Western New York Bridging Gaps in Care for the Medicaid Population

Dr. Carlos Santos, MD Medical Director, Community Partners of WNY Amy White-Storfer, MBA, PMP Director, Community Partners of WNY

Agenda: Part 1 DSRIP year 1 Budget Overview Dr. Dapeng Cao Project Focus: Nurse Family Partnership Julie Lulek Compliance Officer's Update Kimberly Whistler Chautauqua Network Update Telemedicine Update Physician outreach Dr. Carlos Santos Addressing comments from last time Cara Petrucci

Agenda: Part 2 Review of materials on CPWNY website Mark Gburek Additional Status Updates for all Project/Work-streams: Amy White-Storfer IT Update: Pete Capelli Patient Engagement Numbers Overview Dapeng Cao - Reporting Planned Timeline Overview Cara Petrucci Workforce update Mark Gburek Cultural Competency and Health Literacy Patti Podkulski Last call for questions Amy White-Storfer

Audience Questions Please use the provided index cards to write your question(s) for CPWNY. Questions: - Write your question on the index card. (Be sure to include who your questions is directed to and the topic) - Hold up your card and a CPWNY member will come pick it up - *NOTE* For audience members on the phone, please submit questions through chat.

DSRIP Budget Overview Dr. Dapeng Cao Senior Data Analyst

CPWNY Potential Award Overview Valuation Bucket Amount Risk At What Risk? # of Payments Safety Net Equity Infrastructure (previously Safety Net Equity Guarantee) $23,856,680 Low CPWNY reporting to MCOs on selected activities 10 Safety Net Equity Performance $15,904,454 Moderate CPWNY reporting to MCOs on selected 4 metrics Net Project Valuation $43,394,151 Moderate CPWNY reporting & performance Domain 1-4 metrics (report to NYS) 11 Net High Performance Fund (3%) $5,062,760 High CPWNY higher performance on selected metrics (report to MCOs) 4 Additional Performance Fund (State Only) $4,035,358 High NYS overall performance metrics unknown 4

CPWNY Potential Award Overview

CPWNY 5 Year Revenue Expenditure Projection Budget Items DY1 DY2 DY3 DY4 DY5 TOTAL Waiver Revenue $13,252,634 $13,049,065 $18,153,991 $16,619,080 $12,534,159 $73,608,929 Cost of Project Implementation & Administration 67% 55% 45% 45% 45% 51% Costs for services not covered 5% 9% 7% 5% 3% 6% Revenue Loss 18% 18% 18% 18% 18% 18% Internal PPS Provider Bonus Payments 9% 17% 29% 30% 32% 24% Contingency Fund 1% 1% 1% 1% 1% 1% Other 0% 0% 0% 1% 1% 0% Total Expenditures $13,252,634 $13,049,065 $18,153,991 $16,619,080 $12,534,159 $73,608,929 Undistributed Revenue $0 $0 $0 $0 $0 $0 Assumptions CPWNY achieves 100% of at-low-risk dollars CPWNY achieves 80% of at-moderate-risk dollars At-high-risk dollars are not budgeted for until further clarification.

DY1 Allocation of Revenue by Project 2.a.i IDS 2.a.i Integrated Delivery System DY1 Revenue Safety Net Equity Infrastructure 771,081 Safety Net Equity Performance 168,344 Net Project Valuation 850,222 Net High Performance Fund Additional Performance Fund NYS Total DY1 Revenue 1,789,646 50% of Net Project Valuation received to date. Revenue Allocation by Project Timing of payments Allocation based on Project Index Score and Application Score Some projects realize a net loss while others realize a net gain Budget to breakeven in aggregate

DSRIP Nurse Family Partnership Julie Lulek Project Coordinator/ Lead for Nurse Family Partnership

Nurse-Family Partnership in the Continuum of Care A Model for Increased Patient Centered Care

13 "There is a magic window during a moms first pregnancy it s a time when the desire to be a good mother and raise a healthy, happy child creates motivation to overcome incredible obstacles including poverty, instability or abuse with the help of a well-trained nurse." David Olds, PhD, Founder, Nurse-Family Partnership

Overview 14 Cover this gray area with one of the 8 provided filmstrip photo JPG files. Nurse-Family Partnership is An evidence-based, community health program Transforming lives of vulnerable first-time mothers living in poverty Improving prenatal care, quality of parenting and life prospects for mothers by partnering them with a registered nurse Every dollar invested in Nurse-Family Partnership can yield more than five dollars in return. Copyright 2011 2013 Nurse-Family Partnership. All rights reserved.

