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NYP/Q DSRIP Executive Committee Meeting

Thursday July 28, 2016- 4:00p.m.-5:00p.m. – KW Board Room

EXECUTIVE COMMITTEE MEMBERS:

Maureen Buglino (Chair) - NewYork-Presbyterian/Queens

Anthony Somogyi M.D. (Vice-Chair) - NewYork-Presbyterian/Queens

Maria D’Urso - NewYork-Presbyterian/Queens

Chris Caufield - NewYork-Presbyterian/Queens

Mark Greaker - NewYork-Presbyterian/Queens

John Lavin - Mental Health Provider of Western Queens

Daniel Muskin - The Grand Nursing Home

Lorraine Orlando - NewYork-Presbyterian/Queens

Faivish Pewzner - Americare

Ashook Ramsaran - PAC Member

Michael Tretola - Silvercrest Center for Nursing and Rehabilitation

Paul Vitale - Queens Coordinated Care Partners

AGENDA:

I. Welcome M. Buglino

II. Review & Approve Minutes of Previous Meeting – Action Item M. Buglino

III. PPS Network Changes– Action Item M. Buglino

a. Voluntary Removal of Partners

b. Opt-Out Letter

IV. Workforce– Action Item L. Orlando

a. Target State

V. IT Systems– Action Item M. Greaker

a. Plan for Attributed Patients in QE

b. IT Security Plan

VI. Performance Reporting Strategy – Action Item A. Simmons

VII. Mid-Point Assessment M. Buglino

a. Project & Organizational Narratives

VIII. Compliance Update D. Marsden

IX. Questions / Open Discussion

X. Adjourn

NYP/Queens PPS Opt-Out Partners

NYP/Queens PPS Opt-Out Partners

Partner Opt-Out Reason

Bernard Fineson Developmental Disabilities Services Office

As Per Ann Morgan, the Partner has requested to be disenrolled in the NYPQ DSRIP PPS

The Fortune Society As Per Lisa Taylor, The Fortune Society has requested to be disenrolled from the NYPQ DSRIP PPS due to their internal decision to not participate.

Yohan and Jia Park (Private MD and NYP/Q) As Per Maria, Dr. Yohan and Jia Park have requested to be disenrolled from the NYPQ DSRIP PPS.

Mohammad Rahman As Per Dr. Rahman, requested to be disenrolled from the NYPQ DSRIP PPS due to time constraints.

NYPQ DSRIP OPT-OUT LETTER

July 12, 2016

NewYork-Presbyterian/Queens

DSRIP Project Management Office

56-30 Main Street

Flushing NY 11355

To whom this may be concerns,

This letter is regarding an opt-out option from the Delivery System Reform Incentive Program (DSRIP)

within the NewYork-Presbyterian/Queens PPS.

________________________ has requested to opt-out of participating in NYS DSRIP program with the

NewYork-Presbyterian/Queens PPS.(NAME) has confirmed that they are unable or unwilling to continue

to participate in the clinical projects and provide the required data to meet the expectations of the

program. Based on the feedback received by the PPS, (NAME) has indicated the following reasons for

disengaging from the DSRIP program: ☐ Time Constraints

☐ Lack of resources

☐ Too Many Requirements from the PPS

☐ Focus on engagement in a different PPS

☐ Other: _______________________________________

The Project Management Office will submit all required documentation to the NYS DOH to request the

removal of ______________________ from the NYP/Q PPS Network in August 2016.

By signing this opt-out letter it confirms that ________________ will no longer be a member of the

NYP/Q PPS Network.

Thank you for participation and cooperation thus far with the NewYork-Presbyterian/Queens PPS.

Partner Name NYP/Q PPS Executive Lead Name

Partner Signature NYP/Q PPS Executive Lead Signature

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NewYork-Presbyterian/Queens PPS

DSRIP Workforce Target State

PLAN OVERVIEW

Organization: NewYork-Presbyterian/Queens PPS

Name of Analysis: DSRIP Workforce Target State

Approval Required: NYP/Q PPS Executive Committee

Approval Date: TBD

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Table of Contents

BACKGROUND AND PURPOSE ................................................................................................ 3

NewYork-Presbyterian/Queens PPS ........................................................................................... 3

Purpose & Overview ................................................................................................................... 3

WORKFORCE CURRENT STATE .............................................................................................. 3

Labor ........................................................................................................................................... 4

Practitioner Shortages ................................................................................................................. 4

Recruitment Challenges .............................................................................................................. 4

WORKFORCE TARGET STATE ................................................................................................. 5

Recruitment and Redeployment .................................................................................................. 5

Training and Retraining .............................................................................................................. 6

Reduction .................................................................................................................................... 6

CONCLUSION ............................................................................................................................... 6

Workforce Next Steps ................................................................................................................. 7

APPENDIX ..................................................................................................................................... 8

A. FTE Count by Job Title .......................................................................................................... 8

B. Community Needs Assessment Data .................................................................................... 11

C. Training Index ...................................................................................................................... 12

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BACKGROUND AND PURPOSE


The NYP/Q PPS is one of 25 PPS’s participating in the New York State Delivery System

Incentive Payment (DSRIP) Program. The PPS is located in Queens Borough and covers 33 zip

codes, approximately 60% the population in the borough. The PPS is led by NewYork-

Presbyterian/Queens (NYP/Q) hospital, which is the only hospital in the PPS network; NYP/Q is

subspecialties. The PPS network includes partners from over 100 organizations.

The PPS consists of 1,200 partners, and includes

practitioners, clinics, skilled nursing facilities,

hospices, community based organizations, and a

hospital. Over the course of the 5-year DSRIP

program, the NYP/Q PPS aims to reduce potentially

avoidable inpatient and emergency department visits

by 25% (triple aim) for Medicaid beneficiaries and

uninsured patients. The PPS will work toward this goal

through the implementation of 9 projects aimed at

reducing the health disparities found in the PPS service

area. Through the implementation of the DSRIP

projects and the achievement of the triple aim, the

PPS’s intention is to create a sustainable system

centered on value-based care. 1

Purpose & Overview

The goal of the DSRIP workforce target state is to outline the future of the workforce within the

PPS network. The target workforce state utilizes the current state assessment, compensation &

benefit analysis, DSRIP application for the PPS, and forecasted impact of the projects to create

the future state of the workforce. The target state will enable the PPS to collaborate with partner

organizations to create a transition roadmap to ensure a successful shift to value-based care from

volume based care.

WORKFORCE CURRENT STATE

The NYP/Q PPS engaged BDO to complete the DY1 compensation and benefit analysis for the

PPS to meet the milestone. In alignment with the process for collecting information on

1 Count in PPS Network is based on data provided by DOH in November 2015. The count includes a combination of practitioners

and organizations as well as instances of duplicate counts. The duplicates are a result of some partners being counted in multiple

provider types, i.e. a mental health provider may also be a substance abuse provider.

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compensation & benefit, the PPS also

collected data on the current state of the

workforce at the partner organizations. The

entire PPS network was surveyed and the PPS

received 56 responses from a variety of

partner organizations. The survey responses

included 12,932 employees (headcount) and

10,228 FTEs. Additionally, the survey

collected FTE counts by job titles which align

with the DOH job classifications for DSRIP.

The inventory of job titles and FTE counts is listed in Appendix A.

Labor

The PPS network incudes workforce who are represented by collective bargaining agreements.

The largest union representation is from 1199SIEU and includes several divisions of employees.

Local 30 Operating Engineers

Local 1199SEIU

Local 1199SEIU Registered Nurse Division

The PPS is committed to a partnership with labor to ensure a successful transition of the

workforce through DSRIP. The PPS has included a representative from 1199SIEU on the

workforce committee and the PAC committee to ensure seamless communication and input into

the development of the DSRIP program and execution of the workforce deliverables.

Practitioner Shortages

In addition to the survey data compiled by BDO, the PPS looked to the community needs

assessment, completed in 2014, for historical data on practitioner shortages in the service area.

Based on the data, available in Appendix B, the PPS has a shortage of safety net providers,

specifically primary care / family care practitioners, dentists, and specialty providers including

behavioral health. This information has a direct impact on the PPS target state and transition

roadmap to ensure that Medicaid beneficiaries have access to care within the service area.

Recruitment Challenges

The PPS identified numerous areas of challenge when recruiting both staff and practitioners for

partner organizations. The themes of recruitment challenges included:

Bilingual and diverse staff

RNs with sufficient experience for the role

Behavioral health providers

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Competitive salary & benefits for staff

WORKFORCE TARGET STATE

Recruitment and Redeployment

Based on the CNA data, the NYP/Q PPS service area has a lower inpatient bed ratio that NYS.

Therefore, the PPS does not anticipate DSRIP resulting in a bed reduction for the PPS. Based on

this, the target workforce state will be similar to the current workforce state as there will be

minimal redeployments and likely no reductions. The PPS forecasted needing 68 new hires in

various job categories based on the DSRIP program.2

Position Approximate # of New Hires

Administrative 4

Physician 3

Mental Health Providers / Case Managers 10

Social Workers 1

IT Staff 2

Nurse Practitioners 10

Other 38

The new hires outlined above will include both filling vacancies that currently exist and the

recruitment of new emerging job titles. The PPS DY1 Compensation and Benefit Analysis3

includes a detailed list of requirements by job title including experience required, licensure

requirements, and skills needed. The PPS has identified the following as emerging job titles

across the PPS network and the PPS PMO:

Director, PMO

Medical Director

Population Health Manager

Sr. Data Analyst

Data Analyst

Registered Nurse (RN)

o Population Health

o Rapid Cycle

o Chronic Disease Model

o INTERACT/SNF (Educator, Quality, Rapid Cycle)

Care Manager/Coordinator

Patient or Care Navigator

2 The forecasted new hires was provided by the PPS in the 2014 DSRIP application, section 5.4 3 The Compensation & Benefit Analysis is available to the IA through the DY2, Q1 MAPP submission or you can email the

PMO at [email protected]

mailto:[email protected]

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Community Health Worker

Peer Support Worker

In the PPS DSRIP application, the PPS estimated that there would be a shift of 200 RNs from the

inpatient to the outpatient setting due to DSRIP and that redeployment, when identified, would

be mandatory. As the PPS has evolved and better learned the network partners, the PPS no

longer anticipates a large redeployment of RNs but instead there will be a need for new

behavioral health practitioners, primary care practitioners, and staff in various care coordination /

navigation roles.

Training and Retraining

The PPS has completed a robust training plan for the workforce based on project specific

participation and the organizational requirements for a successful transformation. The training

plan4 details the needs and requirements for both meeting the DSRIP deliverables and ensuring

that the workforce is competent in providing care through the transformation process. The

training plan includes information on vendors and platforms that will be utilized by the PPS to

accomplish training across the network as well as learning objectives and measuring

competencies for the various training programs.5 The PPS will update the plan annually based on

feedback from the training sessions, needs identified by the workforce and/or project

committees, and any changes to the DSRIP program.

Additionally, the PPS will be partnering with 1199TEF as the approved workforce vendor. The

partnership will include assistance with completing the workforce milestones but also identifying

and vetting training vendors for the PPS. As the collaboration between the PPS and 1199TEF is

formalized, the PPS will provide additional information and update the appropriate plans.

Reduction

The PPS does not anticipate any workforce reductions due to the DSRIP healthcare

transformation. The PPS will support the partner network to fill vaccanies and new positions

with new hires and/or redeployed personnel as needed.

CONCLUSION

The PPS completed a robust survey process of the entire partner network to determine the

current workforce state and the baseline for the compensation and benefit analysis. Based on this

information, the PPS does not anticipate major shifts in the workforce from the current state. The

4 The PPS Workforce Communication and Training plan was completed and submitted with the DY2, Q1. The training plan is

available on the PPS website. 5 The training plan index is available in Appendix B

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PPS plans to fill current vacancies and emerging job titles with new hires and redeployed

personnel as needed to ensure the success of the integrated system.

Workforce Next Steps

The NYP/Q PPS will utilize the information from the compensation and benefit analysis, current

state, and target state to create a gap analysis and transition roadmap for the PPS workforce.

Through the development of these workforce deliverables, the PPS will continue to update the

workforce-training plan and begun planning for the DY3 compensation and benefit analysis of

the network. With guidance from the NYS DOH and engagement from the partners, the NYP/Q

PPS will aide in supporting a well-trained and prepared workforce as healthcare in NYS moves

from an inpatient and fee for service, to an outpatient value based system.

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APPENDIX

A. FTE Count by Job Title

The 56 survey responses included information on FTE counts by job titles. The total inventory

for the PPS is listed below and includes the number of organizations that reported having FTEs

in that job title.

Job Title Reported

Employees (FTE)

Number of

Organizations* Administrative Staff

Executive Staff 154 41

Financial 125 30

Human Resources 64 26

Other 369 28

Administrative Support

Coders/Billers 165 24

Dietary/Food Service 340 18

Financial Service Representatives 59 6

Housekeeping 353 16

Medical Interpreters 1 1

Office Clerks 376 30

Other 352 19

Patient Service Representatives 12 5

Secretaries and Administrative Assistants 322 43

Transportation 86 6

Allied Health

Nutritionists/Dieticians 102 19

Occupational Therapists 74 14

Occupational Therapy Assistants/Aides 54 9

Other 326 11

Pharmacists 57 4

Pharmacy Technicians 30 4

Physical Therapists 149 17

Physical Therapy Assistants/Aides 65 12

Respiratory Therapists 92 5

Speech Language Pathologists 37 12

Behavioral Health

Licensed Clinical Social Workers 106 12

Other 159 10

Other Mental Health/Substance Abuse Titles

Requiring Certification

69 9

Psychiatric Aides/Techs 0 0

Psychiatric Nurse Practitioners 6 6

Psychiatrists 19 12

Psychologists 9 6

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Social and Human Service Assistants 16 3

Substance Abuse and Behavioral Disorder

Counselors

24 9

Clinical Support

Clinical Laboratory Technologists 152 1

Medical Assistants 78 5

Nurse Aides/Assistants 1,711 16

Other 205 5

Patient Care Techs 32 5

Emerging Titles

Care Manager/Coordinator 257 14

Community Health Worker 15 3

Patient or Care Navigator 71 6

Peer Support Worker 13 4

Health Information Technology

Hardware maintenance 11 4

Health Information Technology Managers 20 16

Other 17 7

Software Programmers 37 7

Technical Support 13 11

Home Health Care

Certified Home Health Aides 180 1

Other 24 2

Personal Care Aides 30 1

Janitors and cleaners

Janitors and cleaners 88 16

Midwifery

Midwives 2 2

Nurse Practitioners

Other Specialties (Except Psychiatric NPs) 6 4

Primary Care 47 8

Nursing

LPNs 439 23

Nurse Managers/Supervisors 253 26

Other 283 8

Other Registered Nurses (Utilization Review,

Staff Development, etc.)

58 14

Staff Registered Nurses 1,441 31

Nursing Care

Managers/Coordinators/Navigators/Coaches

LPN Care Coordinators/Case Managers 2 2

RN Care Coordinators/Case Managers/Care

Transitions

120 15

Patient Education

Certified Asthma Educators 1 1

Certified Diabetes Educators 0 0

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Health Coach 0 0

Health Educators 15 7

Other 28 7

Physician Assistants

Other Specialties 19 5

Primary Care 85 5

Physicians

Other Specialties (Except Psychiatrists) 23 10

Primary Care Physician 76 16

Social Worker Case Management/Care

Management

Bachelor's Social Workers 45 10

Licensed Masters Social Workers 117 26

Other 33 12

Social Worker Care Coordinators/Case

Managers/Care Transitions

15 9

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B. Community Needs Assessment Data

The PPS completed a community needs assessment (CNA) in 2014 as part of the DSRIP

application process. In addition to providing essential information about the population in the

service area, the CNA also included data on physician shortages by specialty for Medicaid

beneficiaries and inpatient bed ratios. The CNA is available on the PPS website:

www.nyp.org/queens/dsrippps

Physician Shortage Data -- In aggregate, the service area has a shortage of approximately 327

safety net providers. The data shows adequate primary care, however, the PCP data is inflated as

internal medicine subspecialties are included in primary care. In reality, there is a significant

shortage of primary care, and a less severe specialty shortage than is shown.

Inpatient Bed Ratio -- 2,369 service area beds is equal to 1.49 beds per 1000 persons. This is

lower than the state average of 3.0 beds per 1000 and lower than the national average of 2.6 beds

per 1000.

http://www.nyp.org/queens/dsrippps

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C. Training Index

The below is an index of tools and trainings that will be required for the PPS workforce based on organizational section and/or project.

This inventory is detailed in the PPS Workforce Training and Communication Plan. This plan will be updated annually based on

identified needs from the clinical projects and the requirements for DSRIP.

Org. / Project Name Training Name PPS /

Vendor? Frequency

Cultural

Competency

& Health

Literacy

Milestone #2

Develop a training strategy focused on addressing the

drivers of health disparities (beyond the availability

of language-appropriate material).

