Clinical Integration Data Elements · 2019. 9. 5. · PPS network partners ... Cayuga Community...

Welcome and Introductions Cayuga EPAC Representative

Liz Smith

Cayuga County Regional Project Advisory Committee

“Value Based Payment and the Year Ahead”

https://youtu.be/jqFipBmg2Rs

https://youtu.be/jqFipBmg2Rs

Promote community-level collaboration via performing provider systems (PPSs) that

support the formation of Integrated Delivery

Networks…

Improve health outcomes and reduce avoidable

hospital readmissions and emergency department

utilization by…

Preserve and transform the State’s fragile health care

safety net system and prepare providers for

success in Value Based Payment…

VBP 25%

Goals of DSRIPThere are Three Primary Objectives of the DSRIP Program

IDN

• 11 DSRIP Projects with required, at-risk Milestones, Provider, and Patient Targets

1. Integrated Delivery System2. DSRIP Care Management3. ED Care Triage4. Care Transitions5. Patient Activation6. Primary Care/Behavioral Health Integration7. Crisis Stabilization8. Cardiovascular Disease Management9. Palliative Care Integration10. Behavioral Health Infrastructure11. Reduce Preterm Births

• Organizational Workstreams, some with required, at-risk Milestones and Targets

• IT/PHM/Clinical Integration• Workforce & Primary Care Plan• Cultural Competency/Health Literacy• Governance & Performance Reporting• Financial Sustainability & VBP (new)Administer a Value Based Payments Needs

Assessment to the PPS network to identify opportunities to support transition to VBP

Develop a VBP support implementation plan to address the identified needs of the PPS network partners

Develop partner engagement schedule for partners for VBP education and trainings

State-Mandated PPS Requirements

CNYCC Phase I Funding

Approved by CNYCC BOD in November 2015Developed a process to distribute funding for participation

Fund Allocation

Distribution of approximately

$13 million

Activity Focus

Implementation Planning Actively Engaged PatientsReporting

Background – CNYCC Funds Flow

CNYCC Phase II Funding

Currently being finalized for BOD approval (June) Development of a formulaic process to distribute funding for participation

Fund Allocation

Distribution of approximately $49

millionBridge Payment

Phase II Project Agreement

Activity Focus

Actively Engaged PatientsReporting Performance ActivityTransition to VBPBridge Payment

New – CNYCC Funds Flow Policy

• 120 Performance Activities approvedby FFWG

• 84 general Performance Activities• 36 Patient Engagement reporting

activities

• 92 activities directly linked to oneor more outcome measures

• 19 foundational activities addressall outcome measures

Copyright © 2017 All Rights Reserved

Total 120

14

Performance Activities SummaryProject # of Performance

Activities2.a.i 51

2.a.iii 72.b.iii 62.b.iv 72.d.i 143.a.ii 7

3.a.iM1 73.a.iM2 8

3.b.i 103.g.i 7

Multi Project 1Total 120

Contracting PeriodQuarter

# of PerformanceActivities

Quarter 1 24Quarter 2 21Quarter 3 43Quarter 4 32

Performance Activity Update

• CNYCC Project Agreement Submission due 12/31/2017

• Q1 Performance Activity Deadline completed on September 30, 2107

• Q2 Performance Activity Deadline Scheduled for December 31, 2017

• Partner Resources for Reporting• PA Reporting • Partner Guide• Webform Notification • CNYCC Office Hours• General Questions via

info@cnycares

10-minute break

Cayuga County Community Forum

Cayuga Community Health Network

Jessica Soule

Partner Spotlight

Listening SessionsLearning from our residents and consumers

Cayuga Community Health Network, Inc.• Rural Health Network of Cayuga County

• 501(c)3 non-profit organization

• Focus on chronic disease prevention and maintenance

• Chronic Disease Self-Management

• National Diabetes Prevention Program

Community Engagement Forums

• Implementation of patient activation activities to engage, educate, and integrate the uninsured and low/non-utilizing Medicaid populations into community-based care

CCHN proposed 2 listening sessions within Cayuga County in February

Subsidized Housing• For residents

• Thursday morning

• $10 gift cards

• Onsite at housing campus

• Questions related to expectations of care levels, barriers

Rural Community• Community leaders by

invite

• Friday over lunch

• Host Lifespan Therapies, King Ferry

• Questions focused on challenges faced by rural population

Listening Sessions’ Audiences

Forum Results• Identified themes,

ideas, suggestions, surprises

• Created report for stakeholders

• Conduct additional information gathering

• Find solutions to address issues

Population Demographics

Auburn Housing Authority

• Consists of three complexes within City of Auburn

• 326 housing units

• All subsidized housing

• 25% of residents racial minority (12% city of Auburn)

King Ferry

• Town of Genoa 1,935 people

• Very rural community

• Many diary farms (migrant workers)

• 6.7% of people don’t speak English at home

• 2% of population is Guatemalan

HealtheCNY.org

A snapshot of the economic conditions for zip code for King Ferry.

