OPCHSM Update CHCANYS Statewide Conference 2015 Daniel Sheppard, Deputy Commissioner, OPCHSM Lisa Ullman, Director, Center for Health Care Policy and Resource Development, OPCHSM Jennifer Treacy, Director, Center for Health Care Provider Services and Oversight, OPCHSM November 2, 2015
November 2, 2015 2 Agenda I. Overview of Office of Primary Care and Health Systems Management II. Certificate of Need Overview and Program Updates III. DSRIP Regulatory Waivers IV. Integration Models and Approaches V. Capital Restructuring Financing Program (CRFP) VI. Questions and Discussion
November 2, 2015 3 I. OPCHSM: Functional Overview
November 2, 2015 4 OPCHSM: Overview The Office of Primary Care and Health Systems Management (OPCHSM) oversees, regulates, and supports New York State s health care providers and licensed facilities to ensure access to safe, high quality, affordable, and equitable health care services.
November 2, 2015 5 OPCHSM: Overview 217 Hospitals 709 Clinics (excluding extension clinics) 631 Nursing homes 571 Intermediate Care Facilities 1,067 EMS (ambulance) Agencies 527 Adult Care Facilities 1,403 Home Care Agencies (138 CHHA S & 1,265 LHCSA s) 1,838 Funeral firms & 3,857 funeral directors 90,000+ Physicians and Physician s Assistants
November 2, 2015 6 OPCHSM: OVERVIEW Regulatory Reform Facilities in Financial Distress Policy Analysis and System Planning DSRIP Waivers ACO/COPA LIFE SAFETY Facility Surveillance CON/Licensure OPMC BNE Facility Emergency Preparedness Workforce Dev. and other Grant Programs Councils and Advisory Groups Medical Marijuana Capital Programs
November 2, 2015 7 II. Certificate of Need Program
November 2, 2015 8 CON Program Overview Authorizes the establishment and construction of: Hospitals Nursing Homes Clinics Home Health Agencies High Technology Specialty Services Hospice Reviews proposed facilities and services for: Public Need Financial Feasibility Character and Competence of Owners and Operators
November 2, 2015 9 Major elements of a CON review include: Public Need Population demographics Use of existing services Epidemiology of selected diseases and conditions Access Financial Feasibility Projected revenues Current financial status Capacity to retire debt CON Program Overview Character and Competence Experience and past performance of proposed owners/operators substantially consistent high level of care Record of violations, if any
November 2, 2015 10 CON Process Improvement NYSE-CON Implemented in December 2010; has streamlined the CON process, improved communications with applicants, and improved transparency From 2011 to 2014 median CON review times have gone down by more than 60%
November 2, 2015 11 CON Process Improvement Pre-Opening Surveys Voice of the Customer: Takes too long to open facility/service Takes too long to receive operating certificate No transparency of the process Difficult to visualize and track entire workload Passive problem identification Difficult for managers to manage workload Staff and customers frustrated by the process
November 2, 2015 12 CON Process Improvement Pre-Opening Surveys Kaizen #1 Nov 2013 Kaizen #2 Dec 2013 Kaizen #3 Jan 2014 MARO Policy Changes Feb 2014 Statewide Roll Out May 2014
November 2, 2015 13 CON Process Improvement Pre-Opening Surveys Key Performance Indicators (KPI) KPI Pre-LEAN Post-LEAN Target Survey Confirmation to Opening Approval Confirmation to Operating Certificate Number of Survey Findings 60 days 24 days 21 days 137 days 44 days 32 days 7.3 3.4 6.1
November 2, 2015 14 CON Process Improvement New NYSE-CON Module Spring 2015 improvements to NYSE-CON include Regional Office Module Identify target opening dates Propose and schedule pre-opening surveys Submit and review pre-opening documentation Correspond within NYSE-CON regarding specific project issues The next phase under development will enable Department staff to post inspection findings and applicants will be able to respond with corrective action plans
November 2, 2015 15 CON Process Improvement 2015 CON Streamlining Workgroup Under Consideration Architectural/Engineering Self-Certification Decrease Department oversight; increase provider accountability/responsibility Eliminate 30 percent drawing requirement Increase project limit for self-certification from $15M to $30M 10% of projects receive post-audits Scheduled periodic Department lead education sessions of best practices and areas of concern Conditions and Contingencies Overall Project Thresholds
