Beyond Hospitals and Shelters: Strengthening the Collaboration among Health Homes and Housing Providers 4 th Annual Meeting 12.2.

Transcription

1 Beyond Hospitals and Shelters: Strengthening the Collaboration among Health Homes and Housing Providers 4 th Annual Meeting Sponsored by the Bronx Health & Housing Consortium

2 Bronx Health & Housing Consortium Mission Statement The Bronx Health and Housing Consortium is a collaborative network of health, housing, social service and government agencies with the shared goal of streamlining client access to quality health care and housing in the Bronx.

3 Bronx Health & Housing Consortium Steering Group Health Homes: Bronx Health Home (Bronx Lebanon, CBC), Bronx Accountable Health Network (Monte=iore Medical Center), Community Care Management Partners (VNSNY), HHC Health Home Housing Organizations: BronxWorks, Urban Pathways, Concern for Independent Living, GEEL, West Side Federation for Senior and Supportive Housing Government: NYC Department of Health and Mental Hygiene, Transitional Health Care Coordination

4 Bronx Health & Housing Consortium Website:

5 Since we last met: Bronx Health & Housing Consortium Accomplishments 2014 Health Home/Homelessness White Paper: The Need for More Housing for People with Complex Needs Hospital HOPE Count Sample Training Program White Pages Funding Publications and Workshops

6 The Health Home Report Bronx Health Home (BHH) HHC Health Home Bronx Accountable Care Network (BAHN) Community Care Management Partners (CCMP)

7 Health Homes: Where are we now? 1. How many people from the Bronx are enrolled in your health home? 2. How many members reported as homeless on question H06 of the FACT- GP/Health Home Functional Assessment? 3. What are the housing needs/issues in your population? What is the need vs. availability and affordability? 4. How have the MRT housing units helped or not helped? 5. Can you give us an example of a success story where health and housing issues were addressed well? 6. What are the barriers to addressing health and housing issues? 7. How do you anticipate DSRIP affecting your health home s ability to address health and housing needs of people with high Medicaid utilization?

8 Leads: Bronx Lebanon Hospital Center Coordinated Behavioral Care (CBC) Virgilina Gonzalez Director, Bronx Health Home, BLHC Amanda Semidey Director of Clinical Operations and Network Management, CBC

9 Health Home Enrollments 11/1/2012: 1142 members 11/1/2013: 2914 members 11/1/2014: 4546 members Housing Enrollees Profile As of 2014 third quarter CMART report, 329 HH Members (7% of enrollees) answered homeless on Fact GP

10 Care Coordina7on Housing Successes and Issues Successes: Network Providers have housing for Members with Behavioral Health issues including substance abuse disorders HIV+ Criminal JusUce Health Home eligibles Linking clients with housing issues to services in the community Network Providers ability to work collaborauvely

11 Care Coordina7on Housing Successes and Issues Issues: Housing regulauon/ eligibility Criteria Time consuming No immediate placements Many opuons are too expensive DifficulUes with Health Home members with children

12 Resources and Collabora7on Housing Partners à Be[er communicauon between Housing providers and Health Homes- let health homes and other down stream providers know of housing opportuniues City and State agencies à allow waiver for health home clients in need a housing ConsorUum à Resource book & process guide

13 Lead: NYC Health and Hospitals Corporation Dr. Deborah Rose Health Home Director

14 NYC HHC HEALTH HOME December

15 15

16 Mission HHC Triple Aim Better care Better health Reduce costs Health Home goals Coordinated and comprehensive care Improve health outcomes Reduce preventable hospitalizations, ER visits and unnecessary care 16

17 Where is HHC? 17

18 HHC FACILITIES Hospitals Diagnostic & Treatment Centers Bronx Jacobi Medical Center Lincoln Medical & MH Center North Central Bronx Hospital Manhattan Bellevue Hospital Center Harlem Hospital Center Metropolitan Hospital Center Brooklyn Coney Island Hospital Kings County Hospital Center Woodhull Medical & MH Center Queens Elmhurst Hospital Center Queens Hospital Center Bronx Morrisania Diagnostic & Treatment Center Segundo Ruiz Belvis Diagnostic & Treatment Center Manhattan Gouverneur Healthcare Services Renaissance Health Care Network Diagnostic & Treatment Center Brooklyn Cumberland Diagnostic & Treatment Center East New York Diagnostic & Treatment Center 18

19 Downstream providers VillageCare Steinway Children & Family Services HHC Home & Health Care APICHA Mental Health Providers of Western Queens Eight CBOs in process 19

20 HHC Health Homes Total HHC Health Home patients Enrolled 2013 In Outreach 4254 Current HHC Bronx Health Home patients Enrolled 323 In Outreach 1504 Reported as Homeless (HH Functional Questionnaire) N = 125 (7%) 20

21 Case Study: Bellevue Case Following inpatient psychiatric admission, patient was discharged to the 30 th Street Bellevue men s homeless shelter and referred for Health Home services, outpatient Mental Health treatment, Primary Care, and substance abuse services. Outcome Patient s case manager helped him get SSI and supportive housing at The Bridge MICA residence. Patient got a part time job at TJ Maxx and attended Chelton Loft, a clubhouse program. Successes Collaboration and communication between the care team providers Comprehensive approach to housing needs Patient felt that he was a part of a larger team and fully supported 21

22 Discussion Areas Referrals DOH assigned Bottom-up enrollment Billing Issues Housing Challenges MRT Housing DSRIP 22

23 DSRIP: Hub-Based Model Designed to Meet Local Needs Community Community Community Community Brooklyn Hub Bronx Hub ManhaGan Hub Queens Hub HHC PPS Hub Configura7on Brooklyn Hub Woodhull Kings Coney Island Bronx Hub Jacobi North Central Lincoln ManhaGan Hub Bellevue (may have role in mul7ple hubs given large geographic draw for ter7ary care services) Harlem Metropolitan Queens Hub Queens Elmhurst

