Central New York Care Collaborative (CNYCC) Oneida County Health Coalition Meeting June 30, 2016

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1 Central New York Care Collaborative (CNYCC) Oneida County Health Coalition Meeting June 30, 2016

2 Agenda 1. Overview of the NYS DSRIP Program 2. History of Performing Provider Systems in Central New York 3. About CNYCC Today 4. Our PPS s 11 DSRIP Projects & the Role of Public Health & Community Agencies Care Transitions (2biv) Patient Activation (2di) Behavioral Health Crisis Stabilization (3aii) 5. Questions

3 Delivery System Reform Incentive Payment (DSRIP) Program In April 2014, New York State announced approval of a waiver to allow NYS to reinvest over $8 billion in federal savings generated by the Medicaid Redesign Team (MRT) Federally funded initiative that provides NY with funding to support hospitals and provider organizations to change how care is provided to Medicaid beneficiaries. $7.62 billion for Delivery System Reform Incentive Payment (DSRIP) program $1.08 billion for other Medicaid Redesign purposes The DSRIP program promotes community-level collaborations via performing provider systems (PPSs) and focuses on system reform Goals of DSRIP Reduce avoidable hospital readmissions and emergency department use by 25% over the next 5 years Preserve and transform the State s fragile health care safety net system

4 Central New York Performance Provider System (PPS) In 2014 New York State established a process for lead healthcare organizations to apply to serve as the lead entity for Performing Provider Systems

5 CNYCC Governance SUNY Upstate Medical University Syracuse Community Health Center Hillside Children s Center Crouse Hospital Loretto Community Memorial Hospital Oneida Healthcare East Hill Family Medical St. Joseph s Health Center Oswego County Opportunities CNY Health Home Regional Primary Care Network Auburn Hospital Sitrin Home Services CNY FQHC Collaborative Faxton-St. Luke s Board Committees Corporate Members (4 Co Leads) Board of Directors (22 Members) Executive Committee Clinical Governance Committee Compliance Committee Finance Committee Nominating Committee IT/Data Governance Committee Executive Project Advisory Committee (EPAC) RPAC Cayuga County RPAC Lewis County RPAC Madison County RPAC Oneida County RPAC Onondaga County RPAC Oswego County

6 CNYCC: At a Glance 6 COUNTIES Cayuga, Lewis, Madison, Oneida, Onondaga, and Oswego 170 Partner Organizations 6,000 SQUARE MILES Nearly 200,000 MEDICAID SUBSCRIBERS New Corporation PPS Lead Agency 1,400 HEALTHCARE AND COMMUNITY BASED SERVICE PROVIDERS

7 Slide 6 2 Update image of NYS to be a watermark that lives behind all the content on that slide. Client wanted this larger as noted in the below notes section -Katie Flemming -,

8 Our PPS s 11 DSRIP Projects System Transformation (Domain 2) Integrated Delivery System (2ai) DSRIP Care Management (2aiii) ED Care Triage (2biii) Care Transitions (2biv) Patient Activation (2di) Population Health (Domain 4) Behavioral Health Infrastructure (4aiii) Reduce Premature Births (4di) Clinical Improvement (Domain 3) Behavioral Health/ Primary Care Integration (3ai) Behavioral Health Community Crisis Stabilization Services (3aii) Cardiovascular Disease Management (3bi) Palliative Care Integration (3gi)

9 Integrated Delivery System (2ai) Karen Joncas Project Manager

10 Integrated Delivery System (2ai) Key Project Components Development of a HIT infrastructure to support the Integrated Delivery Network Community Wide Analytics & Care Coordination Health Information Exchange & Interoperability EMR Adoption, Optimization & MU Attestation Primary care practice transformation to meet PCMH 2014 Level 3 APC Standards Role for Public Health & Community Agencies Current: Explore joining HealtheConnections (RHIO) [DSRIP Year 1 payment] Future: Contribute social & behavioral determinant data to CNYCC s Population Health Management (PHM) system, utilize care coordination platform

11 DSRIP Care Management (2aiii) Kate Weidman Project Manager

12 DSRIP Care Management (2aiii) Key Project Components Integrate an intermediate level of care management for Medicaid patients with 1 chronic condition in the primary care setting Level of service falls between PCMH for the general population and Health Home for the complex super-utilizer population Can be provided by primary care or embedded Health Home or downstream Care Management Agency staff [DSRIP Year 1 payment] Health Home and/or downstream CMAs involved in ongoing data sharing & training Role for Public Health & Community Agencies Health Home/downstream CMAs partner with participating primary care practices Use Universal Referral Form to help eligible clients access DSRIP Care Management