Demographics for the groupsAuburn Housing

• 11 people attended (registered)• 81% has specific health condition

– Asthma, Diabetes, High blood pressure, Depression/anxiety

• 100% had Medicaid, primary dr.• 90% taking medication• 82% smoke• 63% use public transport, 18% have a car,

9% have no transportation• 9% Native, 9% Hispanic, 9% multiracial• Barriers to keeping appt.

– Cost/co-pays– Transportation– Prior experience with dr

King Ferry

• 8 people attended (invited)

• 37% had specific health conditions– Thyroid, diabetes and hypertension

• 88% have private insurance

• 63% take medication

• 12% smoke

• 100% have vehicles

• Multiple people spoke about migrant workers in farming area

• 88% said healthcare was fairly affordable

ThemesTransportation, low health literacy, lack of respect, lack of options

Auburn Housing Authority• Lack of transportation. Most medical offices don’t ask, even

if a note is needed. Call too early, can be rejected.• Lack of respect. Many won’t accept their insurance. Many

referrals out of county but can’t get there.• This culture caused many to feel pushed aside or not valued. • Other challenges to getting quality health care include long

wait times and insufficient time with doctors, issues communicating with doctors –Providers with English as second language, doctors hard

to understand

Auburn Housing Authority continued• Doctors urge clients to make changes. People with success were given

clear directions. Overarching statements don’t work such as lose weight, stop smoking.

• Insurance coverage: Surprised to receive medical bills for procedures and lab work that they didn’t know wasn’t covered. Would have made different choices.

• Preference for healthcare sites for doctors office, urgent care or emergency department:– Urgent care sites are preferred. They see people quicker and are

nicer– ER is challenging because of long waits. It’s uncomfortable and not

clean– Would go to primary care if could get appointments when needed

• Participants provided positive feedback regarding working with insurance navigators

Quotes from Auburn• “They were snotty.” “I never saw my doctor.”

• “Being pushed aside, or not being heard.”

• “They went to college – we have to listen to them.”

• “Don’t look at us like we are stupid because you see we have Medicaid or Medicare.”

• “(Doctors) treat us like we are nothing.”

• “I have a high risk pregnancy and I can’t get an appointment for three months.”

King Ferry• Lack of public transportation. Medical

transport may not pick people up, few buses and no taxi services. Some people have to travel elsewhere to get to care, but can’t physically there.

• Copays and deductibles are a major factor in deciding when and what medical services to seek. Some reject recommended procedures and therapies based on high copays and timing related to insurance.

Town of Genoa = 1,935 people

King Ferry continued• Rural populations are aging. This leads to lack

of volunteers, attrition for those who are involved or donate their time to community efforts.

• Aging in place for residents is limited to those who can afford care. Even then, finding aides willing to come to rural is difficult and inconsistent.

• Internet and cellular service is unreliable and causes major issues. Besides issues with communication to public, and causes difficulty in employee recruitment to small community.

Quotes from King Ferry• “Transportation is a big issue for our families. We’re trying constantly to meet (that need).

There are three of us who offer transportation to the southern end of the county. That’s not enough.”

• “Six months is not acceptable to wait (for dental appointment).”

• “I would say the majority of the people we see here – if we weren’t here (in King Ferry), would not be going to physical therapy and they should. They just can’t drive to Cortland or Auburn. Transportation is an issue.”

Quotes from King Ferry• “All this effort to get people signed up for WIC is almost a waste of time because they will

never get to the appointment.”

• “If our aide can’t come, that’s it. One of us has to be home.” (Isaac has gotten so big that his mom can’t lift him.)

• Immigrants and non-English speakers “are not always welcome at other agencies.”

• “I have a mom coming in today to help her with her taxes, and I’ve been thinking all day with my fingers crossed, ‘I hope the internet works at school’ because for us, it’s hit or miss.”

Next StepsWhat to do with the results

Future Forums • Focus on aging in place, find proposed solutions to seek funding

• Gather more information regarding prediabetes/risk factors

• Referral process survey to healthcare providers

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

Contact Me

Jessica Soule• Cayuga Community Health Network, Inc.

• (315) 252-4212

• [email protected]

Performance & Outcomes Measures (Measurement Year 3, (MY3))November 2015 to November 2016

Performance and Outcomes Measures – Measure SummaryCNYCC Performance Measure Summary MY 2 Total MY 3 Total

Total Measures 48 48

# of Measures with Data Available 24 28# of Measures with No Data Available 24 20

# of Measures on Target 10 16# of Measures off Target 14 12

# of Measures with Unknown Performance 24 20

# of Measures currently Pay for Reporting (P4R)* 39 18/0# of Measures currently Pay for Performance (P4P)* 13 30/48

*18 Measures switch to P4P for the second payment made

Total Available FundingDY4 Payments from MY3 & DY3 Activities

Available Funding for AEP & Performance and Outcomes (Total Available Funding for DY4 - $23,649,197.11)