24 DSRIP: HHC PPS Project List Domain 2: System Transforma7on 2.a.i 2.a.iii 2.b.iii 2.b.iv 2.d.i Create Integrated Delivery Systems that are focused on Evidence Based Medicine / PopulaUon Health Management Health Home At Risk Interven7on Program ProacUve management of higher risk pauents not currently eligible for Health Homes through access to high quality primary care and support services. ED care triage for at- risk populauons Care transi7ons model to reduce 30 day readmissions for chronic health condiuons Project 11 : ImplementaUon of PaUent AcUvaUon AcUviUes to engage, educate, and integrate the UI, NU, and LU Medicaid populauons into community- based care Domain 3: Clinical Improvement Projects 3.a.i 3.b.i 3.d.ii 3.g.i IntegraUon of primary care and behavioral health services Evidence- based strategies for cardiovascular disease management in high risk / affected populauons (adult only) Expansion of asthma home- based self- management program IntegraUon of pallia7ve care into the PCMH model Domain 4: Popula7on- Wide Projects 4.a.iii 4.c.ii Strengthen Mental Health and Substance Abuse Infrastructure across Systems Increase early access to, and retenuon in, HIV care

25 DSRIP: Health Home At-Risk Intervention Program 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services Objective: To expand access to community primary care services and develop integrated care teams (physicians and other practitioners, behavioral health providers, pharmacists, nurse educators and care managers from Health Homes) to meet the individual needs of higher risk patients who do not qualify for care management services from Health Homes 25

26 Contacts Referrals: HOME (4663) Information: Liz Lagone, MPH Deborah Rose, PsyD 26

27 Lead: Monte=iore Medical Center Nicole Jordan- Martin Senior Director

28

29 Program to date: 35,123 Membership (as of October 31, 2014) Current: 15,758 TCM vs Non- TCM 4.4% Eligibility HP 26% 74% TCM Non TCM 26.7% 69.0% FFS Unknown

30 Membership (as of October 31, 2014) Current: 15,758 Assignment vs Referral 20.9% Assignment 23.4% 5.4% 3.1% Acuity High 79.1% Referral 68.1% Low Medium Unknown Duplicate engagement/billing remains unresolved

31 Membership (as of October 31, 2014) Total Ac7ve Homeless (Health Home Func7onal Ques7onnaire): v Program to date: 800 v Current: 706 Outreach Enrollment Rate Rate Assignment to Enrollment Referral to Enrollment Average Months Outreach Average Months Enrollment Conver7ng 11, % Non- 28.2% 15.2% 73.3% Conver7ng 4, % 42.3% 36.6% 76.7% BAHN 15, % 31.8% 21.1% 73.9%

32 Membership (as of October 31, 2014) Housing needs/issues: v No affordable housing v Point persons at key agencies, i.e., HRA v Ongoing nouficauon of availability of housing (type, volume, locauon) v Need to accommodate individual situauons ü Health Home and housing providers in different counues ü Couch surfing vs. street homeless

33 MRT Housing Units Number of units allocated to Bronx severely inadequate Requirements/process for referral to housing provider not standardized No update on ongoing availability Limited relauonship building among care management and housing providers

34 Success Story No response from care management partners

35 Barriers Complexity of process Inability to offer immediate hope Unclear roles/responsibiliues v Client v Health Home Care Manager v Housing provider v City and state agencies Importance of linkage between health and housing lost on providers

36 AnUcipated Impact of DSRIP IdenUficaUon of specific housing experuse v Network development/adequacy Standardized assessment and strauficauon base on idenufied housing need v Informs the plan of care IdenUficaUon and inclusion of appropriate housing provider in care plan v Route to agencies based on required experuse ü ApplicaUon and placement v Becomes a member of interdisciplinary care team v Bi- direcuonal informauon sharing and communicauon

37 Lead: Visiting Nurse Service of New York

38 Bronx Health & Housing Consortium 4 th Annual Bronx- Wide Meeting December 2, 2014

39 CCMP Snapshot Enrolled 10,053 (Across all 5 boroughs) Approximately 5,500 in the Bronx Outreach 1,733 (Across all 5 boroughs) Approximately 700 in the Bronx Approximately 75% of our enrolled Health Home members (across all 5 boroughs) are bottom- up referrals Approximately 39% identify as homeless according to the FACT- GP Outreach to Enrollment Conversion Rates (Numbers below re=lect assignments from NYSDOH Portal and do not include bottom up referrals) FFS: 11% MCO: 19%

40 Health Homes & Housing Housing remains a critical issue for Health Home members Access to (affordable!) housing In neighborhoods where Health Home members would like to live (either close to transportation or where they are receiving services) ADA Compliant apartments Families Individuals released from incarceration Individuals transitioning out of foster care Behavioral health diagnoses Adult Home transition

41 Barriers & The Future Barriers to Health & Housing Access Affordability Acclimating Area DSRIP Unclear the role housing will play in DSRIP

42 The Housing Report Supportive Housing Network of NY Corporation for Supportive Housing Urban Pathways

43

44 Supportive Housing in the Bronx

45 What is it? n Affordable independent housing linked to on-site services aimed at keeping the person housed. n Either scattered site apartments in community visited by caseworkers or single site buildings in which 50% or more of units set aside for people with disabilities

46 Who s it for? n People with serious mental illness, especially those who are chronically homeless n Chronically homeless substance abusers n Homeless people with HIV/AIDS n Other discrete populations: homeless families with a disabled head of household; youth aging out of foster care; homeless veterans

47 How does that break down in the Bronx? n About 3,000 scattered site units n Nearly half of those are for people with severe mental illness n About 800 for people with AIDS n About 500 for people struggling with chronic substance abuse

48 For single site n About 4,500 units in 100 residences n About 2,600 units for individuals and families coping with severe mental illness n Some 780 units for people with HIV AIDS n 350 for individuals coping with chronic substance abuse n 650 other homeless

49 How do I get someone in? For SPMI: either DHS or OMH For SA: either DHS or OASAS (very few) For HIV/AIDS: HASA

50 How can I get access for my clients? n For a lot of the units, you must complete HRA s 2010e n Trainings on the 2010e are available through HRA and CUCS

51 What about MRT supportive housing MRT provided $ for housing in 3 ways 1) MRT provided capital to several buildings just now opening/in development, but they all used NY/NY III rent/service subsidies, so referral/placement processes the same as those listed above (DHS/OMH mostly)

52 MRT OMH/OASAS/DOH AI scattered site contracts 2) MRT funded three scattered site initiatives to Health Home enrollees through OMH, OASAS and DOH AIDS Institute. Each had its own eligibility criteria. Referrals were made through these agencies directly. n OMH had 22 units in Bronx; n OASAS had 25 units in Bronx, 25 units in Bronx/Manhattan; n DOH AIDS Institute provided housing services to 3 Bronx agencies.

