DUE TO THE STATE ON MONDAY, DECEMBER 22, 2014 BY 5:00PM. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 1 of 159

Transcription

1 Finger Lakes Performing Provider System Draft DSRIP Project Plan Application Posted for public comment: December 12, 2014 Public comment due: December 15, :00 pm DUE TO THE STATE ON MONDAY, DECEMBER 22, 2014 BY 5:00PM DRAFT FOR PUBLIC COMMENT NOT FINAL Page 1 of 159

2 Table of Contents Contents Section 1 Executive Summary... 3 Section 2 Governance... 6 Section 3 Community Needs Assessment Section 4 DSRIP Projects a.i Create integrated delivery systems Project Justification, Assets, Challenges, and Needed Resources (1500 word limit, Total Possible Points 20) System Transformation Vision and Governance (1500 word limit, Total Possible Points 20) Scale of Implementation (Total Possible Points - 20) Speed of Implementation/Patient Engagement (Total Possible Points - 40): Project Resource Needs and Other Initiatives (750 word limit, Not Scored) b.iii ED Care Triage for At-Risk Populations Project Justification, Assets, Challenges, and Needed Resources b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions b.vi Transitional Supportive Housing d.i Project a.i Integration of Primary Care and Behavioral Health Services a.ii Behavioral health community crisis stabilization services a.v Behavioral Interventions Paradigm f.i Increase support programs for maternal and child health a.iii Strengthen Mental Health and Substance Abuse Infrastructure across systems b.ii Increase access to high quality chronic disease preventive care and management in both clinical and community settings Section 5 PPS Workforce Strategy Section 6 Data-Sharing, Confidentiality & Rapid Cycle Evaluation Section 7 PPS Cultural Competency/Health Literacy Section 8 DSRIP Budget & Flow of Funds Section 9 Financial Sustainability Plan Section 10 Bonus Points Section 11 Attestation Appendix A Currently Known Scale & Speed DRAFT FOR PUBLIC COMMENT NOT FINAL Page 2 of 159

3 Section 1 Executive Summary Description The PPS & Project Plan Application must include an executive summary clearly articulating how the PPS will evolve into a highly effective integrated delivery system. The executive summary should address the following: Succinctly explain the identified goals and objectives of the PPS. PPS Response (1000 characters max): Current: 2,096 characters Transformation from volume to value based payments, and from sick to wellness care, requires dramatic changes in the current health care delivery system. The Finger Lakes PPS (FLPPS) is committed to strong, systemized partnerships for health care delivery among a wide range of care providers with the purpose of creating a more integrated care delivery system that is accountable for some of the most vulnerable patient populations in our region. The specific changes required to ignite transformation vary widely across the diverse communities and geographies represented in the FLPPS. The variations include not only differences in currently available resources, the demographics and ethnography of the various urban and rural populations, available competencies and capacities of community based organizations (CBOs) throughout the PPS, but also the existing health care delivery infrastructure and the current flow of financial incentives to providers, as well as for patients based on contracts and benefit plans. The highly comprehensive network of roughly 130 home- and communitybased partners ranging from acute health care, behavioral health, community service agencies, housing, health planning and FQHCs share the vision to create an accountable, coordinated network of care that improves access, quality and efficiency of care for the safety net patient population across our participating counties. This represents an unprecedented commitment to region-wide, crossorganizational, and cross-silo collaboration. Based on the issues, needs, and resources identified in our CNA, the FLPPS has identified the following goals: - Improve access to care, quality of care, member safety and satisfaction, efficiency and costeffectiveness of care. - Improve long term financial stability of caregivers within the network. - Provide strong clinical leadership and resources to the network. - Drive advocacy and policy development to improve access to care. - Provide the best practice opportunities for physicians and other practitioners who want to treat patients in underserved communities. Explain how the PPS has been formulated to meet the needs of the community and address identified health care disparities. PPS Response (1,200 characters max): Current: 917 characters Throughout the development of the PPS, there has been a focus on engaging not only traditional health care providers and payers, but also community based organizations and other stakeholders. Additionally, there has been a focus on identifying, cultivating and engaging with leadership across the large number of communities within the 5 Naturally Occurring Care Networks (NOCNs). This has been facilitated in partnership with the Finger Lakes Health Services Agency (FLHSA), which also drove the development of the FLPPS CNA and deeper engagement with rural primary care providers. The proactive engagement with DRAFT FOR PUBLIC COMMENT NOT FINAL Page 3 of 159