Cultural Competency Background &

Benefits

Providing Culturally Competent Care

HealthStream Annual

Cultural Competency GNYHA Bi-Monthly

Health Literacy PPS Partner &

HealthStream Annual

PPS Resource Center NYP PPS As Needed

IT Systems &

Processes

Milestone #2

Develop an IT Change Management Strategy

IT Solutions:

ACD

Cureatur

Performance Logic

RHIO

eMOLST

PPS &

Vendors Once Milestone #3

Develop roadmap to achieving clinical data sharing

and interoperable systems across PPS network

Milestone #5

Develop a data security and confidentiality plan Compliance Training

PPS via

HealthStream Annual

Clinical

Integration

Milestone #2

Develop a Clinical Integration strategy

Project Specific Trainings PPS & Vendor Ongoing

IT Solutions:

ACD

Cureatur

Performance Logic

RHIO

PPS &

Vendors Once

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Vendor? Frequency

eMOLST

Performance

Reporting

Milestone #2

Develop training program for organizations and

individuals throughout the network, focused on

clinical quality and performance reporting

Metrics & Quality Improvement PPS Ongoing

Performance Logic Performance

Logic As Needed

2.a.ii –

PCMH

Milestone #7

Ensure that all staff are trained on PCMH or

Advanced Primary Care models, including evidence-

based preventive and chronic disease management.

Physician Champion https://hanys.adobeconnect.com/twy87da.psev5f/

HANYS

Solutions

Once *Recorded for

future use

Care Coordination GNYHA Once

PCMH Training Curriculum HANYS

Solutions 3 Waves

2.b.vii –

INTERACT

Milestone #4

Educate all staff on care pathways and INTERACT

principles. INTERACT Champion Training

INTERACT

Certified

Vendor

Once Milestone #6

Create coaching program to facilitate and support

implementation.

Milestone #7

Educate patient and family/caretakers, to facilitate

participation in planning of care.

Partner Engagement of

Patient/Family/Caregiver

PPS & PPS

Partner Ongoing

2.b.viii –

Home Care

Milestone #2

Ensure home care staff have knowledge and skills to

identify and respond to patient risks for readmission,

as well as to support evidence-based medicine and

chronic care management. INTERACT-like Tool Champion

Training

INTERACT

Certified

Vendor

Once Milestone #4

Educate all staff on care pathways and INTERACT-

like principles.

Milestone #6

Create coaching program to facilitate and support

https://hanys.adobeconnect.com/twy87da.psev5f/

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Vendor? Frequency

implementation.

Milestone #7

Educate patient and family/caretakers, to facilitate

participation in planning of care.

Partner Engagement of

Patient/Family/Caregiver

PPS & PPS

Partner Ongoing

Milestone #9

Measure outcomes (including quality assessment/root

cause analysis of transfer) in order to identify

additional interventions.

Root Cause Analysis PPS Quarterly

3.a.i – PC/BH

Integration

Milestone #3

Conduct preventive care screenings, including

behavioral health screenings (PHQ-2 or 9 for those

screening positive, SBIRT) implemented for all

patients to identify unmet needs.

Best Practice Training PPS Ongoing

3.b.i – Cardio

Milestone #3

Ensure that EHR systems used by participating safety

net providers meet Meaningful Use and PCMH Level

3 standards and/or APCM by the end of DY 3.

Physician Champion https://hanys.adobeconnect.com/twy87da.psev5f/

HANYS

Solutions

Once *Recorded for

future use

Care Coordination GNYHA Once

Milestone #9

Ensure that all staff involved in measuring and

recording blood pressure are using correct

measurement techniques and equipment.

BP Competency PPS & Partner

Organization Annual

Milestone #18

Adopt strategies from the Million Hearts Campaign. Million Hearts Campaign PPS As Needed

3.d.ii –

Asthma

Milestone #4

Implement training and asthma self-management

education services, including basic facts about

asthma, proper medication use, identification and

avoidance of environmental exposures that worsen

asthma, self-monitoring of asthma symptoms and

asthma control, and using written asthma action

plans.

Asthma Education Program PPS & CBO

Partner Ongoing

https://hanys.adobeconnect.com/twy87da.psev5f/

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Vendor? Frequency

3.g.ii –

Palliative

Care

Milestone #4

Engage staff in trainings to increase role-appropriate

competence in palliative care skills and protocols

developed by the PPS.

Education in Palliative and End-of-

Life Care (EPEC) PPS Bi-Monthly

4.c.ii – HIV

Milestone #2

Increase peer-led interventions around HIV care

navigation, testing, and other services.

NYC HIV Collaborative Education NYC HIV

Collaborative As Needed

Milestone #3

Launch educational campaigns to improve health

literacy and patient participation in healthcare,

especially among high-need populations, including:

Hispanics, lesbian, gay, bisexual, and transgender

(LGBT) groups.

Cultural Competency Background &

Benefits

Providing Culturally Competent Care

HealthStream Annual

Cultural Competency GNYHA Bi-Monthly

Health Literacy PPS Partner &

Healthstream Annual

PPS Resource Center NYP PPS As Needed

Milestone #6

Empower people living with HIV/AIDS to help

themselves and others around issues related to

prevention and care.



Milestone #7

Promote delivery of HIV/STD Partner Services to at

risk individuals and their partners.



1

Document Title: NYP/Q PPS Member Segments Analysis

Purpose:

The purpose of this document is to define member segments and

associated specific engagement needs (e.g., geo-access assessment,

cultural/linguistic needs)

Reviewing

Committee: IT/Performance Reporting Committee & Executive Committee

Date Reviewed: TBD

NYP/Q PPS Service Area

PPS service area consists of 33 of the 52 zip codes in Queens

County

o This represents an urban population of 1.59M

Queens County, specifically the NYP/Q PPS service area, is one

of the most areas of New York

o Geographic and economic disparities:

Percentage of families living in poverty ranges

from 4.6% – 23.8%

o Medicaid Beneficiaries:

692k Medicaid Beneficiaries in the service area

Enrollment ranges from 18% – 69% of

population based on zip code

o Uninsured:

360k people, 19.2% of population, are uninsured

Population demographics in NYP/Q PPS service area:

o Race and Ethnicity:

Whites – 394,481

Blacks – 227,432

Asian – 422,309

Hispanic – 479,486

Other – 70,584

o Disability – 9.3%

o Age 65+ – 36%

o Non-US citizen –22.1%

o Education

19.7% do not have a high school diploma

PPS Member Segments

Population by gender:

o Male Population – 780K

o Female Population – 814K

White colored area represents

the NYP/Q PPS Service Area

2

Median Age – 37.8 years old

o Health service utilization has variable rate by age within the population

The diverse demographics of the population impact health services in the following ways:

o Cultural diversity

o Language and health literacy

o Disease prevalence

o Disease manifestation

Tools needed to engage the population.

Geo-Access: Patient Portals to enable two way communication between the patient and

their providers, Telehealth/Telemedicine gadgets and tool, email, electronic reminders

Ads, and Population Health Tools

Cultural and Linguistics: Population Health Tools, Patient Portal with multiple

language capability and translation services

Summary

The population in the NYP/Q PPS service area is older compared to New York but has fewer

65+ residents; this translates to a large non-Medicare adult population. Providers must prepare as

this pre-Medicare population ages and transitions to a higher utilization of health services.

Queens County is a highly diverse county, inclusive of numerous cultures, spoken languages,

and varied health literacy rates, all of which contribute directly to disease prevalence and

manifestation among the population in the PPS service area. The poverty rate of the service area

is comparable to the New York State rate, but the rate within both the county and service area

varies significantly by geography. To address the health gaps evidenced in the NYP/Q

community needs assessment interventions and resources will be convened at local levels. In the

NYP/Q service area, there are 692k Medicaid beneficiaries, which encompasses 43% of the

population and is significantly higher than the NYS rate for Medicaid. The highest concentration

of Medicaid beneficiaries is located in North Central and North West zip codes; this includes

306k uninsured individuals. Queens County has a relatively low rate of uninsured individuals

with 306k located within the service area.

To address the health disparities seen, the PPS will invest in two main tools for partners,

specifically a population health management software and a patient portal. The population health

tool will enable providers to more effectively identify, manage, and treat patients including

performing risk assessments based on diagnosis, co-morbidities, and utilization of health care

resources. The patient portal tool will provide a platform where patients and providers will be

able to engage in a two-way communication. The patient portal will also provide patients with

the ability to perform open access scheduling, at specific practice sites, along with the capacity to

both send and receive secure messages to providers.

Document Title: Data Security & Confidentiality Plan

Approval Needed: IT Committee & Executive Committee

Approval Date: TBD

Document

Objective/Summary:

IT Chair to develop a data security & confidentiality plan that includes

monitoring and auditing of PPS-wide protocols for protected data

Purpose of the Data Security and Confidentiality Plan

The purpose of the data security and confidentiality plan is to establish standards and

recommendations for the NYP/Q PPS providers and affiliates to prevent or limit the potential

compromise of healthcare data being accessed and shared. The data security and confidentiality

plan establish that all NYP/Q PPS partners will maintain reasonable procedures to prevent

unauthorized access to data, including:

Administrative Safeguards

Assign Security Responsibilities

Information Access Management

Security Awareness and Training

Security Incident Procedures

Contingency Plans

Business Associate Agreements

Arrangements

Physical Safeguards

Facility Access Controls

Workstation Use

Workstation Security

Device and Media Control

Technical Safeguards

Access Control

Audit Controls

Integrity

Person Authentication

Transmission Security

Elements of the Data Security & Confidentiality Plan

The elements of the data security and confidentiality plan are based on the existing NYPQ

security standards, implemented to protect patients’ health information when being accessed or

exchanged. The NYP/Q IT leadership recommends that all PPS partners follow the NYP/Q

security standards matrix to establish their own security policies and protocols. PPS partners will

be monitored and audited to determine if the minimum standards of data security and

confidentiality are being met. It is the recommendation of the PPS that partners follow and

implement policies from the security grid in order to establish Administrative, Physical and

technical Safeguards. In addition or in parallel to the adoption of the adoption of the PPS

standard model, partners can also follow HHS guidelines as well.

Covered DSRIP Data Streams

1. PHI generated within the PPS. This includes demographic data, claims data and clinical

information

2. PHI generated by a managed care organization (MCO). This may include demographic

data, claims and encounters data, and clinical data.

3. PHI managed in a Qualified Entity (QE). The QE may perform at least two different roles

related to PHI management: a) as a provider of analytic services and/or b) as a health

information exchange (HIE). For the latter role, this would include clinical data generated

by providers and shared through interfaces between electronic health records set up by

QEs

New Presbyterian Queens - Security Standards Matrix

ADMINISTRATIVE SAFEGUARDS

Standards Sections Implementation

Specifications

R=Required, A=Addressable

Status Policy

Number

Policy Name

Security

Management

Process

164.308(1)

Risk Analysis R In Sentact 9100-204 Risk Analysis

Risk Management R

In Sentact 9100-032 Security Management

Process

Sanction Policy R


Process

Activity Review R


Process

Assigned

Security

Responsibility

164.308(2)

R

In Sentact 9100-033 Assigned Security

Responsibility

Workforce

Security 164.308(3)

Authorization and/or

Supervision A

See: Human

Resources

Policies

On Intranet

9237(100-131

and 700-702)

See: Human Resources

Policies

On Intranet

Workforce Clearance

Procedure A

See: Human

Resources

9237(100-131

and 700-702)


Policies

Policies

On Intranet

On Intranet

Termination Procedures

A

See: Human

Resources

Policies

On Intranet

9237(100-131

and 700-702)


Policies

On Intranet

Information

Access

Management

164.308(a)(4)

Isolating Health Care

Clearinghouse Functions R

In Sentact 9100-034 Isolating Health Care

Clearinghouse

Functions

Access Authorization A In Sentact 9100-035 Access Authorization

Access Establishment and

Modification A

In Sentact 9100-036 Access Establishment and

Modification

Security

Awareness and

Training

164.308(a)(5)

Security Reminders A In Sentact 9100-037 Security Reminders

Protection from Malicious

Software A

In Sentact 9100-004 Protection from Malicious

Software

Log-in Monitoring A In Sentact 9100-038 Log-in Monitoring

Password Management A In Sentact 9100-205 Password Management

Security

Incident

Procedures

164.308(a)(6)

Response and Reporting

R

In Sentact 9100-039 Response and Reporting

Contingency

Plan 164.308(a)(7)

Data Backup Plan R In Sentact 9100-040 Contingency Plan

Disaster Recovery Plan R In Sentact 9100-040 Contingency Plan

Emergency Mode

Operation Plan R

In Sentact 9100-040 Contingency Plan

Testing and Revision

Procedures A


Applications and Data

Criticality Analysis A


Evaluation 164.308(a)(8) R In Sentact 9100-042 Evaluation

Business

Associate

Contracts and

Other

Arrangements

164.308(b)(1)

Written Contract or Other

Arrangement

R

In Sentact 9200-331 Business Associate

Agreements

PHYSICAL SAFEGUARDS


Specifications


Status Policy

Number

Policy Name

Facility Access

Controls 164.310(a)(1)

Contingency Operations A In Sentact 9100-044 Contingency Operations

Facility Security Plan A In Sentact 9100-015 Facility Security Plan

Access Control and

Validation Procedures A

In Sentact 9100-030 Access Control and

Validation

Procedures

Maintenance Records A In Sentact 9100-045 Maintenance Records

Workstation

Use 164.310(b)

Acceptable Use Policy R

In S e ntact 9200-385 Acceptable Use Policy

Workstation

Security 164.310(c)

In Sentact 9100-041 Workstation Security

Device and

Media Controls 164.310(d)(1)

Disposal R In Sentact 9100-031 Device and Media Controls

Device and Media Controls



Media Re-use R In Sentact 9100-031

Accountability A In Sentact 9100-031

Data Backup and Storage A In Sentact 9100-031

TECHNICAL SAFEGUARDS


Specifications


Status Policy

Number

Policy Name

Access Control 164.312(a)(1)

Unique User

Identification R

In Sentact 9100-043 Unique User Identification

Emergency Access

Procedure R

In Sentact 9100-0047 Emergency Access

Procedure

Automatic Logoff A In Sentact 9100-219 Automatic Logoff

Encryption and

Decryption A

In Sentact 9100-029 Encryption

Audit Controls 164.312(b) R In Sentact 9100-048 Audit Controls

Integrity 164.312(c)(1)

Mechanism to

Authenticate Electronic

Protected

Health Information

A

In Sentact 9100-0046 Mechanism to Authenticate

Electronic Protected Health

Information

Person or

Entity

Authentication

164.312(d)

R

In Sentact 9100-0049 Person or Entity

Authentication

Transmission

Security 164.312(e)(1)

Integrity Controls A In Sentact 9100-0050 Integrity Controls

Encryption A In Sentact 9100-029 Encryption

Page | 1


PPS Performance Reporting Strategy

PLAN OVERVIEW

Document Title: NYP/Q PPS Performance Reporting Strategy

Version 1.0

Purpose:

This document outlines the PPS performance reporting strategy to include

policies, processes, and procedures to ensure confidential data exchange and

effective communications for quality and operational data between the PPS

and its provider network.

Approving

Committee: IT Committee – Clinical Integration Committee – Executive Committee

Approval Date: TBD

Page | 2

Table of Contents

OVERVIEW ........................................................................................................................................................................... 3

GOVERNING PROCESS....................................................................................................................................................... 3

TARGET AUDIENCE ........................................................................................................................................................... 4

KEY STAKEHOLDERS ........................................................................................................................................................ 4

MILESTONES ........................................................................................................................................................................ 5

REPORTING OF PERFORMANCE ...................................................................................................................................... 5

Data Sharing Process – .............................................................................................................................. 5

Project Engaged Patient Data Collection – ............................................................................................... 5

Project Requirement Status / Achievement Reporting – ......................................................................... 6

Quality Metrics Data Collection – ............................................................................................................. 6

RAPID CYCLE EVALUATION ............................................................................................................................................ 7

ROOT CAUSE ANALYSIS ........................................................................................................................................................... 8

POLICY ALIGNMENT ......................................................................................................................................................... 8

DATA SECURITY ................................................................................................................................................................. 9

DATA WAREHOUSING / TOOL UTILIZATION ............................................................................................................... 9

PPS Secure Network Claims Data ............................................................................................................ 9

MAPP / Salient Tool Utilization ............................................................................................................... 9

Performance Logic .................................................................................................................................. 10

Population Health Management Tool ..................................................................................................... 10

PERFORMANCE DASHBOARDS / SUMMARIES ...................................................................................................................... 11

EXECUTIVE SUMMARY ............................................................................................................................ 11

QUALITY BASED OUTCOMES ................................................................................................................... 12

EXECUTIVE DASHBOARD ......................................................................................................................... 12

COMMUNICATIONS & ROLL-OUT PLAN ..................................................................................................................... 13

ATTACHMENT A: EXECUTIVE SUMMARY ............................................................................................................................. 14

ATTACHMENT B: EXECUTIVE DASHBOARD .......................................................................................................................... 20

ATTACHMENT C: QUALITY BASED OUTCOMES .................................................................................................................... 21

ATTACHMENT D: PATIENT ENGAGEMENT DATA REQUEST ................................................................................................. 22

ATTACHMENT E: QUALITY BASED OUTCOME METRICS ....................................................................................................... 26

Page | 3

OVERVIEW

The NYP/Q PPS includes over 134 network partners covering the service area of Queens County representing

33 of the 52 zip codes in the borough. These partners represent the full healthcare spectrum, including

homecare, post-acute care, hospice, pharmacies, behavioral health and substance abuse, primary care, and

community based organizations. Nine projects including primary care, behavioral health, long term care,

palliative care, asthma, cardiovascular, and HIV were selected based on the needs of the community we serve.