15 "They always say babies don t come with instruction manuals, but if there was one, the Nurse-Family Partnership would be it." Andrea, Mom from Pennsylvania

Overview 16 Cover this gray area with one of the 8 provided filmstrip photo JPG files. Nurse Family Partnership is a voluntary program for first-time, low-income mothers who enroll prior to their 28 th week of pregnancy Program Goals Improve pregnancy outcomes Improve child health and development Improve parents economic self-sufficiency Copyright 2011 Nurse-Family Partnership. All rights reserved.

Overview 17 Home Visit Overview Personal Health Health Maintenance Practices Nutrition and Exercise Substance Use Mental Health Functioning Environmental Health Home Work, School and Neighborhood Life Course Development Family Planning Education and Livelihood Maternal Role Mothering Role Physical Care Behavioral and Emotional Care Family and Friends Personal network Relationships Assistance with Childcare Health and Human Services Service Utilization Copyright Copyright 2014 Nurse-Family 2014 2013 Nurse-Family Partnership. Partnership. All rights All reserved. rights reserved.

Research 18 Trials of the Program Dr. Olds research & development of NFP continues today 1977 Elmira, NY Participants: 400 Population: Low-income whites Studied: Semi-rural area 1988 Memphis, TN Participants: 1,139 Population: Low-income blacks Studied: Urban area 1994 Denver, CO Participants: 735 Population: Large portion of Hispanics Studied: Nurse and paraprofessionals Copyright 2014 2013 Nurse-Family Partnership. All rights reserved.

Outcomes 20 Cover this gray area with one of the 8 provided filmstrip photo JPG files. Near-Term Outcomes: Pregnancy 79% in pre-term births 35% fewer hypertensive disorders of pregnancy Fewer cases of preeclampsia or complications of pregnancy Fewer subsequent births on Medicaid and increased birth spacing/fewer closelyspaced (less than 6 months) births Near-Term Outcomes: Child Development 48% in child abuse & neglect 56% in ER visits for accidents and poisonings 39% fewer injuries among children 50% in language delays Long-Term Outcomes: Self-Sufficiency 83% in labor force participation by child s 4 th birthday Education 67% in behavioral/intellectual problems at age 6 yrs Crime 59% fewer arrests among 15 yr olds (who were infants in the program) Copyright 2011 Nurse-Family Partnership. All rights reserved.

Monetary Benefits to Society 22 Cover this gray area with one of the 8 provided filmstrip photo JPG files. Nurse-Family Partnership is Cost-Effective The RAND Corporation estimates Nurse-Family Partnership can return up to $5.70 for each $1 spent on the program.* Savings accrue to government from decreased spending on: health care criminal justice child protection mental health education public assistance And increased taxes paid by employed parents Nurse-Family Partnership ranked among the highest programs reviewed in terms of net benefit to society among pre-k, child welfare, youth development, mentoring, youth substance prevention and teen pregnancy prevention programs. A 2012 cost-benefit update by WSIPP estimated long-term benefits of almost $23,000 per participant.** (Washington State Institute for Public Policy 2012) * RAND Corporation 1998, 2005; return for highest risk families ** Savings related to low birth weight, child injuries and immunizations not included Copyright Copyright 2014 Nurse-Family 2011 2013 Nurse-Family Partnership. Partnership. All rights All reserved. rights reserved.

