Cayuga County Regional Project Advisory Committee

Cayuga County Regional Project Advisory Committee Welcome and Introductions Cayuga EPAC Representative Liz Smith

Value Based Payment and the Year Ahead https://youtu.be/jqfipbmg2rs

Goals of DSRIP There are Three Primary Objectives of the DSRIP Program Promote community-level collaboration via performing provider systems (PPSs) that support the formation of Integrated Delivery Networks Preserve and transform the State s fragile health care safety net system and prepare providers for success in Value Based Payment Improve health outcomes and reduce avoidable hospital readmissions and emergency department utilization by IDN VBP 25%

State-Mandated PPS Requirements 11 DSRIP Projects with required, at-risk Milestones, Provider, and Patient Targets 1. Integrated Delivery System 2. DSRIP Care Management 3. ED Care Triage 4. Care Transitions 5. Patient Activation 6. Primary Care/Behavioral Health Integration 7. Crisis Stabilization 8. Cardiovascular Disease Management 9. Palliative Care Integration 10. Behavioral Health Infrastructure 11. Reduce Preterm Births Organizational Workstreams, some with required, at-risk Milestones and Targets IT/PHM/Clinical Integration Workforce & Primary Care Plan Cultural Competency/Health Literacy Governance & Performance Reporting Financial Sustainability & VBP (new) Administer a Value Based Payments Needs Assessment to the PPS network to identify opportunities to support transition to VBP Develop a VBP support implementation plan to address the identified needs of the PPS network partners Develop partner engagement schedule for partners for VBP education and trainings

Background CNYCC Funds Flow CNYCC Phase I Funding Approved by CNYCC BOD in November 2015 Developed a process to distribute funding for participation Fund Allocation Distribution of approximately $13 million Activity Focus Implementation Planning Actively Engaged Patients Reporting

New CNYCC Funds Flow Policy CNYCC Phase II Funding Currently being finalized for BOD approval (June) Development of a formulaic process to distribute funding for participation Fund Allocation Distribution of approximately $49 million Bridge Payment Phase II Project Agreement Activity Focus Actively Engaged Patients Reporting Performance Activity Transition to VBP Bridge Payment

Performance Activities Summary Project # of Performance Activities 2.a.i 51 2.a.iii 7 2.b.iii 6 2.b.iv 7 2.d.i 14 3.a.ii 7 3.a.iM1 7 3.a.iM2 8 3.b.i 10 3.g.i 7 Multi Project 1 Total 120 Contracting Period # of Performance Quarter Activities Quarter 1 24 Quarter 2 21 Quarter 3 43 Quarter 4 32 Total 120 120 Performance Activities approved by FFWG 84 general Performance Activities 36 Patient Engagement reporting activities 92 activities directly linked to one or more outcome measures 19 foundational activities address all outcome measures 14 Copyright 2017 All Rights Reserved

Performance Activity Update CNYCC Project Agreement Submission due 12/31/2017 Q1 Performance Activity Deadline completed on September 30, 2107 Q2 Performance Activity Deadline Scheduled for December 31, 2017 Partner Resources for Reporting PA Reporting Partner Guide Webform Notification CNYCC Office Hours General Questions via info@cnycares

10-minute break

Partner Spotlight Cayuga County Community Forum Cayuga Community Health Network Jessica Soule

Listening Sessions Learning from our residents and consumers

Cayuga Community Health Network, Inc. Rural Health Network of Cayuga County 501(c)3 non-profit organization Focus on chronic disease prevention and maintenance Chronic Disease Self-Management National Diabetes Prevention Program

Community Engagement Forums CCHN proposed 2 listening sessions within Cayuga County in February Implementation of patient activation activities to engage, educate, and integrate the uninsured and low/non-utilizing Medicaid populations into community-based care

Listening Sessions Audiences Subsidized Housing For residents Thursday morning $10 gift cards Onsite at housing campus Questions related to expectations of care levels, barriers Rural Community Community leaders by invite Friday over lunch Host Lifespan Therapies, King Ferry Questions focused on challenges faced by rural population

Forum Results Identified themes, ideas, suggestions, surprises Created report for stakeholders Conduct additional information gathering Find solutions to address issues

Population Demographics Auburn Housing Authority Consists of three complexes within City of Auburn 326 housing units All subsidized housing 25% of residents racial minority (12% city of Auburn) King Ferry Town of Genoa 1,935 people Very rural community Many diary farms (migrant workers) 6.7% of people don t speak English at home 2% of population is Guatemalan

A snapshot of the economic conditions for zip code for King Ferry. HealtheCNY.org

