3bi Cardiovascular Disease Management – 3/15/16

Attendees

Amanda Beattie , Christine Close , Kara Corey, Thomas Filiak, D Anthony Gray, Gale Grunert, Bruce Hathaway, Emilie Hauger, Penny Ingham, Uzma Iqbal, Stacey Keefe, Heather Kemmis, Brenda LaMay, Steven Mariani, George Markwardt, Kim McNamara, Mary Jane Milano, Gagan Singh, Dawn Sampson, Tim Scanlon, Michelle Slade, Michael Svendsen, Sherry Willis Buglione, Ann Marie Derecola, Lisa Larkin, Tom Norton CNYCC: Karen Joncas, Shana Rowan, Kate Weidman JSI: Alec McKinney, Eric Turer

Discussion

Introductions Eric Turer – JSI Target Workforce State Analysis and Planning Overview (Slideshow) For discussion today is how we are going to plan for and target the workforce state of the future of Cardiovascular Disease Management/3bi. We acknowledge that partners are all at various stages of implementation. We are currently focusing on prevention strategies and amelioration as well as the concept of the care coordination team. Slide: Workforce Milestones flow chart Slide: Purpose of Developing Target Workforce Plan

- Satisfy DSRIP Workforce Reporting Requirements (plan due June 2016) - Internal PPS Planning - Monitoring of Implementation and Progress

As Workforce data flows back in, we can see how requirements are being met. Slide: Plan – People → Process → Outputs → Outcomes

- Outcome Goal (25% reduction in ED use/avoidable hospitalization) - Output goal: speed and scale of patient engagement - Plan, People, Process (staffing needs – hiring vs. redeployment vs. retraining)

Slide: Developing the Target State plan – Preliminary Steps

- Definition of Job Titles and FTE (initial targets submitted to DOH in 2014) - Project Workforce Planning Template

Developing the Target State Plan – Next Steps

- Review with Workforce Workgroup - Review/Revise with PICs - Discuss with Partner Organizations - Monitor against ongoing reporting by partners

Slide: Staffing Changes/Staffing Assumptions spreadsheet

Discussion (continued)

- NP/PA, NP/PA, RN, Dietician, Social Worker, Health Coaches The care coordination element is very important, and there are a number of components that participating sites are required to have on-board (on-site or subcontracted) with required employee types to ensure patient needs are met. The hiring model is important, but it will not just be participants in the project who will be hiring. Retraining, versus hiring new staff, may be a better option for some organizations. The assumptions in the spreadsheet may be slightly off, as qualified staff in this region may not exist as specified in worksheet. Clinical Governance Committee Update

- Approved as-presented guidelines listed in agenda. - Next step is training, retraining and monitoring of training of strategies – we expect

a new Workforce Strategy Project Manager hire in the next month - We are looking into copyright issues that are preventing us from making many of

these documents public, particularly related to published guidelines and medication recommendations.

Slide- Actively Engaged Patient Goals/Update

- Eligible to report: organizations that provide primary care, and that treat patients with cardiovascular disease or hypertension

- Reporting criteria: Adult Medicaid patients with active applicable cardiovascular disease diagnoses and a documented self-management goal in health record

Slide: CVD reporting: DY1Q4 target is 300, current number is 0. No reporting partners as of March 11. (Update as of March 15- 125 patients) (Update as of March 31-519 patients) Slide: CVD Management Reporting

- Table of future targets presented with highlights on exponential increases beginning DY2Q1

Some practices are working with patients on self-management goals; there are many IT issues that have precluded these patients from being identified. These issues are being reviewed. Telephone Survey on Current State Karen Joncas stated she is undergoing an assessment of current CVDM practices and asked that primary care partners look for a telephone call to set up a session in the coming weeks regarding seeking input needed on our current state. New Workgroup Charge Needed We will also be looking for PIC approval on a new charge for the clinical work group, now that the Clinical Governance Committee has approved the clinical workgroup recommendations. The new charge will be issues related to the implementation of these

PIC Member Q & A

recommendations. Dr. Iqbal asked whether home blood pressure monitoring equipment is covered by Medicaid. If not, this is a potential barrier. Michelle Slade shared that review of the Medicaid manual indicates that part of the cost may be covered. There is also the need to assess the need for manual vs automatic equipment. There may be a need for partners to secure agreements with vendors. Michelle Slade also shared that they are doing a manual review of patients with hypertension and self-management goals, starting in October of last year to in order to report patients. Clinic staff is being asked to do chart reviews to verify self-management goal documentation. Next Steps