13 ED Care Triage (2biii) Kate Weidman Project Manager

14 ED Care Triage (2biii) Key Components ED patient navigator educates patients with ambulatory-sensitive conditions on appropriate use of ED, arranges a follow-up appointment with primary care practices, and connects to Health Home care manager (if applicable) Primary care practice establishes or re-establishes relationship, addresses ambulatory-sensitive condition, and reinforces patient education Role for Public Health & Community Agencies Current: PCP Scheduling Resource: Future: Community-based resources to address other patient needs

15 Care Transitions (2biv) Tammy VanEpps Project Manager

16 Care Transitions (2biv) Key Project Components Provide targeted care transitions intervention to reduce 30-day readmission rate among high risk Medicaid patients Improve communication & documentation between hospitals and post-acute providers, human service agencies/community-based organizations Role for Public Health & Community Agencies Participate in regional Care Transitions Coalitions jointly sponsored by CNYCC and IPRO [DSRIP Year 1 payment]

17 Patient Activation (2di) Kelsie Montaque Project Manager

18 Patient Activation (2di) Key Project Components Uninsured & low- and non-utilizing Medicaid patients/clients receive: 1. PAM screening & appropriate referral 2. Coaching to increase patients activation in their own health care (CFA ) 3. Coordination & follow-up (under development) CNYCC is partnering with a broad range of organizations, from community-based organizations to traditional health care providers to offer #1, #2, and #3 Role for Public Health & Community Agencies Current: Sign up staff for PAM and CFA training [DSRIP Year 1-2 payment] Current: PAM screenings begin April 1 [DSRIP Year 2 payment]

19 Primary Care & Behavioral Health Integration (3ai) Kelly Lane Project Manager

20 Primary Care & Behavioral Health Integration (3ai) Key Components: Primary care practices integrate behavioral health services; behavioral health providers integrate primary care services Patients receive appropriate evidence-based screenings, treatment, & follow-up Role for Public Health & Community Agencies Current: If your organization currently provides primary care or behavioral health, consider integrating services, providing screenings [DSRIP Year 1 payment] Future: Cultural competency & health literacy support

21 Behavioral Health Community Crisis Stabilization Services (3aii) Kelly Lane Project Manager

22 Behavioral Health Community Crisis Stabilization Services (3aii) Key Project Components: Assemble a comprehensive crisis services program that builds upon existing services & resources Where three key services are absent or at capacity, CNYCC is funding: Traditional Mobile Crisis Teams Enhanced Mobile Treatment Teams Peer respite Role for Public Health & Community Agencies Current: Report crisis stabilization services being provided [DSRIP Year 1 payment] Future: Establish central line for access, enhance referrals to community resources

23 Cardiovascular Disease Management (3bi) Karen Joncas Project Manager

24 Cardiovascular Disease Management (3bi) Key Project Components Primary care practices adopt: Clinical guidelines for hypertension, elevated cholesterol and related clinical processes Strategies from the Million Hearts Campaign Multi-disciplinary care coordination teams for adult patients with cardiovascular disease Role for Public Health & Community Agencies Community-based resources for diet, exercise, tobacco cessation, and chronic disease self-management Cultural competency & health literacy assistance for providers

25 Palliative Care Integration (3gi) Tammy VanEpps Project Manager

26 Palliative Care Integration (3gi) Key Project Components Integrate Primary Palliative Care services into primary care practices Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice Patient education and staff training to increase awareness & acceptance of the benefits of palliative care on length and quality of life Role for Public Health & Community Agencies Future: Inform & support efforts to increase public awareness & acceptance of palliative care Future: Cultural competency & health literacy support

27 Behavioral Health Infrastructure (4aiii) Kelly Lane Project Manager

28 Behavioral Health Infrastructure (4aiii) Key Project Components: Strengthening of infrastructure for MEB health promotion and MEB disorder prevention Collaboration among leaders, professionals, and community members working in mental, emotional, and behavioral health promotion across counties & silos Role for Public Health & Community Agencies Current: Many partners participated in development of PPS-wide strategic plan Future: Once approved, strategic plan & RFP will be posted, proposals accepted

29 Reduce Premature Births (4di) Kelsie Montaque Project Manager

30 Reduce Premature Births (4di) Key Project Components Development of clinical standards to reduce preterm labor with provider education and adoption support Expansion, creation, & ongoing support for CenteringPregnancy, maternal & child community health worker, & home visiting programs Extend centralized screening, referral, coordination, and follow-up for at-risk women across the 6-county PPS region Role for Public Health & Community Agencies Current: Many participated in development of standard at-risk definition Future: Clinical Standards Technical Assistance & CenteringPregnancy RFPs

31 Thank You

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