4 CBOs and geographically diverse leaders from across the health and wellness continuum will ensure that in the long run FLPPS will have identified the highest priority health disparities and will be set up for success with addressing them and closing existing gaps in care, cultural competency and access. Provide the vision of what the delivery system will look like after 5 years and how the full PPS system will be sustainable into the future. PPS Response (1,200 characters max): Current: 966 characters The FLPPS performing providers are committing to a long-range and permanent transformation, starting with the five-year, multi-phase process of DSRIP-driven care transformation that requires ongoing collaboration, trial-and-error, and piloting innovative systems and concepts that will provide a strong, clinically integrated foundation. During this process, FLPPS will work with the local MCOs to establish commons systems and processes, along with risk sharing and value-based reimbursement that rewards improvements in quality of care, population health outcomes, member satisfaction, and overall annual per member cost savings. We are confident that the initiatives taken on by FLPPS in conjunction with partnerships with local, state and federal officials to attain the triple aim will lead to integrated, coordinated patient-centered care that will ultimately improve the health of the population, and that will lead to long term financial sustainability. Regulatory Relief Is the PPS applying for regulatory relief as part of this application? (Please see Regulatory Flexibility Guidance for Performing Provider Systems, available at: (Please mark the appropriate box below.) Yes No If yes, for each regulation for which a waiver is sought, identify in the response below the following information regarding regulatory relief: Identify the regulation that the PPS would like waived (please include specific citation); Identify the project or projects in the Project Plan for which a regulatory waiver is being requested and outline the components of the various project(s) that are impacted; Set forth the reasons for the waiver request, including a description of how the waiver would facilitate implementation of the identified project and why the regulation might otherwise impede the ability of the PPS to implement such project; Identify what, if any, alternatives the PPS considered prior to requesting regulatory relief; and Provide information to support why the cited regulatory provision does not pertain to patient safety and why a waiver of the regulation(s) would not risk patient safety; include any conditions that could be imposed to ensure that no such risk exists, which may include submission of policies and procedures designed to mitigate the risk to persons or providers affected by the waiver, training of appropriate staff on the policies and procedures, monitoring of implementation to ensure adherence to the policies and procedures; and evaluation of the effectiveness of the policies and procedures in mitigating risk. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 4 of 159

5 PPS Response (100 characters to list regulation; 3,000 to answer above questions for each regulation) This will be developed over the next week as more of the detail related to project implementation and capital budget requests become clearer. PPSs should be aware that the agencies may, in their discretion, determine to impose conditions upon the granting of waivers. If these conditions are not satisfied, the State may decline to approve the waiver or, if it has already approved the waiver, may withdraw its approval and require the applicant to maintain compliance with the regulations. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 5 of 159

6 Section 2 Governance Section 2 Governance (25 percent of the Overall PPS Structure Score) Description An effective governance model is key to building a well-integrated and high functioning DSRIP PPS network. The PPS must include a detailed description of how the PPS will be governed and how the PPS system will progressively advance from a group of affiliated providers to a high performing integrated delivery system, including contracts with community based organizations. A successful PPS should be able to articulate the concrete steps the organization will implement to formulate a strong and effective governing infrastructure. The governance plan must address how the PPS proposes to address the management of lower performing members within the PPS network. The plan must include progressive sanctions prior to any action to remove a member from the PPS. Governance Organizational Structure (worth 20 percent of total points available for Section 2) Please provide a narrative that explains the organizational structure of the PPS. In the response, please address the following: Outline the organizational structure of the PPS, for example, please indicate whether the PPS has implemented a Collaborative Contracting Model, Delegated Model, Incorporated Model, or any other formal organizational structure that supports a well-integrated and highly functioning network. Explain why the selected organizational structure will be critical to the success of the PPS. In addition, please attach a copy of the organizational chart of the PPS. Also, please reference the Governance How to Guide prepared by the DSRIP Support Team for helpful guidance on governance structural options the PPS should consider. PPS Response (3,900 characters max): Current: 4,486 characters FLPPS recognizes that the region it serves is both geographically large and diverse. From the beginning it was determined that Medicaid and uninsured members and providers would be best represented with a system of local governance which would be structured to allow for central services and vision informed by adaptable leadership and problem-solving at the local level. To accomplish this, five Naturally Occurring Care Networks (NOCNs) were formed based on geographic layout and patient flow: 1. Monroe County 2. Western Region (Genesee, Orleans, & Wyoming counties) 3. Southern Region (Allegany, Livingston, and northwestern Steuben counties) 4. Southeastern Region (Chemung, southeastern Steuben, & Schuyler counties) 5. Finger Lakes Region (Cayuga, Ontario, Seneca, Wayne, & Yates counties) In order to best facilitate broad governance representation from across the NOCNs, and the overall PPS, FLPPs has chosen to develop a hybrid model that is the combination of the delegated and hub models, including the development of a new 501(c)3 corporation. The lead applicant parent corporations, Rochester Regional Health System (RRHS) and University of Rochester (UR) Medicine, have provided the not only all of the initial capitalization and the bulk of the in-kind staffing and resource contributions during the start-up phase, but have committed to providing adequate ongoing capitalization, in-kind resources and operational support. As the entities taking primary accountability for initial development and financial viability of the FLPPS, URMC and RRHS are the sole corporate members of the new FLPPS corporation. FLPPS has a representative Board of Directors consisting of 19 individuals as follows: (i) 10 clinical or lay executives from each of the 2 corporate members; (ii) 5 DRAFT FOR PUBLIC COMMENT NOT FINAL Page 6 of 159

