Community Needs Assessment for Albany Medical PPS Stage 1 Summary Results 1 HCDI Assessment Team 9/29/14
HCDI Assessment Team Healthy Capital District Initiative Project Management Kevin Jobin-Davis, Executive Director Michael Medvesky Public Health Input Next Wave Policy & Data Linking, Benchmarking John Shaw, President Colleen McVeigh, Information Manager Kormos and Company LLC Mapping, Stakeholder and Recipient Feedback Liz Kormos, President 2 Healthy Capital District Initiative www.hcdiny.org
Person-Centered CNA: Link All Available Driver Data to Better Target Community Resources & Needs Health Systems Forces Service Availability Socio-Demographic Drivers Individual & Community In Current Models Outcomes: Avoidable Encounters IP Admissions IP Readmissions ED Visits NOT In Current Models 3 Clinical Characteristics #&Severity: Co-Morbid and Chronic Conditions Behavioral Health Needs Primary & Co-morbid Mental & Substance
Driving Towards An Effective DSRIP PPS Improvement Plan Literature, Best Practice Tools, Trends Validate Local Benchmark Data Stage 1 Data Supporting Promising Targets & Preliminary Target Selection Stage 2 Stakeholder Input Quantitative Input Prevention Indicators Performance Indicators Providers/Encounters Measurable Drivers Outcomes/Impacts Refinements Feasibility ROI Pick Qualitative Input Expert Interviews Web Surveys Listening Sessions Focus Groups DOH Support Contractor Input 4
CHIP-CSP Summary 5 All Counties - Mental Health/Substance Abuse Reducing opiate abuse, improving the mental health infrastructure or reducing suicide All but one County (Warren) - Obesity or Diabetes 5 Counties - Chronic Disease Preventive Care and Management Diabetes; CHF; Asthma/COPD 3 Counties - Asthma including preventive care and management 3 Counties - Smoking-Related Illness 2 Counties - Adolescent Pregnancy/Risky Sexual Behavior Other focus areas: Tick-borne Diseases(2); HAI(1); Occupational Injuries(1); Reduction of Inappropriate ED Use(1) Healthy Capital District Initiative www.hcdiny.org
6 NYSDOH Prevention Agenda Data Supporting Domain 2, 3, & 4 Projects
7 NYSDOH Prevention Agenda Data Supporting Initial Project Consideration
Prevention Quality Indicators (PQI)-Adults Risk-adjusted Rates per 10,000; All Payer and Medicaid Chronic PQI 8 Healthy Capital District Initiative www.hcdiny.org
Pediatric Quality Indicators (PDI)-Children Risk-adjusted Rates per 10,000; All Payer and Medicaid Overall PDI 9 Healthy Capital District Initiative www.hcdiny.org
Potentially Preventable Emergency Visits (PPV) Risk-adjusted Rates per 100; All Payer and Medicaid Overall 10 Healthy Capital District Initiative www.hcdiny.org
Potentially Preventable Readmission Rates (PPR) Risk-adjusted Rates per 100 At Risk Admissions; All Payer and Medicaid Overall 11 Healthy Capital District Initiative www.hcdiny.org
New SPARCS Analysis Findings Affecting Stage 1 Project Classification Dual Eligibility Confirmed as Most Important Driver High Physical Need and Limited Other Fiscal Resources Duals are 2.4 times higher risk for readmission Behavioral Health (BH) Need Patterns Within Uninsured Similar to Medicaid Support for Targeting Both Together Some Coverage Effect Less Overall Use if paid out-of-pocket 12
Major Findings Affecting Stage 1 Project Classification (cont.) DSRIP Behavioral Health Definition (Pdx) only identifies 24% of Population with Behavioral Health (BH) Needs Similar Impact for BH_DSRIP and BH Any within each Payor Combine for Simplicity Just use BH Any Refined BH Metrics Second Most Important Drivers Pervasive Across ALL Counties, See Maps for Hot Spots Provides Strong Support for all BH Specific Projects Add as Focus in IDS, Care Transitions, Health Home at Risk 13
Major Findings Affecting Stage 1 Project Classification (cont.) Comorbid MI&SUD (any Severity) Highest Risk For Medicare, MI&SUD adds Risk on top of other high needs For Non-Medicare, MI&SUD equivalent to Severity 4 or higher For Non-Medicare Payors, Readmission Risk Increases Steeply with BH Severity Significant Age Variation Noted vs. Benchmark Address in Project Targeting in Stage 2 14
