FLPPS Projects Roles & Responsibilities 6/15/2015 Project Hospital PCP/Pediatrician FQHC Health Home/Care Management

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Gwenda Flowers
6 years ago
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1 FLPPS Projects Roles & Responsibilities 6/15/2015 Project Hospital PCP/Pediatrician FQHC Health Home/Care 2.a.i-Create Integrated Delivery System THIS PROJECT IS MANDATORY FOR ALL PARTICIPATING PROVIDERS all assessments by PPS and contracting process Implement CEHRT RHIO interoperability interface RHIO Consents Use Alerts and Direct messaging Assess patients for Health Home eligibility and make referral all assessments by PPS and contracting process Implement CEHRT Achieve PCMH 2014 Level 3 Certification RHIO interoperability interface RHIO Consents Use Alerts and Direct messaging Assess patients for Health Home eligibility and make referral all assessments by PPS and contracting process Implement CEHRT Achieve PCMH 2014 Level 3 Certification RHIO interoperability interface FLPPS/RHIO Consents (more to be developed on this) Use Alerts and Direct messaging Assess patients for Health Home eligibility and make referral FLPPS/ RHIO Consents (more to be developed on this) Ensure connectivity with RHIOs for submission of Care Plan Ensure use of Direct/Alerts/Pati ent Record Lookup by Heal Home and CMAs all assessments by PPS and contracting process FLPPS/RHIO consents (more to be developed on this) Use of Direct messaging/alert s/patient Record Lookup Assess patients for Health Home eligibility and make referral all assessments by PPS and the contracting process Implement CEHRT (if ) or other EHR technology RHIO interoperability interface FLPPS/RHIO Consents (more to be developed on this) Use of Direct messaging/alerts/ Patient Record Lookup Assess patients for Health Home eligibility and make referral all assessments by PPS and the contracting process Implement EHR RHIO interoperability interface Follow provider type pathway based on provider types within organization

2 2.b.iii-ED Care triage for at risk population Establish ED Care Triage program for at-risk populations Medical screening examination Navigator in place that collects data on current PCP Schedule apt with PCP Navigator will assist the patient with identifying and accessing support resources Partnership with care providers that have 2014 PCMH certification EHR Connectivity to RHIO Engage Health Home Encounter Notification Service is installed in ED Use EHR to track all patients engaged in this project Relationship with hospital to share schedules Willing to accept Medicaid patients Increased Access Patient no show process for follow up EHR Connectivity to RHIO Encounter notification is installed Relationship with hospital to share schedules Willing to accept Medicaid patients Increased access for patient appointments Patient no show process for follow up EHR Connectivity to RHIO Engage Health Home Link patient to transportation if Encounter notification is installed Establish relationships with all hospitals in service area Ensure that patient goes to PCP appointment Care management Assist in educating patient about use of ED Provide social to patient in need Reconnect to preventative care/bh Strategy to improve quality of care to prevent avoidable ED visits (Patient Centered Medical Home Concepts) Establish relationships with all hospitals in service area Ensure that person goes to PCP appointment Care management

3 2.b.iv Care Transitions --- reduce 30 day re-admissions Develop standardized for a Care Transitions Intervention Model, partnering with home care service In-patient assessment Identify Health Home eligible patients Notification process to Transition care coach 30-day care plan developed and communicated with required network social, including medically tailored home food PCP notified Policies and Procedures are in place for early notification of planned discharge to case manager (PCMH, Health Home, ) Program in place that allows case managers access to visit patients in the hospital and provide care transitions and advisement Reviews 30-day care plan with the individual Able to provide timely access for follow up appointment after discharge Communicate with case manager as Use EHR s to track all patients engaged in project Reviews 30-day care plan with the individual Able to provide timely access for follow up appointment after discharge Communicate with case manager as Use EHR s to track all patients engaged in project Care agency notified of admission Review of care plan with individual Address barriers identified in the care plan (i.e. transportation) Communicate with medical providers as Provide social to patient in need Coordinate & Communicate with other Care providers Work with Care Plan for existing patient Medicaid Service Coordination agency notified of admission Review of care plan with person Communicate with medical providers as

