Central New York Care Collaborative DSRIP Application Findings

Transcription

1 Central New York Care Collaborative DSRIP Application Findings Primary Care & Behavioral Health Assessment and Integration Effort Deloitte Consulting LLP December 2, 2014

2 Preface Deloitte Consulting LLP was engaged to support Upstate University Hospital, in their role as the lead for the Central New York Care Collaborative, in the assessment of the market and development of materials related to the DSRIP project. This document is intended to address the various deliverables as noted in Deloitte Consulting LLP s Proposal to Provide Primary Care and Behavioral Health Assessment and Integration Services in Support of Upstate University Hospital s Application Development dated August 27 th, CNYCC DSRIP Behavioral Health Primary Care Findings pptx

3 Primary Care & Behavioral Health Integration Proposal Deliverables Item Deliverable Key 1 1.a. PPS Primary Care, Behavioral Health, & Integration work plan, including methodology, data collection plan, and stakeholder engagement process 1.b. 1.c. 1.d. Recommendations to target at-risk populations for DSRIP initiatives Gap analysis highlighting variances between the current state of the PPS and targeted regions and goal of one primary care and behavioral health entity with integrated operations, incorporating both findings from data analysis and experience of Subject Matter Advisors Targeted and well-defined organizational and cultural change management strategy recommendations to move stakeholders and partner organizations from being passive observers to owning and driving improvement during implementation 2. Compilation and summary of capacity findings, conclusions, and next steps as determined by Upstate University Hospital 3. Potential partner assessment tool 4. 5.a. 5.b. 6.a. Recommendations for PPS partner list, supplemented with partner information, scoring sheets and potential benefits of collaboration Compilation of interview summaries Key themes and outcomes of interviews Preliminary conclusions gathered from partner surveying 7. Report on PPS strengths and needs compiling findings with secondary data analysis 8. Updated gap analysis highlighting variances between the current state of the PPS as evolved from new partnerships, incorporating both findings from data analysis and experience of Subject Matter Advisors 9. Presentation to CCCN representatives to brief coordination and integration - 3 -

4 Contents Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52 Note: Originally, Deloitte was engaged by Central New York Coordinated Care Network (CCCN) and references to CCCN exist in this document. It is recognized that, through consolidation of several PPS networks, this title has been retired. The title "CCCN" will exist in this document when referring to documents that were developed prior to the consolidation

5 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52 CNYCC DSRIP Behavioral Health Primary Care Findings pptx

6 Interview Findings The following interview key findings, observations and implications are aggregated themes which were found to be consistent across many of the stakeholder interviews conducted between October 6 th and October 29 th. Throughout this period Deloitte engaged in 29 individual interviews with 20 unique organizations and over 40 stakeholder participants. Outside of the individual interviews, many of these findings were further corroborated or generated from the October 21 st PAC meeting in which more than 60 unique organizations were registered. CNYCC DSRIP Behavioral Health Primary Care Findings pptx

7 Physician Integration and Provider Capacity Key finding Observations Implications Physician Integration Lack of coordination between primary care, homecare and health homes Lack of physician collaboration and integration across behavioral health and primary care Primary care providers tend to focus more on medical diagnoses while homecare providers discover behavioral challenges during the home visit need communication between the two Lack of interface between the two settings leads to inefficiencies to managing care Assigning social workers to coordinate with health homes can reduce admits for frequently admitted patients with behavioral and social issues Disparate treatment philosophies between physical medicine and mental health lead to lack of collaboration among providers Often providers are unaware of who to contact and refer to, or what services exist Primary care is often reluctant to perform basic behavioral health services resulting in patients targeting more acute services to receive care, or neglecting care altogether Coordination between these two providers should lead to a more coherent and holistic level of care Providers are not always aware that a homecare manager exists, therefore do not notify the manager when patients are in hospital or have appointments with other providers Results in patients more likely to return to hospital for further care, if needed Undiagnosed or lack of treatment plan to address behavioral health issues complicates patient compliance with physical medical issues Patients may be readmitted for untreated behavioral health issues because issue wasn t addressed during initial hospitalization Provider Capacity Difficult to recruit and retain primary care and behavioral health specialist Hospital administration reports that efforts to recruit PCPs and behavioral health specialists are lengthier than other specialties; positions often go unfilled for long periods of time CHWS reported that NY state only retains 44% of newly trained physicians which creates recruitment issues, particularly in rural areas since 86% of physicians that stay, plan to practice in the same region which they were trained Lack of recruitment (primarily in the rural areas) requires providers to use creative forms of care such as telehealth or video conferencing Many community providers expressed interest in expanding programs that do not require a provider, but will provide care to their population such as peer counseling, telehealth services, etc. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research - 7 -