53 MRT pilots: n MRT also funded nine pilot programs designed to test ways to improve healthcare/reduce costs through housing-like solutions. n One of these is the Health Home Supportive Housing Pilot.

54 Health Home Pilots DOH recently made 10 awards to supportive housing providers working with Health Homes to provide housing to High Cost/High Need Recipients, 6 in NYC, 4 ROS

55 Health Home Pilots for Bx n BronxWorks intends to create permanent scattered site housing opportunities for High Cost-high need Medicaid Recipients (HCMR) who are eligible for/enrolled in Bronx Health Homes. n Fortune Society will create units citywide for Health Home eligible HCMRs with history of incarceration.

56 More to come n The Network and 150 other nonprofits are advocating for more units as part of a new large-scale supportive housing agreement, Campaign 4 NY NY Housing n DOH is committed to creating housing opportunities for HCMRs COLLECT DATA TO HELP MAKE THE CASE!

57 Questions? Cynthia Stuart Supportive Housing Network of NY

58

59 Targeting and Assessment Trends Around the U.S. The Source for Housing Solutions Presented By Kristin Miller, NY Program Director at the Bronx Health & Housing Consortium: December 2, 2014

60 Frequent User Initiatives King Co FACT Hennepin Co FUSE Washtena w FUSE/ SIF Detroit FUSE Columbus BJA FUSE Rhode Island FUSE CT FUSE KCC/SIF Denver FUSE Chicago FUSE CT SIF NYC FUSE Wash. DC FUSE SIF+FUSE/ Just in Reach 2.0 Louisville ACT Richmond FUSE MeckFUSE Project 25 Travis Co BJA Maricopa Co FUSE Re-entry FUSE Operating Re-entry FUSE Significant planning Health FUSE Operating Health FUSE Significant planning

61 CSH Social Innovation Fund 5-year national effort to pilot supportive housing linked to coordinated health care for high utilizers of crisis health services to: Increase health and housing stability for at least 549 high-need, high-cost individuals with chronic health challenges Develop a replicable model for integrating housing with care management and health services Design a blueprint for linking mainstream housing and health resources (Medicaid) to scale models

62 SIF continued Initiative includes: Grantmaking: CSH awarded $2.8 mm in two-year grants to 4 organizations in four communities State of CT; Washtenaw County, MI; LA County; and San Francisco Systems Change & TA: CSH assisting subgrantees to implement and scale models through a national learning network Evaluation: Researchers from NYU s Schools of Medicine and Education completing a rigorous multimethod evaluation to measure impact on recipients health and housing stability, use of crisis services and Medicaid, and other public costs

63 Key Components of Model Supportive Housing as a Health Care Intervention Data-driven identification of target population Prioritization of highest-need, highest-costs clients; identified through data Homeless, high utilizers with one or more chronic health condition Assertive targeting, outreach and recruitment Taking place in crisis health services, homeless, and institutional settings Supportive Housing Quality, safe and affordable housing Informed property/landlord management Housing stability services Care management, service coordination Patient navigation Primary and behavioral health care

64 CSH Frequent User Initiative Timeline and Outcomes 1. CSH s Frequent Users of Health Systems Initiative in CA 4. Integrating FQHC Health Care Services with PSH in Los Angeles Report 5. CSH Awarded Federal Social Innovation Fund Grant 7. CSH SIF subgrantees in Los Angeles, San Francisco, Ann Arbor, and CT begin targeting & housing frequent users of health services and integrating housing & health care Program Selected Outcomes 1. FUHSI ED visits/charges, inpatient admits/days/ charges all decrease by 60% or more after 2 years in program 6. San Diego Project LA County FUSE/10 th Decile Project Cost savings over $1.4 million in reduced emergency services (ER and ambulance trans.) after 12 months 81% average decrease in costs per tenant; ER utilization down 71%; hospital readmits and inpatient stays down by more than 80% CSH helps launch health frequent user housing initiatives in LA County, Detroit, Phoenix, and San Diego 9. CSH Awarded HRSA National Cooperative Agreement

65 Other Frequent User Studies Health Outcomes Cost Savings SF study found 5-year survival rates of 81% for PLWAs in supportive housing compared with 67% who remained homeless Chicago study found 55% survival for PLWAs in supportive housing compared with 35% of control group, and lower viral loads among housed group Seattle study found 30% reduction in alcohol use among chronic alcohol users in SH Denver study found 50% of tenants improved health status and 43% had improved MH Direct Access to Housing in San Francisco found that supportive housing reduced nursing home costs by $24,000. Chicago Permanent supportive housing saved almost $25,000 per person, per year Downtown Emergency Shelter Center in Seattle showed 41 percent in Medicaid savings by reducing ER visits and hospital inpatient stays. Portland, Maine - Medicaid costs were reduced by almost $6,000

66 The Strongest Health Care Intervention for Frequent Users is Housing

67 ACA Goal - Triple AIM Reduced Costs Improved Quality Improved Access High Quality Health System

68 Examples of what it takes to make it happen South Bend, IN: helping stakeholders, including regional PCA, to access health system data to target frequent users of emergency room and ambulatory services for a housing initiative Indianapolis, IN: Training/providing direct technical assistance to case management staff of a new supportive housing building on coordinating care for high utilizer residents with a Community Health Clinic Missouri: Training for rural Health Centers on different care coordination models for frequent user patients Texas: Targeted TA throughout the state focused on connecting FQHCs with housing providers

69

70 The Government Report OHIP, NYS Department of Health NYC Department of Homeless Services NYC Department of Health and Mental Hygiene

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72 NYS DSRIP, Health Homes and Housing a Bronx View December 2, 2014 Gregory S. Allen, Policy Director New York State Medicaid Program Office of Health Insurance Programs