23 Nurse-Family Partnership (NFP) delivers on the Triple Aim and can positively impact your bottom line by delivering a significant return on investment. I recommend that you consider this evidencebased nursing intervention, which provides great career satisfaction for your staff, while notably improving community outcomes. Dr. Thomas E. Beeman President/CEO Lancaster General Hospital

Healthcare Integration 24 Improving Care Helping clients obtain insurance coverage Conducting ongoing health and psychosocial risk assessments and screenings Providing anticipatory guidance and preventive services based on need, counseling around: weight gain blood pressure potential complications of pregnancy Helping clients plan future pregnancies and improve interconception care Making appropriate referrals and coordinating care with other services Copyright 2014 Nurse-Family Partnership. All rights reserved.

Healthcare Integration 26 Reducing Costs For every 1000 families served NFP can expect to prevent: 78 preterm births 38% reduction in childhood injuries treated in Emergency Departments up to age 2 23% increase in immunizations at age 2 14% increase in mothers who choose to breastfeed 73 second births to young mothers 230 person years of youth substance abuse 3.4 infant deaths Copyright 2014 Nurse-Family Partnership. All rights reserved.

Implementation of Western New York Nurse-Family Partnership 27 WNY Nurse-Family Partnership Chautauqua County (all staff hired and trained) Nurse Supervisor = 0.5 Nurse Home Visitors = 2.5 Total client enrollment at capacity = 65 slots/families at one time Started in September 20 clients enrolled Erie County Nurse Supervisor = 1 Nurse Home Visitors = 5 Total client enrollment at capacity = 125 slots/families at any one time Goal to implement in 2016 Maximum enrollment at any one time for WNY NFP = 190 families Copyright 2014 Nurse-Family Partnership. All rights reserved.

28 Cover this gray area with one of the 8 provided filmstrip photo JPG files. Questions? Copyright Copyright 2014 Nurse-Family 2011 2012 Nurse-Family Partnership. Partnership. All rights All reserved. rights reserved.

29 Cover this gray area with one of the 8 provided filmstrip photo JPG files. For More Information Nurse-Family Partnership National Service Office 1900 Grant Street, Ste 400 Denver, Colorado 80203 Julie Lulek, NFP Program Coordinator jlulek@chsbuffalo.org O: 716.923.9784 C: 917.232.2664 www.nursefamilypartnership.org Aimee Gomlak, VP Women s Service Line AGB@chsbuffalo.org O: 716.862.2182 Copyright 2011 2013 Nurse-Family Partnership. All rights reserved.

DSRIP Compliance Kimberly E. Whistler Compliance Officer

Principles of Compliance Compliance is a comprehensive program that helps providers and their employees conduct operations and activities ethically; with the highest level of integrity, and in compliance with legal and regulatory requirements.

Compliance Plan and Policies Partners can obtain the Compliance Plan on the CPWNY website: http://wnycommunitypartners.org/ Specific policies are available on request. Can contact Compliance Officer directly or the project manager

8 Elements of a Compliance Plan 1. Written policies and procedures. 2. An employee vested with responsibility for day-to-day compliance program operation. 3. Training and education of all affected employees and persons. 4. Communication lines to the responsible compliance position. 5. Disciplinary policies to encourage good faith compliance program participation. 6. A system to routinely identify compliance risk areas. 7. A system for responding to compliance issues as they arise. 8. A policy of non-intimidation and non-retaliation for good faith compliance program participation.

Compliance Concerns Fraud and Abuse Fraud Defined: An intentional deception or misrepresentation that could result in some unauthorized benefit to a person or CPWNY Abuse Defined: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care

Additional Compliance Concerns Inaccurate, incomplete, or missing Documentation Improper billing and coding Offering or receiving kickbacks, bribes, or rebates A service has not been rendered by the identified provider, to the identified person, or on the identified date Failure to comply with government rules and regulations affecting healthcare Receipt of incentives for patient referrals

Even more Compliance Concerns Lack of integrity Ethical incidents Theft or misuse of services Improper political activity Breach of corporate confidentiality Improper use of proprietary information Environmental health and safety issues Dishonest communication (spoken or documents) Improper business arrangements Failure to follow Record Retention policy

Reporting a Compliance Concern A compliance issue or concern can be reported in four ways: Report supervisor or to an appropriate department such as Human Resources. Report the matter to a higher level manager. Report the matter to the CPWNY Compliance Officer, Kimberly Whistler, 716-821-4471. Contact the Catholic Health Compliance Line at 1-888-200-5380 and is available 24 hours a day, 7 days a week and calls may be placed anonymously.