8 Provider Capacity and Community Indicators Key finding Observations Implications Provider Capacity Time to first appointment exceeds best practices Primary Care Physicians not sufficiently diagnosing and treating Behavioral Health issues It was reported that, it can take over a month from discharge to get a first appointment (well beyond 3 7 day best practice) if hospital patient lacks a primary care provider A typical 15 minute primary care visits result in time constraints for PCPs to adequately address BH issues If BH issues diagnosed during PCP visit, there is a tendency to refer out to specialists for treatment Results in patients more likely to return to hospital for further care, if needed Patients may never get follow up care and may revert back to severe condition Insufficient diagnosis of behavioral health issues Insufficient treatment of behavioral health issues; opportunity to strengthen medical education (GME & CME) to equip PCPs with knowledge of appropriate diagnosis and treatment of behavioral health issues within the primary care setting Community Indicators A high rate of mental health conditions and substance abuse exists: High rates of inappropriate hospital utilization are driven by a high rate of comorbid medical and behavioral health issues According to the Community Needs Assessment performed by JSI, Major Personality Disorders, Drug/Alcohol Abuse and Myocardial Infarction are the leading causes of inpatient admissions across all counties in CNY The Community Needs Assessment indicates Depression as the most prevalent chronic condition across all 6 counties in CNY While behavioral health conditions are driving inpatient admissions, more inpatients are placed in general acute medical beds and not psychiatric beds. This data may indicate BH is a strong comorbidity that is complicating the ability to treat an acute medical condition. Untreated and uncontrolled depression reduces the ability for the patient to maintain other medical and health issues. Interviewees cited published statistics that patients with depression die at earlier ages than those not reporting BH issues. Patients with depression are more likely to be unemployed and dependent on assistance programs. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research - 8 -

9 Access to Care and Social Challenges Key finding Observations Implications Access to Care Social Challenges Patients have difficulty securing post-acute care providers for follow-up care Insufficient residential care for psychiatric patients Transportation barriers reduce access to care Rates of smoking/alcohol/drug use is higher among Medicaid and uninsured populations Inadequate housing among target population Substitution of inpatient care for basic needs Social issues are not discovered during inpatient stay Interviewees report that patients run out of medications they received post-discharge and seek care again at ED due to inability to access outpatient care Social workers must seek placement via antiquated systems to locate long term bed availability ( bed finder list supplied by Office of Mental Health) Medicaid eligible care services require 24 hours notification; some taxi services require pick up hours before appointments Patients with substance abuse issues tend to be less compliant with both behavioral health and physical health treatments Target population moves frequently making patients difficult to reach Home conditions can complicate patients ability to be compliant with self care (hygiene, medication regimens, etc.) Patients present to ER for basic needs (housing, food, clothing) Home health workers uncover complex social challenges in the home environment that were not known during inpatient stay Home health workers discover illicit activities (narcotic use, criminal activity) in home environment Over utilization of ED for post-acute care due to relapse Longer acute care lengths of stay while long term placement is delayed High cancelation and no show rates due to ineffective/inefficient transportation Higher utilization rates of ED & inpatient hospitalizations High no show rates due to inability to contact patients for reminders about appointments Insufficient compliance with self care Patients are admitted for inappropriate reasons with long lengths of stays and difficult discharge placement Patient compliance with initial treatment plan is reduced due to complications in home environment Home health agencies cannot accept risk of sending employees to these locations and must discontinue care Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research - 9 -

10 Regulatory Barriers and Crisis Intervention Key finding Observations Implications Regulatory Barriers Crisis Intervention Billing restrictions on providing multiple encounters on same day Minimal reimbursement for telehealth Department of Health restrictions on colocating physical medical services within Behavioral Health facilities Oswego County's inpatient care for BH and Medical services are not co-located Limited funding to expand Mobile Crisis services Training opportunities to certify peer counselors Patients must be scheduled for behavioral health and medical visits on separate days due to Medicaid billing requirements Providers are reluctant to invest in telehealth (equipment and logistics) to provide telehealth due to poor reimbursement State codes are complex and more difficult to meet when attempting to co-locate physical medical services within a behavioral health facility Patients who seek BH services regularly are comfortable with the facilities and would have a higher compliance/utilization of medical care if their physical medical needs could be addressed in the same facility BH beds are located on a separate campus from main hospital; resulting in duplication of services and an inconvenience to patients Providers must apply for 1915i waiver for services not billable under current NY Medicaid (i.e., peer intervention) Peer Counselors must be certified and interviewees reported that opportunities to become certified are limited Without enhanced billing for same day encounters, patients must return for encounters on separate days, leading to inconvenience, cancellations and no shows Strong demand for telehealth to alleviate provider shortages, but providing telehealth may not be feasible Capital improvement costs are prohibitive and approval process is long Access to capital and regulatory issues may be preventing enhanced care Expanded Mobile Crisis teams could reduce ER utilization by intervening at the home setting Law enforcement officials tend to be first responders and transport to ER Certifying Peer Counselors can be supplemental staff to help meet demand in Behavioral Health/Substance Abuse Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

11 Care Coordination Key finding Observations Implications Patients with complex medical issues are not accepted into LT psychiatric facilities Incomplete knowledge of existing resources Hutchings does not accept patients with complex medical issues (feeding tubes, IV medication), making post-acute hospitalization difficult Care coordination is disjointed when a full complement of resources is unknown Patients have extended stays in the inpatient environment while placement is coordinated. Stays can exceed weeks and months in duration. Inappropriate use of resources (ED, higher levels of care) and longer lengths of stay in inpatient care Care Coordination Discharge planning and care management is not initiated early enough in the inpatient stay Services not colocated Restricted documentation of Behavioral Health within the Medical Record Interviewees reported adult care not being as organized and coordinated as pediatric care as also evidenced by the disparity between reported PQIs by County versus state average (adult) and the PDI90 scores versus state average (pediatrics) in the Community Needs Assessment Coordination difficulties arise when discharge planning is delayed Target patient population must schedule multiple visits over different days at different sites of care to receive appropriate treatments Over shielding (due to HIPPA hurdles) of behavioral health provider documentation limits other providers from optimizing other treatment plans Lack of EMRs among behavioral health providers Consulting psychiatrists/psychologists in SNFs do not immediately chart in medical record Opportunity to adapt adult medicine coordination and philosophy to the model within pediatric care Earlier discharge planning to address BH needs will reduce unnecessary lengths of stay Patients have high cancellation and no show rates due to inconvenience in accessing care Revise HIPAA consents to allow providers to discuss and share diagnosis and treatment plans Information is not readily available to all members of care team Consulting psychiatrists/psychologists do not involve Skilled Nursing staff, causing delays in adjusting patient treatment plans Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