The NYP/Q PPS must ensure a robust performance reporting strategy and policy to ensure the collaboration and

communication among multiple organization and provider types that have individual clinical and operational

strategies to best serve their patient base. The PPS Project Management Office (PMO) will utilize this strategy

to:

Establish reporting expectations of monthly, quarterly, and annual data sets

Outline a governing structure of how the data will be managed, shared, and used for reporting to the

NYS DOH or within the network to perform continuous quality improvement efforts

Create a communication strategy among network partners to ensure actionable data & reports are

generated

Align with the PPS Training Strategy and evolve based on the needs of the network

Establish expectations for IT tools to be used for data sharing, analytics, and reporting (operational)

Create processes that utilize existing tools used by NYS DOH for data gathering and analytics

GOVERNING PROCESS

The IT Committee will govern the approval and implementation of the performance reporting strategy and

policies. Strategy and policy implementation and updates will be brought to the PPS Executive Committee for

review, recommendations, or final approvals. The strategy and policies will be reviewed annual for adjustments

based on PPS performance or network needs.

The PMO IT and Data Analytics resources will work with partners monthly to ensure compliance of the

strategy and will report compliance issues to the IT Committee based on findings. All partner compliance

issues will be reported to the Executive Committee quarterly, or more frequently as needed, with an action plan

to remedy the issues identified.

Page | 4

TARGET AUDIENCE

All network providers of the PPS will be educated on this strategy and all policies that are aligned. The

audience will include the clinical providers, organizations, as well as the operational support staff that are

identified for data collection, analytics, or DSRIP project management/implementation.

The strategy has been written for a general network audience while each training will be customized based on

the needs of the individuals being trained.

KEY STAKEHOLDERS

The following key stakeholders and responsibilities align with the performance reporting strategy:

ROLE RESPONSIBILITY

Lead Entity (NYP/Q) Oversight of PPS to ensure confidentiality of data, adherence to policies,

and compliance with state and federal regulatory requirements

PPS Project Management

Office

Establishing reporting policies & expectations

Gathering data elements & reporting to NYS and partners

Monitoring use & compliance of partners with policies

Data warehousing of partner performance data

Ongoing reporting to Executive Committee

PPS Executive Committee Oversight of the PMO processes

Chair accountable to the Lead Entity for ongoing updates

PPS Network Partners Fulfill project requirements, engaged patient reporting, and outlined quality

outcome data gathering as outlined in the performance reporting strategy

Identify risks or concerns regarding the PPS process

Directly communicate with the PMO regarding data & reporting processes

Page | 5

MILESTONES

This strategy & accompanying policies will address the following milestone:

Performance Reporting – Milestone #1 – Establish a reporting structure for PPS-wide performance

reporting and communication

This document will address all steps associated with the milestone and will meet the minimum standards

expectations of the DSRIP program.

PPS Training Strategy addresses the following milestone:

Performance Reporting – Milestone #2 – Develop a training program for organization and individuals

throughout the network, focused on quality and performance reporting

REPORTING OF PERFORMANCE

Performance reporting will be managed monthly by the Project Management Office Data Analytics team and

will include the following processes:

Data Sharing Process – o The PMO Data Analytics team will receive patient-level data on a monthly basis from the NYS

DOH via a secure sFTP server. Only two team members of the PMO staff will have access to

analyze the claims-based files, which are required to remain on the secure sFTP server. The

claims-based files can be compared with the quality-based outcomes data located on the

Medicaid Analytics Performance Portal (MAPP). From MAPP, the summary-level data can be

exported and shared with clinical workgroups for process improvement analysis and planning. In

addition, the PMO Executive Team, Clinical Integration Committee, and Executive Committee

will be provided with the summary-level data of the actively engaged patient count compilation.

The data will then be used to determine whether the speed and scale commitments targets are

met for each reporting quarter.

Project Engaged Patient Data Collection – o Committed partners will report actively engaged patient detail monthly to meet the definition as

set by the NYS DOH. The PMO utilizes a secure intake process in order to compile PPS partner

data for forecasting of performance as well as quarterly MAPP reporting of performance. The

data collection process consists of the PMO sending project-specific data request templates to the

participating partners. The template is an excel workbook with four separate tabs, see

Attachment D. The first tab provides instructions to partners for completion of the request. The

following three tabs contain a data dictionary, an attestation form, and a data worksheet, all to be

Page | 6

returned by the partner prior to a scheduled deadline. The data is collected monthly and entered

into an aggregate file, where the data is validated to ensure that it is accurate and contains no

duplications.

o The standard tool that the PPS is recommending to partners, for the secure exchange of the

patient count data is the Cureatr Messaging App. All NYP/Q partners who are participating in

the engaged patient data collection will be provided with a user account and access to send and

receive related data files. On a monthly basis, partner will receive the patient engagement

template for the NYP/Q PPS data analyst. The file will be sent via the Cureatr App and partners

will be expected to complete the template and communicate the data files using the App. NYP/Q

will maintain administration of the Cureatr application to include auditing and user support.

Additionally, training for appropriate use of the application will be provided courtesy of a user

guide and screenshots. These resources will be provided vendor and distributed by the NYP/Q

team.

o Upon receipt of the monthly patient level information, the PMO team compiles and analyzes the

engaged patient information to ensure no duplication of engaged patient count and to ensure a

complete representation of patient information to include CINs, NPIs, etc. Any missing,

incorrect, or duplicated information is communicated to the originating partner to ensure strong

communication regarding the process.

Project Requirement Status / Achievement Reporting – o PPS partner agreements outline project requirements for all partner types based on the project

commitments made by individual or group partners. The PMO will work with each partner

monthly / quarterly / annually to outline progress towards project requirements to ensure

completion by designated project dates. The PMO Performance Logic tool will be utilized for

tracking of the project requirements as there are no PHI elements associated with this

expectation.

Quality Metrics Data Collection – o Majority of the data elements for the quality based outcome metrics will be provided by the NYS

DOH utilizing tools such as 3M, AHRQ 4.4, HEDIS 2015, and CAHPS Audits. The NYS DOH

will provide reports to the PPS in order to fulfill the requirement of pay-for-reporting or pay-for-

performance. Attachment E provides an overview of the quality metrics.

o Additional metrics will be completed by an annual chart audit. The audit will be managed by a

NYS DOH vendor in order to identify random partners for quality outcome sampling. The PPS

will be engaged in the process of chart audits and will receive feedback and results upon

completion of the audit.

Page | 7

Project Measure Description Measure Type

3.a.i Screening for

Clinical

Depression and

Follow-up

Percentage of Medicaid enrollees age 18

and older who were screened for clinical

depression using a standardized depression

screening tool, and if positive screen,

received appropriate follow-up care

Hybrid – G Codes &

Chart Review

Information

3.b.i Controlling High

Blood Pressure

Percentage of Medicaid members 18-85

years of age who had a diagnosis of

hypertension (HTN) and BP effectively

controlled during the MY.

HEDIS

o The PPS PMO Rapid Cycle Evaluation Unit will identify additional processes for data reporting

& tool utilization for more timely data collection in order to influence process improvement

efforts. The performance reporting strategy will be updated based on the development and

outcomes of the Rapid Cycle Evaluation Unit.

The timing of performance metrics will be based on the implementation plan or the NYS designated

measurement years. Timelines include:

Description From To

Implementation Plan –

Distribution Year (DY)

April 1st March 31

st

Quality Metrics – Measurement

Year (MY)

July 1st June 30

th

RAPID CYCLE EVALUATION

The tools and processes outlined in this strategy will establish partner expectations for data reporting to ensure

ongoing quality improvement efforts are made for the PPS. A Rapid Cycle Evaluation (RCE) Unit will be

established in DSRIP DY2 to utilize performance data reported by partners as well as data available in MAPP

(Salient) and other tools for quality improvement efforts. A CQI (Continuous Quality Improvement) technique

will be established with expectations that align with PPS performance of metrics as well as the timing

associated with such metrics.

Upon recruitment of the Rapid Cycle Unit team, a focused strategy will be developed to outline the processes

associated with the unit. This strategy will outline partners, data sources, process improvement strategies,

follow-up methods for improvements, and risks associated by quality based outcomes. National best practices

will be utilized to build the strategy & processes for the PPS.

Page | 8

ROOT CAUSE ANALYSIS

The long term care project workgroups have established a process of analyzing an actual patient encounter

recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency

department utilization. The patient information and facility information is blinded and the encounter from

beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause

Analysis (“RCA”) is completed in a workgroup where the team reviews items such as pre-condition/admission

indicators, clinical indications, facility processes, communication among facility partners, access to electronic

health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons

learned to make local performance improvement changes to clinical operations in order to avoid ED utilization,

admissions, and re-admissions. The RCA will become an integral part of the Rapid Cycle Evaluation Unit to

allow team input for process improvement efforts.

POLICY ALIGNMENT

As recommended by DOH, the New York Presbyterian of Queens PPS has established a specific strategy to

address Privacy and Data Sharing within the PPS. Our strategy will be based around a Data Security and

Confidentiality plan. Within the Data Security and Confidentiality Plan, the PPS will establish and outline

appropriate policies to address Administrative, Physical and Technical Safeguards. Additionally the policies

outlined in the Data Security and Confidentiality Plan, are aligned with the existing policies implemented at

NYP/Q to address Privacy and security of protected health information. These policies and standards will be

available for review and guidance on the NYP/Q, PPS website.

The following are the NYP/Q PPS data sharing and security policies and procedures:

o Acceptable Use

o Access Authorization

o Access Control and Validations

o Access Control Procedure

o Access Establishment and Modification

o Account Management

o Audit Controls

o Automatic Logoff

o Configuration Management

o Data Use and Sharing

o Encryption

o Facility Security Plan

o Identification and Authentication

o Integrity Controls

o Log-In Monitoring

Page | 9

o Person or Entity Authentication

o Protection from Malicious Software

o Remote Access

o Secure Access To Electronic Protected Health Information

o Security Management Process

o System and Communications Protection

o Two Factor Authentication

o Unique User Identification

o Vulnerability Scanning

DATA SECURITY

The NYP/Q PPS will apply and maintain quarterly audits to ensure that recommended data security policies and

standards are being met by all participating DSRIP partner. These audits will be performed using surveys and

individual reviews of partner’s policies and methods of data to sharing. The objectives of the audits will be to

determine if partners are using recommended standards and policies to maintain the Privacy and Security of

data being shared.

DATA WAREHOUSING / TOOL UTILIZATION

PPS Secure Network Claims Data

NYS DOH provides claims based data to the PPS, which is housed on a secure server, to allow each PPS the

ability to analyze data depending on the need of the analysis. The claims based data will be a tool that allows

the PMO Data Analyst to complete in-depth analysis including disease profiling by facility or partner, trending

of patient activity by network partner, and much more.

MAPP / Salient Tool Utilization

The MAPP tool, managed by the NYS DOH, will be a data gathering source for the PPS. The tool provides a

dashboard approach to quality and network data that is drillable. The tool is fed by Salient, an additional NYS

data warehouse. Both the MAPP and Salient tools will be limited to the PMO staff and will be used to provide

network analysis to project committees and executive leaders for quality outcomes and network attributions.

Page | 10

Performance Logic

The Performance Logic project management tool will be utilized as the primary warehouse for non-patient

related data such as the implementation plan steps & milestones, project requirements, meeting documents,

strategy & policy documents, etc. This tool will be used as the primary operational connection tool between the

PMO and network partners in order to establish expectations of deliverables, outline timing of tasks and project

requirements, and maintain a database of PPS reference documents for the partners.

The operational functions of the PL tool will be managed by the PPS Project Management Office while the

security related maintenance will be managed the PMO IT staff. The collaboration of operations and IT will

allow for a comprehensive tool with appropriate security levels in order to be compliant with all PPS policies.

Population Health Management Tool In support of Population Health requirements, the NYP/Q PPS will implement the Allscripts Care Director

(ACD) application. As specified by the DOH, the PPS is required to “perform population health management by

actively using EHRs and other IT platforms to track attributed lives by creating registries”. Allscripts Care

Director will support population health and performance reporting, through the use of a standardize care plan,

Event Notifications, Attribution Plans, Patient Registries, Risk Stratification and Care Coordination. Once fully

implemented the Allscripts Care Director System will provide a central location for the management and

tracking of all engaged patients. The system will also support performance reporting thorough its Ad hoc

reporting capabilities. All actively engaged attributed patient will be enrolled into the population health system,

where they will be able to be managed and tracked through the various tools such as Event Notifications, Care

Plan and Assessment. Implementation of the Population Health System will follow a two phase roll-out plan.

Phase 1 will provision system design to include; Interface builds, Assessments, Care Plans, Patient/Provider

Upload, Attribution Plans and Security configuration. Additionally, phase 1 will also include the creation of

user accounts for the designated care coordinators within the lead PPS. Phase-II, of the implementation plan

will include the design and configuration of the tool to accommodate identified safety net providers who are not

currently using a population health tool. Also within phase II of the implementation plan, PPS partners will also

be trained how to leverage the tool efficiently, in order to meet population health management and reporting

requirements. All Participating safety net partners, will be expected to manage their PPS attributed lives in the

Allscripts Care Director application using the designated attribution plan/registries, assigned by the lead PPS,

NYP/Q.

Page | 11

PERFORMANCE DASHBOARDS / SUMMARIES

The PPS PMO team will produce the following performance dashboards:

EXECUTIVE SUMMARY The PMO will generate a monthly Executive Summary that will encompass all functions of the PPS to include

organization and project expectations and performance. The summary is based on a ‘stoplight’ approach and

will identify risks by category associated with the PPS roll-out or transition to a sustainable model. Details of

functions or projects will be reflected in the document to ensure progress along with risks & mitigation

strategies, next steps & focus, and questions identified for NYS regarding implementation of the DSRIP

program. This tool will be distributed to the Executive Committee and the NYS/IA monthly as a driving

communication tool. Attachment A provides an example of the summary.

Page | 12

QUALITY BASED OUTCOMES Quarterly quality based outcome dashboards will be produced for all project workgroups. The dashboards will

encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure

server. Each dashboard will be unique to the clinical project and will be shared with the project workgroups for

further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle

Evaluation Unit team to identify trends & risks associated with quality based outcomes.

Scoring methodology of the quality based outcomes will align with the NYS DOH metric target & high

performance goals produced annually (MY) for the PPS. The baseline year (MY) and goals will be

communicated to the network through clinical project committees, PAC, Clinical Integration Committee, and

the IT Committee to ensure improvements. The Rapid Cycle Evaluation Unit will utilize metric goals as

performance baselines to do continuous quality improvement efforts. The MY2 baseline and goal information

can be found in Attachment E.

Quality Indicator Dashboards have been created by project grouping to monitor progress and work internally

with the project workgroups to identify process improvement efforts for all partners involved. An example of

the dashboard can be found in Attachment C.

EXECUTIVE DASHBOARD A quarterly executive dashboard will be created and shared with the Executive Committee. The dashboard

(Attachment B) provides a high level view of the following indicators:

Overall Performance

Financials

Workforce

Operations

Clinical Integration & Quality

Risks & Mitigations

The dashboard will be a guiding tool for the Executive Committee to inform and drive change based on

quarterly performance.

Page | 13

COMMUNICATIONS & ROLL-OUT PLAN

The PMO and the DSRIP IT Project Manager will take a proactive role in ensuring effective communications

on this strategy. The PPS will focus to utilize existing communication sources, sited in the Communications &

Engagement Plan, to maximize efforts currently in place. If project information is communicated via secure

means or through internal company resources, all stakeholders, internal and external, must have the necessary

access to receive project communications.

The Project Management Office will partner with the network to continue the roll-out of the performance

reporting strategy. The roll-out of this strategy began in DY2 beginning with dashboard development and use,

Performance Logic builds, and NYS data compilation and warehousing. The network partners will have

multiple access points for roll-out to include:

Access to Performance Logic

Access to Population Health Management Tool

Engagement in committee meetings & workgroups

PMO partner meetings regarding performance of attributed lives (Rapid Cycle Evaluation Unit)

It is critical that communications and roll-out for our network is efficient and effective to ensure partner

engagement and use of products developed. The PMO management team will perform continuous outreach to

partners for feedback on the process, tools, reports, and data for ongoing updates.

Page | 14

ATTACHMENT A: EXECUTIVE SUMMARY NewYork-Presbyterian/Queens PPS – DSRIP

Executive Update

This memo will serve as an Executive Summary of the development of the NYP/Q PPS to include accomplishments and

upcoming focus and deliverables in order to ensure strong communication and effectiveness of PPS implementation.

Memo Date Range: May 27, 2016 – June 20, 2016

Organizational Milestones & Focus

Org Function Status Indicator

Red/Yellow/Green

Status / Notes

Governance Green 45 contracts executed to date

In process of finalizing CBO addendums for contractual

engagement expectations (Asthma Coalition, etc.)

