Central New York Care Collaborative Primary Care Transformation Project Implementation Collaborative Kickoff Meeting Friday, February 26, 2016
Welcome and Introductions CNYCC Team Karen Joncas-Project Manager for Primary Care Transformation (and CVDM) PIC Moderator 703-2981 Karen.Joncas@cnycares.org Lauren Wetterhahn-Director of Program Operations PIC Facilitator Liz Fowler-Operations Coordinator Scribe
Learning Objectives
Learning Objectives Topics What is the Delivery System Reform Payment Program(DSRIP) What is the Central New York Care Collaborative (CNYCC) Project Implementation Collaborative (PIC)-Who, What, When DSRIP Primary Care Transformation Requirements Overview Patient-Centered Medical Home (PCMH) Readiness Assessment Overview Getting Started with PCMH Transformation A Word about Advanced Primary Care (APC) A Word about PCMH 2017 Redesign CNYCC Partner Support Resources Q & A and Next Steps
Introduction to DSRIP and the CNYCC
DSRIP - Delivery System Reform Incentive Payment Program Created in 2014 allowing NYS to re-invest federal savings generated by the Medicaid Redesign Team (MRT) Funding provided to support hospitals and other service provides to change how healthcare is provided to Medicaid beneficiaries Provides incentives to promote community-level collaborations through Performing Provider Systems (PPSs) $6.42 billion for payments to all state PPSs to meet DSRIP goals of system reform and cost reduction Goals of DSRIP Reduce avoidable hospital readmissions and emergency department use by 25% over the next 5 years Preserve and transform the State s fragile health care safety net system
performance CNYCC Central New York Care Collaborative Mission: Working together for better health Vision: To improve the health of our community by coordinating services and building partnerships throughout the healthcare system Guiding Principles: Better Integrate Services Collaborate on Patient Care Improve Healthcare Quality Lower Cost of Healthcare
CNYCC: At a Glance 6 COUNTIES Cayuga, Lewis, Madison, Oneida, Onondaga, and Oswego 170 Partner Organizations 9,700 SQUARE MILES Nearly 200,000 MEDICAID SUBSCRIBERS New Corporation PPS Lead Agency 1,400 HEALTHCARE AND COMMUNITY- BASED SERVICE PROVIDERS
CNYCC Governance Corporate Members (4 Co-Leads) Board of Directors (22 Members) Executive Project Advisory Committee (EPAC) RPAC Cayuga County RPAC Lewis County Board Committees Executive Committee Finance Committee RPAC Madison County RPAC Oneida County Clinical Governance Committee Nominating Committee RPAC Onondaga County Compliance Committee IT/Data Governance Committee RPAC Oswego County
Partner Engagement Structures Inform
Project Implementation Collaborative (PIC) Overview
Project Implementation Collaborative (PIC) Purpose The PIC will develop, update, and guide the CNYCC s project implementation plans over time with an eye toward meeting state project requirements, implementation of best practice, and broad system transformation
Project Implementation Collaborative (PIC) Who-Roles and Responsibilities All partner organizations who have signed up to participate in projects are encouraged to actively participate (Remember: Our joint success is based on individual partners meeting goal). Participants will have a voice in the full PIC meetings and may volunteer to participate in smaller, targeted cohorts or work groups that meet more often and report back to full PIC CNYCC Project Manager is the PIC facilitator ensuring that information flows between smaller groups and full PIC and monitors partner project plans against goals
Project Implementation Collaborative (PIC) What Primary Care Transformation is integral to the Integrated Delivery System project Primary Care Transformation PIC purpose is to assist all eligible partners in achieving NCQA PCMH 2014 Recognition Assist in identifying and sharing best practices Support project monitoring and quality improvement processes Promote/Celebrate project success and the system transformation
Project Implementation Collaborative (PIC) When Primary Care Transformation PIC will begin monthly meetings by Webinar Primary Care Transformation PIC will periodically meet jointly with the Health Information Technology PIC to discuss common goals
Primary Care Transformation PIC Partner Member Role Actively Participate in the Meetings Share expertise (best practices) with other Members Share concerns or risks in meeting project goals Achieve success in meeting project goals and deadlines Project Manager Role PIC moderator ensuring that information flows between all partner members Educate Partners in project requirements Mitigate project risks Monitor Partner Plans to ensure meeting NYS Project Implementation Plan Deadlines
Primary Care Transformation PIC Purpose Work together to ensure the success of the collaborative integrated delivery system and all eligible partners achieve transformation validated by NCQA PCMH 2014 Recognition What Collaborative venue for sharing best practices across the partner network Communication link for updates/issues to partner organizations Who Partner organization s Project Leadership, Clinical Leadership, HIT Leadership, Quality Leadership, Administrative Leadership Partner organization s DSRIP Coordinator
Relationship Between PICs HIT PIC Exploration, Vetting and Development Of Technical Solutions Clinical & Operational Requirements Development Project & Primary Care Transformation PICs
PCMH and DSRIP
PCMH and DSRIP PCMH required across multiple DSRIP projects including: Integrated Delivery System (2ai) DSRIP Care Management (2aiii) ED Care Triage (2biii) Primary Care/Behavioral Health Integration (3ai) Cardiovascular Disease Management (3bi) Palliative Care PCMH Integration (3gi) Implement strategies for contracted projects into your PCMH plan.
