Patient-Centered Medical Home Assessment & Roadmap

Transcription

1 11/30/2016 Patient-Centered Medical Home Assessment & Roadmap Population Health Management Workstream Milestone 1

2 Table of Contents 1) Executive Summary 2) Overview of Primary Care Providers 3) PCMH Timeline 4) Gap Analyses 5) DSRIP & NCQA PCMH Alignment 6) Technical Assistance 7) Workgroup Learning Collaborative 8) Clinical Integration 9) Cultural Competency & Health Literacy Initiatives 10) Workforce Trainings 11) Performance Reporting Appendix A: NCQA PCMH 2014 Standards Appendix B: GNYHA DSRIP & PCMH Crosswalk 1 P age

3 EXECUTIVE SUMMARY There are 9 primary care partners participating in Staten Island Performing Provider System projects that require NCQA 2014 PCMH Level 3 recognition. All but three partners are on track to receive this recognition prior to March 31, Two of these partners will receive PCMH technical assistance through HANYS Solutions. The DSRIP primary care-based projects and organizational workstreams are interconnected and in line with the PCMH requirements. In addition to the technical assistance offered to partners, the PPS efforts to implement the projects and meet workstream milestones will support the PCMH transformation for these partners. The SI PPS anticipates that between these 9 primary care partners and the primary care practices participating in 4.b.ii, there will be significant expansion of the patient-centered medical home model on Staten Island further improving the quality of primary care in the borough. OVERVIEW OF PRIMARY CARE PROVIDERS As the United Hospital Fund s publication The Growth of Medical Homes in New York State, indicates, the NCQA PCMH recognition program has had limited penetration in Staten Island. The borough has the lowest percentage of PCMH recognized providers in the city at 10%. While the reasons for this are not identified, Staten Island is dominated by small primary care practices composed of one to two physicians. Other boroughs tend to have many more medium to large size primary care practices and health centers with the human and technological resources to support the PCMH model and the Medicaid volume to financially support those resources through the New York State Department of Health Medicaid PCMH incentive payment program. According to the NCQA Recognized Clinician Directory, there are 13 primary care practices in Staten Island that have PCMH recognition with a combined total of 62 primary care providers. Ten of those practices are in the PPS network and nine of them have executed agreements to participate in PPS projects. Table 1 has a breakdown of the practices, their recognition status, and involvement with the Staten Island PPS. 2 P age

4 Table 1: NCQA PCMH Practices in Staten Island * Practice # PCPs Standards Level Expiration Date Beacon Christian Community Health Center Community Health Center of Richmond PPS Network /29/17 Yes /17/19 Yes DSRIP Projects 2.a.iii 2.d.i 3.a.i 3.c.i 2.a.iii 2.d.i 3.a.i 3.c.i Melvin Koplow, MD /24/19 Yes N/A Metro Community Health Center /15/2019 Yes 2.a.iii 2.d.i 3.a.i 3.c.i NYC HHC Coney Island Hospital - Mariner s Harbor Family Health Center NYC HHC Coney Island Hospital - Stapleton Family Health Center Richmond University Medical Center Comprehensive Medical Care Richmond University Medical Center Comprehensive Pediatric Care /15/18 No N/A /15/18 No N/A /25/17 Yes 2.a.iii 2.d.i 3.a.i 3.c.i /25/17 Yes 2.a.iii 2.d.i 3.a.i 3.c.i Salvatore Volpe MD PC /25/18 No N/A South Shore Physicians PC /4/18 Yes 4.b.ii Staten Island Physician Practice 2.a.iii /24/18 Yes Clove Road Location 3.a.i (dba AdvantageCare Physicians) Staten Island Physician Practice Hylan Blvd Location (dba AdvantageCare Physicians) Mt. Sinai Doctors Victory Medical Group /5/19 Yes /18/2019 Yes 3.c.i 2.a.iii 3.a.i 3.c.i 2.a.iii 3.a.i 3.c.i * NCQA Recognition Directory, (Accessed 10/31/16) Chief Medical Officer of the Staten Island Performing Provider System 3 P age