Public agency coordination plan blended into the

Communications & Engagement Plan to ensure alignment with

engagement strategies and communications – Due DY2Q2

Remediation feedback completed & returned to IA

DY1Q4 reporting expectations completed - AV driving quarter –

Payment anticipated in July 2016

Finance Green Payment #2 final payments in process – pending

BAA’s/agreements

Expenses & Revenue reconciled for 2016 YTD May

Partnering with NYP on VBP MCO contracting strategy,

negotiations, and baseline assessment process

VBP Baseline Survey beginning June 2016

Workforce Yellow BDO Compensation & Benefit Analysis Draft received &

pending review / approval by Executive Committee

Pending meeting with 1199 TEF to review revised scope based

on need of PPS and available workforce budget

Healthstream training tool contract signed – Kick off call

scheduled for PMO July 7th

Training & communications strategy in draft form & pending

review / approval by Executive Committee (June 2016)

Workforce Impact analysis underway with project committees

Workforce expense analysis ongoing for quarterly reporting –

YTD spending expectations met by PPS

Page | 15

Cultural Competency &

Health Literacy

Green CCHL Strategy implementation in process

Aligning with Communications Committee to align with

communications & engagement processes

Poverty Simulator tool not being utilized by PPS due to down-

state tool not developed (only upstate developed). We are

reviewing the purchase of the curriculum but it is on backorder

IT Systems Yellow Phase II RHIO Pilot partners identified – 20 Partners in process

TOM project completed – EIP Measure

Security workbooks in progress for July 2016 submission

Performance Reporting Strategy & Policy in development for

June 2016 Executive Committee approval

Clinical Integration Green Metric Review & Planning Day – June 22, 2016 – review,

educate, and begin process improvement for metrics overall &

those out of compliance with goals

Clinical Integration Strategy in development – June 2016

Executive Committee review/approval

Ongoing best practice recommendations for review & approvals

PMO Green PMO Director – Hired – Welcome Sadia

Financial Analyst – Hired – Begins June 27th

Active Recruitment –

o Population Health Manager

o Data Analyst

Page | 16

Project Milestones & Focus

Org Function Status Indicator

Red/Yellow/Green

Status / Notes

ALL PROJECTS Green DY2 Q1 Actively Engaged Patient Counts

o All projects on track for achieving goals set

MAPP Dashboards – Data Analyst presenting at all project

workgroups

Mid-Point Assessment Narratives in development – Due July 31,

2016

2.a.ii – PCMH Green On track to meet requirement – 36 PCPs

Care Coordinator training held 6/15/16

Primary Care Plan in development – due August 31, 2016

2.b.v; 2.vii; 2.b.viii; 3.g.ii

– LTC Projects

Green Facility Champions are in the process of being identified at sites

2nd

Root Cause Analysis September 9, 2016

INTERACT training scheduling in progress

3.a.i – PC / BH Yellow Evaluating how to move forward based on co-location limitations

(regulations) with the lack of capital funding

Site visits under way to outline potential placement of PC’s in

BH site(s). (Brightpoint, MHPWQ)

3.b.i – Cardio Green Working with internal million hearts campaign team member to

roll out requirements for the project

3.d.ii – Asthma Green Training of school based staffing continues

Action plan in development for bigger plan of school based

education of staff

IT Tools (Population Health) under review for connectivity and

engaged patient tracking

2 Partners attending NYS Asthma Home Based Services

Conference – June 24, 2016

4.c.ii – HIV Green Continued engagement in the NYS HIV Collaborative

Peer led intervention strategy completed

Discussions underway for expanding existing activities

Page | 17

Next Steps / Focus:

Focus / Strategy Description

Performance Reporting Strategy & Policy Development of a robust performance reporting strategy

& policies

Quarter Close – DY2Q1 – Workplan review Workplan review of all deliverables to identify risks /

completion / next steps

Preparation for July 2016 reporting

PPS Partner Agreements Identifying critical partners for additional contracting

needs

Aligning commitment provider counts with scale &

speed goals

Mid-Point Assessment Understanding NYS expectations

Completing project & organizational narratives

Educate partners of 360 review potentials

Identifying risks & mitigation strategies

Workforce 1199 Training & Education Fund contracting

Healthstream Roll-out

Training & Communication Plan Roll-Out

Clinical Clinical Integration of projects

Utilization of MAPP Dashboard data in project

committees

Rapid Cycle Evaluation Unit Development Continued recruitment of a Population Health Nurse

NYS Workforce meeting Lean concepts – to be discussed

internally by team for potential identification of

initiatives

EIP/EPP Contracting Partnering with NYP on MCO contracting

Page | 18

Risks & Challenges

Risk Project/Function Description Mitigation /

Accountability

Owner

EPP & EIP

Payments

Overall Unsure how the collaborating contracting PPS

model will apply to the new DOH expectations for

EPP & EIP payments

M. Buglino

Primary Care :

Behavioral Health

Co-location Billing

PC : BH Co-location primary care & behavioral health

billing practices create complexity within

organizations sharing locations

M. D’Urso

Limited Revenue to

Create Robust

Incentive Plan

Overall Need to ensure a robust incentive structure for

partners to allow for buy in of requirements

A. Simmons

Value Based

Payment Model

Financial

Sustainability

The ability to move to a VBP process with multi-

organizations while being compliant with state &

federal regulations within the limited amount of

time allotted for DSRIP

M. Buglino

Improvement of

Non-Compliant

Metrics

Metric Outcomes Timing of project implementation with the

MY/DY spread of metrics is a challenge to ensure

process improvement that will result in quality

outcomes

Team

Page | 19

Questions & Clarification

Topic Questions

Pending from 11/13/15 Meeting

Non-Safety Net Provider

Status

Spreadsheet provided 10/14/15 to KPMG/PCG includes a list of

providers that only render services at the Article 28 extension clinics

of NewYork-Presbyterian/Queens but are listed by DOH as non-

safety net

New Questions

MAPP Data When will the MAPP system be updated to fix the provider level

detail of attribution / quality outcomes by provider? Currently we

have numerous metrics that have over 90% in No PCP Assigned by

MCO and all other provider counts seem severely. We were told

that the June 2016 update caused this issue.

Salient Training We have brought on new staff and will continue to as we grow the

PMO and we were informed that there will be no Salient training

until further notice; therefore, we cannot get our new Director and

data analyst access to the system. Can you tell us when they plan to

have additional trainings or to assign our users access?

Page | 20

ATTACHMENT B: EXECUTIVE DASHBOARD

Actual Spend Application $ Discount $Variance to

Discount

Amount Rolled

to next DY

128,455$ $ 188,702 $ 113,221 $ 15,234 $ 60,247

YTD Actual Pending Payouts

Expense

Budget % of Rev Notes On Target for Deliverables

AOH 518,866$ -$ 35.30%

COI 156,652$ -$ 10.66% Caution or Risk of Not Meeting Expectations

Non-Cov 26,775$ 45,150$ 4.89%

Rev Loss 96,468$ 50,521$ 10.00%

Contingency 73,499$ -$ 5.00% Not Meeting Expectations

Incentives 42,500$ 252,181$ 20.05%

Proj Rqmt Incentives -$ 285,383$ 19.41%

Totals 914,760$ 633,235$

Spend

Grand Total

Includes

Grant

Funded

Items

%'s will not

balance to

application

as revenue

does not

include

EIP/EPP $s

367,497$

Pending DY1 Q4 IA Review

1,469,988$

Legend

Payment 3

Payment 2

PPS Expense to Budget

NYP/Q PPS Executive Performance Dashboard

Quarter Date Range: January 1, 2016 - March 31, 2016

Delivery System Reform Incentive Payment (DSRIP)

Executive Operations Workforce

DY1 Q4 - DY1 Year End

Q3 = Non Revenue

producing quarterNetwork Development / Partner Engagement

39 Partner contracts completed to date

Continued signatures based on partner engagement

CBO Contracts signed = Asthma Coalition & Elmcor

Payment Cycle #1 & #2 Completed - Next cycle = September 2016

March 31, 2016 ends the DY1 of the NYP/Q DSRIP Program. The PPS has met all

expectations to maximize revenue to the network. Nine projects are currently in the

implementation phase with vast partner engagement ranging from primary care

physicians to pharmacies. Partners are engaged with all committees and contracts

allow the PPS to flow funds based on engagement, non-covered service, revenue

loss, and actively engaged patient reporting.

Milestone / Task Status

Clinical Integration & Quality Financial

DY1 Q4 Reporting submitted April 27, 2016. Pending NYS Independent Assessor review &

feedback for final AV values.

PPS Revenue

Project Committees meet monthly - full partner engagement

CBO Contracting continued with refinements to scope of agreements

See Monthly Executive Summary for specific project updates

Payment 1 1,102,491$

Project Implementation

Mitigation / Action Plan - Not Meeting Expectation KPI's

Meeting with legal council to identify regulatory issues related to BH : PC co-location.

Partnering with NYP, who is responsible for the NYP/Q PPS managed care contracting, to complete the EIP/EPP contracts for the paired payers as well as to outline a VBP plan.

Comp & Benefit Analysis

- BDO hired to complete the Compensation & Benefit Analysis

- Survey process underway. 58 surveys completed from 35+ organizations

- On target to meet milestone by DY2 Q1

Target Workforce State & Roadmap

- Current State Analysis completed

- Target State under development to include the development of the roadmap

- On target to meet milestone by DY2 Q1

Impact Analysis

- Utilizing existing budget work completed which outlines workforce needs to define impact

analysis

- Working with each project committee to outline impact

- On target for DY2Q1 completion

Training Strategy

- Training strategy in development across all functions & projects to align need with workforce

budget

- On target for DY2 Q2

1199 TEF Contract

- Working to develop scope & budget for training contract

Overall Performance Scorecard

Total Avs Avs Awarded Notes

150 150

Quarter Reporting Status

Project Management Office

Project Coordinator & Data Analyst - Staffed

Director - Hired - June 2016 start date

Financial Analyst - Offer pending

Data Analyst - Interviews underway

Population Health Manager (RN) - Applicants under review

Risks Identified

Quality Metrics

The Population Health Manager is in recruitment to establish a Rapid Cycle

Evaluation Unit (RCE)

The newly recruited PMO Director has a vast quality background

Project Committees will begin to focus to operational improvements focused to

quality metrics

Long term care committee to begin a Root Cause Analysis with multiple partners

on an actual blinded patient case

Primary Care & Behavioral Health co-location regulatory issues identified

EPP / EIP Contracting for a Collaborative Model PPS with NYP partnership

Value Based Payment contracting in a collaborative model PPS

Page | 21

ATTACHMENT C: QUALITY BASED OUTCOMES

Page | 22

ATTACHMENT D: PATIENT ENGAGEMENT DATA REQUEST

An Excel document is utilized with all committed partners by project to outline expectations and ensure data integrity and

security of patient level information. The following tabs are included in the monthly collection process from partners.

Tab 1- Instructions for Completion of the Request

Page | 23

Tab 2- Data Dictionary

Page | 24

Tab 3- Partner Attestation Form

Page | 25

Tab 4- Data Worksheet to be completed by partners

Page | 26

ATTACHMENT E: QUALITY BASED OUTCOME METRICS

Page | 27

Measure Baseline for MY2 Increase Flag

MY2 Annual Improvement Target

MY2 High Performance Target

Change needed to meet MY 2 Target

Statewide Performance Goal

2.a.ii

Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP))

Adult Access to Preventive or Ambulatory Care - 20 to 44 years 83.44983553 ▲ 84.21332151

0.763485987 91.0846954


0.302166457 94.3516309

Adult Access to Preventive or Ambulatory Care - 65 and older 94.16058394 ▲ 94.18896999

0.028386046 94.4444444

CAHPS Measures - Care Coordination with provider up-to-date about care received from other providers 86.35595281 ▲ 86.91135753

0.555404719 91.91

Children's Access to Primary Care - 12 to 19 years 95.38281707 ▲ 95.72791629

0.345099223 98.8338093

Children's Access to Primary Care - 12 to 24 Months 96.31053036 ▲ 96.67947733

0.368946964 100

Children's Access to Primary Care - 25 months to 6 years 95.42124542 ▲ 95.72122614

0.299980718 98.4210526


0.21685254 100

Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) 90.65300129 ▲ 90.83970116

0.186699871 92.52

H-CAHPS - Care Transition Metrics (Q23, 24, and 25) 93 ▲ 93.4

0.4 97

Helpful, Courteous, and Respectful Office Staff (Q24 and 25) 92.66679517 ▲ 92.99811565

0.331320483 95.98

Medicaid Spending on ER and Inpatient Services +/- 300.89391

Page | 28






Medicaid spending on Primary Care and community based behavioral health care 50.75988688

PDI 90 - Composite of all measures +/- 655.2525893

593.8638304

-61.38875893 41.365

Percent of eligible providers meeting Meaningful Use criteria who conduct bidirectional exchange with qualified entities (RHIOs) 45.28301887 ▲

Percent of eligible providers meeting Meaningful Use criteria who have participating agreements with qualified entities (RHIOs) 48.42767296 ▲

Percent of PCP meeting PCMH (NCQA) or Advance Primary Care (SHIP) standards 28.73134328 ▲

Potentially Avoidable Emergency Room Visits +/- 39.2739968

35.95649712 32.63899744 -3.31749968 6.099

Potentially Avoidable Readmissions +/- 1352.948368

1235.719131 1118.489894 -117.2292368 180.656

PQI 90 - Composite of all measures +/- 2454.780362

2241.407726

-213.3726362 321.054

Primary Care - Length of Relationship - Q3 83.16443129 ▲ 83.50198817

0.337556871 86.54

Primary Care - Usual Source of Care - Q2 86.38296794 ▲ 86.99167115

0.608703206 92.47

2.b.v

Care transitions intervention for skilled nursing facility (SNF) residents


0.763485987 91.0846954


0.302166457 94.3516309


0.028386046 94.4444444


0.555404719 91.91

Page | 29







0.345099223 98.8338093


0.368946964 100


0.299980718 98.4210526


0.21685254 100


0.186699871 92.52


0.4 97


0.331320483 95.98




593.8638304

-61.38875893 41.365





35.95649712 32.63899744 -3.31749968 6.099


1235.719131 1118.489894 -117.2292368 180.656

Page | 30







2241.407726

-213.3726362 321.054


0.337556871 86.54


0.608703206 92.47

2.b.vii

Implementing the INTERACT project (inpatient transfer avoidance program for SNF)


0.763485987 91.0846954


0.302166457 94.3516309


0.028386046 94.4444444


0.555404719 91.91


0.345099223 98.8338093


0.368946964 100


0.299980718 98.4210526


0.21685254 100


0.186699871 92.52


0.4 97


0.331320483 95.98

Medicaid Spending on ER and Inpatient 300.89391

Page | 31






Services +/-



593.8638304

-61.38875893 41.365





35.95649712 32.63899744 -3.31749968 6.099


1235.719131 1118.489894 -117.2292368 180.656


2241.407726

-213.3726362 321.054


0.337556871 86.54


0.608703206 92.47

2.b.viii

Hospital-Home Care Collaboration Solutions Adult Access to Preventive or Ambulatory Care

- 20 to 44 years 83.44983553 ▲ 84.21332151

0.763485987 91.0846954


0.302166457 94.3516309


0.028386046 94.4444444


0.555404719 91.91

Page | 32







0.345099223 98.8338093


0.368946964 100


0.299980718 98.4210526


0.21685254 100


0.186699871 92.52


0.4 97


0.331320483 95.98




593.8638304

-61.38875893 41.365





35.95649712 32.63899744 -3.31749968 6.099


1235.719131 1118.489894 -117.2292368 180.656

Page | 33







2241.407726

-213.3726362 321.054


0.337556871 86.54


0.608703206 92.47

3.a.i

Integration of primary care and behavioral health services

Adherence to Antipsychotic Medications for People with Schizophrenia 61.79775281 ▲ 63.26503635

1.467283539 76.4705882

Antidepressant Medication Management - Effective Acute Phase Treatment 57.46606335 ▲ 57.71945701 57.97285068 0.253393665 60

Antidepressant Medication Management - Effective Continuation Phase Treatment 39.36651584 ▲ 39.77769034 40.18886485 0.411174506 43.4782609

Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia 72.72727273 ▲ 74.67754545 76.62781818 1.950272727 92.23

Diabetes Monitoring for People with Diabetes and Schizophrenia 58.33333333 ▲ 61.47959184 64.62585035 3.146258507 89.7959184

Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication 80.17241379 ▲ 81.05425498

0.881841191 88.9908257

Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) 25.56390977 ▲ 25.8345188

0.270609023 28.27

Follow-up after hospitalization for Mental Illness - within 30 days 60 ▲ 62.82352941 65.64705882 2.82352941 88.2352941

Follow-up after hospitalization for Mental Illness - within 7 days 50 ▲ 52.41935484 54.83870968 2.41935484 74.1935484

Follow-up care for Children Prescribed ADHD Medications - Continuation Phase 85.71428571 ▲ 85.71428571

0 78.65

Follow-up care for Children Prescribed ADHD Medications - Initiation Phase 70.21276596 ▲ 70.41838012

0.205614164 72.2689076

Page | 34






Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) 56.14035088 ▲ 56.24031579

0.099964912 57.14

Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) +/- 93.49881797

87.67753617 81.85625437 -5.821281797 35.286

Screening for Clinical Depression and Follow-Up Plan 13.07189542 ▲ 17.38770588

4.315810458 56.23

3.b.i

Evidence-based strategies for disease management in high risk/affected populations (adult only)

Aspirin Use 40 ▲ 42.286

2.286 62.86

Discussion of Risks and Benefits of Aspirin Use 55.68 ▲ 56.839

1.159 67.27

Flu Shots for Adults Ages 18 - 64 38.4 ▲ 40.905

2.505 63.45

Health Literacy - Describing How to Follow Instructions 87.12729487 ▲ 87.38456539

0.257270513 89.7

Health Literacy - Explained What To Do If Illness Got Worse 89.30038121 ▲ 89.78034309

