RFA Application Process • Letter of Intent invitation to

submit full proposal • Innovation Fund Application • Structured Abstract • Rationale (Definition of

Need) • SMART Goals

• Strategy (Intervention Description)

• Evaluation Plan • Impact on Quadruple Aim

Innovation Fund

Innovation Fund RFP

Introduction

Aim: To incentivize innovation and collaboration between health care providers and CBOs (especially Tier 1 CBOs).

If… then..

Incentivizing CBO Engagement in a Community of Care: MHVC’s Three-Pronged Approach to CBO Integration

Damara Gutnick MD, Marlene Ripa, Allison McGuire MPH, Rachel Evans LCSWR, Bruce Rapkin PhD, Kathleen McAuliff PhD, Danny Childs, Kristin Woodlock RN, Rosy Chhabra PhD,

Montefiore Hudson Valley Collaborative, Yonkers, NY

Prioritize projects: • Responsive to Regional needs • Potential to impact high priority clinical outcome metrics - data driven evaluation

plan • Address social determinants of health • Provide services not currently billable to Medicaid, or expand services to meet

community needs • Demonstrate multi-stakeholder collaboration • Strong sustainability strategy • Support IHI Quadruple Aim

Sustainability – Definingnm

Technical Assistance for CBO’s “Coaching” provided by Subject Matter Experts (Einstein Researchers) on: • Project design and LOI development • Proposal development • SMART goal & evaluation metrics & strategy. • ROI Calculation & Planning for Sustainability

CBO Integration Strategy

Project If . . . Then. . .

Meals on Wheels

If we train volunteers to conduct health checks and link “at risk” patients to care.

Then we can decrease ED utilization

Nyack Hospital/ Rockland: Community Paramedicine Collaboration

If we use Community Paramedics to do follow up transitions of care visits

Then we can decrease ED visits and readmissions

Yonkers Public Library: Offering Support Services for Library Patrons

If we train librarians how to link people to social services

Then we can help eliminate health disparities and effectively address “What Matters” to our population

Touch: Together Our Unity Can Heal

If we provide healthy meals and self management support to patients with Diabetes and food insecurity

Then we can improve glycemic control and reduce health consequences due to poorly controlled diabetes.

Identification of Cost Proxies to Guide ROI Calculations

Outcomes • Innovation Funding Awarded: 17 Projects • Planning Grants: 2 Projects • Collaborate with CBO on Final Design • High Touch Technical Assistance

• Survey Design Expertise • Introducing Strategic Partnerships • Feasibility Assessments and ROI

• CBOs appreciated the education and Technical Assistance • As a network administrator. . .

• CBO readiness assessments, VBP education and “coaching” are foundational. • MHVC can foster strategic partnerships by linking aligned projects together.

• Focus on metrics, sustainability and attainment of IHI Quadruple Aim • Prioritize “Patient Experience” (WMTY) and “Joy in Work”

Conclusions

Savings 1pt drop A1c

BH Admission

Hospital Admission

Cost Proxies

ED Visit

Contracting MHVC incentivized foundational elements needed for future VBP

contracts

CBO VBP Training

Regional Meetings Fostered Partnerships

RocklandCounty

FQHC’s

Hospitals

SmallPractices

Specialists

BH

SA&SU

PharmacySkilledNursingFacilities

HealthHomes

CBO’s

CMA’s

DD

Communities of Care

Let’s shift healthcare from. . .

“What’s the Matter?

to

What Matters to you?”

Damara Gutnick MD, Medical Director, MHVC

Being Person Centered About ..

“Things That Matter”

Social Determinants of Healthcare Costs

Targeted Interventions - DSRIP Year 3-5

Outreach & Empowerment - DSRIP Year 1-5

Supporting Sustainability – DSRIP Year 1-5

Kristin Woodlock provides user- friendly VBP preparation to MHVC

Regional Meeting

Clinical Partners CBOs Contracting via Innovation Fund

Contracting metrics include SDH screening & CBO Linkage Survey

Technical assistance by NYAPRS

Regional Forums fostered collaborative proposals

Regional Meetings provided VBP trainings and encouraged CBO linkages

MCTAC VBP Readiness survey Clinical partner and Tier 1 CBO linkages incentivized

WMTY Campaign VBP Training (From Government Agent to Retail)

Sustainability plan TA: ROI

Innovation Fund Proposal TA Patient engagement metrics

Recognizing the important roles played by CBOs in a “Community of Care”, and the need for CBOs to be sustainable in a value-based health care environment, MHVC implemented a three-pronged approach to CBO integration by: • Incentivizing clinical partners to build infrastructure and link to CBOs • Providing technical assistance and training to CBOs to improve readiness for

outcomes measurement • Implementing the Innovation Fund, a playground to spark collaboration and a

roadmap for contracting with CBOs

Get Rid of Your Agent of Government Thinking and Get your Retail Healthcare

On!