73 NYS DSRIP PROGRAM: KEY GOALS o TransformaUon of the health care safety net at both the system and state level. o Reducing avoidable hospital use and improve other health and public health measures at both the system and state level. o Ensure delivery system transformauon conunues beyond the waiver period through leveraging managed care payment reform. o Near term financial support for vital safety net providers at immediate risk of closure. 73 ALLEN

74 NYS DSRIP PLAN: KEY COMPONENTS (SPECIFICS) o Key focus on reducing avoidable hospitalizauons by 25% over five years. o Statewide iniuauve open to large public hospital systems and a wide array of safety- net providers. o Payments are based on performance on process and outcome milestones. o Providers must develop projects based upon a selecuon of CMS approved projects from each of three domains. o Key theme is collaborauon! CommuniUes of eligible providers are required to work together to develop DSRIP Project Plans. 74 ALLEN

75 DSRIP PROGRAM PRINCIPLES PaUent- Centered Transparent CollaboraUve Accountable Value Driven Improving pauent care & experience through a more efficient, pauent- centered and coordinated system. Decision making process takes place in the public eye and that processes are clear and aligned across providers. CollaboraUve process reflects the needs of the communiues and inputs of stakeholders. Providers are held to common performance standards, deliverables and Umelines. Focus on increasing value to pauents, community, payers and other stakeholders. Be#er care, less cost 75 ALLEN

76 PERFORMING PROVIDER SYSTEMS (PPS): LOCAL PARTNERSHIPS TO TRANSFORM THE DELIVERY SYSTEM Partners should include: Hospitals Health Homes Skilled Nursing Facili7es Clinics & FQHCs Behavioral Health Providers Home Care Agencies Community Based Organiza7ons Prac77oners and Other Key Stakeholders Responsibili7es must include: Community health care needs assessment based on mulu- stakeholder input and objecuve data. Building and implemenung a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies. MeeUng and reporung on DSRIP Project Plan process and outcome milestones. ALLEN 76

77 DSRIP IS PROJECTS SAMPLE FROM PROJECT TOOLKIT ALLEN 77

78 DSRIP IS PROJECTS SAMPLE FROM PROJECT TOOLKIT ALLEN 78

79 DSRIP IS PROJECTS SAMPLE FROM PROJECT TOOLKIT ALLEN 79

80 BEHAVIORAL HEALTH OPPORTUNITIES IN MEDICAID WAIVER Managed Care Contrac7ng ü Development of 1915i programs including: Psychosocial rehab; Community Psychiatric Support and Treatment (CPST); Crisis and Mobile Crisis; Empowerment services including Peer Supports; Habilita7on; Respite; Family Support and Training; Employment and Educa7on Support Services; and Self Directed Services (Pilot). Redesign Medicaid in New York State 80

81 HEALTH HOME OPPORTUNITIES IN MEDICAID WAIVER State Plan Opportuni7es ü Health Home Development Fund including: Member Engagement and Health Home Promo7on; Workforce Training and Retraining; HIT Implementa7on Clinical Connec7vity; and Joint Governance Technical Assistance and Implementa7on Funds. ü Health Home Development Funds will be distributed through an rate add on. Redesign Medicaid in New York State 81

82 BROADER IMPLICATIONS OF THE NYS DSRIP PROGRAM ALLEN 82

83 FIVE KEY THEMES OF DSRIP 1. CollaboraUon, CollaboraUon, CollaboraUon!!! 2. Project Value drives a) Transforma7on à # and types of projects b) # of Medicaid members served (avribu7on) c) Applica7on Quality 3. Performance Based Payments 4. Statewide Performance Ma[ers 5. LasUng Change a) Long- Term Transforma7on b) Health System Sustainability ALLEN 83

84 DSRIP FINANCE FRAMEWORK Outcome Metrics & Avoidable Hospitalizations $ Process Metrics Population Health Measures Time TransiUoning to payments for measurable outcomes! ALLEN 84

85 The DSRIP Vision: Five Years in the Future How The Pieces Fit Together: MCO, PPS & HH Other Providers MCO* PPSs ROLE: - Insurance Risk Management - Payment Reform - Hold PPS/Other Providers Accountable - Data Analysis - Member Communica7on - Out of PPS Network Payments - Manage Pharmacy Benefit - Enrollment Assistance - U7liza7on Management for Non- PPS Providers - DISCO and Possibly FIDA/MLTCP Maintains Care Coordina7on ROLE: - Be Held Accountable for Pa7ent Outcomes and Overall Health Care Cost - Accept/Distribute Payments - Share Data - Provider Performance Data to Plans/State - Explore Ways to Improve Public Health - Capable to Accept Bundled and Risk- Based Payments HH #1 HH #2 Other PPS Providers ROLE: - Care Management for Health Home Eligibles - Par7cipa7on in Alterna7ve Payment Systems *Mainstream, MLTC, FIDA, HARP & DISCO ALLEN ImplementaUon of the state s managed care contracung plan and movement toward a goal of 90 percent of managed care payments to providers using value- based payment methodologies. 85

86 HOUSING AND HEALTH HOMES ADDRESSING SOCIAL DETERMINANTS OF HEALTH NYSDOH is commiged to the Housing is Healthcare model MRT Affordable Housing Resources - $222 million over two years (FY and FY ) Regional statewide trainings to bring Health Homes and Housing Providers together More than ten Pilot Projects, administered by seven agencies, primarily focused on targeung housing funds to high cost, high uulizers of Medicaid, including those enrolled or eligible for Health Homes. Health Home Suppor7ve Housing Pilot provides funds for: rental subsidies for housing units; Services that facilitate provision of housing; ImplementaUon of best pracuces, procedures and methods for SupporUve Housing Providers to collaborate with Health Homes 86

87 MEDICAID REDESIGN TEAM SUPPORTIVE HOUSING HEALTH HOME PILOT PROJECT As part of the Pilot, Suppor7ve Housing Providers were required to iden7fy and receive a commitment from one or more designated New York State Health Homes to be the Housing Provider s partner in implemen7ng the procedures and terms specified by the Housing Provider in their applica7on. The intent of the Pilot Program is to iden7fy best prac7ces, procedures and methods for Suppor7ve Housing Providers to collaborate with Health Homes to: IdenUfy and locate homeless or unstably housed enrolled Health Home Members and individuals eligible for Health Homes; Provide housing as a means to facilitate access to health services and improve the health status of Health Home members; Coordinate the efforts of the Health Home Care Manager and the Housing Specialist to implement the Health Home Member s Plan of Care; and Provide an opportunity for housing providers and Health Homes to develop innovauve services or methods to ensure that Health Home members remain stably housed. 87