0.479961879 94.1

Health Literacy - Instructions Easy to Understand 97.21571584 ▲ 97.37614426

0.160428416 98.82

Medical Assistance with Smoking and Tobacco Use Cessation - Advised to Quit 89.29 ▲ 89.919

0.629 95.58

Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Medication 68.52 ▲ 70.056

1.536 83.88

Medical Assistance with Smoking and Tobacco Use Cessation - Discussed Cessation Strategies 55.36 ▲ 57.351 59.342 1.991 75.27

Prevention Quality Indicator # 13 (Angina without procedure) +/- 33.999728

30.8748552

-3.1248728 2.751

Prevention Quality Indicator # 7 (HTN) +/- 122.3990208

111.3911187

-11.00790208 12.32

3.d.ii

Page | 35






Expansion of asthma home-based self-management program

Asthma Medication Ratio (5 - 64 Years) 52.98245614 ▲ 55.2883772

2.305921056 76.0416667

Medication Management for People with Asthma (5 - 64 Years) - 50% of Treatment Days Covered 51.41509434 ▲ 53.13072777

1.715633426 68.5714286

Medication Management for People with Asthma (5 - 64 Years) - 75% of Treatment Days Covered 31.13207547 ▲ 32.51324994

1.381174473 44.9438202

Pediatric Quality Indicator # 14 Pediatric Asthma +/- 507.3500715

460.8699644

-46.48010715 42.549

Prevention Quality Indicator # 15 Younger Adult Asthma +/- 52.52790545

48.6315149

-3.896390545 13.564

4.c.ii

Increase early access to, and retention in, HIV care

Age-adjusted percentage of adults who have a regular health care provider - Aged 18+ years 76.8 ▲

Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years 109.1

Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years - Ratio of Black non-Hispanics to White non-Hispanics 1.67

Age-adjusted preventable hospitalizations rate per 10,000 - Aged 18+ years - Ratio of Hispanics to White non-Hispanics 0.97

Chlamydia case rate per 100,000 women - Aged 15-44 years 1432.9

Newly diagnosed HIV case rate per 100,000 22.6

Page | 36






Newly diagnosed HIV case rate per 100,000 - Difference in rates (Black and White) of new HIV diagnoses 27.6

Newly diagnosed HIV case rate per 100,000 - Difference in rates (Hispanic and White) of new HIV diagnoses 23.8

Percentage of adults with health insurance - Aged 18-64 years 76.4 ▲

Percentage of premature death (before age 65 years) 23.9

Percentage of premature death (before age 65 years) - Ratio of Black non-Hispanics to White non-Hispanics 2.04

Percentage of premature death (before age 65 years) - Ratio of Hispanics to White non-Hispanics 2.15

Primary and secondary syphilis case rate per 100,000 females 0.5

Primary and secondary syphilis case rate per 100,000 males 15.7

Domain 1 Measure

Health Home assigned/referred members in outreach or engagement 69.30966469 ▲

Health Home engaged members with a care plan during the measurement year 52.25225225 ▲

Health Home members who were in outreach/engagement who were engaged during the measurement year 18.95276039 ▲

NYP/Q PPS Governance

DSRIP Mid-Point Assessment - Organizational Narratives

PPS must submit a narrative highlighting

the overall organizational efforts to date.

PPS Name: NewYork-Presbyterian/Queens

Highlights and successes of the efforts:

Organizational Section: Governance Successes to Date: The NYP/Q PPS created a successful collaborative contracting model for the PPS governance structure. The PPS Executive Committee is comprised of members from the PPS lead, NYP/Q, as well as partners from LTC, Behavioral health, Home Care, and a community member. The executive committee oversees the progress and partner engagement for the PPS. Additionally, the PPS has built a PMO team which includes a Director, Program Coordinator, Data Analyst, Financial Analyst, and IT staff. The PMO is continuing to recruit for clinical staff (rapid cycle, chronic disease, and behavioral health) and an additional data analyst. The PMO team works with the NYP PPS PMO to ensure collaboration and consistency across some areas of DSRIP such as VBP and IT resources. This collaborative relationship between the PPSs ensures the appropriate leveraging of resources and tools across both PPSs when available and knowledge sharing for the successes and challenges of DSRIP. The PPS has created an organizational structure for the projects to be grouped based on deliverables and partner engagement for each. The projects are bucketed into 5 groups – Asthma (3.d.ii), HIV (4.c.ii), Primary Care/Behavioral Health (3.a.i), Long Term Care (2.b.v, 2.b.vii, 2.b.viii, 3.g.ii), PCMH & Cardiovascular (2.a.ii, 3.b.i). The clinical workgroups report into the Clinical Integration and Population Health Management Committee, which is comprised of the chairs from the clinical projects, IT committee chair, and a representative from the RHIO Healthix. The grouping of these projects ensures efficiency for partners by grouping the deliverables to make the scope of the projects more manageable where possible. The PPS holds bi-annual town hall meetings to promote staff and community engagement and provide a forum for educational sessions and communication on the DSRIP initiatives. Previous town hall meetings have included presentations on DSRIP 101, DSRIP funds flow, pediatric asthma and PCMH. The PPS has been featured in local media from the town hall meetings.

DRAFT

NYP/Q PPS Governance

The China Press 03

14 16.pdf The PPS has executed 45 contracts to date and flowed funds to 49 partner sites1. A robust communication and engagement plan has been approved by the PPS and outlines the communication process for partners, CBOs, and public agencies for the PPS. Challenges: The PPS has identified

95%/5% Funding Rule – Per the STCs of the DSRIP waiver, the PPS is only permitted to flow 5% of fund to non-safety net providers. As the PPS engages non-safety net partners, specifically CBOs, in the DSRIP projects, the ability to incentivize these organizations is limited by this requirement.

Value Based Payment – The NYP/Q PPS is a collaborative model approach which has no accountability of MCO contracting for engaged partners. Along with no direct-accountability, the PPS is also limited to assisting with negotiation and planning due to federal regulatory compliance limitations.

Mitigations:

95%/5% Funding Rule – The PPS is working on engaging CBO partners through project participation and educational opportunities for the PPS. The PPS is also working with partners to identify potential sub-contracting opportunities for CBOs and external revenue sources, such as grant funding. DOH is currently in the process of requesting an extension of the safety net definition to any provider who sees a minimum of 25 Medicaid patients. If this is approved, the PPS will have more flexibility with incentive funding as additional providers in the PPS will be eligible for the 95%.

Value Based Payment – The PMO team is partnering with the NYP PPS to build an educational program focused to value based payment conversion. The models will provide educational materials as well as financial modeling tools for partners in order to internally prepare for MCO negotiations and contracting.

1 Partners are contracted at an organizational level and funds are flowed by DOH categorization, therefore the PPS may contract

with an FQHC that has 3 sites. This results in 1 contract but 3 funds flow to each of the sites within the FQHC.

DRAFT

NYP/Q PPS – Financial Sustainability, Funds Flow, Budget






Organizational Section: Funds Flow / Financial Sustainability / Budget Successes to Date: The PPS continues to meet the expectations associated to the financial aspects of the PPS. This mid-point assessment narrative will address (1) Funds Flow, (2) Financial Sustainability, and (3) Budget.

o Overall – o A Financial Analyst was recruited to the PMO and currently is focused to developing monthly

financial tools to include budget, actual spend, forecasting, and variance explanations. This team member will work in partnership with the Finance Committee and executive leadership to consistently track and trend financials as well as complete finance deliverables.

o Additional recruitment is underway for numerous positions to include both clinical & non-clinical positions to support operations as well as clinical integration.

o Funds Flow –

o Quarterly partner distributions continue with a schedule of March & September to align with the NYS DSRIP payments to include payments for incentives, cost of implementation, and revenue loss.

o PIT Updates in MAPP include payments made to partners based on actual checks cut in quarter being reported.

o CBO payments are included in the incentive funding and will be reviewed monthly to ensure compliance with the 95% / 5% safety-net provider ruling.

o The NYP/Q PPS Executive Leadership is working with the NYP Managed Care team to complete the contracting for the EIP/ EPP funding. One contract has been signed and a second contract is in final phases of signatures.

o Financial Sustainability – o The financial sustainability partner analysis was completed and two partners were identified

as potential risks within the network. The Financial Analyst is working to complete the follow-up action items that are identified in the PPS Financial Sustainability plan.

o The PPS Executive Leadership is partnering with the NYP PPS to align strategies of Value Based Payment transition of the lead hospital as well as partners.

DRAFT


o Budget –

o Actual spend has met expectations outlined with the DSRIP application to include: 5% Contingency, 2% Workforce, 30% Administrative Overhead, 5% Non-Covered Services, 10% Revenue Loss, 18% Cost of Implementation, and 30% Incentives.

o Expense forecasting is underway to ensure availability of funds pending the EIP/EPP Contracting.

Challenges: The PPS has identified the following challenges related to performance reporting:

Funds Flow: 95% / 5% Safety Net Limitation – A number of the clinical programs require a direct connection to CBO’s for engagement and education and the organizations are not safety-net providers.

Financial Sustainability: Value Based Payment Adoption – The NYP/Q PPS is a collaborative model approach which has no accountability of MCO contracting for engaged partners. Along with no direct-accountability, the PPS is also limited to assisting with negotiation and planning due to federal regulatory compliance limitations.

Funds Flow: Delayed EIP / EPP Contracting – The NYP/Q organization depends on the NYP organization to complete all MCO negotiations and contracting. The leadership at NYP is working on behalf of both NYP & NYP/Q PPS in order to complete the EIP/EPP contracting as a system strategy.

Transition of the Funds Flow Model to Performance Based – The existing PPS funds flow model was built to encourage engagement, project requirements, and engaged patient volume. In order to meet the quality based outcomes for performance the model will need to evolve into a true pay-for-performance model blended with other indictors which will ensure engagement, productivity, and quality.

Mitigations: The PPS has identified mitigation strategies to the challenges:

Funds Flow: 95% / 5% Safety Net Limitation – The PPS is working with partnering organizations in order to identify potential sub-contractor relationships with CBO’s in order to ensure engagement for education and engagement.

Financial Sustainability: Value Based Payment Adoption – The PMO team is partnering with the NYP PPS to build an educational program focused to value based payment conversion. The models will provide educational materials as well as financial modeling tools for partners in order to internally prepare for MCO negotiations and contracting.

Funds Flow: Delayed EIP / EPP Contracting – Both NYP & NYP/Q PPS’s are working closely with the NYP managed care operations executives to complete the contracting in a timely manner. The PMO teams are providing financial analytics and input into the negotiating processes to ensure full understanding of drafted contracts.

DRAFT


Transition of the Funds Flow Model to Performance Based – The Financial Analyst and PMO leadership are working on modeling additional phases of the funds flow models focused to engagement as well as outcomes. It is anticipated to have models presented to the Finance Committee late 2016.

DRAFT


DRAFT

NYP/Q PPS Cultural Competency & Health Literacy






Organizational Section: Cultural Competency & Health Literacy Successes to Date: The NYP/Q PPS successfully completed both the Cultural Competency and Health Literacy strategy and training strategy. The PPS has built both the organizational structure and clinical projects with CCHL as the foundational principle. The PPS has built the strategies on national best practices including the NQF CLAS standards, Teach Back, and AskMe3. The PPS is leveraging the expertise of partners who has historically done trainings for the community on health literacy to determine the best ways to educate the community. Challenges: The PPS has identified three primary challenges to ensuring the success of the CCHL work.

CC/HL Leadership – The PPS currently does not have an expert within the PPS to lead the CC/HL committee. The committee is currently being run by the PMO and leveraging experience within the partner network but lacks a true subject matter expert in this area.

Training Competencies – The PPS has created a comprehensive training plan which includes the CCHL trainings. The PPS will be using an e-learning platform for the majority of the trainings. There are currently no national standards for competencies for CCHL. The PPS will include pre- and post- tests in the training to ensure that participates are going through the modules and can track the change in the results. The PPS would like to include additional competencies to ensure that the trainings are comprehended as opposed to being another item that staff click through but do not make any changes to their processes.

Cultural Shift for the Workforce – The PPS will be providing training to the partner network workforce through both in person trainings and e-learning platforms. The PPS will monitor training and the embedded tests to track the changes in competency for the CCHL trainings. The PPS is aware that completing training does not necessarily result in a paradigm shift for the workforce in how they interact with the patients and present information about healthcare and self-management.

Mitigations: The PPS has identified mitigation strategies to the challenges to the success of the workforce work stream.

DRAFT

NYP/Q PPS Cultural Competency & Health Literacy

CC/HL Leadership – The PPS is hoping to engage 1199TEF to act as an expert in CCHL and help lead the committee. The committee has successfully created a strategy and training strategy but is looking to engage an expert for the execution and engagement of these plans. The PPS is in the process of contracting with 1199TEF and aims to have this included within the scope of work.

Training Competencies – The PPS will include embedded pre- and post-tests for staff in the eLearning platform and provide questionnaires for in person trainings to monitor the success of the training. The PPS will continue to monitor updates from NQF on competencies on CCHL to incorporate into the trainings and evaluation processes.

Cultural Shift for the Workforce – The PPS will provide training for the workforce and track the progress of the embedded competencies. The PPS will continue to work with partners to ensure that CCHL is embedded as a philosophy within the organization beginning at the leadership level. The PPS will strive to engage partners and partner leadership to incorporate the NQF principles in the workflows of the organization and begin to encourage the cultural shift that accompanies this workstream.

DRAFT

NYP/Q PPS Performance Reporting






Organizational Section: Performance Reporting Successes to Date: The PPS has drafted a performance reporting strategy that includes the partners and processes associated with performance outcomes. The strategy includes the plan for existing data sources as well as planned tools and data sources focused to partner engagement and performance improvement. The strategy aligns IT with clinical operations in order to maximize partner engagement and ensure positive improvements to quality metrics. The PMO team recruited staff which includes a data analyst and financial analyst. The role of the data analyst is to manage the monthly intake of engaged patient information, development of dashboards specific to need of the projects or leaders, and to partner with the Rapid Cycle Evaluation Unit to complete forecasting and risk assessments as outlined in the Population Health Management strategy. The financial analyst will partner with the data analyst on maintaining databases which allow for complete analysis of partners based on outcome data. The PMO Director will manage the overall performance reporting process and brings a vast amount of quality experience. The PPS dashboards have been rolled out and each project committee began utilizing the quality based dashboards to educate partners and began the conversations of process improvement focused to quality based outcomes. The claims based data will be utilized to deepen the analysis of patients, partners, and processes. The long-term care project lead began a root-cause analysis (RCA) exercise with the committee members focused to actual patient outcomes. The blinded patient process is discussed from beginning to end in order to identify areas that the network could have changed processes, tools, or communication channels to avoid an emergency department visit, admission, or re-admission. The exercise is not intended to place blame but to identify process improvement opportunities or gaps in care in order for the long-term care network to improve quality outcomes. The RCA will continue and will be a tool that is utilized in the Rapid Cycle Evaluation Unit.

DRAFT

NYP/Q PPS Performance Reporting

Challenges: The PPS has identified the following challenges related to performance reporting:

Salient Access – The new PMO team members currently do not have access to the Salient tool and we have been informed that the team will not be given access until training occurs and the state has no future training dates set.

Timeliness of Quality Data – The quality data provided in the MAPP tool is dated due to the process of utilizing claims based data sources.

Ability to Receive Real Time Quality Data – The PMO is working with a partner PPS to identify potential opportunities for data analytics tools to utilize for the Rapid Cycle Evaluation Unit and Performance Improvement. The analytics tool will provide the ability to load real-time quality data from partners, but the PMO will have challenges obtaining the data from partners with so many other requirements and commitments in daily operations.

MAPP “No Assigned PCP” – The current amount of patient activity in MAPP that has no ability to trend based on a provider due to “No Assigned PCP” is substantial and severely limits the team’s ability to complete provider based analytics.


Salient Access – The PMO has brought the training & access issue to the attention of PCG//IA and will continue to maximize other tools such as MAPP and the claims based data until the team receives training.

Timeliness of Quality Data /Ability to Receive Real Time Quality Data – The PMO team is working with NYP PPS to identify possible analytical tools & processes to build a process of tools & analytics in a more timely fashion. Questions regarding data security have been posed to PCG and the team will continue the planning based on the response.

MAPP “No Assigned PCP” – The PPS continues to communicate this issue to the PCG/IA teams and will utilize the claims based information to build provider level analytics in order to prioritize partners to align with process improvement techniques.