Introduction to PCMH
What is PCMH? Patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. The evidence indicates how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.
Readiness Assessment & Planning Process Overview
PPS PCMH and MU Readiness Assessment Goals Identified current state including PCMH recognition, MU attestation, readiness to transform practice to PCMH Final Reports On-site or telephone assessments of each practice Summary of PPS Partner recognition status and EMR platform Cohort strategy for small workgroups and learning collaborative sessions
PPS PCMH Readiness Assessment
Planning for Transformation
Educate
Educate Practice Eligibility Practice provides coordinated, team-based whole-person care at outpatient primary care sites https://www.youtube.com/embed/zc4yclg4h5k Personal clinician (MD, DO, APRN, PA) with their own patient panel and provides first contact, continuous, comprehensive care for at least 75% of its patients Does not include urgent care clinics or those offering seasonal care Provides scheduled routine and urgent care appointments http://www.ncqa.org/programs/recognition/practices/patientcenteredmed icalhomepcmh/beforelearnitpcmh/pcmheligibility.aspx
Educate Determine Type of Submission Single Site(s) submission Confirm Eligibility for submitting a multi site application Three or more eligible sites Use same EMR system Operate under the same policies and procedures Telephone Consultation with NCQA Project Leader for mulit-site application http://www.ncqa.org/programs/recognition/recognitionprogramsmultisite Process.aspx
Educate NCQA PCMH 2014 Standards Obtain a copy of PCMH 2014 Recognition Standards and Guidelines (www.ncqa.org) NCQA offers recorded trainings http://www.ncqa.org/programs/recognition/relevanttoallrecognition/recognitiontraining/recordedtrainings.aspx Community Health Care Association of NYS (CHCANYS) PCMH resources http://www.chcanys.org/index.php?src=gendocs&ref=2013%20presentation%20hcnn-qi%20forum&category=nys_hccn Patient Centered Primary Care Collaborative (http://www.pcdcny.org/) Download the PCMH 2014 Self- Assessment tool http://www.pcdc.org/performance-improvement/special-content/pcmh-2014-self-assessment.html
Already PCMH 2011 Recognized? Conversion vs Renewal
Educate Conversion to PCMH 2014 Documentation required for six standards Must complete the full survey tool All positive survey responses subject to audit Submission of Record Review not Required-Sample care plan only Does not extend recognition expiration date Must have achieved PCMH 2011 Level 3 Option if 2 years of quality data is not available
Educate Renewal to PCMH 2014 Documentation required for eleven standards Must complete the full survey tool All positive survey responses subject to audit Extends recognition expiration date for three years Must have achieved PCMH 2011 Level 2 or 3
Plan
Project Planning Payment Policy Planning Develop and Submit a Project Charter including Names and Contact Information and Defined roles of Project Team Members Complete Project Plan Documentation Template (Under Development) Complete and Submit Planning Questions in Appendix B/Payment Mechanism 3 Complete Provided Excel Template with Provider Information
Components of a Project Charter
Project Charter Suggested Components Determine the Project Mission and Objectives Determine the Project Deliverables and Timeline Develop a Project Team Determine a communication plan and decision making process Determine Frequency and Location of Project Meetings Determine if outside resources will be used Determine where project documentation will be kept
Establish a Project Team
PCMH Project Team Suggested Team Members Physician Champion Project Leader Clinical Leader Administrative Leader Quality Leader HIT Leader Scribe Some team members could take on multiple roles or share roles with multiple staff. Team Members should always strive for sustainable change with the goal to improve care for all patients.