12 Information Technology (HIT/HIE) Key finding Observations Implications Systems may not adequately identify repeat admissions Same individual can present at multiple facilities for various reasons, and HIT/HIE systems do not easily identify the repeat utilization Opportunity to adapt current systems to alert providers when same individual presents at multiple locations Information Technology (HIT/HIE) Social Work notes not captured and shared easily Desire for enhanced capability to view claims history and prescription medication fills Upload and download speeds of RHIO RHIO does not capture Social Work activities, nor allow Social Workers access via the portal PSYCKES is a web-based program which allows providers to track patients' psychotropic medication prescription use (fills, refills, timeliness of refills) Interviewees reported that timely and appropriate access to data among all BH providers is insufficient in current state and prevents timely and appropriate treatment of all patients' issues Missed opportunities to address social needs and duplication of efforts Expanded access to PSYCKES and more information can help facilitation care management Enhanced and timely access to electronic medical records across all providers in the CNY area could enhance care and reduce duplication of services Telehealth is limited for Behavioral Health applications Access to telehealth is limited, due to acquisition costs and logistics (linking up with willing providers) Improved access to care via telehealth could enhance treatment capabilities with a limited workforce Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

13 Patient Education Key finding Observations Implications Patient Education Patients are not properly educated on how to appropriately access care Assumption is that upon discharge, patients understand discharge materials and are capable of further progressing their care Most communities have several outpatient BH options, yet entry points are difficult to find/navigate and inpatient care demand outpaces capacity At-risk population is in need of more education regarding their health care options and should be more carefully communicated to when facilitating care plan Patients and providers are unaware of resources available Literacy issues must be addressed to provide patients appropriate instructions in an understandable format so that patient can manage their care Increased use of translators (when language is a barrier) and use of "teach back" message to ensure patient is understanding their care instructions Patients go without treatment or seek care at higher levels of care (ED) Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

14 Shared Vision and Goal Alignment The Shared Vision and Goal Alignment assessment is a unique look at 22 select interviews conducted by the Deloitte team, focusing specifically on organizational and cultural implications. In addition to the interview notes reviewed, many themes were captured during the Governance and Work Force Strategy breakout sessions of the October 21 st PAC meeting. CNYCC DSRIP Behavioral Health Primary Care Findings pptx

15 Executive Interviews Summary of Key Findings Vision / Mission / Strategy & Goal Alignment Leaders agree that the effort to integrate primary care and behavioral health is step in the direction of helping to reduce ER visits and chronic care cases, while improving health outcomes. There is a high amount of alignment among leaders due to the incentives provided by DSRIP; however, competition and overlapping initiatives with other PPS could serve as barriers to success. Healthcare leaders have a clear understanding of DSRIP, but additional education is needed for Primary Care Physicians (PCPs) and community members. Leadership Leaders note that lasting change needs to be driven top down, from leaders throughout the organization. Leaders from the insurance companies have been unwilling to get involved with the initiative to date if this group is not engaged, they could case a significant barrier in the future. Workforce Management There is believed to be a disconnect between clinical education and practice. Leaders emphasize that PCPs should be well-trained in identifying behavioral health challenges. The healthcare industry is changing at a rapid pace, and the workforce is feeling change fatigue. There is simply a lack of behavioral health professionals in the State of New York, especially in rural areas. School-based nurses should be involved in any DSRIP efforts that involve behavioral health, as they are often the group that catches issues the earliest, before they have escalated to an inpatient setting. Culture Organization Agility Physical health professionals and behavioral health professionals have had challenges collaborating well. There is still some confusion among clinicians in the differentiation between behavioral health and psychosocial issues. Reimbursement models reinforce physician behaviors that serve as barriers. Leaders believe that individuals in the community who have behavioral health needs frequently use the ER as their first line of defense. Leaders recognize that hospitals need to refer patients to PCPs before discharge and that follow-up after discharge is incredibly important in decreasing inpatient admissions. There is a lack of capacity in ambulatory clinics in Upstate (especially in rural areas), as well as a dearth of certain services in general, such as substance abuse and psychiatric services. Leaders note that excessive wait times and transportation issues cause patients to seek care in the ER rather than in primary care clinics. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

16 Executive Leadership Interview Detailed Findings by Dimension Vision / Mission / Strategy & Goal Alignment Leadership Leaders agree that the effort to integrate primary care and behavioral health is step in the direction of helping to reduce ER visits and chronic care cases, while improving health outcomes. The incentives offered through DSRIP have created a high amount of alignment among leaders for the integration of primary care and behavioral health initiative. However, there does appear to be some alignment needed on how to accomplish the DSRIP initiatives overall, mainly around utilizing existing services versus recreating the wheel through these new initiatives. Healthcare leaders throughout Central New York have a good understanding of DSRIP, but additional education is needed for Primary Care Physicians (PCPs) and community organizations. The leadership team agrees that coordination among providers is important, but recognize that patients engagement in their own health is also key to success. For example, leaders would like to see more participation in the PSYCKES program. Workforce Management Culture Physician engagement is frequently cited as a barrier to the success of integrating primary care and behavioral health. o Additional physician education is needed around DSRIP and key contributors to the integration of primary care and behavioral health (e.g., looking for both physical and mental health challenges during examinations). o Incentivization models may be perpetuating the collaboration challenges among physicians. Similar, or overlapping, PPS initiatives should be coordinated with the DSRIP efforts to avoid cannibalizing resources and time. Leaders have noted that behavioral health resources (e.g., Liberty Resources) will be difficult to share across multiple PPS. Organization Agility Leaders recognize that competition among providers within a PPS could be a barrier to success. The needs of the local communities may vary across the State of New York (e.g., the high amount of refugees in some counties) and could result in a fragmentation of goals and strategies. Some leaders notes that the availability of capital may prevent the attainment of these goals. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