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NYP/Q PPS – Population Health Management






Organizational Section: Population Health Management Successes to Date: The PPS has initiated conversations with project workgroups to outline a roadmap strategy for population health management. The roadmap will align with the nine projects and will select a focused patient base to manage with the existing tools to be implemented by the IT team to include Allscripts Care Director, Cureator, and an analytical tool to be announced. The following steps will be the focus of the PMO & clinical leads to outline this strategy:

o Recruitment of a Population Health Manager (RN preferred) – The PMO leadership currently has a vacant position for a PH Manager and will continue to interview to fill as soon as possible. This position will be accountable for building the Rapid Cycle Evaluation Unit while partnering with the clinical leads to implement the PHM strategy.

o Population Analytics – The PHM strategy will identify a select patient set to manage as the PPS funding limits the ability to manage the entire population. NYP/Q chose project 2.a.ii versus 2.a.i and will not create an integrated delivery system to align with a PHM strategy. The focused PMH strategy will align with the selected projects such as the PCMH integration in order to address gaps in care, care coordination, patient tracking, provider identification & engagement, etc. The PMO data analytics team will work with the existing data elements to identify a select population to maximize the benefit of implementing a PHM strategy. The data will be categorized and prioritized to include utilization, chronic conditions, access, and gaps in care and will be presented to the Clinical Integration Committee for final prioritizations and decisions.

o Alignment of Focused Patient Base to Projects – The analytics completed above will then be aligned with complimenting projects to outline process workflows, plans to ensure proper provider engagement, and address any gaps in care focused to care coordination & quality improvements.

o Completion of the PHM Strategy – Upon final analytics and vetting among partners and clinical leads, the PMO team will finalize a strategy roadmap to outline the PPS strategy to include processes, partners, and IT tools for the focused patient base.

o Clinical Workgroup, Clinical Integration & PAC Presentation – A complete PHM strategy roadmap will be reviewed by multiple partner outlets to include clinical workgroups and PAC. The final PHM strategy will be reviewed & approved by the Clinical Integration and Executive Committees.

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NYP/Q PPS – Population Health Management

Challenges: The PPS has identified the following challenges related to population health management:

Limited Funding for a Complete PHM Strategy – The available funding for the NYP/Q PPS is limited and will be consumed by the clinical integration of the nine projects. A strategy of population health for the entire attributed network would require more funding to ensure complete processes and tools are implemented (ex: Care coordination, data analytics, etc.)

Manual Processes for IT Tool Registration – The PMO IT team has identified tools needed to implement the PHM strategy which requires a large amount of workforce time to manually register patients for tracking.


Limited Funding for a Complete PHM Strategy – The PMO team is working to identify a select group of patients to build a PHM strategy focused to quality improvements. The population that will be identified during the ‘population analytics’ process on page one of this document will focus to the most relevant patient population based on need and opportunities for improvements in order to maximize the return of investment for processes and tools.

Manual Processes for IT Tool Registration – The PMO IT team is working with the IT vendors in order to identify additional batch methods for the registration of the attributed lives for the NYP/Q PPS. The complexity of this task is to ensure no duplication of records when we receive a monthly performance attributed patient registry from NYS.

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NYP/Q PPS - Clinical Integration

DSRIP Mid-Point Assessment

Clinical Integration

Organizational Narrative

PPS Name:NewYork-Presbyterian/Queens


The NYP/Queens PPS has been working towards the creation of an integrated clinical network through the DSRIP program. The PPS, through its organizational committees, project committees, and partner engagement and outreach initiatives, has determined the fundamental needs of a sustainable integrated network. The robust and effective structure of the Clinical Integration committee, which is responsible for the Clinical Integration and Population Health workflows in addition to ensuring clinical quality and oversight of the project committees, engaged both internal stakeholders and PPS partners in the identification of gaps in integration. As the oversight committee for clinical quality, the Clinical Integration Committee in NYP/Queens PPS is also responsible for approving best practices, evidence based standards, and protocols that have been recommended by the project committees and/or are deemed necessary by the Clinical Integration Committee. To date, the Clinical Integration Committee has reviewed and approved over 15 best practices for the PPS. NYP/Queens PPS continues to work with partners in vetting out evidence based best practices for various clinical processes. It is necessary to analyze gaps in clinical and operational workflows at the same time as the PPS practices the ongoing approval of best practices. Therefore, NYP/Queens PPS is continuing their search for recruitment for population health nurse who in collaboration with PMO team will work extensively on PDSA (Plan, Do, Study, Act) cycles. The NYP/Queens PPS will also establish a Rapid Cycle Evaluation (RCE) unit in DSRIP DY 2 to utilize performance data reported by partners as well as data available in MAPP (Salient) and other tools for quality improvement efforts. In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in project committees. In June 2016, a metrics review and planning day was organized as well within the group, the objective of which was to review, educate and begin process improvement for metrics overall and those out of compliance with goals. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for all project workgroups. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. Each dashboard will be unique to the clinical projects and will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes. Another big highlight of the NYP/Queens PPS in the Clinical Integration organizational project is the establishment of Root Cause Analysis (RCA) workgroup. The long term care project workgroups have

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established a process of analyzing an actual patient encounter recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency department utilization. The patient information and facility information is blinded and the encounter form beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause Analysis is completed in a workgroup where the team reviews items such as pre-condition/admission indicators, clinical indications, facility processes, communication among facility partners, access to electronic health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons learned to make local performance improvement changes to clinical operations in order to avoid ED utilization, admissions and re-admissions. The RCA will also become an integral part of the Rapid Cycle Evaluation Unit to allow team input for process improvement efforts. Furthermore, as learned in the June 21, 2016 DOH Conference in Albany, the PPS also plans to utilize Lean concepts and create effective workflows with minimal waste in the process. The PPS leadership and PMO team are in discussion for potential identification of such initiatives. But all these successes and efforts happened after overcoming multiple challenges, some of which the PPS still continues to face. The next few bullet points outline some of many challenges NYP/Queens has been facing and how we tried to resolve them. Challenge 1: Non-current data and limited tools and resources for data analytics Timing of project implementation with the MY/DY spread of metrics is a challenge to ensure process improvement that will result in quality outcomes. The PPS has received several DSRIP data feeds, including the member roster and the MAPP performance dashboards. While this information is a necessary start to the quality data process, there continues to be limited availability of data to the PPS and at the partner level. The member roster contains minimal information while the MAPP dashboards have limited access. This data is necessary both as claim based feeds from DOH, but also has real time information to enable rapid cycle improvement in the PPS. Moreover, due to some movement of employees in the PMO team since the beginning of DSRIP project, the new staff members who are responsible for data analysis and trending do not have access to Salient as they were never present when the initial training was first offered to all PPSs. No upcoming Salient trainings are offered as well. Despite the PPS' interest to be active participant in the Salient Interact Miner workgroup and utilize the data efficiently and meaningfully, the limited tools, staff, and available data for this continues to pose a risk to integration. Mitigation strategy by NYP/Queens PPS: The PPS is continuing their efforts in working with DOH and Salient contacts who can possibly manage to offer additional Salient training to the new staff in PMO office. In addition, the PPS is working best to use the data that is currently made available to us and create dashboards and summary to be presented to project committees and possibly utilize for further analysis by RCE unit. Challenge 2: Partners are engaged with more than 1 PPS and are asked to implement multiple best practices Two thirds of the NYP/Queens PPS partner network is participating in more than 1 PPS for DSRIP. These

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partners are asked to participate in data reporting, implementation of clinical projects, and adoption of best practices by multiple PPSs. This creates conflict when PPSs are doing the same project, 3.b.i Cardiovascular project for example, and are requesting difference best practices to be implemented. As the PPS needs to report out quarterly on partner participation and completion of requirements based on the speed and scale commitments, this poses a risk for partners who are asked to implement multiple best practices. Due to the large overlap of network providers in the PPS, there is an inherent risk in how these practices will be adopted by partners and their capacity to continue to partner with multiple PPSs based on the volume of requests and requirements. Mitigation strategy by NYP/Queens PPS: The PPS is working with committees and sub-committees to engage partners in the implementation process for the projects. The goal is to ensure that robust partner participation can reduce the burden of having numerous parallel but separate requests from PPSs surrounding the implementation process. In addition, the PPS is continuing to reach out to neighboring PPSs and look for collaboration opportunities to ensure that these requests are streamlined whenever possible to partners. The NYP/Queens PPS will continue to post the approved best practices to the PPS website to ensure transparency and seamless communication with the public, including community members, other PPSs, and network partners. Challenge 3: Limited revenue to create robust incentive plan It is important to ensure a robust incentive structure for partners to allow for buy in of requirements. As a small PPS, NYP/Queens PPS receive very small funding which make it very difficult to create an attractive funds flow model. Mitigation strategy by NYP/Queens PPS: The PPS is trying to be creative as always and is in the process of formulating an updated incentive plan which will revolve around partners meeting the quality outcome based measures. This will not only make effective use of the limited funding and create a robust incentive plan, but will also serve as a good buy-in strategy for partners to comply with requirements and adopt best practices as needed.

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NYP/Q PPS – Practitioner Engagement


Practitioner Engagement

Organizational Narrative



The NYP/Queens PPS has made enormous efforts to date to build a sense of efficiency and community among PPS practitioners, partners, and leaders by sharing regular, organized communications. We also continue to encourage transparency among practitioners and partners in order to instill public trust in the changes being proposed and community belief in the potential for successful outcomes. The NYP/Queens PPS is organized as a collaborative contracting model. It is made up of dozens of healthcare, mental health and community service providers in the region. These community partners, agencies, patients, and providers participate in 15 subcommittees that function under an Executive Committee that reports in to New York-Presbyterian/Queens and its Board of Trustees. One of these sub-committees is a Communications Committee. Community partners also participate in a Project Advisory Council (PAC) that oversees development of the NYP/Queens DSRIP’s nine (9) approved community projects as well as a bi-annual Town Hall meeting that focuses on PPS function and project updates to the community at large. To date, the internal NYP/Queens internal practitioners participate in the project workgroups, executive committee and professional group meetings. The monthly / quarterly project workgroups are focused to (1) Primary Care & Behavioral Health, (2) Cardiovascular, (3) Long Term Care, (4) Palliative Care, (5) Asthma, and (6) HIV. Executive committee meetings occur monthly which are focused to PPS development, approvals, risks, and financials. The numerous Professional Group meetings occur based on the scheduling of each organization. Agenda items include general topics, DSRIP specific items, and related professional topics. Additionally, the PPS is working on rolling out multiple IT tools for project management, population health management, event notifications etc. With that, the PPS also recognizes that it is critical that communications and roll-out for our network is efficient and effective to ensure partner and practitioner engagement and use of products developed. The PMO management team will continue to perform continuous outreach to partners for feedback on the process, tools, reports, and data for ongoing updates. In order to ensure active and meaningful practitioner engagement, the NYP/Queens PPS has arranged several trainings which encourage the practitioner to be subject matter expert or champion and educate others at their respective sites. Examples include trainings to recruit Physician champions for PCMH, Palliative Care champions and INTERACT champions for the long term projects. For the sites who are undergoing the PCMH transformation and for those that have completed the transformation, the PPS is appointing a physician champion at each site. Physician champion training is provided to selected practitioners. The training is focused on NCQA's 2014 PCMH standards, True practice

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transformation, role of change management, role of HIT, and lessons learned. Then, the physician champion is expected to be engaged in various ways. They will partner with HANYS PCMH Advisory Services to ensure buy-in from the team and effective roll out of processes. They will serve as the liaison between CMO and other physicians. In addition, they will be the go to person for escalations and reinforcement with other providers. They will partner with Project Manager and PCMH team to educate clinicians and staff on goals and standards. Moreover, they will also report monthly updates to appropriate parties. Besides PCMH training, the PPS will provide training to the long-term care providers participating in the INTERACT and home care project. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. In collaboration with GNYHA, the NYP/Queens PPS has hosted an all-day training session on June 15, 2016 for care coordinators in the PPS. Care coordinators are those who would play a coordination role in the continuum of care for patient. The PPS observed very good attendance record for this training. The assigned care coordinators from each partner site were very engaged. This specific training was intended to specifically educate the coordinators about the fundamental, evidence-based concepts for building an effective care coordination process to achieve improved outcomes and understands roles, responsibilities and best practices within their individual sites. Another way of encouraging practitioner engagement that the PPS has adopted is through building training modules and requiring partners/ practitioners to comply by watching the modules and testing their knowledge in it. The NYP/Queens PPS aims to train the PPS partner's workforce on DSRIP through DSRIP 101 training, which includes what DSRIP is, the goals of the program, the specifics of the NYP/Queens PPS, how to participate, and the funds flow incentive model. Similar to the DSRIP 101 training, the PPS has also undertaken training specific to each of the projects for the partners participating in each. These project specific trainings are aimed at providing baseline knowledge of the goals and requirements of each project and provide a platform for in depth project specific training. These baseline trainings have taken place at committee meetings with participating providers/partners and at town hall meetings for the PPS. The PPS will continue to engage partners in these forums and through individual encounters to ensure any new participants/practitioners in DSRIP have a thorough understanding of the projects that have been selected. The PPS also educates partners/practitioners on various policies, procedures and approved documents and best practices. For instance, Performance Reporting Strategy is an approved document crafted by the PPS that includes policies, processes, and procedures to ensure confidential data exchange and effective communications for quality and operational data between the PPS and its provider network. Partners/Practitioners will be educated on the Performance Reporting Strategy as well. Given the hundreds of partners that the NYP/Queens PPS has, the liaison role that partners play is a critical one to ensure success, overall and in specific projects. The goal is to have partner organizations take ownership of PPS projects by developing knowledge and enthusiasm. Below are a variety of communications vehicles and engagement methods that are already implemented or will be in near future to stimulate partners’ active participation, helping them to lead and manage potential issues: Web site: A microsite has already been created for use by all stakeholders, including PPS partners. This is a common work environment that provides plans, schedules, materials, and links to other content and engagement tools of various types. The website will be continually updated based on the development of

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the PPS.

Message track: This outlines key messages to be used in discussing programs. It includes citations for data used to support those programs, as well as messaging around the Community Needs Assessment that details the needs around which those programs were created.

Elevator speech: A one-page document that describes DSRIP, what the PPS is doing and the route to success. Partner leaders and team members should customize this speech and use it to talk about DSRIP with external stakeholders and their own staff.

Frequently Asked Questions (FAQs): Responses to commonly asked questions collected from leaders, employees and physicians. It provides answers directly from the DSRIP project team.

Glossary of Terms: A common list of terms that people may hear during the DSRIP rollout – terms they may not be familiar with or understand.

Master deck: A collection of slides that tells the story of DSRIP. It will include a healthy dose of visuals and infographics suitable for varying audiences. The deck is not meant to be used in its entirety; partner leaders will be encouraged to pull out necessary slides and graphics to suite their purposes.

Community Needs Assessment 101: A brief on the highlights of fall 2014 findings and what they mean to the community.

Templates for Milestone Announcements: Models of ads, press releases, media advisories and letters will be provided for partner use in communicating with their external stakeholders. Other items will be developed if needed as programs roll out.

Link to possible Introductory Video: If feasible from budget perspective, a video will be produced to introduce Partner leadership, their employees and physicians to the DSRIP project. It will include description of DSRIP projects, why the projects are being developed and what it means for individual stakeholder organizations.

Project List, Descriptions, Timeline and Site-Specific Involvement: Timeline of when major project milestones will occur and what it means for partners. The timeline will change as projects progress.

Archive and Links: Relevant content, as well as tools on other web sites, including NY State Department of Health.

Mini-White paper, “What does Transformation look like”? This will be provided to PPS partners for use within their organization and with external stakeholders.

Performance Logic: A project management software, will be rolled out to all engaged partners to track project progress and action items for proper PPS quarterly reporting.

Function and Project Committees and Sub-Committees: All partners were surveyed as to their interest in all function and project committees and sub-committees, based on the projects committed or subject matter expertise. Committee rosters are maintained and partners are encouraged to add additional members based on the evolution of each group. (All meetings allow in person and call in options with occasional webinars)

Project Advisory Council (PAC): All external partners hold a seat on the PAC and are invited to engage quarterly.

Town Hall: Meetings allow external stakeholders to participate and / or present as a subject matter expert to the community, based on the topic being covered.

MAX Series: Identified engaged partners that align with the NYS MAX series topics are given the

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opportunity to participate and receive additional funds flow based on the approved PPS funds flow model.

TOM Series: IT focused committee that allows for partner engagement to collaborate on information technology scenarios and how they relate to a project to anticipate the PPS need for operational changes to improve IT and patient care. This is an additional item that links to the funds flow model approved.

NYS All PPS Meetings: The PPS leadership reviews all PPS meeting agendas to identify partner attendance to allow access to all state PPS meetings. As PPS project implementation accelerates, regularly scheduled Partner/team conference calls will be instituted to provide updates, identify issues as they develop, answer questions, and share ongoing communications guidance

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NYP/Q PPS - Workforce






Organizational Section: Workforce Successes to Date: The NYP/Q PPS has completed 2 workforce milestones, target state and compensation & benefits analysis; in addition the PPS has successfully achieved the DY1 committed workforce spend and anticipates meeting the commitments for DY2-DY5. Additionally, the PPS completed a workforce communication and training plan that details the workforce needs for each DSRIP organizational work stream and clinical project. Challenges: The PPS has identified two primary challenges for completing the workforce milestones.

Tracking and Reporting of Staff Impact – The PPS currently has limited infrastructure across the partner network to track and report on staff impact for all of the required categories. This information is currently housed by some HR systems but is not tracked by workforce category (recruitment, redeployment, retraining, and reduction) nor by job title and organization type.

Limited Funding – The PPS has limited revenue to support the partner network including providing vendor and/or in person training sessions, providing IT solutions for tracking and reporting the workforce staff impact, and recruitment of new practitioners needed to address the safety net gap identified in the CNA.

Mitigations: The PPS has identified mitigation strategies to the challenges to the success of the workforce work stream.

Tracking and Reporting of Staff Impact – The PPS is in the process of creating a manual process to collect data from partners on staff impact by organization type, job title, and workforce impact category. The PPS will continue to look for IT solutions to provide to the partner network to ensure that the staff impact process can be streamlined if possible.