88 MEDICAID REDESIGN TEAM SUPPORTIVE HOUSING HEALTH HOME PILOT PROJECT Total amount available for this procurement is up to $8 million, (up to $4 million per year for two years). Maximum award made to successful Applicant does not exceed $400,000 per fiscal year. Award le[ers have been sent to 10 applicants. Contracts will be awarded soon. Contracts will be one- year with opportunity for 12- month renewal, renewal will be based on outcomes Awards have been made in all Health Home regions in New York State Pilot Program is projected to serve people Current Status: DOH negouaung contract details with awarded providers and developing outcome measures and reporung criteria 88

89 MEDICAID REDESIGN TEAM SUPPORTIVE HOUSING HEALTH HOME PILOT PROJECT BronxWorks one of ten awarded providers. Le[er of Agreement to work with two Bronx Health Homes: Bronx Lebanon Hospital Center and Bronx Accountable Healthcare Network Outreach Tac7cs/Approaches outlined in RFA applica7on Physician will travel with outreach staff to engage homeless Use/operate muluple sites in order to reach and connect with homeless "drop- ins". Sites operate as temporary stays and staff is on hand to a[empt outreach/engagement for Health Home program and other services Outreach staff will visit Bronx area hospitals regularly, and engages homeless individuals who are seeking shelter in the Emergency Department. Hospitals (Bronx Health Home and Bronx Accountable Healthcare Network) noufy BronxWorks if a person visits the ER Known homeless alert system set up with Montefiore Medical Center Emergency Department Innova7ve Approach outlined in RFA applica7on Create/use a mobile medical unit with Homeless Outreach Team to engage and provide medical care for chronically street homeless individuals Include all 'Bronx Health and Housing Consor7um' providers in care plan for connecuon to health, housing, social services, government agency services Establish support groups led by peers for all levels of interacuon in the housing process Use of legal services and mobile technology by staff to increase mobility, find and enroll clients 89

90 BRINGING HEALTH HOMES AND HOUSING PROVIDERS TOGETHER Six Regional workshops have been conducted by the Corpora7on for Suppor7ve Housing (CSH) in coopera7on with DOH and other State Agencies. Trainings occurred Statewide to provide guidance to Health Homes and Housing Providers on: IdenUfying and accessing the various types of housing resources available Roles and ResponsibiliUes of Health Homes and Health Home Care Managers Roles and responsibiliues of Housing Case Managers Developing collabora7ve rela7onships between HH Care Managers and Housing Case Managers, encouraging housing providers to join Health Homes networks Regional webinar based trainings will con7nue through December 2014 Focused on best pracuces, working methods, and problem solving 90

91 HEALTH HOME ENROLLMENT: BRONX # of Members Enrolled + Outreach - Oct # of Members Enrolled + Outreach - Jan to Oct # of Members Enrolled - Oct # of Members Enrolled - Jan to Oct # of Members Outreach - Oct # of Members Outreach - Jan to Oct Health Home Health Home A 11,708 17,641 9,254 11,535 2,454 6,895 Health Home B 10,917 29,046 5,298 8,306 5,619 24,037 Health Home C 7,206 32,901 3,695 8,354 3,515 27,126 Health Home D 6,212 9,573 2,125 2,249 4,087 7,404 Health Home E 4,233 10,641 3,466 4, ,414 Health Home F 0 12, , ,874 Total 40, ,029 23,838 37,538 16,442 73,146 91

92 HEALTH HOME OUTREACH AND ENROLLMENT: BRONX 92

93 HEALTH HOME CONTACT INFORMATION Visit the Health Home website: hgp:// medicaid_health_homes/ Get updates from the Health Homes listserv. To subscribe send an to: (In the body of the message, type SUBSCRIBE HHOMES- L YourFirstName YourLastName) To Health Homes, visit the Health Home Website and click on the tab NYS Health Homes Program hgp:// medicaid_health_homes/ Call the Health Home Provider Support Line:

94 We want to hear from you! DSRIP e- mail: Like the MRT on Facebook: h[p:// Follow the MRT on Subscribe to our listserv: h[p:// 94 ALLEN

95

96 Bronx Health and Housing ConsorUum PresentaUon December 2, 2014

97 Overview of PresentaUon Snapshot of the homeless services system Vulnerability of homeless clients and effecuve intervenuons DHS work with Health Home providers and exisung opportuniues

98 Snapshot of Homeless Services System 58,532 individuals in shelter 11,256 single adults 12,241 families with children 2,133 adult families 10% shelter census increases across the board comparing present to this Ume last year Over 3,000 individuals sleeping on the streets; 526 staying in Safe Havens; 387 served in Drop- In Centers (99, overnight) Top reasons for homelessness Discord (single adults) DV (families with children) EvicUon (adult families)

99 Snapshot of Single Adult and Adult Family Homeless PopulaUon 30% of single adult clients in shelter live with serious mental illness; many of these individuals require and will be moved into supporuve housing We believe substance abuse negauvely impacts the lives of 60% of single adults in shelter The homeless single adult populauon is highly transient and typically reside in muluple locauons over any period of Ume

100 Leading Causes of Death July 1, June 30, 2010 Rank NYC Homeless PopulaUon General NYC PopulaUon 1 Heart Disease Heart Disease 2 Drug Overdose Malignant Neoplasms (Cancer) 3 Accidents except Drug Poisoning Influenza and Pneumonia 4 Alcohol Abuse Diabetes Mellitus 5 Assault (Homicide) Cerebrovascular Disease (Stroke)

101 Snapshot of a Vulnerable Client In January 2009, a 32 year- old chronically homeless intoxicated man was found unresponsive on NYC sidewalk Brought to the Bellevue ED and pronounced dead from hypothermia 428 prior Bellevue ED visits and nine intensive care admissions Was not known to the homeless system His case prompted us to rethink our standard of care for such pauents.