17 Executive Leadership Interview Detailed Findings by Dimension Vision / Mission / Strategy & Goal Alignment Leadership Workforce Management Leaders note that lasting change needs to be driven from the top down. o The new Upstate CMO (Dr. Weiss) is a psychiatrist and will help champion the DSRIP initiatives related to behavioral health. He is a driver of change. o Innovative leaders such as Kinney, who has proprietary methodology for coaching patients at home, are important to the success of this initiative. o Carl Coyle at Liberty Resources is leading an integration effort to open a physical health clinic inside their mental health clinic. It was noted that leadership from the insurance companies (e.g., Fidelis Care) has not been willing to get involved with the initiative to date this group could cause a significant barrier in the future if they are not properly engaged. Trust will need to be built across partnering organizations over time. o Partners are concerned about the right leaders having a voice in directing programs and decisions, including geographical coverage, physicians, and other community partners outside of the major hospitals. o Smaller entities believe they are focused on being nimble, and are concerned with some of the rigor and process being put in place from a governance standpoint that may become tedious and hamper their way of functioning. o Governance leadership has asked that partners don t kick each other under the table but instead put it out on the table as various entities work to integrate. Culture Organization Agility Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

18 Executive Leadership Interview Detailed Findings by Dimension Vision / Mission / Strategy & Goal Alignment Leadership Workforce Management Leaders note that PCPs should be well-trained in identifying behavioral health challenges. o PCPs need to look beyond just the physical ailments. PCPs often limit scope to medical and physical examinations and overlook psychiatric indicators, leading to missed treatment and referral opportunities. o Mental health screenings should be completed upon entry to any provider. o Additional physician education is needed, particularly around the importance of Home Health. o Nurses also need more education on how to identify triggers for behavioral health issues. o PCPs need to improve their communication with SNFs, assisted living homes, adult day care facilities, etc. There is believed to be a disconnect between clinical education and practice. o Historically, the culture of Academic Medical Center is such that the teaching comes first and the patient care comes second. This culture could cause challenges with integration. o Medical schools are not teaching healthcare professionals the latest behavioral health that need to practiced in the field today (e.g., abstinence versus harm-based models). o Physicians need to be taught to overcome their fear of working with mental health patients. The healthcare industry has faced a disproportionately high degree of change in recent years and there is a degree of change fatigue in the workforce. Culture Organization Agility It was noted that many PCPs are unwilling to take Medicaid patients or patients with histories of behavioral health. There are no consequences for this behavior. There is simply a lack of behavioral health professionals in New York, especially in rural areas. Leaders recommend sharing psychiatric nurse practitioners across communities as one way to help fill the gap. It is believed that very few primary care providers are familiar or comfortable with managing the comprehensive care needs (physical and and behavioral health) of geriatric populations and assisted living residents. School-based nurses should be involved in any DSRIP efforts that involve behavioral health. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

19 Executive Leadership Interview Detailed Findings by Dimension Vision / Mission / Strategy & Goal Alignment Leadership Workforce Management Culture Historically, physical health professionals and the behavioral health professionals have had challenges collaborating and communicating well (especially at Oswego where the facilities are physically separate). High rates of comorbidity are just one reason why this behavior cannot continue. Overall, leaders recognize that behavioral health is often not treated like a serious public health issue, but rather as a secondary consideration that does not warrant prioritization. And, there is still some level of confusion for clinicians in the differentiation between behavioral health and psycho-social issues. Payment models reinforce physician behaviors that serve as barriers to the integration of primary care and behavioral health. PCPs sometimes do not want to accept Medicaid patients or patients with histories of mental illness; leaders feel that they are cherry-picking patients. It was noted that behavioral health care can be more geared towards physician teaching than to the patient (e.g., outpatient psychiatric clinics appear to only accept patients who would be good teaching cases ). This behavior may be contributing to the challenges with referring behavioral health patients. Leaders believe that individuals in the community who have behavioral health needs use the ER as their first line of defense (which attributes to a high rate of readmissions). These patients are being positively reinforced because they can come to the ER with an un-related ailment and receive their psychiatric medications. It was mentioned that there have been some difficulties in collaboration between different providers (e.g., Syracuse Community Health Center). Organization Agility Overall, there is a greater continuity of care in the pediatric patient population than the adult patient population. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