Auburn Housing 11 people attended (registered) 81% has specific health condition Asthma, Diabetes, High blood pressure, Depression/anxiety 100% had Medicaid, primary dr. 90% taking medication 82% smoke Demographics for the groups 63% use public transport, 18% have a car, 9% have no transportation 9% Native, 9% Hispanic, 9% multiracial Barriers to keeping appt. Cost/co-pays Transportation Prior experience with dr King Ferry 8 people attended (invited) 37% had specific health conditions Thyroid, diabetes and hypertension 88% have private insurance 63% take medication 12% smoke 100% have vehicles Multiple people spoke about migrant workers in farming area 88% said healthcare was fairly affordable

Themes Transportation, low health literacy, lack of respect, lack of options

Auburn Housing Authority Lack of transportation. Most medical offices don t ask, even if a note is needed. Call too early, can be rejected. Lack of respect. Many won t accept their insurance. Many referrals out of county but can t get there. This culture caused many to feel pushed aside or not valued. Other challenges to getting quality health care include long wait times and insufficient time with doctors, issues communicating with doctors Providers with English as second language, doctors hard to understand

Auburn Housing Authority continued Doctors urge clients to make changes. People with success were given clear directions. Overarching statements don t work such as lose weight, stop smoking. Insurance coverage: Surprised to receive medical bills for procedures and lab work that they didn t know wasn t covered. Would have made different choices. Preference for healthcare sites for doctors office, urgent care or emergency department: Urgent care sites are preferred. They see people quicker and are nicer ER is challenging because of long waits. It s uncomfortable and not clean Would go to primary care if could get appointments when needed Participants provided positive feedback regarding working with insurance navigators

Quotes from Auburn They were snotty. I never saw my doctor. Being pushed aside, or not being heard. They went to college we have to listen to them. Don t look at us like we are stupid because you see we have Medicaid or Medicare. (Doctors) treat us like we are nothing. I have a high risk pregnancy and I can t get an appointment for three months.

King Ferry Lack of public transportation. Medical transport may not pick people up, few buses and no taxi services. Some people have to travel elsewhere to get to care, but can t physically there. Copays and deductibles are a major factor in deciding when and what medical services to seek. Some reject recommended procedures and therapies based on high copays and timing related to insurance. Town of Genoa = 1,935 people

King Ferry continued Rural populations are aging. This leads to lack of volunteers, attrition for those who are involved or donate their time to community efforts. Aging in place for residents is limited to those who can afford care. Even then, finding aides willing to come to rural is difficult and inconsistent. Internet and cellular service is unreliable and causes major issues. Besides issues with communication to public, and causes difficulty in employee recruitment to small community.

Quotes from King Ferry Transportation is a big issue for our families. We re trying constantly to meet (that need). There are three of us who offer transportation to the southern end of the county. That s not enough. Six months is not acceptable to wait (for dental appointment). I would say the majority of the people we see here if we weren t here (in King Ferry), would not be going to physical therapy and they should. They just can t drive to Cortland or Auburn. Transportation is an issue.

Quotes from King Ferry All this effort to get people signed up for WIC is almost a waste of time because they will never get to the appointment. If our aide can t come, that s it. One of us has to be home. (Isaac has gotten so big that his mom can t lift him.) Immigrants and non-english speakers are not always welcome at other agencies. I have a mom coming in today to help her with her taxes, and I ve been thinking all day with my fingers crossed, I hope the internet works at school because for us, it s hit or miss.

Next Steps What to do with the results

Future Forums Focus on aging in place, find proposed solutions to seek funding Gather more information regarding prediabetes/risk factors Referral process survey to healthcare providers https://www.surveymonkey.com/r/lifestylechangeprogramsurvey

Contact Me Jessica Soule Cayuga Community Health Network, Inc. (315) 252-4212 Jsoule@cayugahealthnetwork.org

Performance & Outcomes Measures (Measurement Year 3, (MY3)) November 2015 to November 2016

Performance and Outcomes Measures Measure Summary CNYCC Performance Measure Summary MY 2 Total MY 3 Total Total Measures 48 48 # of Measures with Data Available 24 28 # of Measures with No Data Available 24 20 # of Measures on Target 10 16 # of Measures off Target 14 12 # of Measures with Unknown Performance 24 20 # of Measures currently Pay for Reporting (P4R)* 39 18/0 # of Measures currently Pay for Performance (P4P)* 13 30/48 *18 Measures switch to P4P for the second payment made

Total Available Funding DY4 Payments from MY3 & DY3 Activities

Available Funding for AEP & Performance and Outcomes (Total Available Funding for DY4 - $23,649,197.11) Actively Engaged Patients (AEP), $1,399,824.35 Performance & Outcomes Measures, $22,249,372.76

Available Funding for Performance and Outcomes P4R vs. P4P (Total Available Funding for DY4 - $22,249,372.76) $1,644,227.34 $19,725,386.85 Pay for Reporting Guaranteed Funds Pay for Performance Funds Dependent on Results

Available Funding for Performance and Outcomes P4R vs. P4P (Total Available Funding for DY4 - $22,249,372.76) $1,644,227.33 $7,770,201.41 $8,307,321.10 $4,527,622.93 Projected to Receive Payment Projected NOT to Receive Payment Pay for Reporting Guaranteed Funds Performance Unknown Pay for Performance