Actively Engaged Patients (AEP), $1,399,824.35

Performance & Outcomes Measures, $22,249,372.76

Available Funding for Performance and Outcomes – P4R vs. P4P(Total Available Funding for DY4 - $22,249,372.76)

Pay for Reporting – Guaranteed Funds Pay for Performance – Funds Dependent on Results

$19,725,386.85

$1,644,227.34

Available Funding for Performance and Outcomes – P4R vs. P4P(Total Available Funding for DY4 - $22,249,372.76)

Projected NOT to Receive Payment

Pay for Reporting – Guaranteed Funds

Performance Unknown – Pay for Performance

Projected to Receive Payment

$1,644,227.33

$8,307,321.10

$4,527,622.93

$7,770,201.41

Performance and Outcomes – Projected Funding Summary• Dollar Values reflected in the Dashboards are based on the available funds paid out in

DY4. Total available to CNYCC is $22,249,372.76

• Performance Measures are broken into 4 Tiers based on measure worth• Tier 1 – 13 Performance and Outcomes Measures worth $13,070,771.62

• Includes Potentially Avoidable Readmissions and Potentially Avoidable ER Visits Measures

• Tier 2 – 11 Performance and Outcomes Measures worth $5,176,420.18• Includes Adult Access Measures

• Tier 3 – 14 Performance and Outcomes Measures worth $3,420,079.94• Includes Follow-up Care Measures

• Tier 4 – 10 Performance and Outcomes Measures worth $582,101.04• Includes Cardiovascular Measures

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY4 – Performance Measures - $22,249,372.76)

Tier 1, $13,070,771.62

Tier 2, $5,176,420.18

Tier 3, $3,420,079.94

Tier 4, $582,101.04

Measure Tiers Based on Total Funding for All Projects

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY4 Performance Measures – Tier 1 - $13,070,771.62)


Performance Unknown – Pay for PerformanceProjected to Receive Payment

$8,203,323.69 $1,304,837.84

$3,562,610.09

Tier 1 Performance Measure Breakdown - Funding

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY4 Performance Measures - $22,249,372.76)



$1,128,886.13

$1,128,886.13

$1,128,886.13

$744,332.06

$744,332.06

$744,332.06

$1,454,783.00

$564,443.06

$564,443.06

$1,304,837.84

$1,128,886.13

$1,304,837.84

$1,128,886.13

Getting Timely Appointments, Care and Information (Q6, Q8 and Q10)

Care Coordination (Q13, 17 and 20)

HCAHPS - Care Transistion Metrics (Q23 to Q25)

ED Use by uninsured

Non-use of Primary and Preventive Care Services

PAM Score

IPOS

Primary Care - Length of Relationship - Q3

Primary Care - Usual Source of Care - Q2

PQI 90 - Composite of all Measures

Potentially Avoidable ER Vists (Rate Per 100)

PDI 90 - Composite of all measures (Rate Per 100,000)

Potentially Avoidable Readmissions (Rate Per 100,000)

$- $200,000.00 $400,000.00 $600,000.00 $800,000.00 $1,000,000.00 $1,200,000.00 $1,400,000.00 $1,600,000.00

Tier 1 Measure Payments ($13,070,771.62)




$2,049,760.54

$2,665,597.64

$461,061.99



Projected NOT to Receive Payment Projected to Receive Payment

$461,061.99

$512,936.14

$512,936.14

$510,952.12

$376,257.75

$376,257.75

$376,257.75

$512,936.14

$512,936.14

$512,936.14

$510,952.12

$- $100,000.00 $200,000.00 $300,000.00 $400,000.00 $500,000.00 $600,000.00

Screening for Clinical Depression and follow-up (Rate Per 100)

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (Rate Per 100)

Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using AntipsychoticMedication (Rate Per 100)

Prevention Quality Indicator # 8 (Heart Failure) ±

Adult Access to Preventative or Ambulatory Care - 20 to 44 (Rate Per 100)

Adult Access to Preventative or Ambulatory Care - 45 to 64 (Rate Per 100)

Adult Access to Preventative or Ambulatory Care - 65 and older (Rate Per 100)

Adherence to Antipsychotic Medications for People with Schizophrenia (Rate Per 100)

Diabetes Monitoring for People with Diabetes and Schizophrenia (Rate Per 100)

Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) ± (Rate Per 100)

Prevention Quality Indicator # 7 (Hypertension) ±


Performance Unknown – Pay for Performance




$291,323.40

$794,974.06

$2,333,782.48



Projected NOT to Receive Payment Performance Unknown – Pay for PerformanceProjected to Receive Payment