102 Medical Physical illness Social Social IsolaUon SUgma AddicUon Systems Fragmented Care The Problem: Barriers to RehabilitaUon Mental illness Housing Homeless Medical training AddicUon Financial Health System CoordinaUon CogniUve Impairment Legal The SoluUon: PaUent- centered Coordinated Services Legal, HIPAA Homeless Outreach Hospital PaUent EMS 35% 56% 50% ED InpaUent Cost Public Health

103 Bellevue s Top Visitor ED OP visits Drug Rehab OP visits IP Visits 10 Visits Time

104 IntervenUons AddicUon Treatment Care CoordinaUon and Management SupporUve Housing and Rapid Rehousing Community Programs: Peer Support, AA Civil Commitment

105 MRT Housing IniUaUve Established under the leadership of Governor Cuomo/ State funded To reduce homelessness and future hospitalizauons and to increase Medicaid savings DHS provides a housing subsidy Clients paired with case management, coordinated medical care, and home health care ParUcipants are homeless and either Health Home or Nursing Home eligible 500 slots for FY15

106 CoordinaUon with Health Homes Paired each of our single adult and adult family shelters with a Health Home provider Health Home providers did onsite presentauons at shelters about their services Health Home providers conduct rouune onsite screening at shelters to determine eligibility Hundreds of clients enrolled through this process

107 OpportuniUes to Build on Current PracUce Expedite Umeframe between iniual screening and enrollment Improve communicauon and coordinauon of care between shelter staff and health home provider Enhance level of care management/case mgt. for homeless populauon Explore possibility of data matching /automated process for DHS to access enrollment status of our clients

108

109 IT S A MATCH: Alison O. Jordan, NYC DOHMH CorrecUonal Health Services Presenta7on to the Health and Housing Consor7um December 2, 2014

110 NYC JAILS AT A GLANCE Jail System Annual Admissions 81,758 Average Daily Population 11,827 Annual Releases 53,000* Average Length of Stay Electronic Health Record (adopted ) 12 jails: 9 on Rikers Island (1 female facility, 1 adolescent facility), 3 borough houses, public hospital inpatient unit 53 days eclinicalworks, customized for jail setting; unidirectional interface with NYC DOC Inmate Information System Sources: NYC Department of Corrections Mayoral Report *Annual releases from NYC DOC Report of Discharges by zip code for CFY 14

111 NYC JAIL POPULATION AT A GLANCE Gender* Male (%) 89.0% Age* Range Mean 34 Race* 16<21 (13.4%) Non-Hispanic Black (%) 54.0% 21<31 (32.8%) Breakdown Hispanic (%) 33.0% 31<41 (21.6%) 41<51 (21.8%) Non-Hispanic White (%) 8.7% 51+ (10.2%) *2011 Correctional Health Services new admission records (N=61,853) Health Indices for New Admissions (July Sept 2014) Self reported HIV- Infected 3.9% Diabetes 5.0% Hypertension 12.0% Asthma 23.7% Mental Health Service 23.4% Report Current Drug Use 46.8% Tobacco Use 58.3%

112 CORRECTIONAL HEALTH SERVICES Medical Service Comprehensive medical intake including history/physical Sick call and chronic care visits Over 42,000 Medical visits/month Mental Health Service (MHS) Initial mental health intake, psychosocial evaluation Initiation/continuation psych meds Over 20,000 MHS visits/month Substance Use Treatment readiness housing areas Methadone maintenance/linkages Buprenorphine pilot Discharge Planning MHS: Population based HIV patients: Population based Others: At high risk of HIV Other Jail-Based Services HIV prevention & peer educator training groups Court advocacy Compassionate Release Visitor Outreach Linkage to HIV testing Condom distribution Overdose prevention

113 JAIL DISCHARGES TO NYC COMMUNITIES (2014) Over 70% of people released to the community after incarceration return to the areas of greatest socioeconomic and health disparities

114 HEALTHCARE ACCESS Increase Medicaid enrollment and health care access for uninsured by providing comprehensive transitional care services Prescreen/determine Medicaid status Initiate the Medicaid application process Discharge planning to high risk patients (i.e. chronic conditions, smokers, substance users) Address need for housing and transportation assistance, social services and medication.

115 RETURN PATIENTS TO MEDICAL HOME Determine PPS/HH affiliation through systems matching Access community health information to view past health system usage and facilitate return to PPS/HH providers Provide comprehensive transitional care services including discharge planning to high risk patients (i.e. chronic conditions, smokers, substance users) including housing, medication and transportation assistance and social services Initiate community referrals to Health Homes for those without current HH assignment

116 PILOT TIMELINE 8/13 Agreement executed 10/13 Tracking system initiated 2/14 Operating protocols with CMOs 4/14 Tracking/ Reporting Systems sharing 6/14 Fortune Society Agreement with BHH 7/14 Share Protocols to inform State DOCCS pilot 10/14 Montefiore HH Match 9/13 Pilot starts 11/13 BHH/CJ Summit 3/14 BHH / Jail Patient Match 5/14 Integration with MHDP 9/14 Southwest BK and CHN HH Match

117 CHS & HEALTH HOME COLLABORATIONS CHS receives rosters from 7 NYC-based Health Homes About 10% of those incarcerated in NYC jails on any given day are on a health home roster Two CHS Health Homes partnerships with dedicated resources Bronx Health Home pilot, initiated 9/13 reaches out to all HH-assigned patients in NYC jails Southwest Brooklyn HH, initiated 9/14 reaches out to behavioral health HH-assigned patients Return patients to medical home Actively link those currently incarcerated with their health home care management organization Facilitate warm transitions and continuity of Primary Care

118 CHS PPS/HH PARTNERSHIPS The NYC Jail popula7on is: Sicker and has greater health disparities than general population More likely to use ED with resulung hospitalizauons CHS has: Demonstrated, evidence-based approach to linkages to care Agreements with extensive network of NYC service providers Together, CHS and PPS/HH partnerships: Remove barriers to engagement in care Avoid unproductive outreach Help patients address basic needs during critical reentry period

