MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE

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1 MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE Presented by: Linda Efferen, MD, MBA Medical Director Suffolk Care Collaborative 19

2 THE MAX SERIES SUPPORTS AN INTERDISCIPLINARY CARE TEAM AT A SPECIFIC LOCATION TO IMPROVE PATIENT CARE H The MAX Series Program focuses on local process improvement for a specific patient population to impact overall DSRIP measures and improve patient health. The DSRIP program focuses on statewide system reform to improve population health. DSRIP GOAL Reduce avoidable hospital admissions and ED use by 25% over the next 5 years Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

3 Composition of the MAX Action Team The MAX Series Program impacts change at the local hospital/provider level. The Action Team is an interdisciplinary front-line team comprised of 8 10 individuals that are directly involved in meeting the target population s diverse medical, behavioral and social needs. Other Care Coordination Programs Community Paramedics Community Health Urgent Care / ED Clinics H Homeless Shelters Mental Health Centers Primary Care Clinics Sample List of Action Team Members Patient or Family Member* ED Physician Primary Care Physician Nurses Care Managers Social Worker Behavioral Health Counsellor / Psychiatry Liaison Manager Other representatives that can be key to providing care for this patient population *Required Source: Emergency Department Super Utilizer Programs, Rural Health Value Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

4 MAX Series Program Topics Topic 1 Topic 2 Topic 3 Super Utilizers: Meeting Complex Patient Needs Integrating Behavioral Health And Primary Care Services Super Utilizers: Meeting Complex Patient Needs Reduce avoidable hospital use by 25% over 5 years (better care, better health, lower costs) Care system redesign to better meet complex and high-cost patient needs October 2015 (pilot limited availability!) Ensure care coordination to improve outcomes for patients with Behavioral Health diagnoses Care system redesign to better meet complex and high-cost patient needs February 2016 March 2016 Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

FOR EACH TOPIC, THE MAX SERIES PROGRAM IS DELIVERED IN THREE PHASES Phase 1: Assessment and Preparation Phase 2: Clinics and Improvement Cycles Phase 3: Reporting Assessment Call with PPS: Discuss

MAX Workshop 3 MAX Series Medicaid Accelerated exchange PPS Baseline Assessment Process (including: surveys, site visit, etc.

5 FOR EACH TOPIC, THE MAX SERIES PROGRAM IS DELIVERED IN THREE PHASES Phase 1: Assessment and Preparation Phase 2: Clinics and Improvement Cycles Phase 3: Reporting Assessment Call with PPS: Discuss questions about the program and confirm interest in topics Enrollment Call with PPS: MAX Team calls with Executive Sponsor, PPS Leads and Champions to confirm enrollment MAX Workshop 1 MAX Workshop 2 MAX Workshop 3 MAX Series Medicaid Accelerated exchange PPS Baseline Assessment Process (including: surveys, site visit, etc.) Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Action Period support: Weekly 30 min telephone status update (between Coach and Team Lead) On-site visit mid-pdsa cycle (during 1 st or 2 nd PDSA cycle) Emergency/Troubleshooting on-site visit by Coach (based on PPS need) Teleconference attendance during presentation of results after each PDSA cycle

6 A JOURNEY TO REDUCE PREVENTABLE COPD ED VISITS Presented by: Julie Vinod, DNP, MS, ANP-C, RN Assistant Director of Nursing Operations Brookhaven Memorial Hospital Medical Center 24

7 A Journey to Reduce Preventable COPD ED visits Presented by: Julie Vinod DNP, MS, ANP-C,RN Date: June 17, 2016

8 MAX Series Team Sponsors: Keisha Wisdom, V.P.CNO and Dr. Zeyneloglu, CQMO Administrative Lead: Karen Shaughness, LCSW Dr. Julie Vinod DNP, MS, ANP C, RN Stanley John MHA, BS, RT, RRT-NPS Tameka Squire BSN Samuel Beckles RN Elfriede Weiss-Paquette LCSW Dr. S. DeAngelis Brianne Rizzo Monica Schlie Jessica Philius Bernadette Peters Jody Felice, RN Steven Sanderson Asst. Director of Nursing (Team Lead) Director Respiratory Care & Support Services Clinical Instructor Nurse Manager, COPD Unit Coordinator Collaborative Care, PCMH Medical Director of ED Director, Care Management Social Worker in the ED Care Manager, COPD Unit Care Manager POE RN Home Care Nurse Decision Support Analyst

9 Problem Statement: Does the implementation of COPD bundle reduce the ED visits by 10% among patients with primary and secondary diagnosis of COPD for a period of one year?