5 Since receiving PCMH recognition, both Beacon Christian Community Health Center and Community Health Center of Richmond have opened additional locations and hired additional PCPs. In addition to the practices identified above, SI PPS has also partnered on projects with another 3 organizations that have not yet received PCMH recognition. Table 2 identifies the additional primary care practices. Table 2: Additional PPS Primary Care Partners Practice # PCPs # Locations DSRIP Projects Brightpoint Health a.iii 3.a.i 3.c.i Staten Island University Hospital a.iii 2.d.i 3.a.i 3.c.i University Physicians Group a.iii 3.a.i 3.c.i As PCMH recognition is only a requirement for projects 2.a.iii, 3.a.i, and 3.c.i, this assessment and roadmap will only focus on practices participating in those projects. However, significant efforts are being made to engage 13 practices in NCQA PCMH recognition through project 4.b.ii. In total, SI PPS PCMH efforts for projects 2.a.iii, 3.a.i, and 3.c.i will include 9 organizations representing 25 practices and approximately 102 primary care providers. The map in Figure 1 demonstrates the locations of these 25 current and future PCMH PPS practices along with the geographic distribution of Medicaid enrollees. 4 P age

6 Figure 1: PCP practices and Number of Medicaid Enrollees New York State Department of Health, 2012 Data, Inpatient-Admissions-and-Em/m2wt-pje4 5 P age

7 PCMH TIMELINE The DSRIP deadline for PCMH recognition under the 2014 Standards is the end of DY3, Q4 (March 31 st, 2018). However, as NCQA will be releasing new 2017 Standards, they will stop accepting applications under the 2014 Standards in September The New York State Department of Health has arranged with NCQA to make an exception for DSRIP participants, allowing practices that submit between September 2017 and January 2018 to receive a shortened two year recognition at a discounted price. While the actual PCMH transformation process is variable, the timeline for submitting for PCMH recognition is specifically prescribed by NCQA. Following NCQA s timeline, SI PPS has outlined the following submission steps in Figure 2 in order to meet the DSRIP deadline. Figure 2: General NCQA Submission Timeline 1 week Data Collection Policies and Procedures 9/23/17 Application Submission Survey Tool Submission NCQA Decision 11/30/17 6/1/17-8/31/17 9/30/17 60 days Following the new NCQA 2014 Standards deadline, the PCMH survey tool must be submitted no later than September 30, 2017 to receive the full three year recognition. As the NCQA review process can take up to 60 days, recognition would be expected around November 30, The PCMH application must be submitted at least one week prior to the survey tool so that NCQA has the time to process that component of the submission. This gives an application deadline of September 23, Per NCQA guidelines, all relevant policies and procedures must be in place at least 3 months ahead of PCMH submission. In addition, the majority of data elements to be included in the submission must be for a minimum of 3 months. Following those timelines, all data should be collected, at the latest, between June and August 2017 and policies and procedures should be instituted before June This gives practices approximately one month to complete their survey tool and compile their supporting documentation related to this data and these policies and procedures. Any organizations submitting as a multi-site (three or more locations operating under the same EMR and same policies and procedures), will have a slightly different timeline as there are additional steps in 6 P age

8 the submission process. Timelines for those organizations would look similar to the one in Figure 3. NCQA will stop accepting corporate applications under the 2014 Standards in March Figure 3: Multi-Site Submission Timeline 1 week 60 days Data Collection Policies and Procedures 12/1/16-2/28/17 3/23/17 Application Submission Corporate Survey Tool Submission 3/31/17 9/30/17 Site Specific Survey Tool Submission NCQA Decision 11/30/17 Practices that already have PCMH recognition will want to submit their materials prior to the DSRIP deadline and before their recognition expires as the renewal process is less arduous than that for new practices. A lapse in recognition will disqualify practices from the streamlined renewal process. Table 3 outlines the PCMH recognition timeline for each SI PPS practice that has not yet submitted its application. The timeline for UPG may change if it applies through a multi-site application. Table 3: Practice Specific NCQA Submission Timeline Data Collection / Policies & Procedures Recommended Application Submission Recommended Survey Tool Submission Recognition Anticipated Beacon 4/1/17-6/30/17 7/22/17 7/29/17 9/29/17 Brightpoint 6/1/17-8/31/17 9/23/17 9/30/17 11/30/17 SIUH 6/1/17-8/31/17 9/23/17 9/30/17 11/30/17 UPG 6/1/17-8/31/17 9/23/17 9/30/17 11/30/17 GAP ANALYSES Six of the seven initial primary care partners submitted PCMH assessments to the PPS. Three partners completed detailed factor by factor responses for the NCQA Standards. The PPS contracted with HANYS Solutions to complete PCMH assessments for the remaining three primary care partners. 7 P age