15 30 Day Readmission Risk: BH Impacts Within Payors
Behavioral Health Opportunity Targeting 16 September 29, 2014
BH Target Opportunities 17 September 12, 2014
30 Day Readmission Risk: Age Impacts Combined Payors 18 Capital Region Better than NYS for Older Adults, Worse for Younger Similar Pattern for Other Payors; Stage 2 look for practice patterns
Stage 1 - Where We Are Now: Project Selection - Categories 19 1. Sufficient Need Evidence, and Selected Need DSRIP PPS PAC Confirmation Focus drill down into specific program details and geography 2. Selected, Additional Evidence Needed Additional evidence gathered to Continue or Drop Assuming evidence found, continue for details and geography 3. Not Selected, Evidence of Need Found Consider for Details within Domain 2 Projects Consider for Fall-Back Projects if Necessary 4. Originally Selected, Not Currently Chosen Consider for Details within Domain 2 Projects September 29, 2014
Sufficient Evidence and Selected DSRIP Project List Project Number Description B. Domain 2: System Transformation Projects Implementation of Care Coordination and Transitional Care Programs Albany Med PPS Score Numbers Impacts ER Use Target Counties 2.b.iii ED care triage for at risk populations Domain 3: Clinical Improvement Projects A. Behavioral Health 3.a.i Integration of primary care and behavioral health services Current selection 43 Current selection 39 PPV 55,237 cases (6 county area) (Albany Co 17,237) Behav admitted 9,165 (Albany Co 2,992), ER visits 31,410 depression, 20,167 stress, etc. High impact on ER visits Medium impact on Behav ER visits Albany, Schenectady, Rensselaer Greene, Rensselaer, Saratoga, Columbia 20
Selected and Additional Evidence Needed Domain 2 DSRIP Project List Project Number Description Domain 2: System Transformation Projects A. Create Integrated Delivery Systems 2.a.ii B. Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP)) Implementation of Care Coordination and Transitional Care Programs Albany Med PPS Score Numbers Impacts ER Use Target Counties Current selection 37 PQI 1,922 prev admits, 4,460 readmit (6 county area) small Greene, Columbia, Rensselaer low primary care (630 admits, 1,241 readmits) 2.b.iv 2.b.ix D. 2.d.i 21 Care transitions intervention model to reduce 30 day readmissions for chronic health conditions Implementation of observational programs in hospitals Utilizing Patient Activation to Expand Access to Community Based Care for Special Populations Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non utilizing Medicaid populations into Community Based Care Current selection 43 Current selection 36 R30 4,460 (6 county area) (Albany Co 1,517) Some impact Prev admits 1,922 (6 county area) (AlbanyCo 680) small Albany, Schenectady, Saratoga Except for minority populations, Warren is the only county that has demonstrated need x (11th project) NA yes Probably Columbia, Greene
Selected and Additional Evidence Needed Domain 3 & 4 DSRIP Project List Project Number Description Domain 3: Clinical Improvement Projects A. Behavioral Health C Diabetes Care 3.c.i Evidence based strategies for disease management in high risk/affected populations (adults only) Current selection 30 Implementation of evidence based strategies to address chronic 3.c.ii disease primary and secondary prevention projects (adults only) 26 D. Asthma Albany Med PPS Score Numbers Impacts ER Use Target Counties Diabetes 383 avoid inpatient, Diabetes 24,542 ER visits Some impact Schenectady, Albany, Rensselaer Development of evidence based medication adherence programs 3.d.i (MAP) in community settings asthma medication F. Perinatal Care 3.f.i 22 Increase support programs for maternal & child health (including high risk pregnancies) (Example: Nurse Family Partnership) Domain 4: Population-wide