4 2.b.vi- Transitional Supportive Housing Referral to housing specialist for assessment Use risk/care management assessment to identify & notify/refer other existing or relevant care (PCP/PCMH, case manager, Health Home, provider) MOUs stipulating that discharge summary/30-day plan is coordinated and/or communicated with Health Home, other CM providers and housing via warm handoff Identify chronic super utilizers and prioritize them for housing access Develop and implement care transition to ensure pop health management of chronic super utilizers Reviews 30-day care plan with the individual Able to provide timely access for follow up appointment after discharge Communicate with case manager as (e g to follow up on noshows, or provide postvisit instructions) Use EHR s to track and share information on all patients engaged in project Reviews 30-day care plan with the individual Able to provide timely access for follow up appointment after discharge Communicate with case manager as (e g to follow up on noshows, or provide post-visit instructions) Use EHR s to track and share information on all patients engaged in project In-person visit within 24 hours of referral/notification Coordinate for discharge planning Coordinate & Communicate with other Care providers including housing/pcp Undertake comprehensive long term care assessment within 15 days and share with other providers including housing Develop long term care management plan in coordination with housing and arrange relevant Housing Provider In-person housing assessment within 24 hrs of referral Identify/ arrange housing site within 48 hours of assessment Face to Face + Telephone follow up at least 2x/month Complete comprehensive assessment within 15 days post discharge (can be informed by assessments from other providers) Develop/arrange Long term housing plan (in coordination with other care management providers) to transition patient out max 90 days post discharge Coordinate & Communicate with other Care providers to identify and arrange relevant support (home care, MH, food, social, etc.)

5 3.a.i-- Integration of Primary Care and Behavioral Health Services Conduct preventive care screenings, including behavioral health screenings (e.g., PHQ9/SBIRT) Meet PCMH 2014 Standards Use EHR s to track all patients engaged in project Create space for behavioral health Determine the behavioral health needs of the practice to inform required availability of BH provider Establish workflow for BH patients Develop for warm handoffs Plan to access crisis within and outside of practice Develop with BH provider medication Ensure evidenced-based care are in place, including medication management and care engagement processes Conduct preventive care screenings, including behavioral health screenings (e.g., PHQ9/SBIRT) Meet PCMH 2014 Standards Use EHR s to track all patients engaged in project Create space for behavioral health Determine the behavioral health needs of the practice to inform required availability of BH provider Establish workflow for BH patients Develop for warm handoffs Plan to access crisis within and outside of practice Develop with BH provider medication Ensure evidencedbased care are in place, including medication management and care engagement processes Join treatment team Establish with Primary Care and BH treatment providers Integral to care engagement processes through addressing barriers to care Provide Services to Primary care Practice (Model 1) Co-locate primary care at BH (Model 2) Conduct preventive care screenings, including behavioral health screenings (e.g., PHQ9/SBIRT) Establish workflow for BH patient Provide BH training for Primary Care provider Collaborate on treatment and care engagement strategies Provide availability for warm transfer Model 2: provide space for physical health Determine with provider scope of physical health Determine physical health needs of patients Join treatment team Establish with Primary Care and BH treatment providers Integral to care engagement processes through addressing barriers to care Article 16/28 Integrate into Primary Care setting (Model 1) Co-locate primary care (Model 2) Establish workflow for BH person Provide BH training for Primary Care Provider Collaborate on treatment and care engagement strategies Provide availability for warm transfer Model 2: provide space for physical health Determine with provider scope of physical health Determine physical health needs of person

6 3.a.ii- Behavioral Health Community Crisis Stabilization Services Hub hospitals to have DSRIP deliverables ( crisis intervention program as well as specialty psychiatric, observation unit, EHR with integration of BH and medical 24/7 access and clear linkages with resources) defined diversion management in the ED agreed upon coordinated written treatment care If hospital has specialty psychiatric provide data to PPS on wait times etc and develop improvement plan if required Develop BH crisis response protocol that includes use of centralized triage agreed upon coordinated written treatment care Connect EHR to RHIO Develop BH crisis response protocol that includes use of centralized triage agreed upon coordinated written treatment care Connect EHR to RHIO Connectivity and availability to centralized triage and other intensive crisis agreed upon coordinated written treatment care Partner with providers to provide and enhance crisis in the patient s Develop (if not in place) a plan with hubs, subhubs and other providers Provide realtime data regarding access to agreed upon coordinated written treatment care development of diversion and treatment Develop with centralized triage system(s) agreements and procedures that facilitate access and also diversion from ED and hospitalization agreed upon coordinated written treatment care Connect EHR to RHIO Include centralized triage system in BH crisis intervention strategies Connectivity and availability to centralized triage and other intensive crisis Partner with providers to provide and enhance crisis in the person s Develop (if not in place) a plan with hubs, subhubs and other providers Provide realtime data regarding access to development of diversion and treatment Develop with centralized triage system(s) agreements and procedures that facilitate access and diversion from ED and hospitalization

