I. Welcome M. Buglino. II. Review & Approve Minutes of Previous Meeting Action Item M. Buglino

Transcription

1 EXECUTIVE COMMITTEE MEMBERS: NYP Queens DSRIP Executive Committee Meeting Thursday June 22, :00p.m. 5:00p.m. Call in# ; Passcode: # Maureen Buglino (Chair) - NewYork-Presbyterian Queens Robert Crupi, MD (Co-Chair) - NewYork-Presbyterian Queens Christopher Caulfield - NewYork-Presbyterian Queens Maria D Urso - NewYork-Presbyterian Queens Mark Greaker - NewYork-Presbyterian Queens John Lavin - Mental Health Provider of Western Queens Daniel Muskin - The Grand Nursing Home Lorraine Orlando - NewYork-Presbyterian Queens Faivish Pewzner - Americare Ashook Ramsaran - PAC Member Michael Tretola - Silvercrest Center for Nursing and Rehabilitation Paul Vitale - Queens Coordinated Care Partners AGENDA: I. Welcome M. Buglino II. Review & Approve Minutes of Previous Meeting Action Item M. Buglino III. IV. Medicaid Accelerated Exchange (MAX) Updates-Informational PMO Updates Informational DY2Q4 Remediation Submission 5 FAST FACTS Communication Tool- Partner Feedback S. Choudhury S. Choudhury V. Questions / Open Discussion VI. Adjourn

2

3

4 MAX Series Final Report Out NewYork-Presbyterian Queens PPS May 9, 2017

5 Agenda Action Team Overview MAX Program Potential Process Opportunity Themes MAX Action Plans Process Improvement Sustainability 2

6 Action Team Overview Action Team Executive Sponsor: Maria D Urso Administrative Director, Community Medicine and Co-Executive lead NYPQ DSRIP PPS, NYPQ Action Team Leads: Caroline Keane VP Care Coordination, Social Work and Transitions of Care, NYPQ, Clinical and Action Team Lead Sadia Choudhury Director, DSRIP Project Management Office, NYPQ, Administrative Lead and PPS Representative Action Team Members: Dr. Robert Crupi, Medical Director Ambulatory Care, NYPQ Adam Dorfman Case Manager RN-BC, NYPQ Janice Hlenski Social Worker, NYPQ Denise Lawson PI Director, Silvercrest Althea Baily Nursing Representative, NYPQ Dr. Johnathan LeBaron Attending ED Physician, NYPQ Juliet Chang 3 Director of Nursing, Franklin

7 PPS Medicaid High Utilizers: MAX Program Potential - Account for 21% of inpatient admissions - Average 6 inpatient admissions per patient per year - Average 9X higher cost ($189k) than the non-high utilizers ($21k) - Concentrated in Queens zip codes serviced by PPS / Lead Hospital PPS Network Alignment: - Long Term Care (LTC) focused network efforts for improvements MAX Participation - Train the Trainer (TTT) - Action Plan MAX series for High Utilizers 4

8 Process Opportunity Themes Action Periods 1 & 2 Identified the Lack of: - Care giver communication & connectivity - Understanding of SNF capabilities to customize patient care planning - Investigation of root cause of inpatient admissions - Connectivity to Health Home staff and enrollment process - Daily case conferencing for care givers - Warm hand-off s for admitted patients to avoid re-admissions

9 Max Action Plans Action Period 1 6

10 Action Plan #1 Warm Hand-off Process Improvement Achievements Pilot began with 1 SNF and grew to 12 SNFs by the end of the MAX program - 12 participating SNFs account for 2/3 of all hospital discharges; Goal is for all SNFs to participate by June 2017 Warm Hand-off PPS process approved and implemented for the network Team is at 50% compliance with warm handoffs as of May Weekly review of medical record to determine if warm hand-off occurred for high utilizers - All patients returning to a SNF will receive a warm hand-off Patient Success Story! Pt admit to ED for vomiting; H/O diabetic retinopathy 6 Admits in 1 year; 3 admissions within 30 days Warm Hand- Off to GI & SW for Detox Counseling No new Admissions/ ED Visits 7

11 Action Plan #2 SNF Capabilities Matrix Process Improvement Achievements NYPQ developed capabilities matrix for all SNF s. The capabilities matrix tool was distributed and used within the Emergency Department as an education & awareness tool for all care providers Capabilities matrices are now available in a binder in the ED and will be maintained for ongoing updates Patient High Utilizer Case Conference Patient Success Story! 87 y/o Alzheimer's SNF Patient 5 Admits in 1 year 4 within 1 month SW determined pt was at times sent to ED prematurely from SNF Spoke to Director of Nursing at SNF for warm hand-off Signed MOLST form 8