119 NEXT STEPS DSRIP ApplicaUon IntegraUon EvaluaUng ED Use and Hospital Admission rates Match Agreements with other Health Homes ReplicaUon & DisseminaUon

120 ACKNOWLEDGEMENTS Sam Shutman and Virgelina Gonzalez at Bronx Health Home Paul Meissner, Henie Lustgarten and the team at Montefiore MC Bonnie Mohan and BronxWorks Tracie Gardner and the team at Legal Action Center Greg Allen and colleagues at NYS DOH & Bronx Health and Housing Consortium & each of you who have supported this collaboration Many Thanks! Contact Alison O. Jordan ExecuUve Director, THCC

121 Integrating Health and Housing NYC Health and Hospitals Corporation Bellevue Hospital Center

122

123 Homelessness and Housing Instability Among Emergency Department Patients Kelly Doran, MD, MHS December 2, 2014 Bronx Health & Housing Consortium Meeting

124 Share results of a study of Bellevue Hospital emergency department pauents housing status. Discuss issues related to hospital screening for homelessness.

125 Disclaimers I will be presenting results of my own research and do not speak on behalf of Bellevue Hospital, NYC Health and Hospitals Corporation, or any other entity. Results are unpublished, please do not share.

126

127 Introduction Social determinants contribute to health outcomes - Housing - Food security - Employment - Income Status quo = social needs of emergency department patients often ignored Importance of social determinants of health, including housing, increasingly recognized - New payment models

128 Emergency Department Study Survey Random sample of patients o 18 years old o Bellevue Emergency Department Study enrollment o June - August 2014 o 8a-11p *, 7 days/week *

129 STUDY RESULTS (n=625 ED patients)

130 Demographics Gender o Male: 58.1% o Female: 41.9% Age o Mean: 44.5 years o Std Dev: 16.2

131 Ethnicity/Race Hispanic / Latino: 40.1% Black or African American: 26.6% White: 27.4% American Indian or Alaskan Native: 1.8% Asian/Pacific Islander: 5.8% Southeast Asian / Indian Subcontinent: 3.6% Other: 34.7%

132 Insurance Status Uninsured: 28.4% Medicaid: 26.7% Medicare: 8.3% Dual: 4.5% Private: 20.9% Other: 11.3%

133 Employment Employed full-time: 34.3% Employed part-time: 16.8% Unemployed: 39.1% Retired: 9.9%

134 Current Homelessness 9.4% currently living in a homeless shelter 4.6% currently living on the streets

135 Housing Insecurity 19.8% have been unstably housed in the past 2 months 20.2% experienced homelessness in the past 12 months - Includes those living doubled up % of ED patients had stayed in a shelter or drop-in center in the past 12 months 30.8% have been homeless in their lifetime

136 Risk for Homelessness 19.9% of patients not currently homeless (street or shelter) reported that they were worried about not having stable housing in the next 2 months 8.2% had been evicted from their home in the past year

137 Other Social Needs 42.0% of patients did not meet all their essential expenses in past year 36.4% often or sometimes worried about food running out before getting money to buy more

138 Other Social Needs 34.1% have problems like pests, leaks, broken windows or plumbing, or holes or large cracks in their apartments 14.3% did not pay full amount of utility bills in the past year 17.2% had telephone service disconnected due to inability pay in the past year

139 Conclusions High rates of homelessness and housing instability among Bellevue ED patients High rates of other social health needs among Bellevue ED patients Addressing housing and social determinants of health key for improving health care for ED patients

140 BEYOND BELLEVUE

141 Hospital Screening for Homelessness Most hospitals do not routinely screen for patient homelessness Currently, identification of homelessness / housing insecurity relies on individual providers The result is underrecognition of homelessness in hospitals

142 VA Hospital Universal Screening Homeless Screening Clinical Reminder Two question screener à links to services initiated if screen positive. Universally conducted at mandated intervals in VHA clinics for all patients not already receiving homeless services

143 VA Screening Questions 1) In the past 2 months, have you been living in stable housing that you own, rent, or stay in as part of a household? 2) Are you worried or concerned that in the next 2 months you may NOT have stable housing that you own, rent, or stay in as part of a household? For more information see efforts led by Ann Elizabeth Montgomery

144 ICD-9 Code for Homelessness

145 Electronic Medical Records (EMRs)

146 Hospitals as Part of a Solution for Homelessness Screening for homelessness / risk Medical respite programs Connections with supportive housing Homelessness prevention New payment models will demand more hospital attention to homelessness and other social determinants of health

147 Acknowledgements Bellevue ED Project Healthcare Volunteers Project Healthcare Coordinators Ada Rubin Samantha Lang Nathan Kunzler Tod Mijanovich Paul Testa Lauren O Donnell

148 Discussion How can we use our successes to improve our collaboration? How can we get more housing for our high- cost, high need participants? How should we target MRT units? Henie Lustgarten, Consultant CMO, Monte=iore Medical Center

149 Bronx RHIO Overview

150 Membership & Data/Consent Providers: Acacia (Promesa) Albert Einstein College of Medicine of Yeshiva University All Med Medical & Rehabilitation Amida Care Anil Gupta, MD APICHA Argus Community, Inc. ASCNYC Bailey House Bronx Accountable Healthcare Network HH Bronx AIDS Services, Inc. (BOOM!Health) Bronx Community Health Network Bronx Gastroenterology OBS Bronx Lebanon Hospital Center Bronx Works Cardinal McCloskey Services Care for the Homeless CenterLight (Beth Abraham) Children of Zion Pediatrics Community Healthcare Network (CHN) Compassionate Care Hospice Essen Medical Associates, P.C. FEGS GMHC Harlem United Hebrew Home for the Aged at Riverdale Help/PSI Services Corp. Housing Works Institute for Family Health James J. Peters VA Medical Center Jewish Home Lifecare Kings Harbor Multicare Center Martin Luther King, Jr. Health Center Medalliance Medical Health Services Metropolitan Jewish Health System (MJHS) Montefiore Medical Center Morris Heights Health Center Muhammad Adam, MD New York City Department of Health New York GI Center Olive Osborne, MD Optimum Family Medicine Perry Avenue Family Medical PET/CT Diagnostic Medical Imaging Richmond Home Need Services Riverdale Family Practice Riverdale Mental Health Association Robert Morrow, M.D. Salud Medical, PC Salvation Army Sindhu Gupta, MD St. Barnabas Hospital Union Community Health Center University Diagnostic Medical Imaging Urban Health Plan Village Care VIP Community Services Visiting Nurse Service of New York Wakefield Pediatrics 1199SEIU