9 Table 4 indicates a preliminary assessment of the partners status in regard to must pass elements and critical factors. If a practice is unable to meet the requirements of a must pass element, it will not receive any recognition from NCQA. For CHCR, Metro, and Victory, the selfreported assessments indicated that they would be able to pass all critical factors and must pass elements and should achieve Level 3 recognition prior to March 31, Similarly, RUMC should have little trouble meeting all must pass elements with a refocus on initial care coordination processes implemented for their current NCQA PCMH recognition. Based on their current operations, both SIUH and UPG will not meet a majority of the must pass elements. Table 4: Preliminary PCMH Assessments Standard Must Pass Element Critical Factor Beacon CHCR Metro RUMC SIUH UPG Victory PCMH 1: PATIENT-CENTERED ACCESS A: Patient Centered Appointment Pending Yes Yes Yes Unknown No Yes Access 1. Providing sameday appointments for routine and urgent care. Pending Yes Yes Yes Unknown No Yes B. 24/7 Access 2. Providing timely Pending Yes Yes Yes No Unknown Yes to Clinical Advice clinical advice by telephone. PCMH 2: TEAM BASED CARE D: The Practice Team Pending Yes Yes Yes No No Yes 3. Holding scheduled Pending Yes Yes Yes No No Yes patient care team meetings or a structured communication process focused on individual patient care. PCMH 3: IDENTIFY AND MANAGE PATIENT POPULATIONS D: Use Data for Population Management Pending Yes Yes Yes Unknown No Yes E. Implement Evidence Based Decision Support 1. A mental health or substance use disorder. Pending Yes Yes Yes Unknown Unknown Yes PCMH 4: PROVIDE SELF-CARE SUPPORT AND COMMUNITY RESOURCES A. Identify Patients for Care Management 6. The practice monitors the percentage of the total patient population identified through its process and criteria. Pending Yes Yes Yes Unknown Unknown Yes B: Care Planning and Self Care Support Pending Yes Yes Yes No Unknown Yes 8 P age

10 Standard Must Pass Element C. Medication Management Critical Factor Beacon CHCR Metro RUMC SIUH UPG Victory 1. Reviews and reconciles medications for more than 50 percent of patients received from care transitions. PCMH 5: CARE COORDINATION & TRANSITIONS A: Test Tracking and Follow-Up 1. Tracks lab tests until results are available, flagging and following up on overdue results. 2. Tracks imaging tests until results are available, flagging and following up on overdue results. Pending Yes Yes Yes Unknown Unknown Yes Pending Yes Yes No Unknown No Yes Pending Yes Yes No Unknown No Yes B: Referral Tracking and Follow-Up Pending Yes Yes No Unknown Unknown Yes 8. Tracks referrals until the consultant or specialist s report is available, flagging and following up on overdue reports. PCMH 6: PERFORMANCE MEASUREMENT & QUALITY IMPROVEMENT D: Implement Continuous Quality Improvement Pending Yes Yes No Unknown Unknown Yes Pending Yes Yes Yes Unknown Unknown Yes SIUH SIUH implemented an electronic medical record in its outpatient practices in July This provides SIUH over a year to collect required data, connect to the RHIO, launch a patient portal, and achieve Meaningful Use functionality. In addition, SIUH will need to work on transforming its clinical operations to achieve the following PCMH components in order to earn enough points to receive Level 3 recognition. 24/7 access to clinical advice Continuity of care Creating care teams and structured communication Population management for preventive and chronic care services Care planning processes and self-management support Lab, imaging and referral tracking Care transition processes Quality improvement processes 9 P age