12 Action Plan #3 Inpatient Root Cause Analysis Process Improvement Achievements 47 Drivers of Utilization (DOU) Assessments given during the MAX program Team experienced issues capturing data in real time due to short length of stay for high utilizer patients and manual processes for data capture and recording Inconsistent rates of DOU capture noticed by team lead - Team schedules adjusted to ensure availability to see patients prior to discharge and daily team huddle at 4pm Goal is to teach weekend staff DOU Assessment process by end of May % 80% 60% 40% 20% 0% Feb 19 Drivers of Utilization Assessments Given Feb 26 Mar 5 Mar 12 Mar 19 Mar 26 Apr 2 % Served Apr 9 Apr 16 Apr 23 New Intervention Implemented! Apr 30 Based on the observed data, the team leads noted that there were inconsistencies in obtaining the DOUs from patients. Schedules were adjusted for key team members to ensure appropriate hours and availability to meet needs. 9

13 Max Action Plans Action Period 2 10

14 Action Plan #4 Health Home On-Site Process Improvement Achievements Health Home education for care givers to ensure understanding of health home benefits, process of referrals, and patient engagement - 1 st training session was completed in April for 15 ED care givers PPS utilized the Town Hall meeting on April 6, 2017 to educate community members on Queens Coordinated Care Partners (QCCP) health home Hospital established on-site Health Home staffing models with QCCP to establish a forum focused to patient centered plan of care Challenges Statewide HH Conversion Rates Manual Tracking Process Education Improved patient care Creative problem solving Mitigations On Site HH Staff in ED Cureatr Alerts Ongoing Education sessions 11

15 Action Plan #5 HU Case Conferencing Process Improvement Achievements Implementation of daily Care Management case conferences for high-utilizing patients Case conferences include patient admissions to address medical, behavioral, and social needs NYPQ High Utilizer Care Pathway Clerk in Case Management pulls daily high utilizer (HU) report Populate Worksheet with list of HU patients Case Manager conducts DOU assessment Patients presented at daily case conference Social worker makes referrals to community services PRN Follow up calls performed within 72 hours 12

16 Action Plan #6 SNF Information Channel Process Improvement Achievements Implementation of a direct access phone line into the ED for Silvercrest (SNF) - 39 Warm Hand-offs completed to date - On average 9/12 patients are being admitted from the ED to the IP Program is expanding to include Franklin SNF and all PCP s 13

17 Process Improvement Sustainability Planning 14

18 Process Improvement Sustainability Planning Implement IT Tools Across PPS Network Cureatr implementation for electronic health records (EHR) Allscripts Care Director to manage care plans & population health management RHIO connectivity for PPS network partners Expansion of Performance Reporting Structure Data warehousing of historic performance to trend patient activity Tableau dashboard creation specific to high-utilizers, providers, SNF, or condition Alignment with PPS Rapid Cycle Evaluation Unit & Hospital Quality Team Activity with the PPS Rapid Cycle Unit Process Improvement & Action Planning Encourage Collaboration and Communication Among Network Bi-weekly call with Health Home provider, QCCP, to track patient activity & conversion rates 15

19 Process Improvement Sustainability Planning Increase Educational Activities for all Network Partners Healthify as community resource directory to refer HU patients Develop sessions based on process improvement findings or patient / provider behaviors Increase Educational Opportunities for Patients & Families Patient Navigator / Care Managers located in the Emergency Department to increase education to patients & families for proper utilization of the ED Education to include Culturally Competent topics and materials to ensure complete understanding Align Cost Saving & Programmatic Changes with Value Based Payment Efforts Ensure reporting & forecasting properly track impact to cost of care for the HU community in order to provide reports within the network for VBP planning Partner with top Medicaid MCO s on anticipated cost impact and associated quality of care for VBP conversations 16

20 Questions? 17

21 DSRIPMAXHighUtilizerProcessImprovement-6/8/2017 ProcessImprovementIntent:IdentifyHighUtilizer(HU)patientswithinthehospitalinpatientunitanddefineprocessimprovementefforts /operationalprocesschangestoavoidfutureadmissionsorre-admissions. HighUtilizerDefinition:Fouradmissionsormoreinoneyear. PayerSources:Alpayers Volumes LOS January February March April PatientsAdmittedtoProgram Expired Living AverageLengthofStay January February March April 30dPrior 30dPost 30dPrior 30dPost 30dPrior 30dPost 30dPrior 30dPost 30DayPrior/PostTrends Hospitilizations Countof30dLOSTren. HospitilizationTrend Improved NotImproved Improved 40 NoHospitilizations NotImproved January February March April ClinicalChampion:CarolineKeane NumberofHospitilizations January February March April dPrior 30dPost 30dPrior 30dPost 30dPrior 30dPost 30dPrior 30dPost ExecutiveSponsor:MaureenBuglino