Project Team Roles
Project Team Members Physician Champion Should have passion for and be able to define organizational values and facilitate culture change to patient-centered team based care. Develop the strategic vision and drive the necessary investment in infrastructure change in people, process and technology. Manage resistance and set a positive tone for the project Embrace performance measurement and partner with project team to communicate quality initiatives and evidence best practices to providers and staff
Project Team Members Project Leader Responsible for the facilitation of the project plan development and project management. Communicates status throughout the team and organization. Ensures the project team and staff completes all aspects of transformation and submission Makes sure that success is continually celebrated with the team and all staff. Communicates with CNYCC Project Manager regarding status of the project and any risks or issues to meeting project goals.
Project Team Members Clinical Leader Responsible for managing and overseeing all clinical functions within the practice including: clinical advice, team based care, population health management, evidence-based decision support, care management and support, medication management. This role is typically held by a physician or mid-level provider. The functions may be assisted by a Clinical Nurse Manager.
Project Team Members Administrative Leader Responsible for supervising and directing all administrative functions within the practice including policy and workflow updates for PCMH topics such as patient access and scheduling, patient orientation and transitions, collecting demographic information, communicating medical home responsibilities, language services and care coordination. A practice manager or administrative director is ideal for this role
Project Team Members Quality Team Leader Leads the practice or organization s Quality Improvement(QI) Team. Works with the QI team to assign roles and responsibilities for quality improvement for all functions in the practice and all QI committee roles Works with the practice/organization to identify performance measures and quality improvement initiatives
Project Team Members HIT Leader Responsible for all Health Information Technology requirements including assessment of capability of systems to meet PCMH (including Meaningful Use) requirements, building of required EMR templates to facilitate the delivery of consistent evidence based medicine; building and running reports (and/or training others). Interfaces with EMR Vendor as required. Interfaces with CNYCC on interoperability capabilites
Project Team Members Scribe Responsible for taking notes at all scheduled and ad-hoc planning meetings. The organization can decide how these will be distributed or stored for easy access by all team members.
Implement
Implementation Early Steps Begin with the steps (standards) that will have multiple impact on culture and where focus will enhance sustainability These should be implemented with buy-in from staff and with the support of practice/organizational leadership Prepare PCMH self-assessment to identify opportunities Develop Care Team Strategy Develop communication strategy to include all team members in PCMH transformation and all quality initiatives Develop Quality Improvement Strategy NCQA Focus: Standard 2D and 6
Implementation Early Steps Assess where new policies, documented processes will be needed Assess PCMH standard alignment with planning strategies Training Strategy Health Information Technology Strategy Prepare Baseline Reporting for QI and Gaps in Care (when available) NCQA Focus: Multiple standards, Standards 2D, 6 and 3D
Implementation Early Steps Determine Patient Engagement Strategy Patient experience measurement Patient Advisory Council; Patients on QI team Care management strategy and workflows Shared decision making aids Self-management support Home monitoring for chronic conditions NCQA Focus: Multiple standards, Standard 2D, 4B, 4E, 6C
Implementation Patient Access Develop understanding of patient access supply and demand Provider patient panels Demand vs. Supply of Same Day Access Appointments Develop minimum standards for wait times for appointments Determine how supply and demand of appointments will be monitored Consider alternative visits Determine baseline no-show rates and review policies to mitigate this affect on patient access NCQA Focus: Standard 1