11 UPG UPG has a robust EMR and an easy ability to make modifications as its Chief Medical Officer is also the CMO of its EMR system. It has been a successful partner in a Pioneer ACO with a strong focus on quality for its Medicare population but has yet to apply this effort to its Medicaid population. In addition, the 13 practices operate as a loose federation of clinics that do not follow standardized policies and processes. Their recent merger with Northwell Health may support more standardized polices and processes for the practices. UPG has nearly two years to complete its transformation to a multi-site NCQA Level 3 PCMH. The assessment identified the following PCMH components as critical gaps for UPG: Same day appointments Creating care teams and structured communication Population management for preventive and chronic care services Care transition processes Patient satisfaction surveys Quality improvement processes Overview Seven out of the nine PPS primary care partners have either become patient-centered medical homes or have the leadership buy-in to pursue the necessary transformation for PCMH. Two partners, SIUH and UPG, are at risk of failing the NCQA recognition process by the DY3 Q4 deadline without significant practice transformation efforts. Both would benefit from increased leadership support of PCMH transformation. Should the Advanced Primary Care requirements be less stringent than the NCQA Patient-Centered Medical Home standards, SIUH and UPG could consider pursuing APC as an alternative. DSRIP & NCQA PCMH ALIGNMENT While NCQA PCMH recognition is a distinct DSRIP milestone, the transformation to a patientcentered medical home directly aligns with a number of milestones from SI PPS projects and organizational workstreams. GNYHA produced a crosswalk that identifies the direct correlation between PCMH Standards and DSRIP project milestones. A modified version of the crosswalk can be found in Appendix B. A summary of the project and workstream alignment with PCMH follows in Table 5. Nearly every PCMH element intersects with some component of the DSRIP program. 10 P age

12 Table 5: DSRIP and PCMH Alignment PCMH Element DSRIP Project DSRIP Workstream 1.A. Patient Centered Appointment 2.d.i Patient Activation Access 1.B. 24/7 Access to Clinical Advice Clinical Integration 1.C. Electronic Access Clinical Integration 2.A. Continuity 2.B. Medical Home Responsibilities Cultural Competency and Health Literacy 2.C. Culturally and Linguistically Appropriate Services Cultural Competency and Health Literacy 2.D. The Practice Team Workforce Cultural Competency and Health Literacy 3.A. Patient Information 3.c.i Diabetes Management Clinical Integration 3.B. Clinical Data Clinical Integration 3.C. Comprehensive Health Assessment 3.a.i Integration of Primary Care and Behavioral Health Cultural Competency and Health Literacy 2.a.iii Health Home At-Risk 3.D. Use Data for Population 2.d.i Patient Activation Management 3.a.i Integration of Primary Care and Behavioral Health 3.c.i Diabetes Management 3.E. Implement Evidence Based 3.c.i Diabetes Management Decision Support 4.A. Identify Patients for Care Management 4.B. Care Planning and Self-Care Support 4.C. Medication Management 4.D. Use Electronic Prescribing 4.E. Support Self Care and Decision Making 5.A. Test Tracking & Follow-Up 5.B. Referral Tracking & Follow-Up 2.a.iii Health Home At-Risk 3.a.i Integration of Primary Care and Behavioral Health 2.a.iii Health Home At-Risk 3.a.i Integration of Primary Care and Behavioral Health 3.a.i Integration of Primary Care and Behavioral Health 2.a.iii Health Home At-Risk 3.a.i Integration of Primary Care and Behavioral Health 3.c.i Diabetes Management Clinical Integration Clinical Integration Clinical Integration 11 P age