22 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response NYP Queens PPS - DSRIP PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 8.1 Section 8 Population Health Management Milestone #2 The IA does not consider this milestone Finalize PPS-wide bed complete. The PPS failed to provide the reduction plan. evidence of an assessment and training schedule as required by the minimum standards. Documentation Submitted for Q4 Bed Management Plan April 2017 Exec. Committee Minutes April 2017 PAC Presentation Milestone Milestone #2 Remediation Response The PPS asked for clarification from the IA in an dated June 1, 2017 as the PPS believes the Bed Management (Reduction) Plan that was submitted was sufficient as it presented the assessment of Queens county facilities and beds, community needs, and DSRIP impact. Also, for Population health Management section, only the training schedule was requested which the PPS has already submitted. On the IA response dated June 6, 2017 (see attached in the supporting documentation section), it was confirmed that this remediation comment was made in error. Hence, the PPS is not submitting any additional document for this milestone. Supporting Documentation 1

23 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response NYP Queens PPS - DSRIP PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback Milestone #3 Perform detailed gap analysis between current state assessment of workforce and projected future state. Staff Impact Section 11 Workforce The IA does not consider this milestone complete. The PPS failed to provide evidence of board approval. The PPS must clarify the Workforce Staffing Impact Report as it appears that the PPS did not submit any values for DY1. Documentation Submitted for Q4 Workforce Gap Analysis & Transition Roadmap DY2 Staff Impact Milestone Milestone #3 Staff Impact Remediation Response The PPS has attached the executive committee meeting minutes from January 2017 which reflects the approval of the workforce gap analysis and transition roadmap document. The PPS has included a staff impact spreadsheet for DY1 for the NYP Queens PPS for the new hires, redeployments, and retraining. As the PPS was in the process of being created during DY1, there was minimal impact to the workforce during that time. During this phase, most of the staff involved had DSRIP as an additional responsibility to an existing job as opposed to a shift in their job category. We anticipate seeing some of this change across all 3 of these categories in the later years as the impact of DSRIP is felt across the PPS system and the reduction to avoidable hospitalizations and ED visits occurs. Also since the provided template does not allow to add any columns, the PPS combined both the DY1 and DY2 numbers in one column. Supporting Documentation NYPQ Executive Committee Minutes Ja Workforce Staffing Impact (Actuals) DY1 1

24 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 2.a.ii.3 Milestone #8 Implement preventive care screening protocols including behavioral health screenings (PHQ-2 or 9 for those screening positive, SBIRT) for all patients to identify unmet needs. A process is developed for assuring referral to appropriate care in a timely manner. Project 2.a.ii PCMH The IA does not consider this milestone complete. The PPS failed to specify the type of screening protocols each provider received training on for Metric 1. The PPS also failed to meet the requirements of Metric 2 by failing to identify the clinical interoperability system used in its referral process for Community Health Network and Advanced Pediatrics PC. Documentation Submitted for Q4 Care Coordinator Description by Site & Training Documentation Milestone Remediation Response Supporting Documentation Milestone #8 For Metric #1, The PPS has compiled the number and types of screenings implemented at each PCMH site which should satisfy minimum documentation standards. PPS compiled the data based on the preventive screening policies from each PCMH site. The policies state the types of screenings implemented at each site. Please see attached excel spreadsheet. Preventative screenings implement 1

25 For Metric# 2, the PPS PMO gathered additional screenshots from the ehr at Advanced Pediatrics PC and Community Health Network that will demonstrate clinical interoperability system used in referral process. The updated referral workflow documents for both these facilities are attached in the supporting documentation. 2

26 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 2.b.v.3 2.b.v.3 2.b.v.3 Milestone #2 Engage with the Medicaid Managed Care Organizations and Managed Long Term Care or FIDA Plans associated with their identified population to develop transition of care protocols, ensure covered services including DME will be readily available, and that there is a payment strategy for the transition of care services. Milestone #4 Establish protocols for standardized care record transitions to the SNF staff and medical personnel. Milestone #6 Use EHRs and other technical platforms to track all patients engaged in the project. Project 2.b.v Care Transitions The documentation submitted by the PPS is not sufficient. The PPS failed to submit relevant documentation to address the specific data source requirement for each metric. For the IA to consider this milestone complete, the PPS must submit one data source that meets the requirement for each metric. If the PPS believes that previously submitted documentation meets this requirement, it must explain why. The documentation provided by the PPS is not sufficient. The PPS must submit data source documentation to demonstrate Clinical interoperability across ALL participating SNF providers. The documentation provided by the PPS is not sufficient. The PPS needs to submit data source documentation to evidence that it has met the requirement for this milestone. Documentation Submitted for Q4 MCO Gap Analysis Care Plan NH Capabilities List Warm Hand Off Document RHIO Connectivity Actively Engaged Template 1