Performance and Outcomes Projected Funding Summary Dollar Values reflected in the Dashboards are based on the available funds paid out in DY4. Total available to CNYCC is $22,249,372.76 Performance Measures are broken into 4 Tiers based on measure worth Tier 1 13 Performance and Outcomes Measures worth $13,070,771.62 Includes Potentially Avoidable Readmissions and Potentially Avoidable ER Visits Measures Tier 2 11 Performance and Outcomes Measures worth $5,176,420.18 Includes Adult Access Measures Tier 3 14 Performance and Outcomes Measures worth $3,420,079.94 Includes Follow-up Care Measures Tier 4 10 Performance and Outcomes Measures worth $582,101.04 Includes Cardiovascular Measures

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures - $22,249,372.76) Measure Tiers Based on Total Funding for All Projects Tier 4, $582,101.04 Tier 3, $3,420,079.94 Tier 2, $5,176,420.18 Tier 1, $13,070,771.62

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures Tier 1 - $13,070,771.62) Tier 1 Performance Measure Breakdown - Funding $3,562,610.09 $1,304,837.84 $8,203,323.69 Projected to Receive Payment Performance Unknown Pay for Performance Projected NOT to Receive Payment

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures - $22,249,372.76) Tier 1 Measure Payments ($13,070,771.62) Potentially Avoidable Readmissions (Rate Per 100,000) PDI 90 - Composite of all measures (Rate Per 100,000) Potentially Avoidable ER Vists (Rate Per 100) PQI 90 - Composite of all Measures Primary Care - Usual Source of Care - Q2 Primary Care - Length of Relationship - Q3 IPOS PAM Score Non-use of Primary and Preventive Care Services ED Use by uninsured HCAHPS - Care Transistion Metrics (Q23 to Q25) Care Coordination (Q13, 17 and 20) Getting Timely Appointments, Care and Information (Q6, Q8 and Q10) $564,443.06 $564,443.06 $744,332.06 $744,332.06 $744,332.06 $1,128,886.13 $1,304,837.84 $1,128,886.13 $1,304,837.84 $1,454,783.00 $1,128,886.13 $1,128,886.13 $1,128,886.13 $- $200,000.00 $400,000.00 $600,000.00 $800,000.00 $1,000,000.00 $1,200,000.00 $1,400,000.00 $1,600,000.00 Projected to Receive Payment Performance Unknown Pay for Performance Projected NOT to Receive Payment

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures Tier 2 - $5,176,420.18) Tier 2 Performance Measure Breakdown - Funding $461,061.99 $2,049,760.54 $2,665,597.64 Projected to Receive Payment Performance Unknown Pay for Performance Projected NOT to Receive Payment

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures - $22,249,372.06) Tier 2 Measure Payments ($5,176,420.18) Prevention Quality Indicator # 7 (Hypertension) ± Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) ± (Rate Per 100) Diabetes Monitoring for People with Diabetes and Schizophrenia (Rate Per 100) Adherence to Antipsychotic Medications for People with Schizophrenia (Rate Per 100) $510,952.12 $512,936.14 $512,936.14 $512,936.14 Adult Access to Preventative or Ambulatory Care - 65 and older (Rate Per 100) Adult Access to Preventative or Ambulatory Care - 45 to 64 (Rate Per 100) Adult Access to Preventative or Ambulatory Care - 20 to 44 (Rate Per 100) $376,257.75 $376,257.75 $376,257.75 Prevention Quality Indicator # 8 (Heart Failure) ± Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication (Rate Per 100) Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (Rate Per 100) Screening for Clinical Depression and follow-up (Rate Per 100) $510,952.12 $512,936.14 $512,936.14 $461,061.99 $- $100,000.00 $200,000.00 $300,000.00 $400,000.00 $500,000.00 $600,000.00 Projected NOT to Receive Payment Projected to Receive Payment Performance Unknown Pay for Performance

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures Tier 3 - $3,420,079.94) Tier 3 Performance Measure Breakdown - Funding $291,323.40 $794,974.06 $2,333,782.48 Projected to Receive Payment Performance Unknown Pay for Performance Projected NOT to Receive Payment