13 PCMH Element DSRIP Project DSRIP Workstream 5.C. Coordinate Care Transitions 2.a.iii Health Home At-Risk 2.b.iv Care Transitions Clinical Integration 6.A. Measure Clinical Quality Performance 6.B. Measure Resource Use and Care Coordination 6.C. Measure Patient/Family Experience 6.D. Implement Continuous Quality Improvement 6.E. Demonstrate Continuous Quality Improvement 6.F. Report Performance 2.d.i Patient Activation Performance Reporting Performance Reporting Performance Reporting Performance Reporting Performance Reporting Performance Reporting TECHNICAL ASSISTANCE SI PPS has offered to support PCMH technical assistance for all primary care practices participating in relevant projects through an agreement with Healthcare Association of New York State (HANYS) Solutions PCMH Advisory Services. HANYS Solutions has a successful track record of PCMH transformation and recognition across the State and with a variety of types of primary care practices. The technical assistance components are outlined in Table 6 and were presented to the Ambulatory Care Workgroup in October Table 6: HANYS Technical Assistance Program Component Client Portal Web-based Advisory Sessions Cohort Project Plan Management Description Approximately forty (40) on-demand learning modules. Each cohort will be given a specific curriculum in alignment with the cohort level project plan, type of practice and type of submission. Regularly-scheduled live, web-based, interactive advisory sessions. This session gives the practice (s) the opportunity to ask questions, seek guidance and clarification. Cohort level project plan by a PCMH advisor and/or analyst for PCMH task management throughout the transformation. PCMH Advisory Services will develop the cohort project plan, monitor due dates, and manage aspects of the project plan while your team gets the work done. 12 P age

14 As the primary care practices are all at different stages of recognition and a few had already executed contracts with other organizations, only a few practices expressed interest in the HANYS Solutions technical assistance. Table 7 outlines the practices and their technical assistance partners. Both Beacon and CHCR chose not to pursue technical assistance as they had recently received NCQA 2011 PCMH recognition. Table 7: PCMH Technical Assistance Partners Practices Beacon Christian Community Health Center Brightpoint Health Metro Community Health Center Community Health Center of Richmond Richmond University Medical Center Staten Island Physician Practice Staten Island University Hospital University Physicians Groups Mt. Sinai Doctors Victory Medical Group Technical Assistance Partner N/A N/A Primary Care Development Corporation N/A HANYS Solutions N/A HANYS Solutions HANYS Solutions Primary Care Development Corporation In addition to technical assistance partners, the SI PPS s Director of Ambulatory Care Initiatives is an NCQA PCMH Certified Content Expert and has facilitated PCMH recognition for facilities in New York City. The SI PPS s Chief Medical Officer was the first solo practitioner to achieve NCQA PCMH 2014 Level 3 recognition in New York. They are both available to provide any needed support to primary care practices. WORKGROUP LEARNING COLLABORATIVE SI PPS has formed an Ambulatory Care Workgroup to address primary care-based projects. While initially focused on projects 3.a.i Model 1 and 3.c.i, the workgroup had a natural alignment with the planned PCMH workgroup and the two workgroups were combined. As the DSRIP and PCMH crosswalk section indicates, the PPS s efforts to promote evidence-based diabetes management and integration of behavioral health align with components of NCQA s PCMH 2014 Standards. The purpose of this workgroup, as outlined by its charter, is to provide clinical and operations expertise to support planning and implementation of primary care-based projects. The Workgroup may also provide guidance for relevant cross-project topics. The Workgroup is comprised of clinical and operations leaders from all seven primary care partner organizations and will guide development and implementation of identified projects, including processes, workflows, standards of care and more. In order to meet PPS-wide goals, the workgroup will 13 P age

15 also serve as a learning collaborative for partners to share best practices and learn from each other and from other committees and workgroups, such as the Care Management Workgroup, Clinical Integration Workgroup, etc. CLINICAL INTEGRATION SI PPS is supporting its partners in the implementation and enhancement of electronic medical records. NCQA PCMH 2014 Standards are aligned with CMS Meaningful Use Stage 2 requirements. Level 3 PCMH recognition has been structured in such a way that it cannot be attained without an EMR. Thus, implementing an EMR and ensuring that it has MU Stage 2 functionality is crucial for all primary care partners and their efforts toward achieving PCMH Level 3 recognition. Table 8 indicates which primary care practices are using EMRs with meaningful use certification. Table 8: Primary Care Practices and MU Status of EMR Practice AdvantageCare Physicians Beacon Christian Community Health Center Brightpoint Health Metro Community Health Center Community Health Center of Richmond Richmond University Medical Center Staten Island University Hospital University Physicians Group Mt. Sinai Doctors Victory Medical Group MU Certified Pending data In addition, SI PPS is supporting its project partners in integrating their electronic medical records with the local RHIO, Healthix. This clinical integration supports partner needs related to PCMH factors focused on electronic exchange of key clinical information and sharing of electronic summary-of-care records for care transitions. Table 9 indicates the RHIO connectivity status for each primary care practice. Yes Yes Yes Yes Yes Yes Yes Yes Table 9: Primary Care Practices and RHIO Connectivity Practice AdvantageCare Physicians Beacon Christian Community Health Center Brightpoint Health Community Health Center of Richmond RHIO In Development In Development Implemented/Operational Implemented/Operational 14 P age