27 Milestone Remediation Response Supporting Documentation Milestone #2 The PPS clinical workgroup outlined the anticipated workflow for the Care Transition process inclusive of staff and facility responsibilities as well as IT system capabilities and connectivity. The workflow was then used to identify MCO/FIDA gaps in patient coverage for the care transitions plan. The initial gap assessment was discussed with the top MCO/FIDA payers and it was agreed to continue the development of the Care Transitions workflow as well as conversations of coverage needs. Examples of MCO meeting agendas as well as the Care Transitions Workflow are included. Memo for MCO Milestone 2.docx Milestone #4 Along with the workflow and MCO gap assessment, the clinical committee approved the NYPQ PPS Best Practice for Care Transition. The adopted Best Practice is the NYS DOH Suggested Model for Care Transition that includes discharge planning, high risk patient identification, and comprehensive assessments. The BP is a guide for the active clinical improvements associated with the MAX high utilizer program and transition of the PPS from clinical integration to quality outcomes (staffing model). The best practice is included. In response to the remediation request, the PPS is submitting the NYP Queens Hospital Care Management policy that addresses how referrals are made and care plans shared upon discharge with SNFs and CHHAs. Additionally, the policy addresses how the Allscripts Care Manager, ACM, is utilized for establishing clinical interoperable communications. The NYPQ Care Management Policy.d 2

28 SNFs also utilize ACM that meets the standard for having clinical interoperable system in place. Milestone #6 Please refer to the attached care management policy from the hospital. Also attached is the SNF Interoperability diagram that provides clear depiction of referral process. The PPS previously submitted the blank report template that is used to track engaged patients. In response to the remediation request, the PPS is now submitting memo providing context to the template submitted and how the template assists in tracking engaged patients. Please refer to the attached memo and blank report template. Memo for Engaged Patients Template.do Blank NYPQ Template for 2.b.v.xlsx 3

29 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 2.b.vii.3 2.b.vii.3 2.b.vii.3 Milestone #1 Implement INTERACT at each participating SNF, demonstrated by active use of the INTERACT 3.0 toolkit and other resources available at Milestone #2 Identify a facility champion who will engage other staff and serve as a coach and leader of INTERACT program. Milestone #6 Create coaching program to facilitate and support Project 2.b.vii INTERACT The IA does not consider this milestone complete. The PPS must submit documentation to support the completion of each metric within this milestone. Although the PPS provided documentation demonstrating decrease in transfers over time for one facility, the PPS must submit a similar level of documentation for all participating SNFs to pass this metric. The IA does not consider this milestone complete. The documentation reflects that representatives from three SNFs have yet to be trained (Cypress Gardens, Forest Hills, Rego Park). The IA requests confirmation that training has been completed for these facilities. Alternatively, the PPS must provide an additional data source to complete this metric. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. The IA does not consider this milestone complete. The PPS provided a narrative that indicates two trainings Documentation Submitted for Q4 Quarterly Narrative Report NH Reduce Readmissions to Hospital INTERACT Imp. Plan Best Practices SNF Training SNF Database INTERACT Imp. Plan INTERACT TTT INTERACT Champions PL Training INTERACT Imp. Plan 1

30 2.b.vii.3 2.b.vii.3 2.b.vii.3 implementation. Milestone #7 Educate patient and family/caretakers, to facilitate participation in planning of care. Milestone #8 Establish enhanced communication with acute care hospitals, preferably with EHR and HIE connectivity. Milestone #9 Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. were held in Oct and Nov 2016 with two champions from each SNF partner. The narrative also notes "Some SNFs who were not in training sessions received training earlier as part of working with other PPSs." While the narrative addresses the majority of requirements for this metric, the IA requires clarification on how many individuals have completed training. Alternatively, the PPS must submit documentation to complete at least one data source for this metric. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. The IA does not consider this milestone complete. The PPS must submit documentation to support the completion of each metric within this milestone. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. If referencing a static PDF document, PPS must provide documentation name, page number(s) and paragraph reference for sections that directly address milestone requirement. The IA does not consider this milestone complete. The PPS must submit meaningful use certification documentation to support the completion of Metric 1 within this milestone. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. The IA does not consider this milestone complete. The PPS must submit documentation to support the completion of each metric within this milestone. For Metric 1, the PPS must provide the staff category for each committee member. For Metric 2, the PPS submitted a CQI meeting agenda which indicates that a Sample Care Plans & Training RHIO Connectivity Rapid Cycle Overview 2