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures - $22,249,372.76) Tier 3 Measure Payments ($3,420,079.94) Antidepressant Medication Management Effective Continuation Phase Treatment (Rate Per 100) Antidepressant Medication Management Effective Acute Phase Treatment (Rate Per 100) Children's access to Primary Care - 7 to 11 years (Rate Per 100) Children's access to Primary Care - 12 to 24 months (Rate Per 100) Follow-up care for Children Prescribed ADHD Medications - Continuation Phase (Rate Per 100) Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) (Rate Per 100) Follow-up after hospitalization for Mental Illness within 7 days (Rate Per 100) Follow-up after hospitalization for Mental Illness within 30 days (Rate Per 100) Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 Children's access to Primary Care - 25 months to 6 years (Rate Per 100) Children's access to Primary Care - 12 to 19 years (Rate Per 100) Follow-up care for Children Prescribed ADHD Medications Initiation Phase (Rate Per 100) Flu Shots for Adults Ages 18 64 Controlling High Blood Pressure $145,661.70 $145,661.70 $256,468.07 $256,468.07 $282,221.53 $282,221.53 $230,531.00 $256,468.07 $256,468.07 $256,468.07 $256,468.07 $282,221.53 $282,221.53 $230,531.00 $- $50,000.00 $100,000.00 $150,000.00 $200,000.00 $250,000.00 $300,000.00 Projected NOT to Receive Payment Projected to Receive Payment Performance Unknown Pay for Performance

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures Tier 4 - $582,101.04) Tier 4 Performance Measure Breakdown - Funding $145,661.70 $436,439.34 Projected NOT to Receive Payment Performance Unknown Pay for Performance

Performance and Outcomes Projected Funding Summary (Total Funding Available for DY4 Performance Measures - $ 22,249,372.76) Tier 4 Measure Payments ($582,101.04) Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80% Statin Therapy for Patients with Cardiovascular Disease - Received Statin Therapy $72,830.85 $72,830.85 Medical Assistance with Smoking and Tobacco Use Cessation Discussed Cessation Strategies Medical Assistance with Smoking and Tobacco Use Cessation Discussed Cessation Medication Medical Assistance with Smoking and Tobacco Use Cessation Advised to Quit Health Literacy (QHL16) Health Literacy (QHL14) Health Literacy (QHL13) $48,462.94 $48,462.94 $48,462.94 $48,462.94 $48,462.94 $48,462.94 Discussion of Risks and Benefits of Aspirin Use Aspirin Use $72,830.85 $72,830.85 $- $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00 Projected NOT to Receive Payment Performance Unknown Pay for Performance

Performance & Outcomes Measures Goals & Results (Performance Period: July 2016 November 2016 [Measurement Year 3]) The Performance and Outcomes Measures below apply to the following projects: Integrated Delivery System (2.a.i) DSRIP Care Management (2.a.iii) ED Care Triage (2.b.iii) Care Transitions (2.b.iv)

Performance & Outcomes Measures Goals & Results Pay for Performance Measures (Performance Period: July 2016 November 2016 [Measurement Year 3]) 100.00% 90.00% 80.00% 85.15% 85.75% 90.77% 89.35% 90.37% 88.78% 95.60% 95.24% 95.30% 95.77% 92.24% 91.55% 96.82% 96.47% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 84.36% 85.40% Adult Access to Preventative or Ambulatory Care - 20 to 44 (Rate Per 100) (1.04) 90.09% 90.54% 87.12% 89.02% Adult Access to Preventative Adult Access to Preventative Children's access to Primary Children's access to Primary or Ambulatory Care - 45 to 64 (Rate Per 100) or Ambulatory Care - 65 and older (Rate Per 100) Care - 12 to 19 years (Rate Per 100) Care - 12 to 24 months (Rate Per 100) 95.32% 95.39% 95.53% 95.49% 91.36% 91.84% Children's access to Primary Care - 25 months to 6 years (Rate Per 100) (0.45) (1.90) (0.07) (0.48) 96.98% 96.61% Children's access to Primary Care - 7 to 11 years (Rate Per 100) Not on Target to Goal Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal On or Above Goal

Performance & Outcomes Measures Goals & Results Pay for Performance Measures (Performance Period: July 2016 November 2016 [Measurement Year 3]) 1,400.00 1,200.00 1,099.88 1,194.82 1,000.00 800.00 599.06 645.55 600.00 400.00 589.88 626.18 1,185.70 1,155.26 200.00-136.73 145.57 152.32 PDI 90 - Composite of all measures (Rate Per 100,000) 157.14 37.02 33.57 33.93 35.57 Potentially Avoidable ER Vists (Rate Per 100) Potentially Avoidable Readmissions (Rate Per 100,000) PQI 90 - Composite of all Measures (Rate Per 100,000) (30.44) P4R/P4P P4R/P4P Not on Target to Goal Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal On or Above Goal P4R/P4P Measure switches to P4P

Performance & Outcomes Measures Goals & Results (Performance Period: July 2016 November 2016 [Measurement Year 3]) The Performance and Outcomes Measures below apply to the following projects: Behavioral Health/Primary Care Integration (3.a.i) Behavioral Health Crisis Stabilization (3.a.ii)