16 Practice Metro Community Health Centers Richmond University Medical Center Staten Island University Hospital University Physicians Group Mt. Sinai Doctors Victory Medical Group RHIO Implemented/Operational Implemented/Operational Implemented/Operational In Development Implemented/Operational By DY3 Q4, all primary care partners will have an EMR implemented and will be connected to the Healthix RHIO. CULTURAL COMPETENCY & HEALTH LITERACY SI PPS has a strong focus on cultural competency and health literacy and, as outlined in the strategy for that organizational workstream, the PPS will be collaborating with primary care practices on the following: Cultural competency training - SI PPS is offering a compliment of trainings including language access, medical interpreting, health literacy health communication, cultural competency and healthcare equality. These trainings will be offered at all PPS sites and to all provider types. Every employee in the PPS will attend Bias, Culture and Values 1199 Training and Employment Fund s introductory Cultural Competency training. SI PPS has also contracted with the Pride Center of Staten Island to conduct PPS wide LGBTQ Healthcare Equality trainings. Population Health Literacy Improvement - SI PPS has convened a workgroup consisting of health care providers and literacy service organizations such as the YMCA, JCC, and the NYPL to assist with developing a borough-wide health literacy toolkit which focus on Staten Island specific health disparities and outcomes related to PPS projects. SI PPS has identified gaps in the provision of culturally and linguistically appropriate services based on results from a PPS wide Cultural Competency and Health Literacy needs assessment. SI PPS has secured a vendor for Language Access Services (including video remote and telephonic interpreting and translating services), has prioritized sites with little to no access to language services and will support sites with video interpreter equipment as needed. PPS is also offering Medical Interpreter Training and train-thetrainer courses available to qualified employees. As identified above, these goals directly align with PCMH requirements for culturally and linguistically appropriate services and assessment of health literacy. In addition, trainings will support PCMH requirements for training staff on communicating with the patient population, especially vulnerable groups. 15 P age

17 WORKFORCE TRAININGS The PPS is tracking a workforce of over 11,500 employees, union and non-union requiring various levels of training. Through a partner survey, SI PPS has catalogued current partner training programs utilized and then created a gap analysis for needed future training. This training will be clinical and non-clinical in nature and will be done in conjunction with 1199 Training and Employment Fund (TEF) and other potential vendors for such topics as LEAN Six Sigma training. Existing internal partner resources and new outside vendors will be used. Future training will be built upon a broad training module on DSRIP 101 a review of how DSRIP transforms relationships between inpatient and outpatient partners to improve care delivery. Partner specific training programs are being developed by using the original survey and also site visits. This approach has permitted a deeper dive into training needs and has led to the creation of training strategies by DSRIP project and job titles associated with each project. This is an on-going analysis, based upon program implementation and the movement of human resources as part of the collaborative health care integration process. Specifically in regards to PCMH transformation, 1199 TEF has a robust care coordination training that will support PCMH requirements for staff training. Additional training components on motivational interviewing will fulfill the needs of primary care practices to train staff on selfmanagement support, self-efficacy, and behavior change. As described above, the PPS will be implementing the cultural competency training. The PPS is also exploring project-specific trainings related to SBIRT, depression management, and diabetes education all of which align with aspects of PCMH. PERFORMANCE REPORTING Through the performance reporting workstream, SI PPS has contracted with SpectraMedix to develop an enterprise data warehouse. This warehouse will combine claims data and EMR data to create performance dashboards for partners. This will support PCMH requirements related to performance measurement and quality improvement. Numerous DSRIP measures fall into the PCMH categories of clinical quality, utilization, care coordination, and patient experience presenting the primary care practices with an array of metrics to incorporate into their quality improvement efforts. In addition, the SI PPS plans to support rapid cycle improvement efforts will further support partners development and enhancement of quality improvement programs. 16 P age