7 clinician or lay executive leaders nominated by each of the five FLPPS NOCNs; (iii) 3 consist of one representative each from an FQHC, County Public Health and County Mental Health, and (iv) 1 is a Medicaid beneficiary who is served by the PPS and who does not have a conflict of interest (or an immediate family member with a conflict of interest) whether financial or otherwise with the PPS. The FLHSA provides a representative to serve as an ex oficio member of the Board. Under the auspices of the Board of Directors, and serving as the PAC executive body, is the Operations Steering Committee. The Operations Steering Committee has evolved from a pre-existing Organizing Committee that consisted of representatives from across the FLPPS and provided leadership during much of the initial planning activities. The Operations Steering Committee is accountable for: Coordination of the work of the operating committees and overall governance of the DSRIP projects. Oversight of FLPPS Partners to ensure the performance targets established by NYS DOHS and the Scale and Speed goals for the FLPPS are met. Advising on system issues that occur across the region (e.g. transportation). The Operations Steering Committee includes the co-chairs of each of the Operating Committees, along with one representative per NOCN, a design that is meant to ensure both representation from across the broad FLPPS service area and also specific finance, clinical, workforce, cultural competency and IT expertise. The FLPPS PAC has 6 Operating committees that are responsible for developing and finalizing the key deliverables required to complete the DSRIP Project Plan Application. Each operating committee is overseen by two Co-Chairs, initially nominated by the FLPPS co-lead organizations and supported by Project Managers and Subject Matter Experts. Reporting to, and interfacing closely with the Operating Committees, are Project Teams consisting of subject matter experts helping to ensure successful design and implementation of each project across the NOCNs and the overall PPS. Finally, each of the 5 NOCNs are developing workgroups that will coordinated closely with the operating committees and project teams, identify regional-level needs and communicate key findings and anticipated regional challenges to project planning and implementation. They are tasked with leveraging existing relationships and developing new relationships to collect the provider-level information needed to ensure successful development of the IDS. The overall PAC is brought together in a variety of formats that specifically cater to a broad region with geographic spread and a mix of small rural and large urban providers. Specify how the selected governance structure and processes will ensure adequate governance and management of the DSRIP program. PPS Response (3,900 characters max): Current: 1,628 characters Within the FLPPS, the NOCN workgroups play a critical role in governance, interfacing via teams of project managers and subject matter experts with the operational committees and the Operational Steering Committee. The NOCNs will help to ensure that DSRIP project implementation and overall PPS transformation are successful in each unique FLPPS community, established based on its specific local needs. Foundational to the PPS success will also be the core principles of the FLPPS that do, and will, DRAFT FOR PUBLIC COMMENT NOT FINAL Page 7 of 159

8 drive every decision. Serving as motivating values, PPS leadership will focus on member and provider needs above all else. The FLPPS core principles are: Focus on the Member/Patient All decisions are weighed against the question How will this impact the member/patient s health care needs, cultural and linguistic preferences, enabling provision of the right care, at the right place, at the right time? Strong Physician and Provider Leadership Physicians and other practitioners have representation and deep engagement in governance and leadership. Accountability, Transparency and Trusting Partnerships Clear and open partnerships with regular, proactive communication to support the design and implementation of truly cost-effective, best practice care delivery. Adaptability Develop the ability to continually transform based on patient needs and environmental changes. Recognize that there is no best, there is only better. Capacity & Capability for Managed Care of a Population Develop the ability to both manage members/patients across the continuum of care with varying disease states, health care and social needs Specify how the selected governance structure and processes will ensure adequate clinical governance at the PPS level, including establishing quality standards and measurements, clinical care management processes, and the ability to be held accountable for realizing clinical outcomes. PPS Response (2,000 characters max): Current: 1,087 characters The oversight of ongoing performance of FLPPS partners will balance a number of goals: 1) the requirements of strong accountability to individual and PPS performance improvement; 2) the need to provide structure, guidance and support to more resource-challenged PPS providers; 3) the importance of data driven 'dashboard' metrics and benchmarking; 4) the need to incorporate feedback from Medicaid beneficiaries. FLPPS will use clear contractual expectations, standardized consensus based performance metrics, improvement support, and consequences for continued poor performance as the processes by which the PPS will monitor performance. Dashboard metrics will continually evolve over the course of the initial DSRIP period to incorporate benchmarks, provider comparison and targeted areas for improvement. Clinical and Performance oversight will be the core responsibility of the Clinical Committee, which will coordinate with the Finance committee, NOCNs, Project Teams, Operational Steering Committee and the Board of Directors in ensuring overall quality across the FLPPS providers. When applicable, outline how the organization structure will evolve throughout the years of the DSRIP program period to enable the PPS to become a highly performing organization. PPS Response (2,000 words max): Current: 1,235 characters Over time, as the FLPPS governance bodies will become more mature and there will be an enhanced understanding of delivery system integration for the transformation of clinical care and payment. This DRAFT FOR PUBLIC COMMENT NOT FINAL Page 8 of 159