Performance & Outcomes Measures Goals & Results Pay for Performance Measures (Performance Period: July 2016 November 2016 [Measurement Year 3]) 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 54.04% 51.55% 53.69% 52.59% Adherence to Antipsychotic Medications for People with Schizophrenia (Rate Per 100) 49.57% 48.41% 49.66% 48.89% Antidepressant Medication Management Effective Acute Phase Treatment (Rate Per 100) 34.51% 33.51% 34.62% 33.93% Antidepressant Medication Management Effective Continuation Phase Treatment (Rate Per 100) 79.76% 78.38% 69.39% 78.96% Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (Rate Per 100) (9.57) 71.93% 69.94% 71.56% 70.77% Diabetes Monitoring for People with Diabetes and Schizophrenia (Rate Per 100) 79.64% 78.60% 78.79% 79.03% Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication (Rate Per 100) (0.24) 20.30% 20.79% 19.78% Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) (Rate Per 100) 19.41% 60.85% 57.81% 59.14% 59.08% Follow-up after hospitalization for Mental Illness within 30 days (Rate Per 100) 43.57% 40.17% 41.77% 41.59% Follow-up after hospitalization for Mental Illness within 7 days (Rate Per 100) 64.08% 62.46% 63.64% 63.14% Follow-up care for Children Prescribed ADHD Medications - Continuation Phase (Rate Per 100) P4R/P4P 59.65% 58.25% 57.19% 58.83% Follow-up care for Children Prescribed ADHD Medications Initiation Phase (Rate Per 100) (1.64) P4R/P4P 44.46% 43.06% 44.43% 43.64% Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) (Rate Per 100) Not on Target to Goal Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal On or Above Goal P4R/P4P Measure switches to P4P

Performance & Outcomes Measures Goals & Results Pay for Performance Measures (Performance Period: July 2016 November 2016 [Measurement Year 3]) 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 95.40 89.39 92.90 83.98 Potentially Preventable Emergency Room Visits (for persons with BH diagnosis) ± (Rate Per 100) Not on Target to Goal Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal On or Above Goal

Performance & Outcomes Measures Goals & Results (Performance Period: July 2016 November 2016 [Measurement Year 3]) The Performance and Outcomes Measures below apply to the following projects: Cardiovascular Disease Management (3.b.i)

Performance & Outcomes Measures Goals & Results Pay for Performance Measures (Performance Period: July 2016 November 2016 [Measurement Year 3]) 180.00 160.00 140.00 120.00 150.17 140.06 90.00% 80.00% 70.00% 60.00% 77.43% 79.69% 60.82% 56.47% 100.00 50.00% 80.00 40.00% 76.83% 78.37% 60.00 40.00 20.00-33.73 30.54 36.11 35.12 Prevention Quality Indicator # 7 (Hypertension) ± 166.44 145.96 Prevention Quality Indicator # 8 (Heart Failure) ± 30.00% 20.00% 10.00% 0.00% Statin Therapy for Patients with Cardiovascular Disease - Received Statin Therapy (Rate Per 100) 55.04% 58.28% Statin Therapy for Patients with Cardiovascular Disease - Statin Adherence 80% (Rate Per 100) (20.48) (1.54) (3.24) Not on Target to Goal Indicates which direction and how much improvement is needed for CNYCC to meet monthly goal On or Above Goal Measure switches to P4P

Performance Summary: CNYCC Management Dashboards- MY3 Results Month 7- July AEP 11 measures not on target gain of 1 measure from previous months data (children s access age 12-19) 10 of the 11 measures with month over month improvement Focus areas include adult access to primary care, patients with schizophrenia, statin therapy and composite of all measures Measure with decrease in performance preventative quality indicator #8 for heart failure (within composite of all measures as well) Strategic Plan to drive performance developed (see additional slides) Continue to trend strongly with potentially preventable ER admissions AEP Performance Periods (AV- Achievement Value Periods) (April 2017- September 2017) (October 2017-March 2018) Behavioral Health/Primary Care integration hitting targets Cardiovascular Disease Management on track to hit target Process verses Performance structure put in place over past 30 days (see additional slides)

PMO Strategic Plan to Drive Performance & Outcomes POST DSRIP Dashboard & Systems Utilization Linking Projects to Outcomes Data Analysis to drive action (MAPP) Rapid Cycle Improvement (MAXNY) Quality Audits- Quarterly reports post milestone completion against 5 step sustainability plans Clinical Sub- Quality Committee s Consultative Services (work flow analysis, process improvement, practice transformation) Service cost analysis (what does it cost to deliver a service) 2020 Clinical Sub-Quality Committee, Development of Outcome Sustainability Plans and Best Demonstrated Practices

Actively Engaged Patients July 2017 (Demonstration Year 3)

Actively Engaged Patients Projected Funding By Project (Total Available Funding for DY4 - $1,399,824.35) Updated w/aug data 3.a.i - Behavioral Health/Primary Care Integration $184,549.20 2.a.iii - DSRIP Care Management 2.b.iii - ED Care Triage 2.b.iv - Care Transitions $203,477.32 $203,323.80 $217,673.41 2.d.i - Patient Activation 3.a.ii - Behavioral Health Crisis Stabilization $175,941.50 $175,085.13 3.g.i - Palliative Care Integration $104,104.67 3.b.i - Cardiovascular Disease Management $135,669.32 $- $50,000.00 $100,000.00 $150,000.00 $200,000.00 $250,000.00 Projected to Receive Payment Projected NOT to Receive Payment Projected to Potentially Receive Payment