18 APPENDIX A 17 P age

19 APPENDIX B: GNYHA DSRIP & PCMH CROSSWALK Modified from (Downloaded 12/14/2015) 18 P age

20 DSRIP Project Project Requirement Metric/Deliverables PCMH Standard 2.a.iii Health Home At- Risk Intervention Program Ensure all PPS safety net providers are actively sharing EHR systems with local health information exchange and sharing health information among clinical partners, including direct exchange, alerts, and patient record look up Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards by end of DY3 Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries Develop a comprehensive care management plan for each patient to engage him/her in care and to reduce patient risk factors EHR meets connectivity to RHIO's HIE and SHIN-NY requirements PPS uses alerts and secure messaging functionality EHR Meets Meaningful Use Stage 2 CMS requirements PPS identifies targeted patients through patient registries and is able to track actively engaged patients for project milestone reporting [SEE ACTIVELY ENGAGED DEFINITION] Procedures to engage at-risk patients with care management plan instituted Standard 5B - Referral Tracking and Follow-up 5.B.7. Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50% of referrals Standard 5C - Coordinate Care Transitions 5.C.7. Exchanges key clinical information with facilities and provides an electronic summary of care record to another care facility for more than 50% of patient transitions of care Standard 6G - Use Certified EHR Technology 6.G.8. The practice has access to a health information exchange 6.G.9. The practice has bidirectional exchange with a health information exchange 2014 PCMH Standards are aligned with Meaningful Use Stage 2 Standard 4B - Care Planning and Self-Care Support 4.B.1. Care team and patient collaborate to develop and update an individual care plan for 75% of high risk patients, incorporating patient preferences and functional/lifestyle goals 4.B.2. Care team and patient collaborate to develop and update an individual care plan for 75% of high-risk patients, incorporating identification of treatment goals Standard 4A - Identify Patients for Care Management The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including consideration of the following:

21 DSRIP Project Project Requirement Metric/Deliverables PCMH Standard 2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions Establish partnerships between primary care providers and the local Health Home for care management services with plans that clearly delineate roles and responsibilities for both parties Establish partnerships between the primary care providers, in concert with the Health Home, with network resources for needed services; the provider should work with local government units, such as SPOAs and public health departments, where necessary Implement evidence-based practice guidelines to address risk factor reduction, as well as to ensure appropriate management of chronic diseases; develop educational materials consistent with the population's cultural and linguistic needs Protocols will include care record transitions with timely updates provided to the members' providers, particularly primary care provider Each identified PCP establishes partnerships with local Health Home for care management services PPS has established partnerships with medical, behavioral health, and social services PPS uses EHRs and HIE system to facilitate and document partnerships with needed services PPS has adopted evidence-based practice guidelines for management of chronic conditions. Chronic condition appropriate evidence-based practice guidelines developed and process implemented Regularly scheduled formal meetings are held to develop collaborative evidence-based care practices PPS has included social services agencies in development of risk reduction and care practice guidelines Culturally competent educational materials have been developed to promote management and prevention of chronic diseases Policies and procedures are in place for including care transition plans in patient medical record and ensuring medical record is updated in interoperable EHR or updated in the primary care provider record 4.A.1. Behavioral health conditions 4.A.2. High cost/high utilization 4.A.3. Poorly controlled or complex conditions 4.A.4. Social determinants of health 4.A.5. Referrals by outside organizations Standard 5B - Referral Tracking and Follow-up 5.B.2. Maintains formal and informal agreements with a subset of specialists based on established criteria 5.B.3. Maintains agreements with behavioral health providers Standard 3D - Use Data for Population Health Management At least annually the practice proactively identifies populations of patients and reminds them of needed care, including for: 3.D.3. Three different chronic disease or acute care services 3.D.4. Patients not recently seen by the practice 3.D.5. Medication monitoring or alert Standard 5C - Coordinate Care Transitions 5.C.2. Shares clinical information with admitting hospitals and emergency departments 5.C.3. Consistently obtains patient discharge summaries from the hospital and other facilities 5.C.5. Exchanges information with the hospital during a patient's hospitalization