31 2.b.vii.3 Milestone #10 Use EHRs and other technical platforms to track all patients engaged in the project. draft plan may have been provided during the meeting. However, the actual plan document was not included. For Metric 4, the meeting minutes submitted do not appear to address how outcomes are reported to stakeholders. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. The IA does not consider this milestone complete. Specifically, the PPS must provide additional detail to indicate how the patients were targeted for this milestone. If the PPS believes the previously submitted documentation meets this requirement, it must explain why. Actively Engaged Template Milestone Remediation Response Supporting Documentation Milestone #1 Milestone #2 Due to the limit of uploads per milestone in MAPP, the PPS could not upload all the committed 24 SNF (as per new speed and scale requirements)hospital readmissions report. In response to the remediation request, the PPS PMO has created hyperlinks to the reports for each SNF. Also attached are the INTERACT implementation training sign in sheets from each of the 24 SNFs. Please refer to the attached excel spreadsheets. The PPS submitted the Train the Trainer list from the SNFs who attended the training sessions hosted by NYP Queens PPS in collaboration with Pathway Heath, certified INTERACT SNF NH Baseline Report.xlsx SNF INTERACT Trainings.xlsx 3

32 Training vendor. Milestone #6 As per the new speed and scale requirement, the PPS is required to have 23 (vs 27 from old speed and scale) committed SNF partners in the project. In response to the remediation request, the PPS has now provided updated facility champion list of all the 24 committed SNF partners. Please refer to the attached memo for more elaboration. Please see the attached excel spreadsheet for the facility champion list for the 24 committed SNFs. Also included is the document outlining expectations set by PPS for INTERACT facility champions. Due to the limit of uploads per milestone in MAPP, the PPS could not upload all the committed SNF INTERACT training sign in sheets from individual facilities. In response to the remediation request, the PPS PMO has created hyperlinks to the sign in sheets for INTERACT Trainings at each SNF. Also included is the list of the facility champions in those SNFs. INTERACT champions.xlsx Memo for Facility Champions.docx INTERACT champions.xlsx SNF INTERACT Trainings.xlsx Please refer to the attached excel spreadsheets. Also attached are the training materials. Tools for NYHQ.xlsx 4

33 Milestone #7 For Milestone#7 the PPS submitted the care plans from each Skilled Nursing Facility (SNF) which showed where the patient/ family education are documented. In response to the remediation request, the PPS is now submitting additional documents to IA to support the notion that all the 24 committed SNFs in the PPS network are committed to providing patient/family education extensively on their care plans etc. Please see the attached memo. Memo for Care Plan Policies.docx SNF Patient Education 2.xlsx Milestone #8 The attached excel spreadsheet has the 24 committed SNFs listed with their patient/family education policies on care plan, medication management etc. As per guidelines from IA released in June 2016, the SNF partners are excluded from Meaningful Use certification requirements. Hence, the PPS do not plan to submit anything for Metric # 1. Please see attached IA guidelines in the supporting documentation (Page# 1) 5

34 Milestone #9 The PPS previously submitted all these information in the pdf packet which had the requested documents incorporated into the packet. Since it was pdf copy, the documents attached inside the packet could not be opened. The PPS PMO is resubmitting the requested documents separately now. Please see the supporting documentation column. Updated minutes are attached as well. Rapid Cycle Agenda.docx Rapid Cycle Unit Overview.pptx Milestone #10 The PPS previously submitted the blank report template that is used to track engaged patients. In response to the remediation request, the PPS is now submitting memo providing context to the template submitted and how the template assists in tracking engaged patients. The memo also includes information on additional 30-day readmissions report from Cureatr that the PPS uses to track its engaged patients in this project. NYPQ PPS CIQ Meeting Minutes 4.20 Memo for Engaged NYP Patients Template.doQueensCureatrRepor NYPQ 4th ED_HA Blank NYPQ Template Data_ ppt for 2.b.vii.xlsx Please refer to the attached memo, Cureatr sample report and power point slides with overview of its use, and blank report template. 6

35 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 2.b.viii.3 2.b.viii.3 2.b.viii.3 Milestone #2 Ensure home care staff has knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence-based medicine and chronic care management. Milestone #4 Educate all staff on care pathways and INTERACTlike principles. Milestone #6 Create coaching program to facilitate and support implementation. Project 2.b.viii Hospital Home Care The PPS has submitted documentation necessary to meet the minimum standards of the Validation Protocols; however, the PPS has not met the provider commitments for this milestone. Failure to meet the provider level commitment may result in the loss of an AV. The PPS has submitted documentation necessary to meet the minimum standards of the Validation Protocols; however, the PPS has not met the provider commitments for this milestone. Failure to meet the provider level commitment may result in the loss of an AV. The PPS has submitted documentation necessary to meet the minimum standards of the Validation Protocols; however, the PPS has not met the provider commitments for this milestone. Failure to meet the provider level commitment may result in the loss of an Documentation Submitted for Q4 HHC Care Plan & Training EB Chronic Disease Mgmt HHC Database INTERACT Champions INTERACT Training In Home Care Site Best Practices Imp. Plan INTERACT TTT Care Plans & Training HHC Database Rapid Cycle INTERACT Imp. Plan 1