Actively Engaged Patients Process vs Performance Process Assessment of AEP reporting requirements are we making things too hard changes made to care transitions and cardiovascular Assessment within partner submission process- looking at trends; has reporting fell off and process support neededreach out conducted as needed Real time follow-up after initial submission- assessment of issues with files, rosters etc., - internal process developedimmediate contact made with partners Assessment for opportunity with retro-active reporting, requesting this data when possible Assessment of education gaps in reporting process and providing that education as appropriate Performance One on one discussions with Project Managers to develop action plans for partners who are struggling with implementation of projects- action plans include on-site visits with Director/PM with monthly one to one meetings scheduled with partner(s)- Focus Patient Activation Assessment of partners who have not been actively engaged in project (have never reported) and those who have just signed up for projects (Phase 2 funds flow) to develop plans for implementation Re-Launch of 2aiii project for re-engagement, education and process improvement of project implementation (October 6, 2017) Focus on Palliative Care Project- implementation underway for 2 partners at this time, 1 partner pending contract execution and 3-5 other partners have expressed interest RFP being finalized to be released Implementation meetings underway Implementation, planning and training dollars being allocated as per payment policy

90 80 70 60 50 40 30 20 10 0 DSRIP Care Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month Oneida Health Systems, Inc. Jul-17 6 Jun-17 9 May-17 11 Apr-17 6 Mar-17 6 Feb-17 14 Regional Primary Care Network Jan-17 4 1 Dec-16 5 Nov-16 5 Oct-16 2 Sep-16 10 Aug-16 6

DSRIP Care Management Actively Engaged Patient Targets DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 5,600 32 747 x 6 months $167,000 DY3Q4 (3/18) 16,700-1112 x 12 months $144,000 Action Steps To increase partnership between Health Homes, down stream providers and medical entities, a finalized sample Service Agreement and Care Coordination communication work flow will be disseminated to partner organizations to assist with implementation strategies. * 80% AEP needed to meet target

ED Care Triage Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month 2,500 2,000 1,500 1,000 500 0 St. Elizabeth Medical Center St. Joseph's Health Center Faxton-St Luke's Healthcare Rome Memorial Hospital Upstate University Hospital Oneida Health Systems, Inc. Oswego Hospital Crouse Hospital Lewis County General Hospital Jul-17 192 110 78 43 40 31 1 Jun-17 145 142 149 43 55 37 19 43 8 Auburn Community Hospital May-17 138 123 156 62 49 53 62 14 22 5 1 Apr-17 202 105 152 71 47 63 41 23 36 1 Mar-17 233 124 94 79 41 46 32 38 6 3 Feb-17 241 123 88 77 58 57 45 33 10 4 4 Jan-17 246 124 92 74 63 52 50 44 15 4 5 Dec-16 213 94 56 73 85 55 12 41 7 4 Nov-16 131 80 32 102 95 55 31 43 29 2 Oct-16 99 136 17 135 74 59 33 17 16 Sep-16 63 94 42 63 44 42 36 21 5 2 Aug-16 44 160 36 184 34 51 27 7 9 Community Memorial Hospital

ED Care Triage Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 7,200 2,562 960 x 6 months $157,000 DY3Q4 (3/18) 14,490-966 x 12 months $134,000 Action Steps Recent change (4/19) to expand AEP Definition by suspending the 2 day business notification of PCP or HH CM appointment. The expanded AEP Definition is: Had either a PCP or Health Home Care Manager appointment scheduled within 30 Days of the ED discharge date OR A PCP or Health Home Care Manager appointment scheduled outside of the 30 Days following the ED discharge BUT had been notified of the appointment within 30 Days of the ED discharge * 80% AEP needed to meet target

Care Transitions Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month 3,000 2,500 2,000 1,500 1,000 500 0 Upstate University Hospital St. Joseph's Health Center St. Elizabeth Medical Center Auburn Community Hospital Oneida Health Systems, Inc. Faxton-St Luke's Healthcare Rome Memorial Hospital Lewis County General Hospital Jul-17 120 214 51 100 42 37 1 Jun-17 249 71 60 56 70 42 May-17 251 66 73 49 75 5 Apr-17 228 65 67 64 59 2 6 Mar-17 308 10 83 11 4 5 Feb-17 292 20 58 12 7 1 Oswego Hospital Jan-17 320 14 29 15 19 1 Dec-16 314 188 72 10 43 37 57 2 1 Nov-16 267 178 61 43 53 17 34 5 15 Oct-16 281 212 82 50 54 15 43 4 11 1 Crouse Hospital