20 Executive Leadership Interview Detailed Findings by Dimension Vision / Mission / Strategy & Goal Alignment Leadership Leaders recognize that hospitals need to refer patients to PCPs before discharge and that followup after discharge is important for reducing admissions. There is a lack of capacity in ambulatory clinics in Upstate (especially in rural areas), as well as a dearth of certain services in general, such as substance abuse and psychiatric services. o PCPs are overwhelmed with behavioral health issues they cannot diagnose, treat, and followup effectively. o The change from fee-for-service to managed care has caused some clinics to close in the community, reducing the availability of behavioral health screenings. o Telemedicine, FQHCs, Mobile Response Units, and additional Nurse Practitioners could provide a partial solution to the lack of capacity and access challenges. Excessive wait times and transportation issues cause patients to seek care in the ER rather than in primary care clinics. The Medicaid taxis have not been sufficient in terms of transport. Workforce Management Culture Home healthcare workers have the ability to identify behavioral health problems before they are diagnosed or escalated to a level where an inpatient admission is necessary. However, the amount of home health services is not sufficient to be effective. o Health Home program is restricted to only a small portion of the population (e.g., the highest utilizers of Medicaid). o Home care facilities sometimes have to discontinue service to a patient if there is narcotic use without a prescription. o Home care needs to get involved earlier in the process to prevent the need for services later. Organization Agility The State of New York is reconfiguring long term psychiatric care, which poses significant challenges to transport, scheduling, etc. (i.e. Adult Psychiatric Long Term Care is being located in Syracuse; whereas Pediatric Psych Long Term Care is being located in Utica). Technology can be a barrier to the integration of primary care and behavioral health. o There are regulations on the types of behavioral health patient information that can be shared, which can prevent the ease of integration. o RHIO does not provide timely or appropriate data, and provides nothing for behavioral health. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

21 Organizational & Cultural Change Management Recommendations Vision / Mission / Strategy & Goal Alignment Clearly articulate the transformation strategy to the organization, including an initial set of compelling strategic milestones associated with the projects. Develop and execute a stakeholder-based comprehensive communications plan. Leadership Workforce Management Agree to desired leadership behaviors and adapt specific methods and tools to encourage demonstration of accountability, teaming, and comfort entering into conflict. Implement methods and measure effectiveness. Drive change management efforts from the top down, demonstrating leadership buy-in and alignment. Define a decision model and gain alignment on accountabilities, roles, and responsibilities. Determine the workforce impacts (organizational sizing, workforce transition and re-training) of shifting services from acute/er sites of care to ambulatory primary care and behavioral health partners. Develop training for PCPs on the importance of identifying both physical and mental health issues. Determine the workforce needs and develop a recruitment plan to incentivize behavioral health professionals to assume roles in rural areas. Develop an engagement plan for groups in the community who have not yet been involved with the primary care and behavioral health integration (e.g., school nurses). Culture Organization Agility Organize meetings and events to bring together behavioral health and physical health professionals (including physicians, nurses, other clinicians and community partners). Develop an outreach plan to educate the community on the health resources outside of the ER. Provide materials on community health resources to Case Managers, Social Workers, and the ER. physicians to ensure they have the information needed to route patients to the correct place. Define a standard discharge process and disseminate the standard throughout the PPS; ensure that performance management is tied to compliance with discharge processes. Assess the organizational structures of CCCN ambulatory clinics to determine where efficiency can be improved; develop an incremental plan to implement these changes. Determine where behavioral health services can be integrated into primary care clinics, as well as the alternative where primary care services can be integrated into behavioral health clinics. Note: Interview findings and observations are derived from the key stakeholder interviews conducted and may or may not be substantiated with further data analysis or research

22 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52 CNYCC DSRIP Behavioral Health Primary Care Findings pptx

23 Variations exist in the demand for physician services across the six counties The table below estimates the number of providers required to meet the demand for services across the six counties based on the demographics in the area. There is a high demand for primary care services in all the counties, but Oneida and Onondaga have a higher demand for medical specialists and surgical specialists Source: High Value Networking Tool (HVNT). Converge Health. Truven Market Expert Provider Analyst

24 The majority of the six county region is expected to see a slight decline in population over the next 5 years Population 5-Year Annual Growth Rates by County Oswego -0.2% Oneida -0.5% Cayuga -0.7% Onondaga 0.2% Cortland -0.4% Madison -2.0% Source: Truven Health Analytics CAGR -2.0% 0.5%

25 While overall population growth in the region is expected to be stagnant, the population is aging Estimated 5 Year Population Growth Rate 6 County Region, CAGR by Age Group 14% 1% -4% -4% Source: Truven Health Analytics The aging population will contribute to an increase in dual eligibles. This population must be effectively managed, as they generate higher utilization and spend

26 There are common themes in the qualitative assessment of the pervasive health issues that exist in each community Summary of Themes Cayuga Cortland Madison Oneida Onondaga Oswego Obesity Alcohol abuse Poor mental health Poor nutrition Lack of physical activity Injury and motor vehicle mortality Obesity Smoking among pregnant women Lung cancer Hepatitis C Lack of physical activity Obesity Substance abuse Need for mental health professionals Poor access to care Shortage of providers Lack of coordination of care Underutilization of services Obesity Mental health Diabetes Lack of physical activity Access to care Teen pregnancy and STDs Obesity Smoking Mental health Substance abuse Underutilization of services Obesity Substance Abuse Mental Health Sources: Community Health Assessment & Community Health Improvement Plan Cayuga County Health Department. Nov ; Cortland Counts: An Assessment of Health and Well-Being in Cortland County. Seven Valleys Health Coalition, Inc ; Community Memorial Hospital Comprehensive Three-Year Community Service Plan. Community Memorial Hospital. Hamilton, New York. Nov ; Community Health Assessment Oneida County Health Department. Nov ; 2013 Community Health Needs Assessment and Community Benefits Implementation Plan. Crouse Hospital.; Community Service Plan Oswego Hospital.; NOCHSI New Access Point Program Smoking