22 DSRIP Project Project Requirement Metric/Deliverables PCMH Standard 2.d.i Implementation of Patient Activation Activities 3.a.i Integration of Primary Care and Behavioral Health Services 3.c.i Evidence-Based Strategies for Disease Management in High- Risk/Affected Populations Diabetes Increase the volume of non-emergent (primary, behavioral, dental) care provided to UI, NU and LU persons Co-locate behavioral health services at primary care practice sites (Model 1) Develop collaborative evidence-based standards of care, including medication management and care engagement processes (Model 1) Conduct preventive care screenings, including behavioral health screenings (PHQ-2 or 9, and for those screening positive, SBIRT) implemented for all patients to identify unmet needs (Model 1) Use EHRs and other technical platforms to track all patients engaged in the project (All Models) Implement evidence-based practices for disease management specific to diabetes in the community and ambulatory care settings Volume of non-emergent visits for UI, NU and LU populations increased Behavioral health services are colocated within the PCMH/APC practices and are available (Model 1) Coordinated evidence-based care protocols are in place, including medication management and care engagement processes Policies and procedures are in place to facilitate and document completion of screenings At least 90% of patients receive screenings at the established project sites Positive screenings result in "warm transfer" to behavioral health provider as measured by documentation in EHR PPS identifies target patients and is able to track actively engaged patients for project milestone reporting [SEE ACTIVELY ENGAGED DEFINITION] Evidence-based practice strategies for the management and control of diabetes in the PPS-designated area are developed and implemented for all participating providers, along with developing protocols for disease management and training staff Standard 6E - Demonstrate Continuous Quality Improvement 6.E.3. Achieving improved performance on one utilization or care coordination measure Standard 5B - Referral Tracking and Follow-Up 5.B.4. The practice integrates behavioral health care providers within the practice site Standard 4C - Medication Management Standard 4E - Support Self-Care and Shared Decision Making Standard 3C - Comprehensive Health Assessment 3.C.9. The practice collects and regularly updates a comprehensive health assessment that includes depression screening for adults and adolescents using a standardized tool Standard 4A - Care Management and Support 4.A.1. The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including behavioral health conditions Standard 3D - Use Data for Population Health Management At least annually the practice proactively identifies populations of patients and reminds them of needed care, including for: 3.D.1. Two different preventive care services 3.D.3. Three different chronic disease or acute care services 3.D.4. Patients not recently seen by the practice 3.D.5. Medication monitoring or alert Standard 3E - Implement Evidence-based Decision Support 3.E.3. The practice implements clinical decision support following evidence-based guidelines for an acute condition

23 DSRIP Project Project Requirement Metric/Deliverables PCMH Standard 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 Develop "hot spotting" strategies, in concert with Health Homes, to implement programs such as the Stanford Model for chronic diseases in high-risk neighborhoods Use EHRs or other technical platforms to track all patients engaged in this project Clinically interoperable system is in place for all participating providers Care coordination teams are in place and include nursing staff, pharmacists, dieticians, community health workers, and Health Home care managers where applicable Care coordination processes are in place If applicable, PPS has implemented collection of valid and reliable REAL (Race, Ethnicity, and Language) data and uses data to target high-risk populations, develop improvement plans, and address top health disparities If applicable, PPS has established linkages to health homes for targeted patient populations If applicable, PPS has implemented Stanford model through partnerships with community-based organizations PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting [SEE ACTIVELY ENGAGED DEFINITION] PPS uses a recall system that allows staff to report which patients are overdue for which preventive services, and to track when and how patients were notified of needed services Standard 5B - Referral Tracking and Follow-up 5.B.7. Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 50% of referrals Standard 3A - Patient Information The practice uses an electronic system to record the following as structured (searchable) data for more than 80% of its patients: 3.A.3. Race 3.A.4. Ethnicity 3.A.5. Preferred Language Standard 3D - Use Data for Population Health Management At least annually the practice proactively identifies populations of patients and reminds them of needed care, including for: 3.D.3. Three different chronic disease or acute care services 3.D.4. Patients not recently seen by the practice