Albany Medical Center AMCH PPS Clinical & Quality Affairs Committee Kallanna Manjunath MD, FAAP, CPE Tara Foster, MS, RN Mingie Kang, MPH Mark Quail, MEd Brendon Smith, PhD Susan Kopp MBA, BSN, RN January 20, 2016
AMCH PPS: Clinical & Quality Affairs (CQA) Committee Presentation Objectives: Committee Charter Review and Approval CQAC Membership Survey - Summary Project Implementation Update PHM System Acquisition Bridge solution
AMCH PPS Organizational Structure - CQAC -- re ri ge is t st ele edi ine BH Integration B risis t ili tion
CQAC - MISSION STATEMENT The purpose of the Clinical and Quality Affairs (CQA) Committee of AMCH PPS is to facilitate and support the development of a high-performing integrated health care delivery system designed to improve access to timely, effective, efficient, quality and patient-centered system of care. Specifically, by year 2020, the CQA committee will support the transformation of the Medicaid health care delivery system across AMCH PPS to: Provide a community-based approach to care through the integration of services Enhance patient experience and improve clinical outcomes Reduce avoidable Emergency Department use and Inpatient Admissions Improve key population health measures Reduce system-wide cost of care by transitioning to a Value-Based Payment System 4
CQAC CHARTER Key Roles Oversee the development of a roadmap to a clinically integrated network required to improve patient access and enhance quality of care. Assure active practitioner engagement by fostering the development and adoption of practice guidelines and evidence-based protocols. Develop a specific care transition strategy for hospital admission and discharge coordination, along with care coordination, and communication among primary care, specialty care, and behavioral health systems of care. Establish project-specific sub-committee structure to achieve project objectives. Assist primary care practitioners in achieving NCQA 2014 Level-3 PCMH recognition and meeting EHR Meaningful Use standards by the end of by the end of 2017 5
Health Home At-Risk Intervention Objective: To facilitate the expansion of access to community primary care services and development of integrated care teams to meet the individual needs of higher risk patients who do not qualify for care management services from Health Homes under current NYS HH standards Charge: Facilitate partnerships and agreements between primary care providers, local Health Homes and other providers for care management services and resources. In collaboration with other sub-committees & workgroups, develop a CC / CM plan that outlines the roles of the identified providers and organization. identify required EHR capabilities and workflows to support implementation and documentation of CC / CM activities. Identify hotspots for HH at-risk populations across AMCH PPS region 6
ED Care Triage Objective: To facilitate development of an evidence-based care coordination and transitional care program that will assist patients to link with a primary care physician/practitioner, support patient confidence in understanding and self-management of personal health condition(s), improve provider to provider communication, and provide supportive assistance to transitioning members to the least restrictive environment. Charge: Identify participating providers and/or sites, including HH providers, Care Management & BH providers. Identify at-risk population and hotspots across PPS region. Complete a project specific current state assessment & Define the future state. Facilitate partnerships between Participating EDs and community primary care providers. Facilitate the implementation of processes to connect patients with non-emergency needs to a primary care provider 7
Primary Care & BH Integration Objective: To integrate primary care & behavioral health services in order to provide coordinated and effective care. Charge: Identify and engage key primary care and/or behavioral health team members Facilitate the education of practitioners on the benefits of co-located services and the IMPACT model Facilitate the development of evidence-based best practice models for PC & BH care Support the development, implementation, and evaluation of policies and protocols for universal screening for behavioral health conditions using evidence-based tools (e.g., PHQ 2). Facilitate ssess ent of providers urrent pro edures for n ging p tients w o re eive positive behavioral health screen. Support t e re tion, i ple ent tion, nd ev lu tion of proto ols for w r ndoffs of t ese patients 8
BH Community Crisis Stabilization Objective: To facilitate the provision of readily accessible behavioral health crisis stabilization services that allow access to appropriate levels of care and support rapid de-escalation of crises Charge: Support the development of regionally-based behavioral health community crisis stabilization programs that include outreach, mobile crisis, and intensive crisis services. Facilitate evaluation of the policies, procedures, resources, and adequacy of the current community-based crisis stabilization services across the PPS. Facilitate implementation of evidence-based protocols and guidelines for central crisis triage services With the ED Triage sub-committee, review evidence-based programs for emergency department diversion for behavioral health crises, and support the development or updating of such diversion protocols as necessary. 9
Cardiovascular Disease Project Objective: To support implementation of evidence-based best practices for disease management in medical practice for adults with cardiovascular conditions Charge: Collaborate with partners to review and adopt national/regional clinical practice guidelines for management of hypertension and elevated cholesterol. Facilitate the establishment of practice/community based care coordination teams to address lifestyle changes, medication adherence, health literacy issues, and confidence in selfmanagement. Develop and approve protocols for implementation of home blood pressure monitoring Facilitate "hot spotting" strategies in high risk neighborhoods utilizing valid and reliable REAL (Race, Ethnicity, and Language) data and establish linkages to Health Homes for the implementation of the Stanford Model for chronic diseases. 10
Cardiovascular Disease Project Charge (contd.): Facilitate deployment of a comprehensive population health system across PPS and at participating organizations to support an effective patient tracking and population health management strategy. Facilitate the adoption of processes to identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension, patients who have not had a recent visit for blood pressure check and schedule them for a hypertension visit. 11