27 A significant decrease in the number of uninsured and small decrease in Medicaid members is expected in the next 5 to 10 years 1,200 5 Year Payer Projections 1 1, Year Payer Projections 1 1,000 1, Membership (1,000s) (200) (85) (41) Commercial +29,200 Medicare +21,400 Medicaid -9,600 Uninsured -43, Membership (1,000s) (200) (85) (36) Includes payer membership estimates for Central NY counties including Cayuga, Cortland, Madison, Oneida, Onondaga, and Oswego Source: Truven Health Analytics Commercial +11,900 Medicare +40,100 Medicaid -7,300 Uninsured -48,700

28 Demand for different services vary across the six counties for Medicaid members vs. non-medicaid members Medicaid members are observed to have higher rates of usage for both primary care and psychiatry procedures versus the general population Procedures per 100 members in Medicaid vs. non-medicaid Procedures per 100 members 1,400 1,200 1, ,208 1, Procedures per non-medicaid member Procedures per Medicaid member Variations exist in the demand for services for Medicaid and non-medicaid members Source: Truven Health Analytics

29 Projected Medicaid procedures growth will rise among all three specialties through 2019 and slowly decline to 2024 Variations exist in the demand for medical specialists between Medicaid and the general population, while other forms of care display similar growth rates between the two 6.0% Projected rate of growth in procedures between Medicaid and general population 5.0% Rate of growth 4.0% 3.0% 2.0%.76% 1.0% 0.0% Medicaid - Medical Specialist Medicaid - Primary Care Medicaid - Surgical Specialist Total Population - Medical Specialist Total Population - Primary Care Total Population - Surgical Specialist Source: Truven Health Analytics

30 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52

31 There is a greater supply of physicians in Oneida and Onondaga counties than in other counties The table below shows the number of physicians per specialty across the six county region Stakeholder interviews indicated that the current supply of physicians in the region is inadequate to serve the needs of the population Source: High Value Networking Tool (HVNT). Converge Health. Truven Market Expert Provider Analyst

32 Number of physicians per 100,000 in Central New York vs. New York state The Central New York region has a lower density of physicians per 100,000 for both primary care and specialty practices compared to the rest of New York state 400 Number of primary care physicians and specialists in central New York vs. New York state Number of physicians per 100, Primary Care Physicians Other Specialists All Physicians Central New York Upstate New York New York state The number of physicians per 100,000 is lower for the Central New York region compared to the rest of the state. Source: New York State Health Workforce Planning Guide. Center for Health Workforce Studies. University of Albany, School of Public Health

33 Onondaga county serves as the epicenter of care for the region as seen by the concentration of healthcare resources there Managing the distribution of health care resources and infrastructure that support Central NY PPS will be critical to managing access and overall utilization of care in the region Despite having only 45% of the population, Onondaga county has 56% of the primary care providers and 62% of the behavioral health practitioners 70% Percent of Population, Beds, and Providers by County 1 60% 50% Part of the DSRIP Collaborative efforts could be a re-distribution of health care assets across the region allowing greater access to health care resources 45% 46% 56% 62% 40% 30% 30% 23% 20% 21% 19% 10% 0% 8% 7% 5% 5% 6% 4% 4% 4% 7% 5% 6% 1. Behavioral Health Providers consist of psychiatrists, psychologists and behavioral health counselors as defined by the CHWS Workforce Planning Guide Source: CHWS New York State Health Workforce Planning Data Guide % Cayuga Cortland Madison Oneida Onondaga Oswego % Population % Beds % PCPs % BH Providers % 7% 7% 7%

34 Compared to Upstate New York provider supply per 100,000 people, the six county CNY PPS region is undersupplied in primary care and behavioral health resources The six county region as a whole is 11% below Upstate NY primary care physician supply average and 16% below behavioral health provider supply average which may limit access to Medicaid and uninsured Of the six counties, Onondaga county is the only region with adequate provider supply CNY DSRIP Collaborative Regional Provider Supply Analysis 1 Primary Care Physicians Behavioral Health Providers 2 MDs / 100,000 Providers / Population Total Supply Total Supply people 100,000 people Cayuga 80, Cortland 49, Madison 73, Oneida 234, Onondaga 464, Oswego 122, Total CNY DSRIP Collaborative 1,024, Upstate 7,409,095 7, , New York State 19,302,448 23, , Physician supply information sourced from CHWS, "New York State Health Workforce Planning Data Guide", data not validated with additional data sources 2. Behavioral health providers consist of general psychiatrists, psychologists and mental health counselors 3. Total supply inferred by number per 100,000; actual number not provided in New York State Workforce Planning Data Guide

35 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52

36 The need for physicians is highest in primary care across all counties The table below combines the analysis of supply and demand in the region to determine the degree of oversupply or undersupply of physician per service line A potential opportunity exists to leverage the oversupply of physicians in Onondaga County to meet the needs of other counties Source: High Value Networking Tool (HVNT). Converge Health. Truven Market Expert Provider Analyst

37 The degree of need in the region is influenced by the growth in Medicaid enrollment and the number of physicians accepting Medicaid Variables Discussion Implications Medicaid Growth Medicaid enrollment rises If Medicaid enrollment continues to rise, the demand on physicians will also rise, shrinking supply Medicaid enrollment shrinks If Medicaid enrollment shrinks, demand will decrease Greater need of physicians and services Need will decrease Physician Acceptance Physicians accept more Medicaid patients Physicians accept less Medicaid patients If physicians accept more Medicaid patients, the supply will increase If physicians accept less Medicaid patients, supply will shrink Need will be better met Need will increase and community health will decline

38 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52

39 Several geographic areas have a significantly higher rate of Potentially Preventable ER visits (PPV 1 ) when compared to the rest of the region Number of Medicaid PPVs by Zip Code Top Ten PPV Zip Codes Zip Code County Number of PPVs Oneida Onondaga Onondaga Oneida Cayuga Oneida Onondaga Onondaga Oswego Cortland 3541 Greater access to primary care services can be bolstered in those areas with a high number of Potentially Preventable ER Visits reducing admissions Source: Health Data NY Medicaid Potentially Preventable Emergency Visit (PPV) Rates by Patient County Note: Potentially Preventable Visits (PPV) is obtained from software created by 3M Health Information Systems for conditions that could otherwise be treated by a care provider in a nonemergency setting.