- Planning template will be reviewed at the next PIC - Development of training strategies - New workgroup charge- - Next PIC meeting – 4/19/16

Central New York Care Collaborative

3bi: Cardiovascular Disease ManagementProject Implementation Collaborative

Target Workforce State Analysis and Planning Overview

March 15, 2016

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Project Summary• Develop community and practice-level resources to promote

collaboration and help practitioners to assist their patients with: Primary and secondary preventive strategies to reduce risk factors Ameliorate the long term consequences of cardiovascular diseases

and other associated chronic diseases• Optionally promote participation in the Million Hearts Campaign• Meet Meaningful Use Stage 2 CMS requirements and connect with HIE• Adopt evidenced-based standards, protocols, regimens, and outreach

practices• Adopt care coordination teams, including use of nursing staff,

pharmacists, dieticians and community health workers

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Workforce Milestones

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Purpose of Developing Target Workforce Plan• Satisfy DSRIP Reporting Requirements Plan Due June 2016

• Baseline & Target FTE, Impact Analysis• Internal PPS Planning Program Level

• Project Level• Partner Level

• Monitoring of Implementation and Progress Plan becomes the benchmark

• Examine against partner on-boarding and workforce reporting• Make adjustments as needed and assess impact on reaching

patient engagement goals

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Plan → People → Process → Outputs → Outcomes• Outcome Goal:

• 25% reductions in ED use and avoidable hospitalization• Output Goal: Speed and Scale of patient engagement

• 3bi: 26,800 Medicaid patients with Cardiovascular Disease or hypertension (an associated risk factor) with documented and reviewed self-management goals in the medical record

• Measured for Achievement Value• Plan, People, Process What types of staff will be needed? What are their roles? How will

they interact with each other?... with patients?• FTE, Job titles, degree/license requirements?

Where will they come from?• Hire, Redeploy, Retrain

When are they needed?• Lead Times: to hire; to train; to reach full capacity (ramp-up)

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Developing the Target State Plan – Preliminary Steps• Definition of Job Titles and FTE Initial targets submitted to DOH in Dec. 2014

• Subsequently revised by CNY staff and consultants• Project/partner input needed for final submission and plan

• Project Workforce Planning Template Incorporates assumptions about lead times, FTE increments,

sourcing of staff, and associated costs Calculates patient load and staffing ratios as a reference point

• Consider which positions are ‘volume dependent’ Integrates with Speed and Scale targets to produce period-

specific staffing needed to reach goals Flexible to permit adjustments as input is received

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Developing the Target State Plan – Next Steps• Review with Workforce Workgroup (10/30/15) Obtain feedback on overall concept and utility

Review/Revise with PICs (today and forward) Adjust staffing categories, requirements, and FTE targets

• Consider implied staffing ratios and patient loads Set other assumptions

• Anticipated staff sourcing• Lag Times for hiring, training, ramp up

• Discuss with Partner Organizations Consider individual organization’s targets and assess alignment with

goals and contribution towards target state• Monitor against ongoing reporting by partners

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Review of Sample Project Workforce Template

Discussion / Questions

ERIC S. TURERSENIOR HEALTH SERVICES CONSULTANT

501 SOUTH STREET, BOW NH 03304PHONE: (603)573-3307 EMAIL: eturer@jsi.com

WWW.JSI.COM

Cardiovascular Disease Management Reporting

Who is Eligible to Report:• Organizations that provide primary care that treat patients with Cardiovascular

Disease or Hypertension

Reporting Criteria:• Adult Medicaid patients with active applicable CVD diagnoses with a documented

self-management goal in their health record• Encounter date where self-management goals are documented

Payment for Reporting• $60.99 (net)/$71.75 (gross) PMPY

Does this sound like your organization?Michele Treinin, Project Manager for Data and Reporting

michele.treinin@cnycares.org

Cardiovascular Disease Management Reporting Actively Engaged Patients

DY1 Q4 Targets

Reporting Partners• None (as of March 11)

Cardiovascular Disease Management Reporting

Q DUE Target Actual Status

DY1 Q4 300 0

Future Targets

Cardiovascular Disease Management Reporting

Quarter TargetDY2 Q1 1850DY2 Q2 3400DY2 Q3 5100DY2 Q4 6800DY3 Q1 3400DY3 Q2 6800DY3 Q3 10,100DY3 Q4 13,400DY4 Q1 6,800DY4 Q2 13,400DY4 Q3 20,100DY4 Q4 26,800DY5 Q1 6,800DY5 Q2 13,400DY5 Q3 20,100DY5 Q4 26,800