7 3.a.v-- Behavioral Interventions Paradigm in Nursing Homes Potential for sharing NP with BH skills, Psychiatric Social Worker assigned to lead multidisciplinary treatment planning Opportunities for telehealth (telepsychiatry), ECHO Implement BIP model using skilled nurse practitioner and psychiatric SW to provide early assessment, reassessment, intervention and care coordination for at risk residents to reduce the risk of requiring transfer to higher level of care Implement INTERACT or risk identification tool EHR tracking of patients engaged in project Connectivity to RHIO RHIO Consents NP with BH skills, Psychiatric Social Worker assigned to lead multidisciplinary treatment planning Implement a Behavior management interdisciplinary team approach to care Implement holistic psychological interventions Provide enhanced Recreational activities Enhanced training and educational experiences for clinical and nonclinical staff developed medication reconciliation program Implement crisis intervention program for facility that include ly trained staff Utilize sitter for crisis intervention where necessary Document patient status in patient health record, including behavioral health interventions and medication use Make changes to facility environment to promote behavioral health

8 Project Hospital OB/GYN and Family Practice and Pediatrician 3.f.i--Increase Support Programs for Maternal & Child health (including high risk pregnancies) EHR Connectivity Submit Early Elective Delivery Information via HCS using DOH form for submission per DOH requirement Upon patient discharge, if not linked to CHW make referral if Prevent Early Elective Deliveries OB/GYN Access for timely OB care and ongoing care per ACOG guidelines Accept Medicaid pregnant women Ability to schedule Post- Partum visit within days post delivery Ability to track no show OB and post-partum patients and notify CHW/NFP of patient non-compliance or refer to social work if not linked to programs Completion and submission of Risk Assessment screening tool for referral to NFP or MICHC Community Health Worker Refer to social work for social needs Refer uninsured OB patients to FCM Pediatricians Perform population health for immunization compliance & lead screening compliance Ensure schedule for 5 visits prior to child s 15 months of age FQHC OB/GYN Access for timely OB care and ongoing care per ACOG guidelines Accept Medicaid pregnant women Ability to schedule Post- Partum visit within days post delivery Ability to track no show OB and post-partum patients and notify CHW/NFP of patient non-compliance or refer to social work if not linked to programs Completion and submission of Risk Assessment screening tool for referral to NFP or MICHC Community Health Worker Refer to social work for social needs Refer uninsured OB patients to FCM Pediatricians Perform population health for immunization compliance & lead screening compliance Ensure schedule for 5 visits prior to child s 15 months of age NFP/MICHC Community Health Worker Programs Train CHW staff in NYDOH CHW training program Employ qualified candidates for CWH/NFP who meet criteria such as cultural competence, and experience and training program per design requirements developed Use EHR s to track patients Refer/connect pregnant woman to OB provider Provide for patient and children, as Develop working relationship with MICHC CHW/NFP programs Accept new patients and participate in care coordination plans for patients

9 4.a.iii Strengthen Mental Health & Substance Abuse Infrastructure across Systems Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder prevention and treatment Increase across the Integrated Delivery System (Integration to ensure coordination of care) activities, as required, to support MEB health infrastructure development across the PPS Assess, train, and engage professionals in MEB cultural competency Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder prevention and treatment Assess, train, and engage professionals in MEB cultural competency For those implementing programs, document interventions and track outcomes using Integrated Delivery System Increase across the Integrated Delivery System Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder Assess, train, and engage professionals in MEB cultural competency Increase across the Integrated Delivery System Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder prevention and treatment Assess, train, and engaged professionals in MEB cultural competency Increase across the Integrated Delivery System Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder prevention and treatment Assess, train, and engage professionals in MEB cultural competency Develop a sustainable education, recruitment and retention initiative focused on increasing access to mental health care Benchmark data against indicators and prevention objectives (For those implementing programs, document interventions and track outcomes using the IDS) Increase across the Integrated Delivery System Conduct regional health needs survey Share survey results and solicit feedback Identify the level of integrated care that is taking place currently Share data and information on MEB health promotion and MEB disorder prevention and treatment Assess, train, and engage professionals in MEB cultural competency Increase across the Integrated Delivery System