9 transformation will be driven by FLPPS Central Office and integrated into the core strategies of each FLPPS partner provider. FLPPS will evolve from a collaborative group of providers working on projects into a true integrated delivery network with core systems and processes that support members and providers in achieving the triple aim and financial sustainability. It is expected that along the journey, an early evolution will include a transition from the interim Board of Directors and Committee members to a more formally nominated and elected slate of Directors and committee members. In parallel, the PPS will hire full time executive leadership. Over time, as the PPS is successful in modifying health plan contractual relationships away from traditional fee for service and toward pay for performance and risk-based contracts, it is expected that there may be a need to adapt the governance structure and recruitment of subject matter experts for various governing positions, as well as the staffing structure of the FLPPS. Governing Processes (worth 30 percent of total points available for Section 2) Describe the governing process of the PPS. In the response, please address the following: Please outline the members (or the type of members if position is vacant) of the governing body, as well as the roles and responsibilities of each member. PPS Response (1,200 characters max): Current: 1,654 characteres As previously stated, FLPPS has a representative Board of Directors consisting of 19 individuals as follows: (i) 10 clinical or lay executives from each of the 2 corporate members; (ii) 5 clinician or lay executive leaders nominated by each of the five FLPPS NOCNs; (iii) 3 consist of one representative each from an FQHC, County Public Health and County Mental Health, and (iv) 1 is a Medicaid beneficiary who is served by the PPS and who does not have a conflict of interest (or an immediate family member with a conflict of interest) whether financial or otherwise with the PPS. A full list of interim Board members is located on our website at Roles & Responsibilities of Board of Directors 1. Prepare for Board and committee meetings by becoming well informed on subject to be discussed, in order to participate actively in Board/Committee discussions and decisions. 2. Attend and participate in regular/special meetings of the Board of Directors, providing subject matter expertise, participating in committees and generally supporting the mission and vision of the FLPPS 3. Be available to the CEO and Senior Management to provide advice, assistance or direction, as may be requested by the CEO. 4. Participate in establishing organization goals: approve annual operating budget, consistent with providing for the solvency and financial stability of the corporation. 5. Support the majority decisions of the Board of Directors. 6. Interpret and promote the philosophy of the FLPPS within and without, to increase understanding and support of FLPPS as its team and partners work to achieve their transformational care goals Please provide a description of the process the PPS implemented to select the members of the governing body. PPS Response (3,900 characters max): Current: 794 characters Members of the Interim Board of Directors were appointed via a nomination process in which the two corporate members (RRHS and UR) each nominated their 5 Directors and the Organizing Committee (just prior to transition to the Operations Steering Committee). PPS member representatives conducted DRAFT FOR PUBLIC COMMENT NOT FINAL Page 9 of 159

10 extensive conversations with PPS partners and stakeholder organizations to generate the nominees for the remaining nine positions. The final slate of nominees was posted for public comment on the PPS website. For the Operations Steering Committee, the majority of the committee consists of the cochairs of the operational committees, which were appointed for initial terms by the corporate members. Additionally, 5 members represent the 5 NOCNs and were nominated by the nascent NOCN workgroups. Please explain how the members included provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. PPS Response (1,000 characters max): Current: 737 characters The process for nominating and selecting initial members of all governing body entities started with the submission of nominations via , followed by a survey with extensive participation by both PPS partners and other stakeholders across the PPS. These nominations were reviewed by project managers, subject matter experts, corporate member leaders, the organizing committee and the initial operations committee co-chairs depending on the governing body for which an individual was nominated. For each governing body, whether the Interim Board of Directors or an operational committee, a matrix was used in order to ensure both representation from each NOCN and from the various types of providers and CBOs engaged with the PPS. Please outline where coalition partners have been included into the organizational structure and the PPS strategy to contract with community based organizations. PPS Response (1,000 characters max): Current: 685 characters There is five percent set-aside in the funds flow to fund contracts with CBOs as the PPS engages them for their critical services provided as components of the new IDS. Initially, it is likely that the CBO services will be funded via a combination of current funding sources, grants and PPS contracts, as well as expansion as possible/appropriate of any existing MCO contracts. Over time the goal will be to completely integrate the CBOs into a PCMH based system of care in which they play a vital role in achieving and improving health for Medicaid and uninsured members and they are therefore contracted by MCOs based on actuarial estimates as to their value to the capitated dollar. Describe the decision making/voting process that will be implemented and adhered to by the governing team. PPS Response (1,800 characters max): Current: 666 characters The Bylaws of the FLPPS corporation allow for clear criteria to arrive at major decisions, defining which decisions require a simple majority vote of the Board of Directors, a supermajority vote and which are held as reserve powers by the two members of the corporation. For DSRIP projects and IDS activities, recommendations will be developed at the NOCN, Project Work Team and Operating Committee level and these recommendations will be elevated via the committee structure for final decisions at the NOCN, Operations Committee, Operations Steering Committee, or Board of Directors as per the Bylaws and the Policies and Procedures of FLPPS that are being drafted. Explain how conflicts and/or issues will be resolved by the governing team. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 10 of 159