Projects: New York Prevention Agenda C. Prevent HIV and STDs 4.c.iii Decrease STD morbidity D. Promote Healthy Women, Infants and Children 4.d.i Reduce premature births Current selection 29 Asthma ER visits 26,828 Some impact Current selection 32 TBD Current selection 15 Current selection 24 Relates to Domain 3 HIV/STD projects TBD, related to 3.f.i High risk pregnancies Some impact on ER visits (prevent premature births & complications) low Some impact on ER visits (prevent premature births & complications) Albany, Schenectady, Rensselaer Albany, Schenectady, Columbia, Greene Albany, Schenectady high rates of STD Albany, Schenectady, Columbia, Greene
Not Selected and Evidence of Need Domain 2 & 3 DSRIP Project List Project Number Description B. 2.b.ii Domain 2: System Transformation Projects Implementation of Care Coordination and Transitional Care Programs Development of co located primary care services in the emergency department (ED) Consider 40 Domain 3: Clinical Improvement Projects A. Behavioral Health 3.a.ii Behavioral health community crisis stabilization services Consider 37 Albany Med PPS Score Numbers Impacts ER Use Target Counties PPV 55,237 cases (6 county area) (Albany Co 17,237) Behav admitted 9,165 (Albany Co 2,992), ER visits 31,410 depression, 20,167 stress, etc. High impact on ER visits Yes, large impact on Behav ER visits Green, Columbia, Rensselaer low primary care (6,570 PPV) Albany, Schenectady, Rensselaer, Saratoga B. Cardiovascular Health Implementation of Million Hearts Campaign Evidence based strategies for disease management in high 3.b.i risk/affected populations (adult only) D. Asthma Original selection 30 Cardiovascul ER top cases 64,545 (Albany 23,716); Hypertension in ER 31,707 (Albany 11,593) Impact on hypertension ER visits Albany, Schenectady, Rensselaer 23 3.d.ii Expansion of asthma home based self management program Consider 31 Asthma ER visits 26,829 Higher impact more ED focus Albany, Schenectady, Rensselaer
Not Selected and Evidence of Need Domain 4 DSRIP Project List Project Number Description Domain 4: Population-wide Projects: New York Prevention Agenda A. Promote Mental Health and Prevent Substance Abuse (MHSA) Strengthen Mental Health and Substance Abuse Infrastructure across 4.a.iii Systems Consider 20 B. Prevent Chronic Diseases 4.b.i. Promote tobacco use cessation, especially among low SES populations and those with poor mental health. Consider 23 Albany Med PPS Score Numbers Impacts ER Use Target Counties Behav admitted 9,165 (Albany Co 2,992), ER visits 31,410 depression, 20,167 stress, etc. ER visits Asthma 26,828, COPD 8,901, other Pulmonary 7,308 Lower impact on ER visits Lower impact on ER visits Albany, Saratoga, Warren, Columbia Columbia, Greene high % smoking; Rensselaer Lung cancer, COPD; see asthma project 24
Originally Selected and Not Chosen Domain 2 & 3 DSRIP Project List Project Number Description Domain 2: System Transformation Projects A. Create Integrated Delivery Systems Albany Med PPS Score Numbers Impacts ER Use Target Counties 2.a.i B. Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management Implementation of Care Coordination and Transitional Care Programs Original selection 56 PPV 55,237 cases (Albany Co 17,237) yes Albany, Schenectady, Rensselaer, Saratoga 2.b.viii Hospital Home Care Collaboration Solutions Domain 3: Clinical Improvement Projects A. Behavioral Health 3.a.iii Implementation of evidence based medication adherence programs (MAP) in community based sites for behavioral health medication compliance Original selection 45 Original selection 29 Prev admits 1,922 (AlbanyCo 680), R30 4,460 (Albany Co. 1,517) Behav admitted 9,165 (Albany Co 2,992), ER visits 31,410 depression, 20,167 stress, etc. small Lower impact on ER visits Albany, Schenectady, Rensselaer, Saratoga Albany, Schenectady, Rensselaer, Saratoga 25 B. Cardiovascular Health Implementation of Million Hearts Campaign Implementation of evidence based strategies in the community to address chronic disease primary and secondary prevention projects 3.b.ii (adult only) E. HIV/AIDS Comprehensive Strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations development of a Center of 3.e.i Excellence for Management of HIV/AIDS Original selection 26 Cardiovascul ER top cases 64,545 (Albany 23,716); Hypertension in ER 31,707 (Albany 11,593) Some impact Original selection 28 TBD TBD Rensselaer, Albany, Columbia, Schenectady Schenectady, Greene, Albany