36 AV. 2.b.viii.3 Milestone #7 Educate patient and family/caretakers, to facilitate participation in planning of care. The IA has reviewed the submitted documentation. The IA has determined that the PPS has not provided information that would support completion of this metric. The Metric is specifically related to the patient and caretakers. The PPS should submit patient/family methodology and or patient/family educational material. HHC INTERACT Training Care Plan & Trainings Milestone Remediation Response Supporting Documentation Milestone #2 Milestone #4 The PPS has met the provider commitment for the home care project and actively engaged 8 home care facilities. The attached spreadsheet shows the organizations that are actively participating. This information was not previously included in MAPP due to a technological limitation of the system. The PPS has met the provider commitment for the home care project and actively engaged 8 home care facilities. The attached spreadsheet shows the organizations that are actively participating. This information was not previously included in MAPP due to a technological limitation of the system. Also attached are the INTERACT Implementation sign in sheets from each of the 8 committed CHHAs. 2bviii Home Care Provider Committmen 2bviii Home Care Provider Committmen 2.b. viii INTERACT Trainings.xlsx 2

37 Milestone #6 Milestone #7 The PPS has met the provider commitment for the home care project and actively engaged 8 home care facilities. The attached spreadsheet shows the organizations that are actively participating. This information was not previously included in MAPP due to a technological limitation of the system. In response to the remediation request, the PPS is now submitting additional documents to IA to support the notion that all the 8 committed CHHAs in the PPS network are committed to providing patient/family education extensively on their care plans etc. 2bviii Home Care Provider Committmen Memo for Care Plan Policies.docx Please see the attached memo. Please see the attached excel spreadsheet for the supporting documentation for each 8 committed CHHAs in the PPS network. HHC Patient Education Template 2 3

38 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 3.a.i.3 3.a.i.3 Project 3.a.i Primary Care / Behavioral Health Co-Location Milestone #2 Develop The IA does not consider this Project Requirement collaborative evidence-based complete. In Metric 1, the PPS failed to provide standards of care including minutes for meetings which occurred on the following medication management and care dates: 3/15/17, 1/13/17, and 1/26/17. For Metric 2, the engagement process. PPS failed to provide a reference to evidence based guidelines in its Brightpoint Policy on medication and adherence and the Child Center NY Policy. The PPS must provide this information for the IA to review. Milestone #6 Develop collaborative evidence-based The IA does not consider this Project Requirement complete. In Metric 1, the PPS failed to provide Documentation Submitted for Q4 ACD Integration Diagram ACD Workflow ACD Training Attendees NYPQ / Child Center NY MT Minutes NYPQ / Brightpoint MT Minutes Preventative Health Guidelines Child Center NY Med. Adherence Brightpoint Med. Adherence Brightpoint Preventative Health Guidelines ACD Integration Diagram 1

39 3.a.i.3 standards of care including medication management and care engagement process. Milestone #8 Use EHRs or other technical platforms to track all patients engaged in this project. minutes for meetings which occurred on the following dates: 3/15/17, 1/13/17, and 1/26/17. For Metric 2, the PPS failed to submit documentation that specifically outlines its policy surrounding evidence-based guidelines and the sources of the guidelines used as it relates to this milestone and metric. The IA does not consider this Project Requirement complete. The PPS submitted a Treatment Plan Review for Metric 1 but failed to demonstrate that medical and behavioral health treatment is captured in an EHR. The PPS must submit a screenshot of the patient's record in the EHR which would suffice under the documentation requirement of the milestone. ACD Workflow ACD Training Attendees NYPQ / MHPWQ Mtg Minutes NYPQ / MHPWQ Mtg Minutes ACQC Referrals Tracking Log MHPWQ Engagement & Retention Policy MHPWQ EBM Mgmt Protocol MHPWQ TX Plan MHPWQ RN Note MHPWQ Med. Eval Record Int. Blank NYPQ Pt Template Tracking Milestone Remediation Response Supporting Documentation Milestone #2 The PPS previously submitted the colocation workgroup meeting minutes with each partner. Also submitted were the medication adherence policies from Brightpoint Health and Child Center of New York. Allscripts Care Director Training sign in sheet was submitted as we had to report out completion of ACD configuration as one of the due tasks under this milestone. In response to the remediation request, the PPS is now submitting the DSRIP Behavioral Health Inte 2

40 Primary Care Behavioral Health Integration committee meeting minutes from June 2015 and July 2015 that clearly talk about discussion collaborative evidence based care practices including medication management and care management. Please see attached. IA requested for minutes for 01/19 and 01/26 meetings. As mentioned earlier, those meetings were colocation workgroup meetings and minutes were already submitted. They are attached once again. The medication management policies from Brightpoint and Child Center of New York are reattached again. To address the IA remediation request, the PPS is submitting the OASAS standards (see link below) and OMH standards (see attached) which are the evidence based guidelines used by the two facilities mentioned above. The policy for Child Center of New York refers to PASAS guidelines at the bottom of the last page of policy as well. OASAS standards guidance document on medication management IA asked for minutes for March 15. That was ACD Training, thus there are no minutes. However, PPS has attached the with the link to watch the video of training, as necessary. Meeting minutes July 15, a.i.docx NYPQ BPH docx NYPQ CCNY docx ACD_Training_Atten deeslist.docx FW EXTERNAL Elizabeth Solaro has G Brightpoint policy medication monitoring 3