Limited Funding – The PPS is contracting with a vendor to provide an e-platform for training across the partner network. This will enable the PPS to provide training required for the organizational work streams and clinical projects to the partner network; this includes the ability to complete training from the office and for the PPS to track the training that has been completed at the PPS

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NYP/Q PPS - Workforce

level across partner organizations for reporting. Additionally, the PPS is connecting partners to outside resources to assist with funding for recruitment such as the Mental Health Service Corps.

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NYP/Q PPS – Project 2.a.ii

DSRIP Mid-Point Assessment - Project Narratives

PPS must submit a narrative in each

Section for every project the PPS is implementing


Project: 2.a.ii

Challenges the PPS has encountered in project implementation:

The PPS has identified several challenges specific to the implementation of the PCMH project. These challenges include

Care Coordination Resources – Approximately 1/3 of partners that are undergoing PCMH transformation are small practices, which may only include a physician and a medical assistant. The PCMH practices, especially these small sites, have limited resources to provide care coordination and generally do not have the capacity to hire a new employee specific to care coordination.

EHR/IT Requirements – NYP/Q is currently undergoing a change in EHR systems for the ambulatory clinics from eCW to Athena Health. The PCMH transformation and application process requires that clinics have reports, population health management, and an EHR. In order to provide this information, the sites are required to have an EHR system that is utilized. The transition from eCW to Athena Health has required a delay for the NYP/Q sites to complete the application and certification process.

Transformation Process – The transformation process for PCMH is a both a time consuming and resource intensive process. Many practitioners have identified this as the largest hurdle to participating in this project.

Efforts to mitigate challenges identified above:

Based on the identified challenges for the project, the PPS has identified the following mitigation strategies:

Care Coordination Resources – The PPS has partnered with GNYHA to provide care coordination training to PPS partners. The PPS hosted the 1st session in June 2016 and had 27 attendees from across the partner network. The PPS aims to continue supporting these in person sessions and will consider including a refresher course on the eLearning platform.

EHR/IT Requirements – NYP/Q sites completed the transition to Athena Health in July 2016. The HANYS Solutions team is in the process of reengaging the NYP/Q sites to complete the application process. NYP/Q sites are on schedule to submit the PCMH 2014 Level 3 application in the fall/winter of 2016.

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Transformation Process – The PPS has engaged HANYS Solutions to assist practices with the transformation process across the partner network. As of DY2, Q2 4 practices (21 practitioners) have completed the PCMH process and received their 2014 Level 3 certification. The PPS is continuing to work with an additional 7 practices (22 practitioners) to complete the certification process by the end of DY3 per the project requirement. Currently, all practices are on track to meet the requirements for certification.

Site Name # of Practitioners PCMH Transformation Status

Brightpoint Health 3 Certified 2014 Level 3

Community Health Network 14 Certified 2014 Level 3

Advanced Pediatrics 3 Certified 2014 Level 3

Ma Jesus Calagos, M.D. 1 Certified 2014 Level 3

Jackson Heights 4 In Progress

TLCC 6 In Progress

ACC 4 In Progress

Jose Quiwa, M.D. 1 In Progress

Rego Park Medical Associates 3 In Progress

Rest Medical Care PC 3 In Progress

Arkhady Takhalov, M.D. 1 In Progress

TOTAL 43

Implementation approaches that the PPS considers a best practice:

The PPS has approved several best practices for the PCMH project:

Roles & Responsibilities – Care Coordination & Physician – The project committee has created an outline of the roles and responsibilities for care coordinators and physician champions in the PCMH project.

Care Coordinator

Role and Responsibilities 01 13 16.pdf

Physician Champion

Role and Responsibilities 01 13 16.pdf

PCMH Roadmap – The PPS, in collaboration with HANYS Solutions, created a roadmap for completing the PCMH process and built a training outline including a timeline and protocols.

PCMH Roadmap 11

30 15.pdf

PCMH Training

Protocols & Timeline 03 22 16.pdf

Additional details on the project implementation efforts beyond what is detailed in PPS Quarterly Reports:

All scale & speed expectations for this project are forecasted to be met based on those partners committed to the project.

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Address any changes to populations that were proposed to be served through the project based on changes identified through the community needs assessments:

There are no current proposals for changes to the populations served by the patient centered medical home project.

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DSRIP Mid-Point Assessment SNF Care Transition Project Narrative


Project:2.b.v


The NYP/Queens PPS selected this project and bundled it with two other projects INTERACT and Hospital Home care as the objectives and deliverables align well together. One of the main objectives of this specific project is to ensure SNF staffs have access to hospital patient records and hospital staff prior to patient discharge; therefore, Information Technology is an integral key to success. The NYP/Queens PPS IT survey revealed that most partner nursing homes have EHR systems. However, there is a lack of interoperability among partners. Currently, SNFs are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below). Also, in implementing several milestones for this project, the PPS has been encountering numerous challenges. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS.


To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO. In order to make sure the SNFs and home care facilities can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites.

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The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016.


The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that.

Development of Advance Care Planning Tools The PPS is encouraging partners to utilize the eMOLST tool for participation in the long-term care bundled projects. eMOLST optimizes the clinicians workflows and helps them to determine the level of appropriate care for terminally Ill, patients. The PPS has engaged Dr. Patricia Bomba, MD, FACP with Excellus BlueCross BlueShield to provide training to PPS partners on how to utilize the tool most efficiently. This training will be provided based on demand by the PPS partners.

INTERACT Implementation checklist shared with the partner facilities This checklist is intended to assist organizations in determining the degree to which the INTERACT Quality Improvement Program is being implemented. INTERACT implementation requires all the key components in the checklist, not just using selected INTERACT tools.

Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.

Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started

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utilization of MAPP dashboard data in the SNF/INTERACT project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.


All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project.


There are no current proposals for changes to the populations served with our Care Transitions Intervention for Skilled Nursing Facility (SNF) residents’ project, as our clinical integration of the project align with the needs outlined in our community needs assessment.

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INTERACT Project Narrative


Project:2.b.vii


The NYP/Queens PPS has selected the INTERACT program as one of the 9 clinical projects as we think this is a best practice for reducing avoidable readmissions from nursing facilities. The PPS intends to support partner sites implementing this program and utilize lessons learned from partners that have already adopted the program to ensure a successful implementation across participating sites. However, in implementing several milestones for this project, the PPS has been encountering numerous challenges. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS. Moreover, in order to build better coordination system and meet the multiple project requirements, the partner organizations needs to have eMR and be connected to RHIO. Currently, SNFs are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below).


The NYP/Queens PPS conducted a survey of participating nursing homes to assess if the INTERACT program had been adopted and the degree of adoption. One facility reported the adoption of seven of the tools designed for nursing homes and was advanced in its practice of INTERACT principles. This entity proved to be a great resource for the quality improvement collaborative. During the assessment, nursing homes were also asked to complete the Interact Version 3.0 Nursing Home Capabilities List to strengthen the match between SNF selection and patient needs at hospital discharge. This is a first step towards the adoption of the INTERACT program and therefore the implementation has begun. In order to make sure the SNFs and home care facilities can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then

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having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016. To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO.


The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that.

Development of Advance Care Planning Tools The PPS is encouraging partners to utilize the eMOLST tool for participation in the long-term care bundled projects. eMOLST optimizes the clinicians workflows and helps them to determine the level of appropriate care for terminally Ill, patients. The PPS has engaged Dr. Patricia Bomba, MD, FACP with Excellus BlueCross BlueShield to provide training to PPS partners on how to utilize the tool most efficiently. This training will be provided based on demand by the PPS partners.

INTERACT Implementation checklist shared with the partner facilities This checklist is intended to assist organizations in determining the degree to which the INTERACT Quality Improvement Program is being implemented. INTERACT implementation requires all the key components in the checklist, not just using selected INTERACT tools.

Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management

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care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.

Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in the SNF/INTERACT project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.




There are no current proposals for changes to the populations served with our INTERACT project as our clinical integration of the project align with the needs outlined in our community needs assessment.

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Hospital Home Care Project Narrative


Project:2.b.viii


The NYP/Queens PPS has identified Hospital Home Care project, alongside Care Transitions in SNF and INTERACT project, as a vital project to make impact to its community based on the community needs assessment. For patients identified as high risk for readmission, transitions from hospital to home are expected to be managed using an interdisciplinary, multi-agency discharge team including patient and family, hospital, PCMH, home care, DME, social services and specialty services as needed. A transition care coordinator is expected to ensure timely patient follow-up with their PCP, that the plan of care is communicated to all involved, and that guidelines and criteria are in place for early identification and treatment of worsening patient conditions. As one of the resources and tools that can be used by home care agencies, the PPS chose the INTERACT Program as it offers a comprehensive implementation package which is compatible with EHR and paper based systems. The NYP/Queens PPS is supporting the adoption and implementation of the INTERACT tools by the home care agencies. This project is well suited to using a quality improvement collaborative model (“learning system that brings together teams to seek improvement in a focused topic area”) to implement the INTERACT program and are used by the NYP/Queens PPS. Since the INTERACT processes and materials are already developed and available, the home health agencies can focus collectively on the systematic implementation of the tools while learning from each other, leveraging common resources such as physician and staff training, and support each other throughout the process. The early adopter in the group can share lessons learned with others just starting. However, in implementing that came some barriers as well. A common barrier for an improvement effort such as this is enabling time for project team participation and for the training required to support implementation. Nursing home leaders are requested to support team participation and training as part of, not in addition to, their day to day job responsibilities. Successful implementation require funding in the project budget to allow for training participation without causing understaffing at the bedside. As the smallest PPS, and with minimal funding, this becomes a challenge for NYP/Queens PPS. As stated in DSRIP application for this project, partner home care agencies will adopt Healthix (RHIO) for real-time exchange of information and the PPS will provide technology guidance through this process. Currently, home care agencies are not eligible for Meaningful Use and therefore minimal incentives to have a certified EHR (as required by DSRIP) and connect to a RHIO. However, as part of mitigation strategy, the PPS has implemented a RHIO pilot to provide resources and a small financial incentive for partners who participate (to be described in the section below).

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In order to make sure home care facilities and SNFs can have INTERACT training for all staff members and at the same time keep the operations undisrupted, the PPS adopted the idea of having facility champions from each partner organization. Facility champions are in the process of being identified at sites. The PPS aims to implement a train-the-trainer model by having the facility champions trained and then having the champions act as the trainers and experts at their own facilities. To date, the INTERACT is close to finalization and budget for the training is drafted as well. The PPS projects to have the training sessions with the 27 SNFs and 8 home care facilities potentially in September 2016. To incentivize partners to both adopt an EHR and connect to the RHIO, the PPS has adopted bilateral strategies, (1) NYCReach and (2) RHIO Pilot. The PPS partnered with NYC Reach, an organization that assists practices with selecting, adopting, and implementing EHR systems. This service is offered to partners that are currently utilizing a paper based clinical documentation system as part of their participation in the NYP/Q PPS DSRIP efforts. Additionally, the PPS selected ‘Infrastructure spending related to SHIN-NY / RHIO’ as an EIP (Equity Infrastructure Payment) measure. As the PPS will receive incentive payments for accomplishing this through the EIP/EPP program, the PPS has incorporated incentive funding for participation into the funds flow model. Participants in the RHIO pilot program currently receive $2,500 for participating in the pilot and connecting to the Healthix RHIO.


The NYP/Queens PPS has undertaken several approaches that we are proud to consider as best practice and below bullet points highlight the efforts to accomplish that:

Root Cause Analysis Workgroups: The long term care project workgroups have established a process of analyzing an actual patient encounter recommended by a partner based on the goal of reducing hospital admissions, readmissions, or emergency department utilization. The patient information and facility information is blinded and the encounter form beginning to end is discussed and analyzed to identify opportunities for process improvement. The Root Cause Analysis is completed in a workgroup where the team reviews items such as pre-condition/admission indicators, clinical indications, facility processes, communication among facility partners, access to electronic health records, etc. in order to improve outcomes for future patients. The teams are using the RCA lessons learned to make local performance improvement changes to clinical operations in order to avoid ED utilization, admissions and re-admissions. The RCA will also become an integral part of the Rapid Cycle Evaluation Unit to allow team input for process improvement efforts.

Population Health Management and Event Notification Tools The PPS has selected vendors for population health management (Allscripts) and event notifications (Cureatr) to contract with on behalf of PPS partners. The Allscripts Care Director (ACD) tool is in the process of an internal roll out at NYP/Queens with the PMO and clinical leads. The goal is to include all engaged patients in the tool and utilize the reporting and care plan functions to improve care coordination and generate required reports for the quarterly reporting

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process to DOH and the IA. After a successful implementation at the PMO, the PPS plans to roll out the tool to partners to continue to load patients requiring care plans and patients that meet the actively engaged definitions for the participating projects. The PPS will complete a phased roll out of the tool beginning with the NYP/Q hospital during DY2, Q2. Cureatr is an event notification tool which provides user notifications of patients registered who have had an admission or discharge to the hospital. NYP/Queens currently utilizes the tool with the case management care coordinators and the PPS aims to roll out the tool to select partners. The PPS aims to roll this tool out to primary care and home care providers in the PPS to ensure timely follow-up on any inpatient or ED admissions. The PPS is in the process of validating need of the tool based on the services provided by partners, but it is likely that the PCMH and home care partners will be provided access to enable enhanced coordination of care.

Project Performance Metrics: In order to succeed as PPS and to effectively impact the population health, NYP/Queens PPS understands the value of data-driven process improvement efforts. As part of that, NYP/Queens PPS has started utilization of MAPP dashboard data in the Hospital Home Care project committee. Moreover, the PPS has decided to produce quarterly quality based outcome dashboards for the project workgroup. The dashboards will encompass summaries of metric data pulled from MAPP, Salient, and PPS claims data housed on the secure sever. The dashboard will be shared with the project workgroups for further analysis and process improvement planning. The dashboards will also provide tools to the Rapid Cycle Evaluation Unit team to identify trends and risks associated with quality based outcomes.


All scale & speed expectations for this project are forecasting to be met based on those partners committed to the project. The PPS is actively exploring different options for telehealth and mobile health technology. Options will be evaluated and best tools will be implemented to best meet the needs of the beneficiary population.


There are no current proposals for changes to the populations served with our Hospital Home Care project as our clinical integration of the project align with the needs outlined in our community needs assessment.

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NYP/Q PPS – Project 3.a.i





Project: 3.a.i


The PPS has identified challenges specific to the integration of primary care and behavioral health and the implementation of the requirements for the project.

Behavioral Health Workforce Recruitment – NYS has a shortage of behavioral health practitioners, including NPs, Case Managers, and physicians. The PPS has also identified a shortage of behavioral health providers, which has been compounded by the closing of several behavioral health clinics in the past several years.

EHR Interoperability – The project requires EHR interoperability between the primary care and behavioral health providers as a requirement of both Models 1 and 2. Based on this, the PPS will need to navigate the regulatory limits of sharing data related to behavioral health between the practitioners to ensure continued compliance.

Capital Funding – The PPS committed to integrating care at 3 sites within PPS; additionally, the PPS committed to purchasing a population health management tool for use by the entire partner network. Both of these are commitments that require capital funding. The PPS applied for CRFP funds from the state but was not awarded any of the submitted application. The PPS therefore has to ensure the success of these commitments on a limited DSRIP valuation and without CRFP funding.

Cultural Stigma – Through the PPS CNA qualitative data compilation, many stakeholders identified significant cultural and/or religious barriers to seeking behavioral health care. The sites that will be integrating services will have a challenge engaging patients in care due to this cultural barrier.


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The PPS has identified several strategies for mitigating the identified challenges for the PPS.

Behavioral Health Workforce Recruitment – The PPS is committed to connecting partners to resources to assist with the recruitment of behavioral health providers, such as Mental Health Corps. The PPS will continue to work to identify opportunities for partners to assist in recruiting behavioral health providers and connecting with resources within the partner network.

EHR Interoperability – The project committee is collaborating with the IT committee, legal counsel, and Healthix to ensure that all regulations are met in the course of implementing the co-location process.

Capital Funding – One PPS partner, Brightpoint Health, was awarded CRFP funding for the integration of primary care and behavioral health project. Brightpoint Health is one of the partners in the network that will be integrating services. The other partners that will be integrating services are Child Center of NY, Mental Health Providers of Western Queens (MHPWQ), and NYP/Q. These partners who did not receive CRFP funding are looking at their internal budgets to ensure that they can fund the requirements for integration.

Cultural Stigma – The PPS is working with partner organizations to provide education and information on behavioral health. The PPS will utilize platforms such as the e-learning to provide training to practitioners and staff, and the bi-annual town hall meeting for community members. Additionally, the PPS will leverage community engagement events that are held by partner organizations.


The PPS has approved best practices related to preventative health screenings, including the PHQ-2/9, SBIRT, lipid screenings, and others.

Preventative Care

Screenings 11 30 15.pdf Additionally, the PPS is in the process of determining tools that can be provided to partners on administering primary screenings at the behavioral health sites and behavioral health at the primary care sites.




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There are no current proposals for changes to the populations served by the integration of primary care and behavioral health.