Originally Selected and Not Chosen Domain 4 DSRIP Project List Project Number Description Domain 4: Population-wide Projects: New York Prevention Agenda A. Promote Mental Health and Prevent Substance Abuse (MHSA) Promote mental, emotional and behavioral (MEB) well being in 4.a.i communities B. Prevent Chronic Diseases Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings (Note: This project targets chronic diseases that are not included in domain 3, 4.b.ii such as cancer Albany Med PPS Score Numbers Impacts ER Use Target Counties Original selection 20 Original selection 17 26
27 DSRIP DOH ER by Diagnosis
28 DSRIP Admit Trends
29 DSRIP Clinical Improvement
Geographic Analysis Potential Target Geographies Looking for High Rates and High Numbers Stage II Provider Resources Community Based Resources Further Drill-Down analysis Some Examples Follow 30
31 Emergency Department Rates
32 PQI Frequent Flyers (Drill Down to Capital Region South)
33 Total PQI Admits and Primary Care Providers
High Severity/Risk Behavioral Health Population (Drill Down to Capital Region North) 34
35 Behavioral Health Need and BH Providers
36 Uninsured: Targets for Project 11
Conclusions and Next Steps ROI Calculations to Demonstrate to DOH that Projects Aligned with CNA Evidence Outline and Refine Program Details CNA will Assist Project Teams to Refine/Align Stakeholder Engagement Timeline 37
Next Steps: Qualitative Input Plan: Parallel Goals ID Promising Topics and Locations: Stage 1 Community Needs Assessment Steering Committee & PAC Input Project Selection, Subject Matter Details Webinar General Partner Initial Input Fill Knowledge Gaps Online Survey Check & Open-Ended Listening Sessions Stakeholder Education & Engagement 38 Focus Groups
NEXT STEPS Stakeholder Online Survey 39 Albany Med PPS verifies Provider database & Community Based Organization database Need key contact, practice/service location and email address Phase I Survey Basic Information Phase II Survey (if needed) Questions directed to specific providers/cbos on specific projects
NEXT STEPS Consumer/Patient Online Survey Specific Population in Targeted Area Project Specific Questions Developed in conjunction with workgroups CBO s to identify and assist in survey completion at their sites Incentive drawing 40
NEXT STEPS Listening Sessions Listening Sessions (estimated 6) Project and Geography Specific Participants: Health Care Providers, Community Based Providers, Recipients, IHANY, PAC 41
NEXT STEPS Focus Groups Focus Groups (estimated 4) Project and Geography Specific Participants: Facilitator and Targeted Patient Population Outside vendor 42
Timeline Analysis, ROI, Stakeholder Engagement, Project Support, and CNA Report Ongoing Stakeholder Engagement and Key Informant Contacts Community & Program ID Contacts Update Contacts Webinar Web Surveys Focus Groups Draft Partner List Due Listening Sessions Oct. 16 Listening Sessions (if Needed) Final Partner List Due Dec. 1 Dec. 16 43 Sept. 29 Nov. 1 Nov. 16 Initial CNA Section Drafts Final Draft CNA Thematic Coding of Qualitative Input Stage 2 Drill Downs Align with Stakeholder Input Review/Refine CNA Proposal Due Review Program Proposal Consistency with CNA
Contact Kevin Jobin-Davis, Ph.D. Executive Director Healthy Capital District Initiative 315 Sheridan Ave. Albany, NY 12206 (518) 462-1459 kjobin-davis@hcdiny.org www.hcdiny.org 44 Healthy Capital District Initiative www.hcdiny.org