40 Several geographic areas have a significantly higher rate of Preventable Quality Indicators (PQIs 1 ) when compared to the rest of the region Number of Medicaid PQIs by Zip Code Top Ten PQI Zip Codes Zip Code County Number of PQIs Oneida Oneida Oneida Cortland Onondaga Onondaga Cayuga Onondaga Onondaga Onondaga 92 Note: The Prevention Quality Indicators (PQIs) are a set of measures for conditions for which good outpatient care could potentially prevent the need for hospitalization. Care management resources and efforts should be prioritized in those areas with the highest rate of Preventable Quality Indicators Source: Health Data NY Hospital Inpatient Prevention Quality Indicators (PQI) for Adult Discharges by County (SPARCS)

41 Medicaid managed care members in the region have higher utilization compared to benchmarks national Medicaid managed care Compared to national Medicaid managed care benchmarks, the central New York region has higher rates of utilization Utilization per 1, TANF Children 1,2 TANF Adults 1, Emergency Room Inpatient Medical / Surgical Admits Utilization per 1, , Emergency Room Inpatient Medical / Surgical Admits Managed Medicaid utilization - Central New York Well-managed bench mark - TANF Medicaid Well-managed bench mark - commercial Managed Medicaid utilization - Central New York Well-managed bench mark - TANF Medicaid Well-managed bench mark - commercial An opportunity exists to reduce utilization by improving care management among Medicaid members Source: Milliman Memorandum. Analysis of Central NY Managed Medicaid Utilization Experience. Nov. 4, Medicaid utilization based on 2013 MMCOR data for central region 2. Benchmark utilization based on Milliman s 2014 Health Cost Guidelines for commercial population in the Central Region, adjusted for demographics & health management; & TANF HCGS July 1,

42 Community resources can assist in meeting key goals Various community organizations and initiatives exist in each of the counties that focus on the most pervasive health issues of each community Cayuga 1 Cortland Madison Oneida Onondaga Oswego Obesity Creating Healthy Places to Live, Work, and Play Booker T. Washington Community Center Cato-Meridian Community Recreation Center Eat Smart NY YMCA / YWCA Healthy NOW! Living Healthy Workshops Community Action Partnership of Madison County ACR Health Cornell Cooperative Extension (Madison County) Nutrition Outreach and Education Rome Hospital Nutrition Counseling St. Luke s Nutrition Counseling YMCA / YWCA Eat Smart NY Creating Healthy Places to Live, Work, and Play Crouse Hospital Educational Seminars Oswego AmeriCorps Program Fulton and Oswego YMCA 4-H Youth Development Program Nutrition Education Substance Abuse & Mental Health 2-1-1/Life Line Alcohol and Substance Abuse Services Prevention Network Auburn City Problem Solving Court C.H.A.D. (Confidential Help for Alcohol and Drugs) Alcohol and Drug Clinic of Family Counseling Services of Cortland Seven Valleys Council on Alcoholism and Substance Abuse Cortland County Mental Health Clinic Think Again! Group Insight House Chemical Dependency Services Madison County Council on Alcoholism and Substance Abuse Catholic Charities Addictions Crisis Center Center for Addiction Recovery Community Recovery Center Mental Health Connections Community Services and Mental Health Association of Onondaga Crouse Hospital Chemical Dependency Treatment Services Syracuse Behavioral Healthcare Syracuse Community Health Center Chemical Dependency Program Conifer Park Alcohol and Drug Treatment Center Farnham Family Services Harbor Lights Chemical Dependency Services Smoking Tobacco Free Network of Central New York Smoker s Quitline Nurse Direct Phone Counseling United Health Services Tobacco Cessation Tri-County Quits Tri-County Quits Tobacco Control Program Tobacco Free Network of Oswego County Sources: Living in Cayuga County Human Service Coalition of Cayuga County. Oneida County Community Resources. Community Services Directory Oswego. Herkimer and Oneida County Resources Created by the Neighborhood Center, Inc. Utica, NY. Cortland County Health Services Community Service Directory Oswego County. Healthy Madison County. 1. Not an inclusive list.