DSRIP Compliance Officer Contact Information: Kimberly E. Whistler, Esq. CPWNY Compliance Officer 144 Genesee Street, 5 th Floor Buffalo, New York 14203 Phone: (716) 821-4471 kwhistler@chsbuffalo.org

Chautauqua County DSRIP Update Dr. Carlos Santos DSRIP Medical Director

CPWNY Attribution for Performance (A4P) By County Erie Chautauqua Niagara Utilizing 47,800 20,781 6,951 Non-Utilizing 6,235 2,711 907 Total 54,035 23,492 7,858 % of CPWNY 63.28% 27.51% 9.20%

CPWNY Partners in Chautauqua County 155 individual practitioners (20 Safety Net) 107 physicians 24 physician assistants 22 nurse practitioners 1 dentist, 1 mid-wife 28 organizational partners (7 Safety Net) 9 hospitals (NYS definition, WCA listed multiple times) 8 SNFs - 2 adult care facilities 1 hospice - 1 health home - 1 longterm services 1 CBO - 1 adult home - 1 ACO 1 rural health network 2 others

Provider Engagement Meetings with individual groups & Practitioners CPWNY will require signed contracts with groups or practitioners by year end (2015) Contract has no downside risk for practitioners Goal is to provide resources to meet gaps in care Financial benefit is tied to performance of project deliverables

Additional Projects for Chautauqua Nurse Family Partnership Started in September 2015; patients now engaged Collaboration with Chautauqua County Health Department Telemedicine Started roll out at WCA Hospital Credentialing Completed Plan to expand Role of new law requiring telemedicine coverage for MCO s in 2016?

DSRIP PAC 8.7.15 Feedback Cara Petrucci Project Coordinator

CPWNY PAC MEETING COMMUNITY REPRESENTATION Mental and Behavioral Health Pharmacy Education MCO Skilled Nursing RHIO Hospice Unions Local Health Departments Hospital Community Based Organizations Physician Groups Services for the Developmentally Disabled

Feedback from CPWNY Project Advisory Committee Meeting 8-20 Feedback Forms Received Interest in Project Advisory Committee 32 29 For Your Information Interest in Participating in Specific Projects Seeking More Information and Updates 5 10 8

Break

DSRIP CPWNY Website Mark Gburek Project Coordinator

http://wnycommunitypartners.org

DSRIP Project Updates Amy White-Storfer DSRIP Director

Reminder: A review the CPWNY projects System Transformation 2ai Integrated Delivery System * 2biii ED Care Triage * 2biv Care Transitions 2cii Telemedicine Clinical Improvement 3ai Behavioral Health Integration * 3bi CVD Cardiovascular Disease * 3fi Maternal and Child Health * 3gi Palliative Care Integration Population-wide Strategy Implementation- The NYS Prevention Agenda 4ai MEB (Mental, Emotional, Behavioral) Well-Being * 4bi Promote Tobacco Cessation * Overlap with Millennium Care Collaborative

2.a.i, Integrated Delivery System Seeking completion of master service agreements with all partners and organizations. Percentage of current Full Time clinical transformation team allocated to DSRIP at Catholic Medical Partners Leverage existing and future performance dashboards to help providers identify areas for improvement. Clinical transformation best practice proven at CMP. Budget allocated to population health management tool (i.e. notify practices when patients hit the ER or are admitted to the hospital.) Engaging of providers in Chautauqua Leadership at WCA Hospital and Chautauqua County Health Network engaged in planning in that county