$145,661.70

$145,661.70

$230,531.00

$282,221.53

$282,221.53

$256,468.07

$256,468.07

$256,468.07

$256,468.07

$230,531.00

$282,221.53

$282,221.53

$256,468.07

$256,468.07

$- $50,000.00 $100,000.00 $150,000.00 $200,000.00 $250,000.00 $300,000.00

Controlling High Blood Pressure

Flu Shots for Adults Ages 18 – 64

Follow-up care for Children Prescribed ADHD Medications – Initiation Phase (Rate Per 100)

Children's access to Primary Care - 12 to 19 years (Rate Per 100)

Children's access to Primary Care - 25 months to 6 years (Rate Per 100)

Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44…

Follow-up after hospitalization for Mental Illness – within 30 days (Rate Per 100)

Follow-up after hospitalization for Mental Illness – within 7 days (Rate Per 100)

Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) (Rate Per 100)

Follow-up care for Children Prescribed ADHD Medications - Continuation Phase (Rate Per 100)

Children's access to Primary Care - 12 to 24 months (Rate Per 100)

Children's access to Primary Care - 7 to 11 years (Rate Per 100)

Antidepressant Medication Management – Effective Acute Phase Treatment (Rate Per 100)

Antidepressant Medication Management – Effective Continuation Phase Treatment (Rate Per 100)


Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY4 Performance Measures – Tier 4 - $582,101.04)

$436,439.34

$145,661.70


Projected NOT to Receive Payment Performance Unknown – Pay for Performance

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY4 Performance Measures - $ 22,249,372.76)

$72,830.85

$72,830.85

$48,462.94

$48,462.94

$48,462.94

$48,462.94

$48,462.94

$48,462.94

$72,830.85

$72,830.85

$- $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00

Aspirin Use

Discussion of Risks and Benefits of Aspirin Use

Health Literacy (QHL13)



Medical Assistance with Smoking and Tobacco Use Cessation – Advised to Quit

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Medication

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Strategies

Statin Therapy for Patients with Cardiovascular Disease - Received Statin Therapy

Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80%

Tier 4 Measure Payments ($582,101.04)

Projected NOT to Receive Payment Performance Unknown – Pay for Performance

Performance & Outcomes Measures – Goals & Results(Performance Period: July 2016 – November 2016 [Measurement Year 3])

The Performance and Outcomes Measures below apply to the following projects:

• Integrated Delivery System (2.a.i)

• DSRIP Care Management (2.a.iii)

• ED Care Triage (2.b.iii)

• Care Transitions (2.b.iv)

Performance & Outcomes Measures – Goals & ResultsPay for Performance Measures(Performance Period: July 2016 – November 2016 [Measurement Year 3])

On or Above GoalNot on Target to Goal – Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal

84.3

6%

90.0

9%

87.1

2%

95.3

2%

95.5

3%

91.3

6%

96.9

8%

85.4

0%

90.5

4%

89.0

2%

95.3

9%

95.4

9%

91.8

4%

96.6

1%

85.75%90.77% 89.35%

95.60%95.77%

92.24%96.82%

85.15%90.37% 88.78%

95.24% 95.30%91.55%

96.47%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Adult Access to Preventativeor Ambulatory Care - 20 to

44 (Rate Per 100)

Adult Access to Preventativeor Ambulatory Care - 45 to

64 (Rate Per 100)

Adult Access to Preventativeor Ambulatory Care - 65 and

older (Rate Per 100)

Children's access to PrimaryCare - 12 to 19 years (Rate

Per 100)

Children's access to PrimaryCare - 12 to 24 months (Rate

Per 100)

Children's access to PrimaryCare - 25 months to 6 years

(Rate Per 100)

Children's access to PrimaryCare - 7 to 11 years (Rate Per

100)

(0.45) (1.90) (0.07) (0.48)(1.04)



P4R/P4P Measure switches to P4P

136.73 33.57

589.88

1,185.70

152.32 35.57

626.18 1,155.26

145.5733.93

599.06

1,099.88

157.14 37.02

645.55

1,194.82

-

200.00

400.00

600.00

800.00

1,000.00

1,200.00

1,400.00

PDI 90 - Composite of all measures (Rate Per100,000)

Potentially Avoidable ER Vists (Rate Per 100) Potentially Avoidable Readmissions (Rate Per100,000)

PQI 90 - Composite of all Measures (Rate Per100,000)

P4R/P4P

(30.44)

P4R/P4P



• Behavioral Health/Primary Care Integration (3.a.i)

• Behavioral Health Crisis Stabilization (3.a.ii)


53.6

9%

49.6

6%

34.6

2%

69.3

9%

71.5

6%

78.7

9%

20.7

9%

59.1

4%

41.7

7%

63.6

4%

57.1

9%

44.4

3%

52.5

9%

48.8

9%

33.9

3%

78.9

6%

70.7

7%

79.0

3%

19.7

8%

59.0

8%

41.5

9%

63.1

4%

58.8

3%

43.6

4%

54.04%49.57%

34.51%

79.76%

71.93%79.64%

20.30%

60.85%

43.57%

64.08%59.65%

44.46%

51.55%48.41%

33.51%

78.38%

69.94%

78.60%

19.41%

57.81%

40.17%

62.46%58.25%

43.06%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Adherence toAntipsychotic