11 PPS Response (1,000 characters max): Current: 741 characters Disagreements at the Board of Directors level will be achieved via the process outlined in the FLPPS bylaws, including specific guidelines as to what issues can be decided via a simple majority vote, a supermajority vote, or are reserved powers to the two sole corporate members. The corporate members have a long history of working together in an overlapping service area and have developed strong relationships across their respective corporate counsel that enable rapid problem-solving when conflicts arise. Provider and/or member conflicts and /or issues will be resolved via the FLPPS staff in coordination with the governance committees and Board of Directors, there will be a formal grievance process for both providers and members. Describe how the PPS governing body will ensure a transparent governing process, such as methodology in which the governing body will transmit the outcomes of meetings. PPS Response (1,000 characters max): Current: 461 characters All of the FLPPS governing bodies, from the Board of Directors to the various operational committees and NOCN workgroups, are populated with diverse and representative groups of providers, stakeholders and Medicaid members, thus ensuring that the process for decision making does not become opaque and/or hospital centric. The minutes of the meetings of all committees and Board meetings, with the exception of executive sessions, will be publically available. Describe how the PPS governing body will engage stakeholders, including Medicaid members, on key and critical topics pertaining to the PPS over the life of the DSRIP program. PPS Response (1,000 characters max): Current: 400 characters FLPPS feels that Medicaid member representation is a critical success factor in ensuring that member needs are met and that Medicaid members have input into the process of delivery and payment transformation. For this reason, there have been, and will continue to be, facilitated focus groups with Medicaid members, as well as a Medicaid member of the Board of Directors and on each NOCN committee. The Project Advisory Committee (PAC) (worth 15 percent of total points available for Section 2) Describe the formation of the project advisory committee of the PPS. In the response, please address the following: Describe how the PAC was formed, the timing in which it was formed, along with its membership. PPS Response (2,400 characters max): Current: 1,633 characters The PAC was formed as a collaborative effort between the co-leads and other stakeholder leaders during a process in which several nascent PPS leads came together to form FLPPS. During the development of the FLPPS project management office (PMO) between May and September, point persons from each of the co-lead organizations hosted general monthly PAC meetings with representation per the State s guidance. Once the PMO launched in early October, the PMO leadership hosted a joint executive visioning session to outline the future-state vision for FLPPS. From this, a more structured PAC was born that now includes five operational committees (Clinical, IT, Workforce, Finance, Transportation, five NOCN workgroups (one for each NOCN) and 11 project teams (one for each FLPPS DSIP project). In addition, monthly - if not m - PPS-wide webinars were held to provide updates and detailed DRAFT FOR PUBLIC COMMENT NOT FINAL Page 11 of 159

12 next steps for DSRIP/FLPPS to the general FLPPS stakeholder audience. Throughout October, the PMO collected committee membership nominations from general PAC members and other representatives from interested providers. Internally identified operations committee co-chairs initially populated the committees with a handful of members who met in the beginning of October to review committee deliverables, roles & responsibilities, and committee purpose. By early November, oversight committees had been fully populated. Project Teams followed shortly after and began meeting in late November. We envision that NOCN workgroups will play a large role in project implementation plans have seen early success in a broad range of NOCN engagement already. Outline the role the PAC will serve within the PPS organization. PPS Response (1,00 characters max): Current: 970 characters The operations committees have played a key role in developing the strategic content necessary to populate the DSRIP Organizational Application. Operations committees will continue to serve as the high level strategists for the FLPPS development during implementation and beyond. In the final weeks leading up to the Project Plan Application deadline, Project Teams worked diligently to ensure Project Plan applications were accurate and reflected the perspectives of the service area providers. Project Teams will continue to be a critical to developing patient engagement strategies and project implementation plans throughout the NOCNs. Beginning in December, NOCN workgroups identified regional-level leads & members. Overtime each NOCN will communicate key findings and anticipated regional challenges to the operations committees for consideration. They will receive input from the project teams to help understand how project implementation will impact their regions. Outline the role of the PAC in the development of the PPS organizational structure, as well as the input the PPS had during the Community Needs Assessment (CNA). PPS Response (1,000 characters max): Current: 439 characters Our initial PAC structure evolved into the newly established FLPPS governance structure. Since the launch of the FLPPS PMO, stakeholder engagement has been a priority in ensuring that the development of FLPPS and the Project Plan Application accurately reflected the perspectives of its stakeholders. Various drafts of the CNA were posted to the FLPPS website for review, and stakeholder comments were submitted to FLHSA for consideration. Please explain how the members included provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. PPS Response (125 words max): Current: 783 characters Committees were populated by nominations received from interested providers from across the FLPPS service area and by members of the Project Advisory Committee. In order to ensure each committee represented the cross-section of provider types and geographies across the FLPPS service area, each committee developed a matrix of provider type by NOCN. Co-chairs and initial committee members, along with project managers who orchestrated a number of NOCN-level planning days, reviewed nominations DRAFT FOR PUBLIC COMMENT NOT FINAL Page 12 of 159