Care Transitions Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 2,970 2,123 396 x 6 months $156,000 DY3Q4 (3/18) 5,940-396 x 12 months $134,000 Action Steps Actively Engaged Patient definition has been finalized and approved. All participating Hospitals received the updated AEP and Reporting Requirements All participating Hospital have until August 14 th at 10:00 a.m. to report AEP for April, May and June of 2017. Following this retroactive reporting, it is anticipated that our target numbers will significantly improve. * 80% AEP needed to meet target

700 600 500 400 300 200 100 0 Patient Activation Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month Lewis County General Hospital Oneida Health Systems, Inc. Catholic Charitie s of Ononda ga County Planned Parenth ood of Mohaw k Hudson, Inc. The Salvatio n Army Finger Lakes Migrant Health Care Project Inc. Crouse Hospital Rescue Mission of Utica ACR Health Faxton- St Luke's Healthc are Auburn Commu nity Hospital Catholic Charitie s of Oswego County Regiona l Primary Care Networ k Jul-17 51 41 32 14 5 9 8 24 3 11 4 3 5 1 St. Elizabet h NOCHSI Medical Center North Country Prenata l Perinat al Council Resourc e Center for Indepe ndent Living Arise, Inc. Planned Parenth ood of Central and Wester n NY Jun-17 88 54 18 28 48 30 15 5 3 12 5 17 7 1 11 1 May-17 89 56 79 35 4 30 7 49 17 5 9 12 3 8 3 2 1 1 2 Apr-17 103 35 46 50 5 23 20 74 23 36 12 9 5 14 4 1 2 7 4 2 1 Mar-17 136 53 14 27 15 4 25 14 2 15 2 4 3 7 8 3 4 6 Feb-17 52 33 12 32 27 32 6 34 3 26 7 1 4 4 3 1 1 1 Jan-17 59 41 23 32 5 35 31 8 4 12 1 1 6 14 1 Dec-16 37 16 19 21 9 26 2 7 8 4 3 2 7 Nov-16 70 24 20 109 6 10 4 13 1 9 3 3 Oct-16 27 31 38 5 7 27 8 12 1 4 8 1 Sep-16 35 3 26 2 12 16 10 6 1 1 2 Aug-16 37 12 62 6 8 11 11 3 5 2 4 Lewis County Health Agency Hillside Childre n's Center ElderCh oice, Inc. Hutchin gs Psychia tric Center Upstate Universi ty Hospital Norther n Regiona l Center for Indepe ndent Living

Patient Activation Actively Engaged Patients/Re-Pamming Status DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 11,100 1,442 1480 x 6 months $135,000 DY3Q4 (3/18) 22,300-1,487 x 12 months $116,000 Action Steps Train-the-Trainer Session scheduled for 8/17/17 Quarterly Implementation Meeting 8/30/17 3:00PM-4:00PM Patient Activation Performance Measure 1 Eligible Re-PAM to Date (Through July 2017) Performance Not Hitting Target * 80% AEP needed to meet target

Primary Care/Behavioral Health Integration Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 St. Elizabet h NOCHSI Medical Center Faxton- St Luke's Healthc are St. Joseph' s Health Center Upstate Univers ity Hospita l Planne d Parenth ood of Mohaw k Hudson, Inc. Syracus e Brick House Commu nity Memori al Hospita l Family Care Medical Group Regiona l Primary Care Networ k Jul-17 582 256 285 72 244 214 49 86 123 41 29 18 34 12 13 Jun-17 687 320 422 160 306 420 43 93 82 256 53 54 97 41 34 15 12 May-17 915 410 528 370 399 204 95 113 105 155 214 67 80 7 47 42 27 8 Apr-17 796 445 569 444 175 97 124 100 186 99 46 98 76 62 19 16 8 Mar-17 491 314 179 269 148 275 226 39 72 69 39 59 51 18 10 7 9 18 Feb-17 471 315 176 210 103 249 208 36 92 92 100 46 48 22 58 21 3 16 12 15 Oswego Hospita l Jan-17 577 417 197 252 164 244 205 42 49 55 132 46 41 24 68 30 7 25 19 18 2 Syracus e Commu nity Health Center, Inc. Crouse Hospita l Liberty Resourc es, Inc. Lewis County General Hospita l Finger Lakes Migrant Health Care Project Inc. Oneida Health System s, Inc. Farnha m Inc. United Cerebra l Palsy Dec-16 439 468 170 254 235 263 164 38 63 76 51 28 19 26 23 11 16 28 Mohaw k Valley Psychia tric Service s Auburn Commu nity Hospita l Arise, Inc.