10 Objective To reduce the number of COPD Super Utilizer ED visits by 10% in one year

11 Sample Individuals with primary and secondary diagnosis of COPD who had 3 ED visits and/or >1 readmissions from Jan 2015 to Sept 2015

12 Sample Size Total number of COPD ED visits/patients from Jan 2015 to Sept COPD ED visits (62 patients) 71 COPD readmissions( 27 patients)

13 Our Accomplished Action Plans Created COPD Super Utilizer List Created a Flagging System Created 62 patient profiles Opened a COPD Unit Created a secured shared drive to document and communicate within the action team

14 Our Accomplished Action Plans Educated the frontline staff Created a multidisciplinary COPD Plan of Care Created a workflow for COPD patients Created a care coordinated note template

15 Our Accomplished Action Plans Created a Home Assessment tool Created a Graduation Protocol Created Health Home enrollment spread sheet Established a Brookhaven Better Breathers Club

16 Flagging System Body Copy here:

17 Patient Profile

18 Stake Holders Executive Team/Leadership Team Nursing Physician Primary Care Provider Respiratory

19 Stake Holders Care Management Education Department IT Pharmacy Coordinator Collaborative Care Home Care and Health Homes

20 Team Strategy Body Copy here Brookhaven Team Meeting Every Wednesday from 230pm to 4pm Team Lead Meeting Every Friday from 10am to 1030 am Contact via as needed (Max Series Group) Contact with Expert on MIX IT website

21 COPD Journey Priority Reasons for ED utilization Medications Pain Comfort/ Security Substance Abuse/ Mental Illness Social Needs

22 Common Attributes Majority lived alone Over 80% have concurrent Behavioral Health diagnosis All met criteria for Health Home Some for Home Care

23 Improved Process Changed the ED and Inpatient Unit culture of treating super utilizers via education of staff, EMR flagging of cohorts; sharing of patient success stories with staff Created in depth Assessment process in ED and referral to HH and PCP immediately Utilized motivational interviewing techniques

24 Improved Process Began true Care coordination with external agencies, such as OP providers, Health Homes, Home Care, residential providers, Inpatient and ED staff Conducted Case Conferences on patient to change their pattern of behavior Care, residential providers, Inpatient and ED staff

25 Key Elements of Success Diverse and Integrated Team who commits several hours a week to project Strong administrative support and Team lead Desire to embrace change Accurate Data Timely Communication Collaboration with community agencies

26 Our Dashboard Metrics Target Base line Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May Percentage of Super Utilizer Cohort with a completed patient profile 100% 0% 0% 22% 69% 85% 85% 85% 85% 2. TBD: Patient Engagement (e.g. Correct Responses to Ask-Teach Moments) 100% n/a 0% 16% 40% 54% 70% 75% 83% 3. Percentage of Super Utilizer Cohort enrolled in Health Home n/a n/a n/a n/a n/a 21% 70% 70% 73% 4. Number of admissions among Super Utilizer Cohort per month Number of ED Visits by defined Super Utilizer Cohort per month

27 Our Dashboard Baseline Nov Dec Jan Feb March April May

28 Our Impact Total Cohort (61patients) Before After Result (%) ED VISITS 65.1/month 36.3/month -44% ED IP ADMISSIONS ED READMISSIONS 15.5/month 8.5/month -45% 5.3/month 3.75/month -29%

29 Our Impact Before After

30 Health Home Data 75% of patients are enrolled in a Health Home Engaged Health Home to educate care managers of their benefit and application process

31 Case Study DD is a 57 year old female with multiple chronic conditions, including depression. She has, 14 hospital visits in a 6 month period including, 5 admissions and 3 readmissions. As the first patient of the program, DD received a needs assessment which uncovered a need for frequent education and support for follow-up appointments.

32 Case Study contd. She is now receiving care coordination services, which have helped connect her to primary care, Medicaid transportation, and alternatives to the ED Ms. DD has been engaged to a Adult Day Care center DD has not returned to the ED since DD graduated in MAY

33 Future Steps Continue to identify new super utilizers Maintain Integrated care approach to assessment and treatment Replication of project with new cohort of patients who have AMI and CHF

34 THANK YOU QUESTIONS???

Program Overview. Medicaid Accelerated exchange Series and Medicaid Accelerated exchange New York (MAXny) Series. June 12, 2018

Program Overview. Medicaid Accelerated exchange Series and Medicaid Accelerated exchange New York (MAXny) Series. June 12, 2018 Medicaid Accelerated exchange Series and Medicaid Accelerated exchange New York (MAXny) Series Program Overview June 12, 2018 2017 New York State, Department Of Health, Office of Health Insurance Programs.