November 2, 2015 16 CON Process Improvement Homeless Shelter Clinic Waivers Providers delivering care to the homeless in transitional housing facilities are seeking relief from certain architectural requirements that are required as part of the CON process Clinics in homeless shelters are typically assigned space in predesignated, underutilized rooms in the shelter. Space is often rented, so difficult for clinic operators to make the necessary structural changes to the building to comply with certain requirements Shelters are ideal settings to increase access to primary and ambulatory care in order to reduce unnecessary hospitalizations DOH formed internal working group consisting of CON, architectural review, and surveillance staff from OPCHSM, as well as OPH staff who are experts in infection control in healthcare facilities Current federal and state statutory/regulatory requirements present some challenges, but certain broad categories of waivers can be granted
November 2, 2015 17 CON Process Improvement Homeless Shelter Clinic Waivers Existing Standard Exam Rooms 80 sq. ft. minimum ADA accessibility achieved in all cases Separate clean and soiled utility rooms Patient toilets separate from public use toilets and located in the patient care areas and, separate staff toilets and lounge requirements Waiver Relief No less than 72 sq. ft. Require reasonable accommodations for all patients and staff. Persons with disabilities that exceed reasonable accommodations must immediately be assigned to a facility that meets their needs Alternatives such as locked cabinet or storage containers in patients' rooms for clean supplies and soiled supplies kept in locked container outside of patients' rooms under direct supervision such as a closet or alcove Residents and staff using toilets in the transitional housing facility areas
November 2, 2015 18 CON Process Improvement Homeless Shelter Clinic Waivers Recommendations, once finalized, will be rolled out as Homeless Clinic Guidelines In the short-term, similar review for Rural and Mobile clinics Longer-term work to address regulatory issues that could provide further flexibility without jeopardizing patient safety
November 2, 2015 19 III. DSRIP Regulatory Waivers
November 2, 2015 20 DSRIP Regulatory Waivers Background PHL 2807(20)(e) and (21)(e) authorizes DOH, OMH, OASAS and OPWDD to waive certain regulatory requirements for DSRIP projects and capital projects that are associated with DSRIP projects. The agencies are authorized to grant such waivers as necessary, consistent with applicable law, to allow applicants to avoid duplication of requirements and to allow the efficient implementation of the proposed projects. Recent Developments First round of requests for regulatory waivers submitted December 2014. Response letters were sent to PPSs in March 2015 and publicly posted on DSRIP web site. 536 requests were received for regulatory waivers from 24 PPSs.
November 2, 2015 21 Next Steps DSRIP Regulatory Waivers Round #2-264 waiver requests submitted by 10 PPSs. DOH will lead coordinated review with OMH, OASAS and OPWDD. Responses will be provided by November 1, 2015 and posted on DSRIP website. Provide determinations on pending Round #1 responses (CHHA expansion). Waiver tracking by provider - DOH developing tool for PPS to submit list of providers linked to each approved waiver. Waiver tracker tool will be provided to survey staff to ensure facility is not cited for regulatory violations for which they have received a waiver. Letters will be sent to each provider that was issued a waiver.
November 2, 2015 22 Ownership/Management DSRIP Regulatory Waivers Policy Area Regulation Determination Revenue Sharing within PPS 10 NYCRR 600.9(c Approved Administrative Function of the PPS 10 NYCRR 405.1 Management Contracts 10 NYCRR 600.9(d) and 10 NYCRR 405.3(f) Corporate Practice of Medicine 10 NYCRR 1003.14(f) Denied No waiver needed No waiver needed if performing administrative functions for purposes of administering PPS activities
November 2, 2015 23 Operating Standards DSRIP Regulatory Waivers Policy Area Regulation Determination Credentialing 10 NYCRR 405.2(e)(3) and 10 NYCRR 405.4(c)(5) Approved Nursing Home PRI 10 NYCRR 400.11(a) Approved with contingencies Admission, Transfer and Discharge within PPS 10 NYCRR 405.9(f)(7) No waiver needed Consent Forms - No waiver needed Off Site Services 10 NYCRR 401.2(b Approved Transfer Agreements 10 NYCRR 400.9 No waiver needed Order for Home Care by Physician Assistant 10 NYCRR 766.4(a) Pending Observation Beds 10 NYCRR 405.19(g)(2) Denied Facility Closure 10 NYCRR 401.3(g) Denied Observation Bed Construction 10 NYCRR 405.19(g)(2)(iii) Denied Integrated Services 14 NYCRR 599.4(r) and (ab) Approved with contingencies Reimbursement of Integrated Services 10 NYCRR 86-4.9(b) Approved with contingencies
November 2, 2015 24 Certificate of Need DSRIP Regulatory Waivers Policy Area Regulation Determination Public Need and Financial Feasibility Methodology 10 NYCRR 670.1, 709 and 710.2 Approved Bed Capacity Need Protocol Change 10 NYCRR 401.3(e) Approved Review of Health IT changes in existing facilities 10 NYCRR 710.1(b) Approved Construction Policy Area Regulation Determination Construction Standards - Notifications 10 NYCRR 710.7(d) Approvable on a case by case basis Construction Standards 10 NYCRR 401.3 and Parts 711-715 Denied Pre- Opening Survey 10 NYCRR 710.9 Denied