Medications forPeople with

Schizophrenia(Rate Per 100)

Antidepressant Medication

Management –Effective Acute

Phase Treatment (Rate Per 100)

Antidepressant Medication

Management –Effective

Continuation Phase Treatment

(Rate Per 100)

CardiovascularMonitoring for

People withCardiovascular

Disease andSchizophrenia(Rate Per 100)

DiabetesMonitoring for

People withDiabetes andSchizophrenia(Rate Per 100)

DiabetesScreening forPeople with

Schizophrenia orBipolar Diseasewho are UsingAntipsychotic

Medication (RatePer 100)

Engagement ofAlcohol andOther Drug

DependenceTreatment

(Initiation and 2visits within 44days) (Rate Per

100)

Follow-up after hospitalization

for Mental Illness – within 30 days (Rate Per 100)

Follow-up after hospitalization

for Mental Illness – within 7 days (Rate Per 100)

Follow-up carefor Children

Prescribed ADHDMedications -Continuation

Phase (Rate Per100)

Follow-up care for Children

Prescribed ADHD Medications –

Initiation Phase (Rate Per 100)

Initiation ofAlcohol andOther Drug

DependenceTreatment (1visit within 14

days) (Rate Per100)(1.64)


(9.57)

(0.24)

P4R/P4P Measure switches to P4P

P4R/P4PP4R/P4P



83.98 92.90

89.39

95.40

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) ± (Rate Per 100)



• Cardiovascular Disease Management (3.b.i)


(3.24)

30.54 166.44

35.12 145.96

33.73

140.06

36.11

150.17

-

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

Prevention Quality Indicator # 7(Hypertension) ±

Prevention Quality Indicator # 8 (HeartFailure) ±

76.83%

55.04%

78.37%

58.28%

79.69%

60.82%

77.43%

56.47%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Statin Therapy for Patients with CardiovascularDisease - Received Statin Therapy (Rate Per 100)

Statin Therapy for Patients with CardiovascularDisease - Statin Adherence 80% (Rate Per 100)

(20.48) (1.54)


Measure switches to P4P

• 11 measures not on target – gain of 1 measure from previous months data (children’s access age 12-19)

• 10 of the 11 measures with month over month improvement • Focus areas include adult access to primary care, patients with schizophrenia, statin

therapy and composite of all measures • Measure with decrease in performance preventative quality indicator #8 for heart failure

(within composite of all measures as well)• Strategic Plan to drive performance developed (see additional slides)

• Continue to trend strongly with potentially preventable ER admissions • AEP Performance Periods (AV- Achievement Value Periods)

• (April 2017- September 2017) (October 2017-March 2018)• Behavioral Health/Primary Care integration hitting targets• Cardiovascular Disease Management on track to hit target• Process verses Performance structure put in place over past 30 days (see additional

slides)

Performance Summary: CNYCC Management Dashboards- MY3 Results Month 7- July AEP

PMO Strategic Plan to Drive Performance & Outcomes

Dashboard & Systems Utilization

Linking Projects to Outcomes

Data Analysis to drive action

(MAPP)

Clinical Sub-Quality Committee, Development of Outcome Sustainability Plans and Best Demonstrated Practices

2020

Rapid Cycle Improvement (MAXNY)Quality Audits-Quarterly reports post milestone completion against 5 step sustainability plans Clinical Sub- Quality Committee’sConsultative Services (work flow analysis, process improvement, practice transformation)Service cost analysis (what does it cost to deliver a service)

POST DSRIP

Actively Engaged PatientsJuly 2017 (Demonstration Year 3)

Actively Engaged Patients – Projected Funding By Project(Total Available Funding for DY4 - $1,399,824.35)

$135,669.32

$104,104.67

$175,085.13

$175,941.50

$203,323.80

$203,477.32

$217,673.41

$184,549.20

$- $50,000.00 $100,000.00 $150,000.00 $200,000.00 $250,000.00

3.b.i - Cardiovascular Disease Management

3.g.i - Palliative Care Integration

3.a.ii - Behavioral Health Crisis Stabilization

2.d.i - Patient Activation

2.b.iv - Care Transitions

2.b.iii - ED Care Triage

2.a.iii - DSRIP Care Management

3.a.i - Behavioral Health/Primary Care Integration

Projected to Receive Payment Projected NOT to Receive Payment Projected to Potentially Receive Payment

Updated w/Aug data

Actively Engaged Patients Process vs Performance

Process• Assessment of AEP reporting requirements “ are we

making things too hard” – changes made to care transitions and cardiovascular

• Assessment within partner submission process- looking at trends; has reporting fell off and process support needed-reach out conducted as needed

• Real time follow-up after initial submission- assessment of issues with files, rosters etc., - internal process developed-immediate contact made with partners