43 Topic Page Deliverables Key Interview Findings 5 Capacity Analysis 22 Demand 22 Supply 30 Need 35 Solutions 38 Partner Assessment Tool 43 Appendix A: Interview Log 46 Appendix B: Primary Care / Behavioral Health Work Plan 52

44 The Partner Evaluation Framework is designed to evaluate partner fit, contribution and requirements from Central New York Care Collaborative The Partner Evaluation Framework survey has been distributed to all providers who have indicated a desire to participate with CNYCC Distributed week of 11/10 to roughly 250 partners in order to facilitate the allocation of partners to each DSRIP initiative Survey consists of: Partner overview information including key contacts, address and phone number Number and type of providers, employees, and union status Level of service provided to target population of Medicaid and uninsured Description of DSRIP initiatives, objectives and requirements Desired level of contribution to the initiatives HIT/HIE sophistication and abilities PCMH certification information Medicaid waiver/program participation Note: Select object to view entire partner survey

45 UID DSRIP Name NPI MMIS DSRIP Contact Name Two distinct analyses of the CNYCC partner organizations were conducted DSRIP Contact Organization or DSRIP Contact Project Scale Label Notes Opcert SN? Phone Physician/NP/PA 5 Access to Independence of Cortland County, Inc. Chad W. Underwood (607) cwunderwood@aticortland.org Organization Community Based Organizations N/A no 59 ARISE CHILD AND FAMILY SER INC RSP Tom McKeown (315) tmckeown@ariseinc.org Organization Behavioral Health N/A no 62 ARISE CHILD/FAMILY SVC SMP Tom McKeown (315) tmckeown@ariseinc.org Organization Behavioral Health N/A no 68 AT HOME INDEPENDENT CARE NHTD-HCSS Zvia McCormick (315) zmccormick@rcil.com Organization All Other N/A no 76 Aurora of Central New York, Inc Debra Chaiken (315) dchaiken@auroraofcny.org Organization All Other N/A no 102 Bernardine Apartments/Loretto Adult Community Steve Volza (315) svolza@lorettosystem.org Organization All Other N/A no 161 Catholic Charities of Herkimer County Deanna Charles (315) dcharles@ccherkimer.org Organization All Other N/A no 163 Cayuga Community Health Network IRV Lyons (315) director@cayugahealthnetwork.o rg Organization All Other N/A no 173 Cedarbrook Village, Incorporated Christa Serafin, CEO (315) cserafin@sitrin.com Organization Skilled Nursing Facilities/Nursing Homes N/A no 174 Cemtral New York Adult Homes Inc Thomas Carlson (315) tcarlson@twcny.rr.com Organization All Other N/A no 178 Central New York Health Systems Agency, Inc Sara Wall Bollinger (315) swbollinger@healtheconnections.org Organization All Other N/A no 349 ELMCREST CHILDRENS CTR FSR Joseph Geglia (315) jgeglia@elmcrest.org Organization All Other N/A no 416 FRANCISCAN HEALTH SUPPORT INC Frank Smith frank.smith@sjhsyr.org Organization All Other N/A no 505 HEALTHeCONNECTIONS Robert Hack (315) rhack@healtheconnections.org Organization All Other N/A no 516 Herkimer ARC Debra Ray (315) dray@herkimerarc.org Organization All Other N/A no 517 Herkimer County HealthNet, Inc. Adam Hutchinson (315) ahutchinson@herkimercounty.or g Organization All Other N/A no 732 Lewis County Community Services Sarah Bullock (315) sbullock@lewiscountyny.org Organization Community Based Organizations N/A no 765 LORETTO HMO Penny Abulencia (315) abulenc@lorettosystem.org Organization All Other N/A no Madison County Rural Health Council, Inc. Bonnie Slocum, Director/Eric Faisst, 787 President (315) bjslocum@elderlifeplan.com Organization All Other N/A no Double Counted as Massena Family Practice a physican and 820 Holly Beamish (315) Doctors-Clinic@NNYmail.com Organization Primary Care Physician practice N/A no 880 MOHAWK VALLEY PC David Peppel (315) david.peppel@omh.ny.gov Organization All Other N/A no 881 Mohawk Valley Perinatal Network, Inc. Diana Y. Haldenwang (315) dhaldenwang@newfamily.org Organization All Other N/A no 884 Mohawk Valley Resource Center for Refugees, Inc. Shelly Callahan (315) shellyc@mvrcr.org Organization All Other N/A no 944 Northern County Physicians Organization, PLLC Joel Duhl (866) jduhl@joelsduhlinc.com Organization Clinics N/A No Provider Code: 947 Northern Regional Center for Independent Living, Inc. Aileen Martin (315) aileenm@nrcil.net Organization All Other N/A Pending 2, pending OMRDD/LIBERTY RESOURCES INC Intensive Behavior 1915i Carl Coyle (315) ccoyle@liberty-resources.org Organization Behavioral Health Services Provider provider A complete list of partners was compiled and analyzed to determine the following: MAPP Data provided: Provider Name NPI (for most) MMIS (for some) Contact (name and ) DOH Data: Safety Net providers OMRDD/OSWEGO INDUSTRIES INC Pending 1915i Provider code: provider 964 OMRDD/MADISON-CORTLAND NYSARC Jack Campbell (315) jack.campbell@madisoncortlanda Organization All Other n/a (VAP) Provider code: Pending 1915i provider Alissa Viscome (315) aviscome@oswegoind.org Organization All other Health Home/Care Onondaga County Department of Adult & Long Term Care Management Joe Scripa (315) jscripa@ongov.net Organization All other discussion? n/a no Onondaga County Office for Aging Lisa Alford (315) lisaalford@onfov.net Organization All other n/a no 981 Oswego County Division of Mental Hygiene Nicole Kolmsee (315) nkolmsee@oswegocounty.com Organization All other n/a no R (clinics), Oswego County Health Department Also a home health Huang, Jiancheng (315) jhuang@oswegocounty.com Organization Health Home/Care Management agency (CHHA) Yes (2) 984 The partner surveys were also collected and analyzed: Received 140 provider survey responses Matched 71.1% of responses to providers (1191/1674) Survey Data provided: Providers committed to projects PCMH level, # of practices