November 2, 2015 25 IV. Integration Models and Approaches
November 2, 2015 26 Integration Models and Approaches Licensure Thresholds Integrated Outpatient Services Regulations DSRIP Project 3.a.i. Licensure Threshold Co-Location/Shared Space
November 2, 2015 27 Licensure Thresholds A MHL Article 31 or MHL Article 32 outpatient clinic site must be licensed by DOH if more than 5 percent of its visits are for medical services or any visits are for dental services. A PHL Article 28 clinic site must be licensed by OMH if it provides more than 10,000 annual mental health visits, or if more than 30 percent of its annual visits are for mental health services. Licensure thresholds are not applicable for OASAS services; a PHL Article 28 outpatient clinic site that would like to provide any substance use disorder service must be certified by OASAS.
November 2, 2015 28 Integrated Outpatient Services Regulations Regulations allow a provider that is licensed or certified by more than one agency to add services at one of its sites without having to obtain an additional license or certification, as long as it is licensed or certified to provide such services: DOH licensed providers - 10 NYCRR Part 404; OMH licensed providers -14 NYCRR Part 598; and OASAS certified providers - 14 NYCRR Part 825. A PHL Article 28 provider seeking to add behavioral health services must submit a CON application or LRA through NYSE-CON. A MHL Article 31 or Article 32 provider seeking to add primary care or behavioral health services must submit the application available on the OMH and OASAS websites.
November 2, 2015 29 DSRIP Project 3.a.i Licensure Threshold Model designed to help providers participating in PPSs facilitate the integration of care under DSRIP Project 3.a.i. Model permits a licensed or certified provider to integrate primary care and behavioral health services under a single license or certification, as long as the service to be added is not more than 49 percent of the provider s total annual visits. A PHL Article 28 provider seeking to add behavioral health services must submit a CON application or a LRA through NYSE-CON. A MHL Article 31 or MHL Article 32 provider seeking to add primary care or behavioral health services must submit the DSRIP Project 3.a.i Integrated Services Application.
November 2, 2015 30 Co-Location/Shared Space Shared Space - Two providers working together in work together by sharing licensed clinical space. Often used interchangeably with Co-Location Offers great potential for facilitating the coordination of care, but it does involve various complexities. Federal Issues - Certain facilities with a federal designation, are limited by federal rules from sharing space. Based on CMS interpretation of federal regulations, FQHCs must maintain separate operations and cannot co-mingle with other providers. The Department is trying to get further clarification on this interpretation as to whether the regulation is limited to providers sharing space concurrently or whether an FQHC can share space with another provider as long as they are temporally separated. Services The agencies are looking at the types of services that may be provided in shared space (e.g., are we going to limit services to primary care and behavioral health or are we able to allow specialty providers to share space as well). Accountability The agencies are discussing how providers will share accountability for violations of applicable regulations or statute Notice/Signage The agencies want to help make sure patients will be apprised that they are being seen by different providers and how the coordination will work, including use of clear signage in languages appropriate to the health clinic s target population; Reimbursement The agencies need to discuss how facility costs will be allocated between the providers to avoid duplicate reimbursement, as well as work through other billing issues.
November 2, 2015 31 V. Capital Restructuring Financing Program
November 2, 2015 32 Capital Restructuring Financing Program Background The Capital Restructuring Financing Program (CRFP) is a $1.2 billion grant program coadministered by the Department of Health and the Dormitory Authority of the State of New York (DASNY). Per law, CRFP grants may only be used for the construction of health care facilities or Health IT costs. Excluded expenses include personnel costs, supplies, utilities and general operating costs Status Initial RFA reissued to address regional equity (i.e., NYC/ROS) in award distribution Over 700 applications have been received from 25 PPS and non-dsrip providers as part of a competitive procurement process Awards expected to be announced by the end of October 2015
November 2, 2015 33 VI. Questions and Discussion