• Assessment for opportunity with retro-active reporting, requesting this data when possible

• Assessment of education gaps in reporting process and providing that education as appropriate

Performance • One on one discussions with Project Managers to develop

action plans for partners who are struggling with implementation of projects- action plans include on-site visits with Director/PM with monthly one to one meetings scheduled with partner(s)- Focus Patient Activation

• Assessment of partners who have not been actively engaged in project (have never reported) and those who have just signed up for projects (Phase 2 funds flow) to develop plans for implementation

• Re-Launch of 2aiii project for re-engagement, education and process improvement of project implementation (October 6, 2017)

• Focus on Palliative Care Project- implementation underway for 2 partners at this time, 1 partner pending contract execution and 3 -5 other partners have expressed interest

• RFP being finalized to be released• Implementation meetings underway• Implementation, planning and training dollars being allocated as

per payment policy

DSRIP Care Management Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

Oneida Health Systems, Inc. Regional Primary Care NetworkJul-17 6

Jun-17 9

May-17 11

Apr-17 6

Mar-17 6

Feb-17 14

Jan-17 4 1

Dec-16 5

Nov-16 5

Oct-16 2

Sep-16 10

Aug-16 6

0

10

20

30

40

50

60

70

80

90

DY Target Actual AEP / Month (*) $ At-Risk

DY3Q2 (9/17) 5,600 32 747 x 6 months $167,000

DY3Q4 (3/18) 16,700 - 1112 x 12 months $144,000

Action Steps

• To increase partnership between Health Homes, down stream providers and medical entities, a finalized sample Service Agreement and Care Coordination communication work flow will be disseminated to partner organizations to assist with implementation strategies.

DSRIP Care Management Actively Engaged Patient Targets

* 80% AEP needed to meet target

ED Care Triage Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

St. ElizabethMedical Center

St. Joseph'sHealth Center

Faxton-St Luke'sHealthcare

Rome MemorialHospital

UpstateUniversityHospital

Oneida HealthSystems, Inc. Oswego Hospital Crouse Hospital Lewis County

General Hospital

AuburnCommunity

Hospital

CommunityMemorialHospital

Jul-17 192 110 78 43 40 31 1

Jun-17 145 142 149 43 55 37 19 43 8

May-17 138 123 156 62 49 53 62 14 22 5 1

Apr-17 202 105 152 71 47 63 41 23 36 1

Mar-17 233 124 94 79 41 46 32 38 6 3

Feb-17 241 123 88 77 58 57 45 33 10 4 4

Jan-17 246 124 92 74 63 52 50 44 15 4 5

Dec-16 213 94 56 73 85 55 12 41 7 4

Nov-16 131 80 32 102 95 55 31 43 29 2

Oct-16 99 136 17 135 74 59 33 17 16

Sep-16 63 94 42 63 44 42 36 21 5 2

Aug-16 44 160 36 184 34 51 27 7 9

0

500

1,000

1,500

2,000

2,500


DY3Q2 (9/17) 7,200 2,562 960 x 6 months $157,000

DY3Q4 (3/18) 14,490 - 966 x 12 months $134,000

Action StepsRecent change (4/19) to expand AEP Definition by suspending the 2 day business notification of PCP or HH CM appointment. The expanded AEP Definition is:

• Had either a PCP or Health Home Care Manager appointment scheduled within 30 Days of the ED discharge date OR• A PCP or Health Home Care Manager appointment scheduled outside of the 30 Days following the ED discharge

BUT had been notified of the appointment within 30 Days of the ED discharge

ED Care Triage Actively Engaged Patients


Care Transitions Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month


St. Joseph'sHealth Center

St. ElizabethMedical Center

AuburnCommunity

Hospital

Oneida HealthSystems, Inc.

Faxton-St Luke'sHealthcare

Rome MemorialHospital

Lewis CountyGeneral Hospital Oswego Hospital Crouse Hospital

Jul-17 120 214 51 100 42 37 1

Jun-17 249 71 60 56 70 42

May-17 251 66 73 49 75 5

Apr-17 228 65 67 64 59 2 6

Mar-17 308 10 83 11 4 5

Feb-17 292 20 58 12 7 1

Jan-17 320 14 29 15 19 1

Dec-16 314 188 72 10 43 37 57 2 1

Nov-16 267 178 61 43 53 17 34 5 15

Oct-16 281 212 82 50 54 15 43 4 11 1

0

500

1,000

1,500

2,000

2,500

3,000


DY3Q2 (9/17) 2,970 2,123 396 x 6 months $156,000

DY3Q4 (3/18) 5,940 - 396 x 12 months $134,000

Action Steps• Actively Engaged Patient definition has been finalized and approved.• All participating Hospitals received the updated AEP and Reporting

Requirements• All participating Hospital have until August 14th at 10:00 a.m. to report AEP for

April, May and June of 2017. Following this retroactive reporting, it is anticipated that our target numbers will significantly improve.