10 4.b.ii Increase Access to High Quality Chronic Disease Preventative Care and in Both Clinical and Community settings Respond to surveys as to identify providers serving project populations As part of PCMH, provide care management to populations identified by PPS Offer interventions to populations, OR Connect patients to interventions Respond to surveys as to identify providers serving project populations As part of PCMH, provide care management to populations identified by PPS Offer interventions to populations, OR Connect patients to based interventions Respond to surveys as to identify providers serving project populations Document risk assessment used to identify populations in an electronic system RHIO interface (as ) to share assessment and yet to be identified encounter data Respond to surveys as to identify providers serving project populations Respond to surveys as to identify providers serving project populations

11 2.d.i Implementatio n of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/nonutilizing Medicaid populations into Community Based Care Embed PAM survey as part of care management plans for 2di populations in particular Participate and contribute to educational forums focused on changing consumer behavior around DSRIP goals, selfadvocacy and provider level education around PAM administration and patient Refer and ensure successful handoffs of patients to care agencies as, with tracking Embed PAM survey as part of care management plans for 2di populations in particular OR Have navigator ly placed to administer the PAM, that is also educated on insurance options Refer and ensure successful handoffs of patients to care agencies as, with tracking Partner with based case agencies to facilitate warm transfers as Track PCP visits, particularly for Medicaid and Uninsured (recently acquired insurance) and perform outreach as Participate and contribute to education forums around changing consumer behavior around DSRIP goals, self-advocacy and provider level education around PAM administration and patient Have members of staff trained in PAM and patient expertise Have navigator ly placed in hot spot to administer the PAM, that is also trained on insurance options Embed PAM survey as part of care management plans for 2di populations Refer and ensure successful handoffs of patients to care agencies as, with tracking Partner with case agencies to facilitate warm transfers as Track PCP visits, particularly for Medicaid and Uninsured (recently acquired insurance) and perform outreach as Participate and contribute to education forums around changing consumer behavior around Conduct outreach and engagement with under-utilizers to connect them to care Embed PAM survey as part of care management plans for 2di populations in particular Refer and ensure successful handoffs of patients to other care agencies as, with tracking Partner with case agencies to facilitate warm transfers as Participate and contribute to education forums around changing consumer behavior around DSRIP goals, self-advocacy and provider level education around PAM administration and patient Have members of staff trained in PAM and patient expertise Conduct outreach and engagement with underutilizers to connect them to care Have navigator ly placed in hot spot to administer the PAM Embed PAM survey as part of care management plans for 2di populations in particular Refer and ensure successful handoffs of patients to other based care agencies as, with tracking Partner with based case agencies to facilitate warm transfers as Participate and contribute to education forums around changing Conduct outreach and engagement with underutilizers to connect them to care, particularly behavioral and substance abuse health care Have navigator ly placed in hot spot to administer the PAM Embed PAM survey as part of care management plans for 2di populations in particular Refer and ensure successful handoffs of patients to other care agencies as, with tracking Partner with case agencies to facilitate warm transfers as Track PCP, behavioral, dental visits, particularly for Medicaid and Uninsured (recently acquired insurance)

12 DSRIP goals, selfadvocacy and provider level education around PAM administration and patient Have members of staff trained in PAM and patient expertise consumer behavior around DSRIP goals, selfadvocacy and provider level education around PAM administration and patient Have members of staff trained in PAM and patient expertise Participate and contribute to education forums around changing consumer behavior around DSRIP goals, selfadvocacy and provider level education around PAM administration and patient Have members of staff trained in PAM and patient expertise

DSRIP Project Integration. Janet King Director of Project Management Office and Project Managers FLPPS Summit July 29, 2015

DSRIP Project Integration. Janet King Director of Project Management Office and Project Managers FLPPS Summit July 29, 2015 DSRIP Project Integration Janet King Director of Project Management Office and Project Managers FLPPS Summit July 29, 2015 FLPPS Project Integration Objectives Provide insight into how the FLPPS DSRIP