13 and posed additional suggestions for membership to ensure that at membership represented at least one member from each of the five NOCNs and at least one member from each of the relevant provider types (i.e. behavioral health, hospital, post-acute, community-based organization, etc.). Identify the designated compliance official or individual and describe the individual s organizational relationship to the PPS governing team PPS Response (1,000 characters max): Current: 482 characters The Finance Committees and Board of Directors, serving as the audit committee, will jointly vet and recommend a full time or contracted resources to serve as the Compliance Officer who will have a joint reporting relationship to the CEO and the Board of Directors. The FLPPS Compliance Officer will periodically report on compliance activities to the FLPPS Board of Directors. The Compliance Officer will attend all meetings of the Board of Directors and Executive Committee. Describe the mechanisms for identifying and addressing compliance problems related to the PPS operations and performance PPS Response (1,200 characters max): Current: 1,152 characters A standing Compliance Committee will be formed and chaired by the Compliance Officer. The Compliance Committee and the Compliance Officer will jointly agree upon the DSRIP, State and Federal rules and regulations that will be included in this oversight role. Written policies and procedures that define compliance, and describe compliance expectations, of all FLPPS staff, FLPPS providers and partners and their respective staffs will be developed and communicated. Executive Committee. These will include guidance to all employees on how to deal with and report potential compliance issues and include the process by which compliance problems are investigated, reported and resolved. An anonymous Compliance Integrity Hot Line will be implemented. The Compliance Officer will be responsible for reviewing the Hot Line and reporting the contents and actions taken to the Executive Team (CEO, CFO, COO) on a monthly basis. All material agreements, contracts, policies and procedures require review by the Compliance Committee prior to execution. The Compliance Officer will also report the compliance plan annually to NYS OMIG Describe the compliance training for all PPS members and coalition partners. Please distinguish those training programs that are under development versus existing programs PPS Response (1,200 character max): Current: 1,049 characters The Compliance Officer will be responsible for developing compliance education and training programs, including a FLPPS-wide HIPAA program, along with establishing audit procedures. Disciplinary policies that encourage good faith participation will also be developed. In addition, included will be a policy of non-intimidation and non-retaliation that will be communicated to all affected persons. Training and education will be provided to all existing and new FLPPS employees, Directors and all affected persons associated with FLPPS through a variety of communicative options. A FLPPS Compliance Website will be developed with an easily accessible link for partners and members to submit complaints. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 13 of 159

14 The Compliance Officer will review code of conduct and compliance policies and programs of all FLPPS partners and how they relate to DSRIP. Any deficiencies will be addressed through the FLPPS compliance program. A schedule will be developed to review and monitor the compliance programs of all FLPPS partners. Please describe how community members, Medicaid beneficiaries and uninsured community members attributed to the PPS will know how to file a compliance complaint and what is appropriate for such a process PPS Response (1,200 characters max): Current: 410 characters Complaints can be filed through the FLPPS Compliance Integrity Hot Line. Awareness of the Hot Line and instructions on how to file a complaint will be communicated to attributed members through various communications including mailings, notices on billing statements, blast s, etc. FLPPS will also work with the various Medicaid Managed Care plans to help make their members aware of the Hot Line. PPS Financial Organizational Structure (worth 10 percent of total points available for Section 2) Please provide a narrative on the planned financial structure for the PPS, including a description of the financial controls that will be established. This narrative should include, at a minimum: Description of the processes that will be implemented to support the financial success of the PPS and the decision making of the PPS governance structure. PPS Response (1,200 characters max): Current: 897 characters The FLPPS Finance Committee has been in place since October The specific tasks for the Finance Committee include: Develop and approve policies and procedures for funds flow. Implement mechanisms for financial accountability and oversight including internal control and cash management policies. Bring material exceptions/questions/issues and variances to budget to the attention of the FLPPS Board of Directors. Introduce action plans for any variances over established benchmarks. Monitor financial performance of FLPPS and all Partners and report to the Board of Directors monthly. Review and approve annual FLPPS operating and capital budgets. Work with the Clinical Committee, Operations Oversight Committee and area Health Plans to develop recommendations for a transition from the current mainly fee for service provider contracts to specific pay-for-performance initiatives that push more financial risk for Medicaid down to the PPS and providers. Description of the key finance functions to be established within the PPS. PPS Response (1,200 characters max): Current: 987 characters The financial structure for FLPPS has three components: The FLPPS corporate Board of Directors The Finance Committee The FLPPS CFO and finance staff DRAFT FOR PUBLIC COMMENT NOT FINAL Page 14 of 159