Care Transitions Actively Engaged Patients


Patient Activation Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

LewisCountyGeneralHospital

OneidaHealth

Systems, Inc.

CatholicCharitie

s ofOnonda

gaCounty

PlannedParenthood of

Mohawk

Hudson, Inc.

TheSalvation Army

FingerLakes

MigrantHealthCare

ProjectInc.

CrouseHospital

RescueMissionof Utica

ACRHealth

Faxton-St

Luke'sHealthc

are

AuburnCommu

nityHospital

CatholicCharitie

s ofOswegoCounty

Regional

PrimaryCare

Network

St.Elizabet

hMedicalCenter

NOCHSI

NorthCountryPrenata

lPerinat

alCouncil

Resource

Centerfor

IndependentLiving

Arise,Inc.

PlannedParenthood ofCentral

andWester

n NY

LewisCountyHealthAgency

HillsideChildre

n'sCenter

ElderChoice,Inc.

Hutchings

Psychiatric

Center

UpstateUniversi

tyHospital

Northern

Regional Center

forIndependentLiving

Jul-17 51 41 32 14 5 9 8 24 3 11 4 3 5 1

Jun-17 88 54 18 28 48 30 15 5 3 12 5 17 7 1 11 1

May-17 89 56 79 35 4 30 7 49 17 5 9 12 3 8 3 2 1 1 2

Apr-17 103 35 46 50 5 23 20 74 23 36 12 9 5 14 4 1 2 7 4 2 1

Mar-17 136 53 14 27 15 4 25 14 2 15 2 4 3 7 8 3 4 6

Feb-17 52 33 12 32 27 32 6 34 3 26 7 1 4 4 3 1 1 1

Jan-17 59 41 23 32 5 35 31 8 4 12 1 1 6 14 1

Dec-16 37 16 19 21 9 26 2 7 8 4 3 2 7

Nov-16 70 24 20 109 6 10 4 13 1 9 3 3

Oct-16 27 31 38 5 7 27 8 12 1 4 8 1

Sep-16 35 3 26 2 12 16 10 6 1 1 2

Aug-16 37 12 62 6 8 11 11 3 5 2 4

0

100

200

300

400

500

600

700


DY3Q2 (9/17) 11,100 1,442 1480 x 6 months $135,000

DY3Q4 (3/18) 22,300 - 1,487 x 12 months $116,000

Action Steps• Train-the-Trainer Session scheduled for 8/17/17• Quarterly Implementation Meeting 8/30/17 3:00PM-4:00PM

Patient Activation Performance Measure

• 1 Eligible Re-PAM to Date (Through July 2017) – Performance Not Hitting Target

Patient Activation Actively Engaged Patients/Re-Pamming Status


Primary Care/Behavioral Health Integration Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

St.Elizabet

hMedicalCenter

NOCHSI

Faxton-St

Luke'sHealthc

are

St.Joseph'

sHealthCenter

UpstateUnivers

ityHospita

l

Planned

Parenthood of

Mohawk

Hudson, Inc.

Syracuse BrickHouse

Community

Memorial

Hospital

FamilyCare

MedicalGroup

Regional

PrimaryCare

Network

OswegoHospita

l

Syracuse

Community

HealthCenter,

Inc.

CrouseHospita

l

LibertyResources, Inc.

LewisCountyGeneralHospita

l

FingerLakes

MigrantHealthCare

ProjectInc.

OneidaHealthSystems, Inc.

Farnham Inc.

UnitedCerebral Palsy

Mohawk ValleyPsychia

tricService

s

AuburnCommu

nityHospita

l

Arise,Inc.

Jul-17 582 256 285 72 244 214 49 86 123 41 29 18 34 12 13

Jun-17 687 320 422 160 306 420 43 93 82 256 53 54 97 41 34 15 12

May-17 915 410 528 370 399 204 95 113 105 155 214 67 80 7 47 42 27 8

Apr-17 796 445 569 444 175 97 124 100 186 99 46 98 76 62 19 16 8

Mar-17 491 314 179 269 148 275 226 39 72 69 39 59 51 18 10 7 9 18

Feb-17 471 315 176 210 103 249 208 36 92 92 100 46 48 22 58 21 3 16 12 15

Jan-17 577 417 197 252 164 244 205 42 49 55 132 46 41 24 68 30 7 25 19 18 2

Dec-16 439 468 170 254 235 263 164 38 63 76 51 28 19 26 23 11 16 28

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

DY Target Actual AEP x Month (*) $ At-Risk

DY3Q2 (9/17) 16,490 12,299 2,199 x 6 months $142,000

DY3Q4 (3/18) 39,865 - 2,658 x 12 months $122,000

Action Steps

• Actively Engaged Patient Reporting Criteria narrows starting April 1st to align with the 3ai Standards of Care

Primary Care/Behavioral Health Integration Actively Engaged Patients


Behavioral Health Crisis Stabilization Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

OnondagaCase

Management

OswegoHospital

SyracuseBrick

House

LibertyResources

, Inc.