System Transformation/Clinical Improvement 2.b.iii, ED Triage Initiative for at Risk Patients: Benefits from work in 2ai Additionally, a percentage of full time team current ED triage staff allocated to DSRIP for hospital partners (i.e. social workers to assist with primary care linkages.) Sisters Hospital, South Buffalo Mercy, WCA Hospital in first wave project work Seeking engagement of community health workers from organizations like Urban League and Catholic Charities (pilot) 2.b. iv., Care Transitions: Benefits from work in 2ai, and items cited above A full-time Social worker allocation on CMP care transition to provide DSRIP focus Exploration of physicians incentives, such as PMPM to support care transition work. 3.b.i., Cardiovascular Disease Management, Evidence Based Strategies: Benefits from work in 2ai and items cited above Crimson will be piloted in March at CHS facilities for window into population and patient engagement opportunities

PCMH Support & Expansion: Support for multiple projects Patient Centered Medical Home part of many projects in DSRIP Generally, current network s 2017 goal is for PCPs moving to 2014 standards. DSRIP funds to help address challenges bringing providers aboard that are new to network (i.e. Chautauqua, Niagara County)

Data current as of 10/30/15

Additional Primary Care Focused Clinical Improvement Initiatives 3.a.i. Integration of Behavioral Health and Primary Care (PCMH level 3) Thank you to Spectrum Health Services (our lead) Heavily collaborative with Millennium Care Collaborative Sorting of physician lists across PPSs is complete. Work to identify the existing referral agreements and relationships. Begin roll out to PCP sites. Continuing discussions on data sharing between the health plans and behavioral health orgs. Piloting with smaller group of plans

Additional Primary Care Focused Clinical Improvement Initiatives 3.g.i Integration of Palliative Care into primary care practices Thank you to Hospice Buffalo (our lead) Teams have begun in earnest their work connecting with a targeted list of PCPs Current team planning outreach to Chautauqua & Niagara County Hospice. Looking at staffing required for PCMH PCP engagement in Chautauqua.

Additional Highlights: Maternal Child Health & Telemedicine 2.c.ii Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services Thank you to WCA Hospital, Jamestown, NY, our pilot Credentialing in progress Consults begin for targeted patient groups this month Looking at chances to use telemedicine for other conditions 3.f.i Increase support programs for maternal and child health through the Nurse Family Partnership Model First time moms Engagements for 18month Thank you to Chautauqua County Department of Health, our first NFP partner

NYS Prevention Agenda: Domain 4 4.a.i. Mental Emotional and Behavioral Health-Well in Communities (MEB) Thank you to ECCPASA/Mental Health Association (our leads) Contract to formally work with Millennium Care Collaborative Hiring and ramp-up beginning now and through first part of the year 4.b.i Promote tobacco use cessation, among low SES or those with poor mental health Thank you to Roswell Park (our lead) Budget in place; program implementation for opt-to quit beginning

DSRIP Information Technology Gap Assessment Update Peter Capelli Vice-President, IT Network and Infrastructure

CPWNY PPS Data Architecture

CHARTIS Project Approach IT Gap Assessment Evaluate the current and potential IT capabilities of the PPS participants, including EHR and practice management system capabilities, interoperability and HIE capabilities, and Meaningful Use attestation status. IT Change Process Gap Assessment Understand current change control processes in place at CHS and among the PPS participants, assess the impact of new processes, and develop communication plan. IT Security / Risk Assessment Understand and assess the IT security policies and procedures in place for each of the PPS participants, and develop / update recommended security policies.