Primary Care/Behavioral Health Integration Actively Engaged Patients DY Target Actual AEP x Month (*) $ At-Risk DY3Q2 (9/17) 16,490 12,299 2,199 x 6 months $142,000 DY3Q4 (3/18) 39,865-2,658 x 12 months $122,000 Action Steps Actively Engaged Patient Reporting Criteria narrows starting April 1 st to align with the 3ai Standards of Care * 80% AEP needed to meet target

Behavioral Health Crisis Stabilization Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month 6,000 5,000 4,000 3,000 2,000 1,000 0 Onondaga Case Managem ent Oswego Hospital Syracuse Brick House Liberty Resources, Inc. St. Joseph's Health Center Syracuse Communit y Health Center, Inc. Arise, Inc. Cayuga County Communit y Mental Health Center The Neighborh ood Center, Inc. Central New York Services Hutchings Psychiatri c Center Mohawk Valley Psychiatri c Services North Country Transition al Living Services Upstate University Hospital Jul-17 59 83 61 25 16 11 2 Unity House of Cayuga County, Inc. Jun-17 443 157 192 94 69 19 21 18 13 2 2 May-17 475 256 168 319 127 26 24 29 18 23 1 4 Apr-17 459 239 149 242 110 21 18 14 21 2 1 Mar-17 172 235 95 35 20 24 3 2 Feb-17 668 257 157 132 109 21 22 20 15 16 Jan-17 745 268 161 133 156 32 47 25 27 31 13 2 2 1 Dec-16 610 259 163 113 136 39 35 24 13 9 2 3 Oswego County Opportuni ties Nov-16 591 252 150 137 141 24 31 19 16 4 7 1 1 4 Farnham Inc.

Behavioral Health Crisis Stabilization Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 10,800 4,033 1,440 x 6 months $135,000 DY3Q4 (3/18) 24,480-1,632 x 12 months $116,000 Action Steps Convening partner-led discussion about Open Access scheduling as a strategy to improve access to services. Workgroup meeting to develop protocols around mobile crisis, peer respite and warm line. Work of the group will continue, but at the county level; exploring overlap with the Care Transition Coalitions and other forums. * 80% AEP needed to meet target

Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 St. Elizabeth Medical Center Faxton-St Luke's Healthcare Upstate University Hospital Rome Memorial Hospital Family Care Medical Group Lewis County General Hospital Syracuse Community Health Center, Inc. Community Memorial Hospital NOCHSI Regional Primary Care Network Physician Care, PC Oneida Health Systems, Inc. St. Joseph's Health Center Jul-17 176 132 45 51 37 29 20 7 14 8 Jun-17 230 179 65 55 86 109 39 31 34 14 23 6 May-17 368 258 89 50 23 81 37 41 17 32 17 23 16 Apr-17 235 93 118 54 81 21 43 48 54 60 8 29 17 Mar-17 218 150 65 31 47 82 29 26 24 3 23 4 Feb-17 218 133 24 26 31 62 14 15 29 23 30 17 13 10 Jan-17 65 166 10 25 65 61 14 22 31 32 32 17 9 Dec-16 46 150 15 21 39 31 4 25 30 23 34 12 1 10 Nov 16 38 136 218 52 70 48 20 35 27 10 16 7 Auburn Community Hospital Oswego Hospital

Cardiovascular Disease Management Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 6,460 3,303 861 x 6 months $104,000 DY3Q4 (3/18) 12,730-849 x 12 months $89,000 Action Steps Supporting partner implementation of Standards of Care. Working with HealtheConnections and other community partners to increase Self-Measured Blood Pressure opportunities to improve patient blood pressure control. Continuing work with Central New York Regional Center for Tobacco Health Systems to support smoking cessation training, 5A s implementation and connections with the NYS Smoker s Quitline. DY3 focus on promotion of community resources and population health management particularly for high risk patients. * 80% AEP needed to meet target 74

Palliative Care Integration Actively Engaged Patient Contribution by Organization by Month 30 25 20 15 10 5 0 St. Elizabeth Medical Center Jul-17 13 Jun-17 4 May-17 1 Mar-17 6

Palliative Care Integration Actively Engaged Patients DY Target Actual AEP / Month (*) $ At-Risk DY3Q2 (9/17) 1,980 18 264 x 6 months $80,000 DY3Q4 (3/18) 3,960-264 x 12 months $69,000 Action Steps Exploring alignment with PCMH and working with Karen Joncas to develop a model for delivery within practices to support implementation. Continued outreach to partner organizations considering the Palliative Care project to help eliminate barriers to engagement Developing repository for IPOS for contracted partners to be able to report Formation of Implementation and Planning Meetings for palliative care integration project partners and community palliative experts to foster/strengthen implementation * 80% AEP needed to meet target 76

Operational Report

New Employees Sue Jessen Director of Project Management and Performance Improvement (315) 703-2976 sue.jessen@cnycares.org Laura Bettina Training Coordinator (315) 703-2988 laura.bettina@cnycares.org Siti Mack Manager for Workforce and Cultural Competency/Health Literacy (315) 703-2978 siti.mack@cnycares.org

Cayuga Next Meeting: TBD