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NYP/Q PPS – Project 3.b.i


Cardio Project Narrative


Project:3.b.i


Cardiovascular disease has the highest prevalence and utilization rates of any disease state in the NYP/Queens PPS community. Improving the health status of persons with cardiovascular disease, and thereby decreasing preventable utilization for cardiovascular disease, will inherently decrease overall preventable utilization. This project was selected as one of the clinical projects with the intention that the PPS would work with high risk patients to address any barriers to managing their cardiovascular disease. However, as the PPS approached in implementing different strategies to meet milestones for the project, we encountered multiple challenges, some of which are outlined below:

Partners are engaged with more than 1 PPS and are asked to implement multiple best practices Two thirds of the NYP/Queens PPS partner network is participating in more than 1 PPS for DSRIP. These partners are asked to participate in data reporting, implementation of clinical projects, and adoption of best practices by multiple PPSs. This creates conflict when PPSs are doing the same project, 3.b.i Cardiovascular project for example, and are requesting difference best practices to be implemented. As the PPS needs to report out quarterly on partner participation and completion of requirements based on the speed and scale commitments, this poses a risk for partners who are asked to implement multiple best practices. Due to the large overlap of network providers in the PPS, there is an inherent risk in how these practices will be adopted by partners and their capacity to continue to partner with multiple PPSs based on the volume of requests and requirements.

Defining true care coordination team As one of the requirements for this project, the PPS needs to develop care coordination teams including use of RN staff, pharmacists, dieticians & community health workers to address lifestyle changes, medication adherence, health literacy issues, & patient self-efficacy and confidence in self-management. Currently the definition for care coordination team is very vague and does not specify if the members in the care coordination team have to be located in same site or can work together remotely, etc. Without a clear description and concept of care coordination tea, it is difficult to build the appropriate team that will meet the patient’s needs and at the same time be operationally feasible.

Non-current data available to the PPS Timing of project implementation with the MY/DY spread of metrics is a challenge to ensure process improvement that will result in quality outcomes. The PPS has received several DSRIP data feeds, including the member roster and the MAPP performance dashboards. While this information is a necessary start to the quality data process, there continues to be limited availability of data to the PPS and at the partner

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level. The member roster contains minimal information while the MAPP dashboards have limited access. This data is necessary both as claim based feeds from DOH, but also has real time information to enable rapid cycle improvement in the PPS.


In order to mitigate the challenges identified above, the NYP/Queens PPS have undertaken multiple efforts and implemented some effective strategies, all of which are briefly summarized below:

For this 3bi project, the PPS has formed a Cardio committee that meet monthly to discuss deliverables, workflows, best practices and partner feedback. The committee also reports out to Clinical Integration Committee. As the oversight committee for clinical quality, the Clinical Integration Committee in NYP/Queens PPS is responsible for approving best practices, evidence based standards, and protocols that have been recommended by the project committees and/or are deemed necessary by the Clinical Integration Committee. To date, the Cardio Committee and the Clinical Integration Committee have reviewed and approved over several best practices for the PPS. NYP/Queens PPS continues to work with partners in vetting out evidence based best practices for various clinical processes.

The PPS is also working with committees and sub-committees to engage partners in the implementation process for the projects. The goal is to ensure that robust partner participation can reduce the burden of having numerous parallel but separate requests from PPSs surrounding the implementation process. In addition, the PPS is continuing to reach out to neighboring PPSs and look for collaboration opportunities to ensure that these requests are streamlined whenever possible to partners. The NYP/Queens PPS will continue to post the approved best practices to the PPS website to ensure transparency and seamless communication with the public, including community members, other PPSs, and network partners.

In collaboration with GNYHA, the NYP/Queens PPS has hosted an all-day training session on June 15,

2016 for care coordinators in the PPS. Care coordinators are those who would play a coordination role in the continuum of care for patient. The PPS observed very good attendance record for this training. The assigned care coordinators from each partner site were very engaged. This specific training was intended to specifically educate the coordinators about the fundamental, evidence-based concepts for building an effective care coordination process to achieve improved outcomes and understands roles, responsibilities and best practices within their individual sites.

Also, to target the medication management piece for care coordination team development concept,

the NYP/Queens PPS is currently in discussion to work with a partner. The given partner has best practices in medication management and the PPS plans to roll that out for whole network as part of developing care coordination interdisciplinary team.

The PPS is continuing their efforts in working with DOH and Salient contacts who can possibly

manage to offer additional Salient training to the new staff in PMO office. In addition, the PPS is working best to use the data that is currently made available to us and create dashboards and summary to be presented to project committees and possibly utilize for further analysis by RCE unit.

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The NYP/Queens PPS has implemented several best practices and undertaken approaches that we consider to be best practices and also highlight our successes to date. The PPS is providing materials related to the Million Hearts Campaign, hypertension diagnosis and medication management, blood pressure check and tobacco cessation referrals for partners. Million Hearts Campaign

The Million Hearts Campaign, http://millionhearts.hhs.gov/, provides resources and protocols on hypertension and tobacco-smoking cessation. These protocols have been provided to participating sites for implementation by the clinical director. The PPS will offer an in service, as needed, with partners and participating sites on how to use the tools and protocols for improving patient care. Blood Pressure Competency

The PPS has approved the competency checklist for both the manual and automatic blood pressure check. Partners will ensure that the BP competency is incorporated into their annual competency check process and provide copies of the completed certification of competency to the PPS.

The PPS will request random audits and documentation of the partner blood pressure competency and utilization of the million hearts campaign. The PPS will use these samples as part of the documentation submission process for the IA quarterly reports. NYS Smokers Quit line Provider Education Resources

In order to make sure providers are comfortable speaking with patients, who are identified as smokers, about the smoking quitting referral, the PPS has provided the partners/providers with education resources from NYS Smokers Quit line program.

Collaborative call- Sep 7, 2016 http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=7050

Continuing Medical Education- online module http://nysmokefree.com/cme/

More tools and resources for Provider & Partners http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=70280

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http://millionhearts.hhs.gov/

http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=7050

http://nysmokefree.com/cme/

http://nysmokefree.com/HCP/HCPSubpage.aspx?p=70&p1=70280





There are no current proposals for changes to the populations served with our cardio project as our clinical integration of the project align with the needs outlined in our community needs assessment.

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NYP/Q PPS – Project 3.d.ii





Project: 3.d.ii


Challenges related to the Asthma Home Based Care project relate directly to funding availability, the ability to influence socio-economic factors within the patient’s home, and the ability to directly improve quality based indictors that cover a broader range of patient outside of a pediatric population. Challenges are detailed below with mitigation strategies outlined in the second section of this file:

Asthma Resource Center (ARC) – The application process originating before the financial valuation created a misalignment of funding and the plans for clinical integration of new service line offerings. Initially in the application, the team planned to develop an Asthma Resource Center (ARC) that would provide care coordination, provider education, and other resources for the provider and patient community.

95% / 5% STC Funding Rule – Understanding that the DSRIP program is focused to maximize efforts and utilization at our safety-net partners, the asthma program has benefits to expanding our relationships with CBO’s and non-clinical providers in order to increase education & access points to the pediatric population. The current 95%/5% rule within the STC limits our ability to incentivize our non-clinical/non-safety net partners to expand the program services.

Home Access & Change – Home access to asthmatic pediatric population has been identified as a challenge as the socio-economic factors of each patient is unique along with the family structure and support system. Gaining access to the home is the initial struggle while influencing changes in the home setting to include behavioral changes of family members is an additional challenge that our program will face.

NYS Assigned Non-Pediatric Quality Metrics – The focus of the Asthma partner network within our PPS is to improve quality outcomes in order to maximize the improvement to our community and partners. The clinical workgroup aligns clinical integration planning with metrics as best as possible but the metrics outlined by the NYS DOH for this project have a wider range of patients that our specific pediatric project. Our application was submitted to serve those 18 years and younger while only two of the five metrics focus to pediatrics (PQI #14 & PQI #15). Three quality indicators cover ages 5-64 (medication management ratio, 50% treatment days covered, and 75% of treatment days covered).

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The process of risk identification & mitigation planning is an ongoing process of the clinical teams. The clinical workgroup structure allow for proper identification and planning of risks as clinical integration tasks are completed at all partner types. The above risks have been vetted utilizing the clinical workgroup structure and include the following mitigation strategies:

Asthma Resource Center (ARC) – The clinical workgroup has identified an alternative to the Asthma Resource Center (ARC) and has created a plan to develop a CBO based process that will focus to provider education based on the access points of patient activity (ED, Inpatient Hospitalizations, School Based Clinics, Clinical & Non-Clinical providers). The CBO based program will also include a patient navigation / coordination effort to ensure connectivity to home-based care. The program dynamic will ensure education of patients and providers based on the access points and the connectivity to home-based care providers based on the need of the patient or family. The CBO contract with The Asthma Coalition of Western Queens has been executed and the PMO team is working to outline a full scope of the agreement to align incentives based on clinical integration and quality based outcomes for a partner that is non-billable.

95% / 5% STC Funding Rule – The above contract with the Asthma Coalition is being forecasted to maintain the 95%/5% ruling, but the team is finding the incentive funding potential limiting as the NYP/Q PPS has limited revenue potential and 5% is limited. The clinical teams are working internally with safety-net partners to identify additional contracting strategies with CBO’s and other safety net providers in order to maximize incentives to critical non-safety net or non-clinical providers. Such contracting strategies include third-party contracting with safety net providers based on existing relationships.

Home Access & Change – The clinical workgroup, which includes community based organizations, clinical partners, behavioral health partners, and non-clinical partners, understands the dynamics associated with such a challenging process of behavior changes for those surrounding the pediatric asthmatic patient and is building an education based model with multiple access points to help influence change. An example of educational opportunities include school based clinic trainings. The partnership with the Asthma Coalition and Mental Health Providers of Western Queens has provided opportunities for education of the staff within the clinic to identify triggers of asthma patients, refer patients to home-based care, and to help educate family members on the processes available to manage this chronic condition.

NYS Assigned Non-Pediatric Quality Metrics – Understanding that we have no ability to change the indicators for our project, our team is aligning our pediatric asthma project with our PCMH project to increase access and care coordination for this chronic condition. Along with project coordination, the PPS will align the Rapid Cycle Evaluation (RCE) Unit to include provider quality analytics in order to outline process improvement opportunities which will include asthma patient populations up to the age of 65. The expertise in the clinical workgroup will be leveraged during the process improvement processes in an effort to increase awareness, communication, and education to our provider network.

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The Asthma clinical workgroup has adopted numerous national best practices for this patient population and are being used as a clinical integration tool with all partners committed to this project. Along with the national best practices, our PPS has identified the following as internal PPS best practices to date:

School Based Clinic Education Program – The clinical team outlined an education program for school based clinic staff that focus to asthma basics, environmental triggers, home-based care opportunities, referrals for home-based care and clinical providers, and other items. This education is an amazing opportunity to access pediatrics patients where they spend most of their time, in school, and helps the clinical staff to decrease absenteeism and potentially reduce emergency department utilization and hospital admissions through multiple access points for education & coordination.




There are no current proposals for changes to the populations served with our pediatric asthma project as our clinical integration of the project align with the needs outlined in our community needs assessment.

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NYP/Q PPS – Project 3.g.ii





Project: 3.g.ii


The PPS has identified challenges specific to the implementation of the Palliative Care in Skilled Nursing Facilities (SNF) project. These challenges include the cultural/religious stigma of palliative care, MOLST/eMOLST tools, and Funding/MCO reimbursement rates for services. Challenges are detailed below with mitigation strategies outlined in the second section of this file:

Cultural/Religious Stigma – Queens County Medicaid Beneficiaries are inclusive of a diverse group of people from various ethnic, racial, religious, and cultural backgrounds. Patients/care givers/ family members in the past have been reluctant to participate in end of life and/or palliative care discussions. The PPS has a large lift to engage the community in these efforts and provide information and education on the importance of the integration of palliative care.

MOLST/eMOLST Tools – The PPS has committed to utilizing the MOLST/eMOLST tool for the project. The PPS is encouraging partners to adopt the eMOLST tool but there is resistance amongst clinicians as the tool takes a significant amount of time to complete compared to the paper version (approximately 45 minutes).

MCO Reimbursement/Project Funding – The project partners has indicated that the MCO reimbursements for palliative care services are insufficient or nonexistent specific to consultations and education for the patient/family/care giver. Additionally, as the smallest PPS in the DSRIP program, NYP/Q PPS has very limited resources to commit to the project and provide as incentive funding for partners.


Based on the identified challenges, the PPS has formulated mitigation strategies to ensure the success of the project. These strategies are detailed below:

Cultural/Religious Stigma – The PPS has begun a training program for practitioners on palliative care from the EPEC (Education in Palliative and End-of-Life Care) program. The training program includes modules on communication and how to address patients/families/care givers on this topic. Additionally, the practitioners will be provided education from the CC/Hl workgroup on cultural competency and health literacy. The PPS also aims to inform patients and the community on palliative and end-of-life care and will use the biannual town hall meeting as a forum for

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NYP/Q PPS – Project 3.g.ii

presentations and discussion on the topic.

MOLST/eMOLST Tools – The PPS is providing support to partners as they adopt the MOLST or eMOLST forms. The PPS is partnering with Dr. Bomba from Excellus BCBS to provide training on the eMOLST tool to help providers better understand how to navigate and document in the tool and provide tips on how to reduce the time burden for completing the eMOLST.

MCO Reimbursement/Project Funding – The PPS is committed to providing partners with aggregate data on partner survey responses for uncovered services and patient outcome data to use when partners begin the VBP process with MCOs. Additionally, the PPS is providing incentives to partners outside of DSRIP funding, such as EPEC certification and CME credits for participation in training.


The Palliative Care committee has adopted several best practices which have been presented to and approved by the Clinical Integration Committee.

EPEC – The training program has been adopted as a best practice for the PPS. The trainings are held bi-monthly and cover two modules per session. The trainings rotate between partner sites and practitioners that attend are eligible to receive CME credits. Additionally, practitioners that attend all of the sessions can receive their certification in EPEC.

EPEC Training

Schedule v3.pdf CAPC— The PPS is engaged with CAPC (Center for Advanced Palliative Care) as an educational

resource for partners. Membership with CAPC has been made available to the partner network at a discounted DSRIP rate. In addition to educational opportunities, CAPC offers information on policy, clinical quality data, networking, and news updates.




There are no current proposals for changes to the populations served with our palliative care project.

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NYP/Q PPS – Project 4.c.ii



section for every project the PPS is implementing


Project: 4.c.ii


Challenges related to the project focused to increasing early access, and retention in, HIV care have been discussed in detail with the project workgroup and are described as follows:

Lack of Dedicated Funding for Non-Covered Medicaid Services – Outreach and education are critical elements of this program and the project workgroup has identified an outreach strategy that will require additional contractual relationships with non-clinical (CBO) partners to expand existing programs & service areas that focus to outreach & education based on the needs of the patient base.

Connectivity of Medical Records for Partner Use – The PPS is focused to RHIO connectivity with a rigorous processes and training for the patient consent process, but the HIV population is a select group of patients, similar to behavioral health and pediatrics that has limitations on access.

95%/5% Safety Net Funding NYS DOH Ruling – The HIV project will rely heavily on relationships/contracts with CBO’s in order to expand access to outreach and educational opportunities. The CBO partners identified are not considered safety net providers due to the fact that they are not billable Medicaid providers yet our project will depend on funding to this partner base.

Lack of Quality Based Outcome Data / Partner Specific – The workgroup is currently focused to hot-spotting patient activity in order to identify unmet patient needs for outreach, HIV testing, education, and access to care. The current data compilation is being derived from public data that is dated and the team would benefit from actual PPS partner data to have more timely data specific to the need of the population we serve.

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Lack of Dedicated Funding for Non-Covered Medicaid Services – The NYP/Q PPS has built a funds flow model that is a group practice method where all projects are considered priority and receive the same formula for an overall resource of revenue received from performance. The HIV project has incentives outlined focused to performance of project requirements, engagement in state level activity, etc. and has educated all partners on the potential to maximize incentives based on their engagement in the project.

Connectivity of Medical Records for Partner Use – The NYP/Q PMO IT team is working with Healthix to identify potential processes for patient consent for this patient population. The team is also working with all partners on the RHIO Connectivity pilot project which is aligned with incentive funding to ensure connectivity.

95%/5% Safety Net Funding NYS DOH Ruling – Partner relationships are being established or expanded for safety-net providers in order to sub-contract with non-safety net providers who are critical to the success of the project. The sub-contractor model is not ideal to ensure timeliness of implementation but will allow partners to maximize return & build on existing relationships with CBO’s.

Lack of Quality Based Outcome Data / Partner Specific – The PPS has been informed that there will eventually be access to this patient level information and the workgroup will complete the hot-spotting activity at that time to continue to identify needs of the community based on geography or partner activity.


The PPS partners to include clinical providers, pharmacies, CBO’s, etc. have identified an outreach strategy that aligns with the patient need based on unconventional access points for outreach, education, and testing. The outreach strategy is attached to outline the current approach and will be used to continue to evolve based on the need of the patients and partners.

NYPQ HIV Outreach

Strategy Final.pdf


The PPS continues to engage in NYS HIV collaboration workgroups to maximize efforts of 6 PPS’s and ensure consistency among partners involved. The collaborative recently identified additional sub-committees focused to topics and the NYP/Q PPS is working with engaged partners to assign members to each workgroup and will work with executive leaders to include in the funds flow method in order to provide incentives to partners for engaging.

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At this time, there has been no changes to populations of patients or network partners that affect the clinical implementation of the HIV project. The PMO team will continue to monitor the patient base and partner network to identify additional changes or trends.

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nyp/q dsrip executive committee meeting … committee...nyp/q dsrip executive committee meeting...

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