses & Definitions


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180 sites offer primary care services across 48 community partners/systems

Community Primary Care Network

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BRONX BROOKLYN MANHATTAN QUEENS CITYWIDE*

# Primary Care Sites

5 12 12 9 142

# Partners with Primary Care

Sites in Borough

5 9 6 8 20

* Community partners with primary care sites in two or more boroughs are classified as “Citywide”

citywide project advisory committee meeting...§ by email: [email protected] ... tmts (dfta,...

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