41 Milestone #6 The PPS previously submitted the colocation workgroup meeting minutes with each partner. Also submitted was the medication adherence policy from Mental Health Providers of Western Queens. Allscripts Care Director Training sign in sheet was submitted as we had to report out completion of ACD configuration as one of the due tasks under this milestone DSRIP Behavioral Health Inte In response to the remediation request, the PPS is now submitting the Primary Care Behavioral Health Integration committee meeting minutes from June 2015 and July 2015 that clearly talk about discussion collaborative evidence based care practices including medication management and care management. Please see attached. Meeting minutes July 15, a.i.docx ACD_Training_Atten deeslist.docx The medication management policies from Mental Health Providers of Wester Queens are reattached again. To address the IA remediation request, the PPS is submitting the OASAS standards (see link below) and OMH standards (see attached) which are the evidence based guidelines used by the facility mentioned above. Also attached is the PSYKES evidence based tool that is utilized by the facility, as mentioned in their policy. OASAS standards guidance document on medication management IA asked for minutes for March 15. That was ACD Training, thus there are no minutes. However, PPS has attached the with the link to watch the video of training, as necessary. FW EXTERNAL Elizabeth Solaro has G Engagement and Retention Policy- TAB MHPWQ Evidenced Based Medication Man 4

42 Milestone #8 The PPS previously submitted treatment plan, RN note, and Medical evaluation record note for Mental Health providers of Queens (MHPWQ). All of those were extracted directly from the integrated ehr, AccuMed, used by MHPWQ. MHPWQ -integration screenshot.docx For further clarification and as requested, the PPS is submitting the actual screenshot of patients record from the ehr of MHPWQ. Please see attached. Also attached are the previously submitted documents for treatment plan, RN note, and Medical evaluation record note. 5

43 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 3.b.i.3 3.b.i.3 Milestone #7 Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management. Milestone #9 Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment. Project 3.b.i Cardiovascular The documentation provided by the PPS is not sufficient. The PPS failed to submit documentation to meet the requirement for metric #2. The list of participating care coordination team members did not comprise: names, license # and full address. Furthermore, the information was not provided in excel spreadsheet format. Additional documentation did not meet the data source requirements for this metric. The PPS must submit at least one complete data source to meet the requirement for metric #2 for completion of this milestone. The documentation provided by the PPS is not sufficient. The PPS failed to submit an inventory of trainings provided to meet the data source requirement for this milestone. The inventory of trainings must include date of the training, focus area or topic, format of the training as well as the number of staff trained. The PPS must submit complete information for IA review to complete the requirement for this milesone. Documentation Submitted for Q4 GNYHA Care Coord. Training Cardio. Refresher Training Sign In Cardio Refresher Sllides Care Coord. Policy Case Conference Brightpoint Sample Report Cardio Refresher Sign In Cardio Refresher Slides NYPQ Policy for BP 1

44 3.b.i.3 3.b.i.3 3.b.i.3 Milestone #11 Prescribe oncedaily regimens or fixed-dose combination pills when appropriate. Milestone #14 Develop and implement protocols for home blood pressure monitoring with follow up support. Milestone #20 Engage a majority (at least 80%) of primary care providers in this project. The documentation provided by the PPS is not sufficient. The PPS failed to provided policies and procedures which articulate procedures for determining preferential drugs based on ease of medication adherence where there are no other significant nondifferentiating factors. The PPS must provide the required policy for IA review. If the PPS believes that previously submitted documentation meets this requirement, it must explain why. The documentation provided is not sufficient. The PPS failed to submit sufficient information to meet the data source requirement for metric #2. The PPS must submit at least one complete data source to meet the requirement for metric #2 to complete this milestone. The documentation submitted by the PPS is not sufficient. The PPS must provide a list that includes the participating PCPs name, license#, type of provider, full address, etc. The information must be provided in an excel spreadsheet format as stated in the data source requirement. Brightpoint Aspirin algorithm Cardio refresher sign in Cardio refresher slides NYPQ Policy for hypertension & cholesterol Cardio refresher sign in Cardio refresher slides NYPQ policy on BP a Home List of all PCPs in Cardio Project List of all PCPs in Network Milestone Remediation Response Supporting Documentation Milestone #7 The PPS previously submitted the the care conference sign in sheets that showed the people involved in the care coordination team. Also included was the GNYHA care coordination training sign in sheet for the PPS partners. As requested, please see attached the excel spreadsheet with name, license numbers, and full address of the facility for Care Coordination Roster_v2.xlsx 2