151 Clinics Nursing Homes Community Based Organiza7on s Health Plans Hospitals BxRHIO Data Quality & Management Databases for AnalyUcs and Portal Viewing Provider Portal REPORTING

152 Current RHIO Data Feeds Demographics Encounter Level Data Procedures Consent Laboratory Text Reports Inpatient Meds Outpatient Scripts Diagnoses Comments Acacia P P P P P Includes BCHN Sites Boom!Health (BAS) P P P P P Bronx Lebanon Hospital Center (w MLK) P P P P P P P P Send problem list Children of Zion Pediatrics P P FEGS - Case Management P P P P Anil Gupta, MD P P Sindhu Gupta, MD P P Hebrew Home - CHHA P P P P Hebrew Home - Home Care P P P P Hebrew Home - LHCSA P P P P Housing Works P P P Institute for Family Health P P P P P P Jewish Home Lifecare P P P P Medalliance P P P MJHS - Hospice P P P P MJHS - Palliative Care P P P P P Montefiore Medical Center P P P P P P P P Includes BCHN Sites Montefiore Behavioral Health (SVTN) P P P P P Morris Heights Health Center P P P P P New York Associates in Gastro P P NY GI Center P P P Optimum Family Medicine P P Olive Osborne, MD P P Perry Ave. Family Medicine P P Riverdale Family Practice P P Salud Medical P P SBH Health System P P P P P P Union Community Health Center P P P P P Urban Health Plan P P Visiting Nurse Service of NY P P P P P P P P FQHCs are highlighted in Yellow As of: September 24,

153 Interventions at BRIC Pilot Sites Site Intervention Bronx Lebanon/MLK FQHC Bronx Veterans Administration Hospital Montefiore & St. Barnabas ACO St. Barnabas Reports and customized queries on cohort of asthmatic patients with mental illness to identify risk factors for ED or hospitalizations Predictive Model to identify patient, at risk for admission, to facilitate targeted interventions (care management) Reports on VA geriatric/primary care patient utilization of IP and ED facilities other than VA; Care Transitions Coordinator uses reports for patient outreach and care transition program enrollment. Identification of ED visits for medication-related adverse events for patient and provider follow up and future prevention. Identification of patients on their rosters not getting follow-up care at their sites Provide weekly clinical (to identify gaps in care) and utilization data for care management Identification of patients for enrollment in Comprehensive Care Centers; data on care received from other facilities for enrolled patients; data about patients lost to follow-up after ED activity Morris Heights FQHC Diabetes focused project; details under development VNSNY BAHN Health Home Sites (various) 30 Day readmission reduction through customized reports of data not available to VNS through current sources and/or RHIO data from BRAD to improve workflow for staff with access to VHR Identification of demographic information to assist with enrollment; patient utilization information to assist care managers with patient management

154 Bronx RHIO and DSRIPs

155 Bronx RHIO Functions For PPS Projects FUNCTION Used For PPS Projects Status Virtual Health Record (VHR) Access X! Registration Alerts (Subscription Messaging) X! Registry Creation and Management X! Direct Secure Messaging X! Population Health Analysis X! Referral Routing X! Advanced Analytics X! 155

156 Bronx RHIO Functions For PPS Projects IN ACTIVE DEVELOPMENT Used For PPS Projects Status Claims Data Files X! State-wide HIE Network Service X! Web-Based Reporting X! Mobile Application for Patient Outreach Data Transfer from RHIO to other applications X! X! 156

157

158 Bronx Health & Housing Consortium Resource Guides HITE BenePits Plus Healthify The Beast

159

160 Search for Social Services Services LocaUon Keyword Languages Spoken

161 Save, e- mail, or print your results Filter by addi7onal services, age, or popula7on Preview lis7ngs and click to view more info

162 HITE listings also include hours, languages, fees/ insurance, eligibility All info is confirmed with agency staff and updated yearly For more info, please contact HITE Manager Francesca Padilla P: E:

163 Discover the rules and procedures that help clients access and maintain their benefits Gain pracucal knowledge to effecuvely access benefits and housing programs Find out what happens when clients return to work IdenUfy documentauon, where to go, and the steps clients need to take when applying Verify whether an agency s determinauon is correct Learn the procedures for appealing an agency s improper acuon And much more!

164

165 Healthify

166 We help address the social determinants of members to reduce costs and improve case management

167 Access Staff is given access to our resource platform on services to search, share, edit, and rate resources.

168 Screen Patients can take our web based screening tool in the waiting room or with a staff member. Our tool is dynamic and focuses on social needs.

169 Connect We automatically connect patients to the resources they need based on how they responded.

170 Engage We engage around needs and referrals with interactive texts

171 Manage Our platform visualizes patient data on social determinants and provides staff tools to address population needs and track referrals.

172 8x Potential Benefits Identify 8x as many members who are at risk Improve crucial quality metrics Increase case management + coordination capabilities LONG TERM Reduce costs by ~2% Lower readmissions Collect enhanced patient data

173 Contact Us

174 Bronx Health & Housing Consortium Training Opportunities Legal Aid Society Overview of Housing Court Proceedings Preventing Evictions Non- payment Proceedings Getting rent arrears assistance Holdover Proceedings Keeping your Section 8 Case healthy Getting apartment repairs NYCHA Tenants Rights Rights of Rent Stabilized Tenants Understanding subsidized housing Disability SSI/SSD Basic Public Assistance Family law/divorce Estate Planning/Wills, Healthcare proxies, Disposal of remains Consumer Debt

175 Bronx Health & Housing Consortium Other Work Areas Housing Marketplace Targeting MRT Housing HOPE Count in Hospital EDs 2010e Psychiatric Evaluations Coordinating the Coordinators Funding Sources Others?

176 Evaluation and Sign- up Sheet

177 Summary and Work Plan James Mutton Concern for Independent Living

178 Contact Us: Bonnie Mohan