Asthma & Telemedicine Project Objective: To ensure access for patients with asthma to care consistent with evidence-based medicine guidelines for asthma management. Charge: Facilitate, in collaboration with the project sub-committee and clinical experts across the PPS, developing a draft document defining the future state for the management of asthma utilizing evidence-based strategies. Facilitate the implementation of national guidelines for asthma management and protocols for access to asthma specialists. Collaborate with Albany Medical College and other educational institutions to conduct annual CE programs to update practitioners and staff on new developments in asthma care and management. 12
Asthma & Telemedicine Project Charge (contd.): Facilitate agreements with MCO for support of care coordination of services for asthma related issues, home-based trigger control and self-management support, smoking cessation services, and other services relevant to this project. Collaborate with TDMC to establish a comprehensive population health system across PPS and at participating organizations to support an effective patient tracking and population health management strategy including identification of patients who have not had a recent visit for asthma check and patients who have not been provided with asthma action plan in the previous 6 months. Facilitate the evaluation of the impact of telemedicine program to serve underserved areas and development of a draft implementation plan to establish a program. 13
CQAC - Membership Survey What do you feel are your roles and responsibilities as a member of CQAC? Any additional ways your experience and expertise might be of benefit to the CQAC and its activities? CQAC meetings: A lot of helpful information has been presented during the monthly meetings. Has this information been helpful to you in understanding DSRIP and the goals of the projects? Do you have any specific feedback on how to improve the process of the CQAC? 14
AMCH PPS: Project Updates
ED Care Triage Subcommittee Update First Official Meeting on Dec 22 nd, 2015 Subcommittee Chair: Dr. Denis Pauze Members: ED directors and representatives from case management at Albany Med, Saratoga, and Columbia Memorial Hospitals Agenda: Review of the Subcommittee roles and responsibilities Review of the project implementation steps Subcommittee membership Next Meeting on Feb 1 st, 2016 at 10am via WebEx
ED Care Triage Subcommittee Update Cont d Stakeholder Engagement Meetings Saratoga Hospital: presentation to the Leadership and Department Managers on January 6 th Albany Med: presentation to the ED attending on January 26 th Columbia Memorial: presentation to the ED department on January 27 th Please reach out to Mingie Kang (kangm1@mail.amc.edu) if your team would like to learn more about this project.
Project 2.d.i Updates Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/ non-utilizing Medicaid populations into Community Based Care December 2015 roll out the PAM Train the trainer method. Initial PAM Trainings facilitated with our 3 major hospital partners (AMCH, Columbia Memorial & Saratoga Hospital). CBO partners & local government entities were also trained on PAM (Catholic Charities, Planned Parenthood, Healthcare Consortium, Columbia County Mental Health, Greene County Family Planning) Total PAM Trained Individuals as of 01/20/2016 is 70. Total number of PAM Surveys completed as of 01/20/2016 is 20. The PMO Project Team continues to roll out the train the trainer method across our PPS network.
5 County Service Area (targeting hotspots) Train the trainer trainings 1. Columbia Memorial Hospital 2. AMCH Practice Administrators 3. Saratoga Hospital 4. Various CBOs Future Trainings 1. Community Caregivers (01/21/16) The PMO Project Team continues to roll out the train the trainer method across our PPS network.
Project Implementation: Next Phase Asthma & Telemedicine Project WebEx presentation on January 21, 2016 at 1 PM 3 objectives for utilizing the webinar approach: Communicating project-specific information Creating a mechanism for feedback Identifying what our partners understand their roles to be, and further insight to their level of interest Cardiovascular Disease Project Health Home at Risk Project Behavioral Health Projects
Behavioral Health Projects update Projects: 3.a.i Integration of Primary Care and Behavioral Health Services 3.a.ii Behavioral Health Community Crisis Stabilization Services Current status of projects, and next steps The role of CQAC 21
DRAFT FOR DISCUSSION Insight Driven Health AMCH DSRIP Interim Phase CQAC January 20, 2016 Copyright 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. Copyright 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 22
DRAFT FOR DISCUSSION Agenda Overview of approach Assumptions Copyright 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 23
DRAFT FOR DISCUSSION Project Overview and Deliverables Three deliverables will be completed during the month of January Milestone Breakdown Functional Category Identification Work Plans Work with PMO to: Review each milestone and understand, based on DOH reporting and validation protocols, activities across people / process / technology Identify enabling activities to complete each milestone Create visual diagrams to represent involved activities Identify functional categories across milestones based on enabling activities (18 mths) Functional categories will be used to organize and align projects to impact several project metrics simultaneously Develop work plans for each functional category (18 mths) Technology inputs identified in the milestone breakdown will be entered in an estimator, which will produce a work plan Copyright 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 24
Assumptions DRAFT FOR DISCUSSION The scope of the detailed project work plans can be categorized by milestone requirement and focused based on assumptions 115 Project Milestones 74 milestones within next 18 months 35 milestones requiring Technology Assumptions There are 115 total milestones across 11 projects Interim solutions will be built for the next 18 months, so milestones ending before or on 9/30/17 were considered Work plans are to be built around milestones requiring Technology Focus on Tier 1 affiliates Based on these assumptions, 35 milestones were reviewed to identify enabling activities to complete each milestone; these milestones span 12 functional categories Focus on Tier 1 12 functional categories Copyright 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture. 25