15 As the fiduciary to DOH, FLPPS will be receiving and distributing DSRIP funds beginning on April 1, The Finance Committee and the FLPPS CFO have principle accountability for and oversight of all financial matters for FLPPS. - The Finance Committee will work with the CFO and the Board of Directors to finalize the financial policies and procedures to be used by FLPPS, including but not limited to: Spending authority limits Completing the design and implementation of DSRIP fund distribution Developing the annual budget process Defining the financial metrics that Partner organizations are expected to meet Developing the financial compliance program in conjunction with the Compliance Officer and the Board of Directors Identify Medicaid & Medicare sanctioned providers and evaluate their further participation in FLPPS Identify the planned use of internal and/or external auditors. PPS Response (1,200 characters max): Current: 821 characters The Board of Directors will serve as the audit committee, and as such, will coordinate with the Finance Committee, CFO, CEO and Compliance Officer to determine if a single audit firm can meet the needs of both financial and general compliance. Irrespective of this decision, the Board of Directors will issue an RFP and select a qualified external auditor for a contract that will be reviewed annually for renewal or re-bid. The auditor contract will be re-bid at a minimum every 3 years. Should a separate contract be required for a general compliance auditor, the RFP and selection for this will be undertaken by the Finance committee in coordination with the Board, as the audit, CFO and Compliance Officer. When complete, the FLPPS compliance program will meet all requirements of New York State Social Services Law 363-d. Description of the PPS plan to establish a compliance program in accordance with New York State Social Services Law 363-d. PPS Response (1,200 characters max): Current: 185 characters The Finance Committee will work jointly with the Compliance Officer in order to draft a compliance program for the review and approval of the Compliance Officer and the Governing Board. Oversight and Member Removal (worth 15 percent of total points available for Section 2) Please describe the oversight process the PPS will establish and include in the response the following: Describe the process in which the PPS will monitor performance. PPS Response (1,200 characters max): Current: 823 characters Performance data, collected and reported via dashboards developed based on a balanced scorecard framework, will be monitored through a series of tollgates, starting with review by the FLPPS staff; then by the Clinical and Finance committees; followed by the Operational Steering Committee and finally reviewed and discussed quarterly at the meetings of the FLPPS Board of Directors. As described earlier in the Governance sub-section, FLPPS will use clear contractual expectations, standardized consensus based performance metrics, improvement support, and consequences for continued poor performance as the processes by which the PPS will monitor performance. Dashboard metrics will continually evolve over the DRAFT FOR PUBLIC COMMENT NOT FINAL Page 15 of 159

16 course of the PPS period to incorporate benchmarks, provider comparison and targeted areas for improvement. Outline on how the PPS will address lower performing members within the PPS network. PPS Response (1,200 characters max): Current: 679 characters FLPPS will have a proactive process involving engagement with PPS partners from planning and into the execution stages by FLPPS project managers, other staff, Project Team SMEs and members of the Operational Committees. An Office of Advanced Performance Improvement will be led by an expert in performance excellence and will have staff resources available to partner with providers for both the initial design of projects and improvement efforts when performance issues arise. Lower performing members will receive feedback as to their performance deficits and technical assistance, as resources allow, to assist and support the provider in gaining performance improvement. Describe the process for the sanctioning or removing a poor performing member of the PPS network who fails to sufficiently remedy their poor performance. Please ensure the methodology proposed for member removal is consistent and compliant with the standard terms and conditions of the waiver. PPS Response (1,200 characters max): Current: 1,127 characters As discussed earlier, FLPPS will use clear contractual expectations, standardized consensus based performance metrics and improvement support to monitor and attempt to improve performance when necessary. Performance data will be transparently shared and discussed on a regular basis such that a poorly performing provider will have early indications and interventions when performance has begun to suffer, or appears at risk. These providers will be placed on a Corrective Action Plan (CAP). Providers on a CAP who are either unable to engage in performance improvement activities to change performance and/or are unwilling to do so will undergo a process of peer review overseen by the Clinical and Operational Steering Committees in coordination with the FLPPS assigned staff and the Compliance Officer. After a prescribed amount of time and set of attempted interventions as per the policies and procedures of FLPPS, which will be compliant with the standard terms and conditions of the Waiver, the Board of Directors may be recommended by the Clinical Committee and Compliance officer to remove the poorly performing member. Indicate how Medicaid beneficiaries and their advocates can provide feedback about providers to inform the member renewal and removal processes. PPS Response (1,200 characters max): Current: 536 characters The PPS will incorporate into its own policies and procedures Medicaid beneficiaries' existing complaint and appeal processes that will reflect concerns regarding dissatisfaction, appointment scheduling, denied referrals. Lower-performing providers will be subject to Corrective Action Plans (CAPs), which will provide a critical focus on improving performance over time. However, it is essential that there is accountability to the entire PPS for continuing failure to improve performance by removing Members after a reasonable period. Describe the process for notifying Medicaid beneficiaries and their advocates when providers are removed from the PPS. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 16 of 159