St.Joseph'sHealthCenter

SyracuseCommunit

y HealthCenter,

Inc.

Arise, Inc.

CayugaCounty

Community Mental

HealthCenter

TheNeighborh

oodCenter,

Inc.

CentralNew YorkServices

HutchingsPsychiatric Center

MohawkValley

Psychiatric Services

NorthCountry

Transitional LivingServices


UnityHouse ofCayugaCounty,

Inc.

OswegoCounty

Opportunities

FarnhamInc.

Jul-17 59 83 61 25 16 11 2

Jun-17 443 157 192 94 69 19 21 18 13 2 2

May-17 475 256 168 319 127 26 24 29 18 23 1 4

Apr-17 459 239 149 242 110 21 18 14 21 2 1

Mar-17 172 235 95 35 20 24 3 2

Feb-17 668 257 157 132 109 21 22 20 15 16

Jan-17 745 268 161 133 156 32 47 25 27 31 13 2 2 1

Dec-16 610 259 163 113 136 39 35 24 13 9 2 3

Nov-16 591 252 150 137 141 24 31 19 16 4 7 1 1 4

0

1,000

2,000

3,000

4,000

5,000

6,000


DY3Q2 (9/17) 10,800 4,033 1,440 x 6 months $135,000

DY3Q4 (3/18) 24,480 - 1,632 x 12 months $116,000

Action Steps• Convening partner-led discussion about Open Access scheduling as a strategy to

improve access to services. • Workgroup meeting to develop protocols around mobile crisis, peer respite and

warm line. • Work of the group will continue, but at the county level; exploring overlap with

the Care Transition Coalitions and other forums.

Behavioral Health Crisis Stabilization Actively Engaged Patients


Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

St.ElizabethMedicalCenter

Faxton-StLuke's

Healthcare


RomeMemorialHospital

Family CareMedicalGroup

LewisCountyGeneralHospital

SyracuseCommunity

HealthCenter, Inc.

CommunityMemorialHospital

NOCHSI

RegionalPrimary

CareNetwork

PhysicianCare, PC

OneidaHealth

Systems,Inc.

St. Joseph'sHealthCenter

AuburnCommunity

Hospital

OswegoHospital

Jul-17 176 132 45 51 37 29 20 7 14 8

Jun-17 230 179 65 55 86 109 39 31 34 14 23 6

May-17 368 258 89 50 23 81 37 41 17 32 17 23 16

Apr-17 235 93 118 54 81 21 43 48 54 60 8 29 17

Mar-17 218 150 65 31 47 82 29 26 24 3 23 4

Feb-17 218 133 24 26 31 62 14 15 29 23 30 17 13 10

Jan-17 65 166 10 25 65 61 14 22 31 32 32 17 9

Dec-16 46 150 15 21 39 31 4 25 30 23 34 12 1 10

Nov 16 38 136 218 52 70 48 20 35 27 10 16 7

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800


DY3Q2 (9/17) 6,460 3,303 861 x 6 months $104,000

DY3Q4 (3/18) 12,730 - 849 x 12 months $89,000

Action Steps• Supporting partner implementation of Standards of Care.• Working with HealtheConnections and other community partners to increase Self-Measured

Blood Pressure opportunities to improve patient blood pressure control.• Continuing work with Central New York Regional Center for Tobacco Health Systems to

support smoking cessation training, 5A’s implementation and connections with the NYS Smoker’s Quitline.

• DY3 focus on promotion of community resources and population health management particularly for high risk patients.

Cardiovascular Disease Management Actively Engaged Patients

74* 80% AEP needed to meet target

Palliative Care IntegrationActively Engaged Patient Contribution by Organization by Month

St. Elizabeth Medical CenterJul-17 13Jun-17 4May-17 1Mar-17 6

0

5

10

15

20

25

30


DY3Q2 (9/17) 1,980 18 264 x 6 months $80,000

DY3Q4 (3/18) 3,960 - 264 x 12 months $69,000

Action Steps• Exploring alignment with PCMH and working with Karen Joncas to develop a

model for delivery within practices to support implementation.• Continued outreach to partner organizations considering the Palliative Care

project to help eliminate barriers to engagement• Developing repository for IPOS for contracted partners to be able to report• Formation of Implementation and Planning Meetings for palliative care

integration project partners and community palliative experts to foster/strengthen implementation

Palliative Care Integration Actively Engaged Patients

76* 80% AEP needed to meet target

Operational Report

Sue Jessen Director of Project Management and Performance Improvement(315) [email protected]

Siti MackManager for Workforce and Cultural Competency/Health Literacy(315) 703- [email protected]

New Employees

Laura BettinaTraining Coordinator(315) [email protected]

CayugaNext Meeting:

TBD

Clinical Integration Data Elements · 2019. 9. 5. · PPS network partners ... Cayuga Community...

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