Report to State, Q2 ending 9/30/2015 Patient Engagement Scale & Speed Dr. Dapeng Cao/ Cara Petrucci Senior Data Analyst/ Project Coordinator

DY1 Q2 Patient Engagement Results (by 9/30/2015) DY1 Q2 Goals DY1 Q2 Results % Achieved 2.b.iii ED Triage 6,128 5,070 83% 2.b.iv Care Transitions 1,644 3,467 211% 3.a.i PC & Behavioral Health 15,472 6,275 41% 3.b.i Cardiovascular Health 4,805 1,096 23%

DY1 Q2 Patient Engagement Results (by 9/30/2015) DY1 Q2 Goals DY1 Q2 Results % Achieved 2.c.ii Telemedicine 250-0% 3.f.i Maternal & Child (NFP) 10 11 110% 3.g.i Palliative Care 107 50 47% 2.c.ii Telemedicine project started engaging Medicaid patients after 9/30/2015

DY1 Q3-Q4 Patient Engagement Reporting Timeline Providers Submit Patient Engagement to PMO DY Year Month Due Date Description Oct-15 2015 Q3 Nov-15 DY1 Q4 Dec-15 Jan-16 Feb-16 December 15 Notification that we will be requesting Data January 1 Formal Request For Patient Engagement Data (DY1 Q3) January 15 Patient Engagement Data due to CMP January 31 CMP Submits Patient Engagement with Quarterly Report DY2 2016 Q1 Mar-16 Apr-16 May-16 March 15 Notification that we will be requesting Data April 1 Formal Request For Patient Engagement Data (DY1 Q4) April 15 Providers Send Patient Engagement Data to CMP April 30 CMP Submits Patient Engagement with Quarterly Report Jun-16 June 15 Notification that we will be requesting Data July 1 Formal Request For Patient Engagement Data (DY2 Q1)

DSRIP Workforce Update Mark Gburek

Highlighted Workforce Updates Baseline survey collection in progress Timed to align with our fellow PPS Millennium Care Collaboration to administer same survey to avoid duplication of effort Rural-AHEC collecting and maintaining all information Planned continued collaboration with MCC on next steps

DSRIP Cultural Competency and Health Literacy Patti Podkulski

Deliverables: CPWNY CC/HL Strategy Identify priority groups experiencing health disparities based on the Community Needs Assessment and other analysis Identify key factors to improve access to quality primary, behavioral and preventive care Define a 2-way communication plan with the population and community groups through specific community forums Identify assessments and tools to assist patients with self management of conditions Identifies community based interventions to reduce health disparities and improve outcomes Copies of material presented at community forums to ascertain the outreach made to the community based upon cultural, linguistic and literacy factors to assist in the self management of conditions and reduce health disparities

Two prong approach: CPWNY CC/HL Strategy 1. Reduce health disparities through identification utilizing registries and individualizing strategies based on findings. 2. Teaching and engagement of partners in cultural competency and health literacy

Collaboration is the key : Strategy Working with P2 and Millennium Community Based CBOs and focus groups of patients, Community Health Worker Network of Buffalo. NYS wide collaborative meeting of all the PPS with the leads on cultural competency and health literacy SUNY of Albany, D Youville, Canisius. Professional peer group of physicians on a quality team

Strategy Designate a point person in each organization accountable for cultural competency and health literacy initiatives such as roll out of training, orientation at the offices. Work with partners to dissect registries and analyze for health disparities Analyze Patient satisfaction surveys for evidence of health disparities. Training on social stigmas and stereotyping (Training strategy will be developed by 6/2016)

Strategy Increase community involvement with health fairs and organizations Population education through health homes, practitioner offices, CBO linkages Increased communication out reach utilizing asset based community development.

Strategy ( cont d) CPWNY projects and deliverables in line with PHIPs grant ( P2) and the NYS Prevention Agenda: ( African American, Hispanic, Immigrants and Refugees, Amish, Native American, Asian depending on county) 1. Cancer screening breast, colorectal and follow up.( Early detection) 2. Blood pressure screening and follow-up 3. Behavioral Health screening and follow up. 4. Universal approach to health literacy. 5. Emphasis on self management.

Closing Received feedback this week from independent assessor regarding Q2 report Full documentation for Q2 submission will be available after Jan 1, 2016 Q1 report is available on-line now at Department of Health Website: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

Questions??? Please take this time to use the provided index cards to write your question(s) for CPWNY and/or complete the evaluation form. Thank you, Community Partners of Western New York, PPS.