17 PPS Response (1,200 characters max): Current: 346 characters Medicaid beneficiaries will receive advance notice, as per FLPPS policies and procedures, of an action to remove their provider from the PPS and will be provided with information on how this may impact Medicaid members and their options for seeking ongoing care if there is a risk that ongoing care may not be available with the removed provider. Domain 1 - Governance Milestones Progress towards achieving the project goals and core requirements specified above will be assessed by specific milestones for the DSRIP program, which are measured by particular metrics. Investments in technology, tools, and human resources that will strengthen the ability of the Performing Provider Systems to serve target populations and pursue DSRIP project goals. Domain 1 process milestones and measures will allow DOH to effectively monitor DSRIP program progress and sustainability. The following outlines the milestones that will be required and expected of the PPS to earn DSRIP payments. The milestone is presented for informational purposes only, however, the PPS will be expected to develop a work plan to outline the steps and timeframes in which these milestones will be achieved. - Implementation plan outlining the PPS commitment achieving its proposed governance structure (Due March 1, 2015). - Periodic reports, at a minimum semi-annually and available to PPS members and the community, providing progress updates on PPS and DSRIP governance structure.. - Supporting documentation to validate and verify progress reported on governance, such as copies of PPS bylaws or other policy and procedures documenting the formal development of governance processes or other documentation requested by the Independent Assessor. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 17 of 159

18 Section 3 Community Needs Assessment Section 3 Community Needs Assessment (25 percent of the Overall PPS Structure Score) Description All successful DSRIP projects will be derived from a comprehensive community needs assessment (CNA). Since DSRIP is about system transformation, the structure of a DSRIP CNA will be different from the usual public health format. The CNA should be a comprehensive assessment of the health care resources and community based service resources currently available in the service area and the demographics and health needs of the population to be served. This will lead to the identification of excesses and gaps in services that will need to be corrected in order to transform the system to one that meets the goals of DSRIP. The CNA will be evaluated based upon the PPS comprehensive and data-driven understanding of its service delivery system and the community it intends to serve. Please note, the PPS will need to reference in Section 4, DSRIP Projects, how the results of the CNA informed the selection of a particular DSRIP project and how the choice of projects combine to result in the envisioned transformed system. The CNA shall be properly researched and sourced, shall effectively incorporate the stakeholder engagement in its formation, and shall identify current community resources, including community based organizations, as well as existing assets that will be enhanced or eliminated as a result of the PPS CNA. Lastly, the CNA should include documentation, as necessary, to support the PPS community engagement methodology, outreach and decision-making process. For more information on DOH s expectations to ensure a successful completion of the CNA, please refer to the document, Guidance for Conducting Community Needs Assessment required for DSRIP Planning Grants and Final Project Plan Applications, and the DSRIP Population Health Assessment Webinars, Part 1 and, particularly 2, located on the DSRIP Community Needs Assessment page: Health data will be required to further understand the complexity of the health care delivery system and how it is currently functioning. The data collected during the CNA should enable the evaluator to understand how the health care delivery system functions, the community the PPS seeks to serve and the key populations where service gaps are identified. The CNA must include the appropriate data that will support the CNA conclusions that drive the overall PPS strategy. Data provided to support the CNA must be valid, reliable and reproducible. In addition, the data collection methodology presented to conduct this assessment should be done with consideration that future community assessments will be required. DOH has provided a significant amount of relevant data that should inform and be leveraged to complete the CNA process. This data, in addition to other relevant data sources produced other state agencies, can be found on the DSRIP Performance Data, found here: It is critical that the PPS leverage the data sources available on the DSRIP Performance Data page to ensure the successful completion of the CNA. Overview on the Completion of the CNA (worth 5 percent of total points available for Section 3) Please describe the completion of the CNA process and include in the response the following: Describe the process and methodology in which the CNA was completed. DRAFT FOR PUBLIC COMMENT NOT FINAL Page 18 of 159