45 people who are involved in case conference and who also attended the cardiovascular refresher webex training. Milestone #9 Milestone #11 Also attached is the GNYHA sign in sheet for care coordination training for members in the PPS partner organizations. Previously, the PPS submitted the cardio refresher training sign in sheet together with the training slides. As requested, the PPS is now submitting the list in excel format, with date and type of training included once again. The training was webex in nature. The training power point slides are attached as well. The PPS updated the policy to reflect what is already practiced in the partner sites for medication preference and adherence. Please see attached policy. Cardio refresher training.xlsx DSRIP Cardiovascular Refres Hypertension and elevated cholesterol_ Milestone #14 Milestone #20 The PPS submitted the updated policy with elaboration on the importance of home blood pressure monitoring (HBPM) and follow up support to patients for HBPM. The policy also addresses the tools recommended for patient to log their BP results, equipments to be used for measuring BP, and emergency criteria when provider should be reported. Please see attached policy Previously the PPS submitted two seprate lists and both were already in excel format. One list contained all primary care providers in the PPS network and another list contained all PCPs in the network who are engaged in the cardiovascular BP monitoring at home_updated.docx List of all PCPs in the network-final.xlsx 3

46 project. Both the lists contained PCPs name, type of provider, full address, etc. License # was missing as our partner list never contained license numbers. List of all PCPs in the cardio project...xlsx As requested by IA, PPS is now resubmitting the two lists with lincense numbers of these providers included. Please see attached. The PPS has 83% of its PCPs engaged in the cardiovascular project. 4

47 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 3.d.ii.3 3.d.ii.3 Milestone #3 Develop and implement evidence-based asthma management guidelines. Milestone #6 Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what happened and how Project 3.d.ii Asthma The PPS must submit documentation sufficient to demonstrate completion of this metric and milestone. If the PPS believes the documentation previously submitted is sufficient, it must explain why. The PPS must demonstrate how a root cause analysis is conducted and shared with a patient and/or family per the project and metric requirement. Documentation Submitted for Q4 PL Training Agenda PL Registration/WebEx PL Registration/WebEx PL Partner Letter MCO Gap Analysis Rapid Cycle Mtg Minutes Rapid Cycle Slides Patient Education Materials Provider Education Materials EB Tools & Checklist Rapid Cycle Mtg Minutes Rapid Cycle Slides Asthma Referral Registry 1

48 to avoid future events. 3.d.ii.3 Milestone #8 Use EHRs or other technical platforms to track all patients engaged in this project appropriate. The IA has reviewed the documentation submitted and does not consider this milestone complete. The PPS failed to meet the specifics for the data source submitted. Asthma registry sample ecw Engaged Patient Template Milestone Remediation Response Supporting Documentation Milestone #3 The PPS has put together a memo which states how we have met the requirements for this milestone as we have submitted all the evidence based asthma management guidelines from Saint Mary s and Asthma Coalition of Queens. Also included are the documents submitted previously: Memo for Evidence-based Asthm Milestone #6 The PPS has previously submitted the roster of pediatric patients who had inpatient admissions with asthma diagnosis and were scheduled for follow up visit with the Pediatric Asthma Center where the root cause analysis discussions happened. Per the minimum documentation standards from IA, that met the criteria. Memo for Root Cause Analysis.docx 2

49 Milestone #8 For further clarification, PPS put together a memo (see attached) which elaborates on the follow up and root cause analysis process that is currently happening. The PPS has put together memo (see attached) explaining how the actively engaged patient reporting template that was submitted is used by the project partners to track the patients referred for home assessment. The PPS has also re-submitted the template (see attached) Memo for Engaged Patients Template.do Patient Engagement - Partner Template (3 3

50 NYS DSRIP Program Independent Assessor Remediation NYP Queens Remediation Response PPS #: 40 DY 2 / Quarter 4 Remediation Date: May 31, 2017 Response Due Date: June 20, 2017 Response Submission Date: June 15, 2017 Section Milestone Feedback 3.g.ii.3 Milestone #6 Use EHRs or other IT platforms to track all patients engaged in this project. Project 3.g.ii Palliative Care in SNF IA does not consider this milestone complete. The PPS failed to submit supporting documentation to meet the metric and data source requirements. Documentation Submitted for Q4 Actively Engaged Template Milestone Remediation Response Supporting Documentation Milestone #6 The PPS has put together memo (see attached) explaining how the actively engaged patient reporting template that was submitted is used by the project partners to track the patients engaged in palliative care. The PPS has also re-submitted the template (see attached) Memo for Engaged Patients Template.do Patient Engagement - Partner Template (3 1