Implementation Integrated and Coordinated Care Develop/update/tighten strategies for care coordination and care transitions Tracking and follow-up on all tests and referrals Manage all care transitions (hospitals, palliative care, referrals, new patients) Behavioral Health Strategy Co-management agreements with specialty care providers Build relationships with community based organizations Engage in the RHIO NCQA Focus: Standards 5 and 2A
Implementation Communication Plan Develop strategy to communicate the roles and responsibilities of a medical home Develop strategy to Communicate Performance Results externally Develop strategy to effectively communicate to patients with consideration to cultural competency and health literacy. Develop strategy for patient education and self-management support Internal communication plans- team huddles, practice process, quality performance results NCQA Focus: Standards: Multiple including 1B, 1C, 2, 4B, 4E,6F
Implementation Evidence-Based Medicine Develop patient safety strategies including: Consistent evidence-based medicine Implement Clinical Decision Support tools Care Coordination NCQA Focus: Standards 3E, 5
Implementation Documentation Gaps Complete Mock Audit-Chart Review using NCQA Record Review Workbook to identify documentation gaps Complete health assessments Medication Care plan Revise workflows as needed NCQA Focus: Standards 3C, 4B, 4C
Implementation Execute Policy, Documented Process, Workflow and Procedure Evidence-based Medicine Clinical Decision Support Quality Initiative Action Plan Population Health Management- Gaps in Care Patient Engagement Plan Internal and External Communication Plans Integrated and Coordinated Care Training Strategies NCQA Focus: Standards: Multiple and 1, 2B, 2D,3D,3E,5, 6
Implementation Execute Care Management Strategy Patient Identification Workflows Care Team Members-Internal Resources vs. External Resources Care Plan Templates Motivational Interviewing Self-Management Support Care Coordination Community Based Resources NCQA Focus: Standards 4B and 5
Implementation Execution of NCQA Application and Survey Final Report Run Complete final Record Review Complete Quality Improvement Worksheet Complete NCQA On-line Application (and fees) Prepare Final Survey tool Final Quality Check of all Documents to be Submitted Upload Documents to NCQA Document Library Submit NCQA ISS Tool and Document Library CELEBRATE
Sustain A Word on Sustaining the Transformation Build process audits into policies Maintain accountability to patients Maintain quality improvement team with continued measurement CONTINUE to CELEBRATE SUCCESS
PCMH Suggested Timeline
Timeline Considerations Current PCMH Recognition Status and Expiration Date EMR Implementation or Upgrade Readiness Multi-site vs. Single Site submissions Organization Mission and Objectives Transformation Process could take 1 year or more PPS to have Staggered Timelines No NCQA submissions in PPS after October 1, 2017
Assessment and Planning Process Timeline Educate, Assess, Plan Care Team Strategy Behavioral Health Strategy and implementation Quality Improvement Strategy Communication Plan-Internal and External HIT Cohort Assistance/Baseline Reporting Training Strategy and Implementation Patient Engagement Strategy Determine and communicate QI plan Execute population health and other QI action plans Patient Access Strategy and Implementation Execute Internal and External Communications Update and Implement Policies and Procedures and workflows Care Coordination and Transitions Monitoring Execute Care Management Strategy Finalize Documentation for Submission Complete On-Line NCQA application Final Document Audit and Sign off Load documents to Document Library and Submit NCQA Survey Tool 31-Mar-16 30-May-16 31-Jul-16 30-Sep-16 30-Nov-16 31-Jan-17 31-Mar-17 31-May-17 31-May-17 31-Jul-17 30-Sep-17 This graphic display is a sample project plan meant to show how educate, assess, plan and implement are often not linear. Also, in order for transformation to be sustainable, transformation and quality improvement continue.
NYS Advance Primary Care Model
Advanced Primary Care Model New York State Innovation Model: Comprehensive, patient-centered care Coordinated care between primary care and other clinical care and community-based services Greater usage of HIT including EHR, Population Health and data analytics Financial support for primary care practices for transformation A shift from encounter based payment to alternative payments supporting services and infrastructure Multi-payer participation and alignment
Advanced Primary Care Model New York State Innovation Model: Meaningful Performance Measures consistent with existing standards and measures (NCQA, CPCI, etc.)-measured on improvement in Core Measures Requires ability to identify high-risk patients and have plan for care coordination Drive change over time instead of one-time certification Be tied to outcomes and facilitated by innovative payment systems State goal is for 80% of care to be paid under a value-based financial arrangement within 5 years Timeline fluid Preliminary Launch scheduled January 2017
Advanced Primary Care Model PCMH or APC? State Project Implementation Plan requires one or the other Recommendation is for PPS practices to pursue PCMH State APC Model has delayed launch date Those with PCMH Recognition with demonstrated transformation will be eligible for earlier access to care coordination payments and/or outcome based payments Measure metrics to be aligned with PCMH and other quality initiatives Existing Medicaid PMPM payments Additional information forthcoming
NCQA PCMH 2017 Re-design
NCQA PCMH 2017 NCQA PCMH Redesign Role out Spring 2017. PCMH 2014 Retires December 2017. Earlier for corporate application. No survey tool purchases after June 2017. Overarching objective is to enhance the value of the recognition for all stakeholders Reduce the burden of non-value added work More focus on outcomes instead of structure and process More support for transforming practices
NCQA PCMH 2017 NCQA PCMH Redesign Two pathways Those with first time recognition will complete an assessment to determine readiness. If more work is needed practice would be directed to additional educational materials. Second pathway-engagement phase-match practice with a facilitator and reviewer, identify education needed, facilitate check-ins with a reviewer where practice would know where they stand during process. Engaging practices in a streamlined annual check-in rather than three year documentation burden Watch for more information on NCQA blog
CNYCC Partner Support Resources Learning Collaborative Sessions
CNYCC Learning Collaborative Sessions
CNYCC Learning Collaborative Sessions
CNYCC Partner Support Resources Health Information Technology Support
Readiness Assessment-Health Information Technology Goals Identify current state of health information technology availability and capability including: Access to RHIO and usage of Direct Messaging EMR certification for Stage 2 Meaningful Use Provide Clinical Decision Support to facilitate evidence based care Access to reporting required for PCMH and other quality performance measurements Format Series of surveys indicating technology capability of each organization Summary of PPS Partner status
Integrated Delivery Network-HIT Support Goals Vendor Engagement to Implement/Optimize EMR Platforms EMR Vendor Selection Toolkit Create clinically integrated networks Build the technical infrastructure including a shared platform to enable care coordination and population health management Develop Project/Reporting Specific HIT requirements Technical Assistance Technical Cohort Development
CNYCC Partner Support Resources Funds Flow
CNYCC Integrated Delivery System Funds Flow Project Activity Description Eligible Partners DY1 Payments 2.a.i Category 1. Regional Health Information Organization (RHIO) Payment 1: Payment for signing a participation agreement and implementing a consent management policy/procedure All Partners Total: $870,349 Per Partner: $2,500 Assumption: 350 responding partner sites 2.a.i Category 2. Electronic Medical Records (EMR) Payment 1: Current State Assessment (Documented plan for upgrading to, or implementing new MU Certified EMR that meets DSRIP requirements; documented plan for making required system changes to meet DSRIP requirements) MU eligible; BH Providers; SNFs; Non- PCPs Total: $1,450,582 Per EMR: $10,000 Assumption: 145 completed assessments 2.a.i Category 3. Patient-Centered Medical Home Payment 1: Per practice site payment for PMCH 2014 Level 3 recognition plan PCPs Total: $1,740,699 Per PCP Site: $10,000 Assumption: 145 responding PCP sites
Questions & Answers
CNYCC Primary Care Transformation PIC: Feedback Do you feel you have a good understanding of the goals of Primary Care Transformation? What type of support would be most useful to you? What topics would you like to see brought to this PIC or learning collaborative sessions? What success stories do you have to share? How have you celebrated success with your staff?
Next Steps & Wrap Up
Next Steps & Wrap Up Next Steps Complete Project Planning Templates Assist CNYCC IT Team in identification of needed IT reports and other technology upgrades to meet NCQA PCMH 2014 Site visits with Project Leaders to review planning process, assess needed support Learning collaborative sessions plan
Next Steps & Wrap Up Next Meeting PIC meeting 3/25/16, 10:00 AM 12:00 PM Joint meeting with HIT PIC with DSRIP IT leads and other PCMH Project Team Leaders and DSRIP Coordinators