Community Partners of WNY DS RIP Proj ect Advisory Committee (P AC) Meeting December 13, 2016
DS RIP Patient Engagement Report, Proj ect & Work S tream Updates Amy White-S torfer Director, Proj ect Management Office
ED Triage (2.b.iii.)-Patient Engagement Recap: state released new definition for this proj ect on June 28 t h • Engagement - care manager/ care coordination follow up appointment for health home engaged population* • Engagement is PCP appointment demonstrated by scheduled appointment with PCP * If t he pat ient has not been engaged in t he HH, we cannot count t hem for t he proj ect
ED Triage (2.b.iii.)-Progress Report Phase I— Health Connections staff (HCs) contact patients with no PCP; warm transfer to clinics (went live 11/ 28) Phase II— Patient Navigators (PNs) added to care management team at S isters and Mercy Hospitals; warm transfer to clinics First round of interviews held; planned start date after Jan 1 4 positions to be filled— still recruiting for qualified candidates Phase III— Patient Navigators and Health Connections staff schedule directly into CHS clinics via S orian scheduling (early 2017) Crimson Care Management (CCM) module workflow tool will be used by both HCs and PNs for connecting patients to services Continue to report patient engagement numbers are from our partner, WCA Hospital
Care Transitions (2.b.iv.) CHS and CMP Care Management teams use Crimson Care Management to log patient communication Care notifications are sent to primary care offices, allowing for communication between PCP and IP facilities WCA continues its reporting and workflows
Telemedicine (2.c.ii.) S pecialists on Call proj ect at WCA Hospital is the only team reporting patient engagement numbers at this time Planning in Progress: Maternal Fetal Medicine (MFM) WCA Hospital and OB/ GYN practice in Erie County are partners for this sub-proj ect Up to 700 patients could be seen annually with this proj ect Credentialing providers in progress Technical start -up includes image licenses for OB/ GYN in Erie County Potential: Triage assessment for developmentally disabled population prior to ED visit Nursing recruitment remains a challenge to start this proj ect
Behavioral Health Integration (3.a.i.) By year end: 5 sites will have additional Behavioral Health services, care management support at Primary Care facilities 4 private practices (1 Niagara County, 3 Erie County) 1 CHS health clinic Continue to discuss options for Model 2
Cardiovascular Health (3.b.i.) Once-daily dose formulary list for hypertension medications has been finalized Communication strategy to practice providers in development
Nurse Family Partnership (3.f.i.) NFP in Chautauqua County Currently at capacity; expansion proposed Per NYS , NFP can now bill for Targeted Case Management Erie County CHWNB/ BUL contracts have been executed 1 CHW hired Nov 2016 – training and shadowing at MCCC Tentative timeline: 2 additional CHWs to be hired early 2017 – placed at S isters and Mercy
Palliative Care & PCP (3.g.i.) Continuing to explore alternative methods for capturing palliative care engagements at primary care sites Team looking to clarify the definition of a palliative care engagement and working with CMP CIS G to develop specific criteria.
Prevention Programs (Domain 4) Promote Emotional, Mental, and Behavioral Well-Being (4.a.i.) 2016-2017 school-based programs are ramping up “ Just Tell One” public awareness campaign to begin soon S eptember 29— CPWNY and MCC hosted a proj ect update meeting to update proj ect partners on program implementation and to reinforce reporting and reimbursement processes Promote Tobacco Use Cessation (4.b.i.) Roswell team continues community outreach, including to manufacturing and homeless shelters NYS S mokers Quit Line will send baseline referral/ call data from the three counties; will be updated annually to track community progress on cessation referrals
Work S tream Updates IT S ystems & Processes CPWNY Change Management Change Management S trategy approved by DIGC and EGB Posted on the CPNWY website under partners only section Available to view by request Outlines the appropriate steps for CPWNY partners to follow when IT system changes are made and the development of a training plan, if determined necessary Qualified Entity (QE), HEALTHeLINK QE plan approved by DIGC and pending EGB approval S ummary of engagement with the local RHIO, HEALTHeLINK Involvement with CPWNY patient consent collection & provider participation with the RHIO
Workstream Updates Performance Reporting Working side by side with Performance Management Partners on the development rapid cycle evaluation (RCE) training webinar. The webinar is based out of a system Articulate. This application allows for pre and post tests to be in place after each of the four training modules. The training was presented to our clinical transformation team in mid- November for review and suggestive trainings. These training will go live in the New Y ear as the Clinical Transformation and CMA staff will work with practices in Niagara and Erie County who have previously been trained in RCE and CCHN will work with Chautauqua County practices.
Work S tream Updates Population Health Clinical Transformation and Care Management teams working with practices on high risk patients and office registries of those patients. Utilizing health plan claims data and office registries for population health DOH Medicaid claims are forthcoming as part of DS RIP data available to PPS
Work S tream Updates Practitioner Engagement Continue engagement with: Newsletters practitioner meetings P AC meetings governance meetings One-on-one visits at practices conducted by the Clinical Transformation and Care Management Advisor teams
Work S tream Updates Cultural Competency and Health Literacy Continue to hold Medicaid focus groups in each county, 1-2 times a year. Purpose is to engage the Medicaid beneficiary in self management and improvement in cancer and blood pressure screenings Also working with the P2 Collaborative of WNY (PHIPS ) to engage businesses to allow employees time from j ob to achieve their health screenings S elf management programs in each county which are related to the community needs assessments performed by PPS . CCHL required training is being delivered to partners, to high volume practices first. Offices are being contacted by email for scheduling in person training. Interested in CCHL training, please contact bbolden@ chsbuffalo.org
Work S tream Updates Clinical Integration (CI) 2016-2017 The integration of clinical information and healthcare delivery services from related and or separate entities. Using data to help drive healthcare quality, cost improvement and improved patient satisfaction. CI plan in place and work is on-going Clinical Transformation and Care Management teams working with practices to improve quality and utilization metrics
Work S tream Updates Workforce R-AHEC/ CPWNY continues to finalize documents for the upcoming DY2Q3 milestones deliverables (e.g. target workforce state, transition roadmap, and training strategy). These documents will be presented at the upcoming Workforce Workgroup meeting on Dec 15, 2016 for approval. Once approved by Workforce Workgroup, the documents will go to the Executive Governing Body for final sign off before submission.
Budget Updates Dapeng Cao, PhD Manager, Healthcare Analytics Catholic Medical Partners
Expense review Total of $7.8 million spent to date Proj ect costs spread among 10 proj ects and proj ect management office expenses (included in 2ai proj ect expenses)
CPWNY Cumulative Distributed Revenue by Project DY1 to DY2 Q2 Project Name Sum of Expense DY1-DY2Q2 % 2ai IDS - PMO & Workstreams Expense $ 1,440,584 18.45% 2ai IDS - Provider Engagement Expense $ 662,838 8.49% 2biii Emergency Department Triage $ 942,810 12.07% 2biv Care Transitions $ 1,539,792 19.72% 2cii Telemedicine $ 433,577 5.55% 3ai Behavioral Health $ 428,405 5.49% 3bi Cardiovascular Health $ 389,196 4.98% 3fi Nurse Family Partnership $ 545,361 6.98% 3gi Palliative Care $ 791,035 10.13% 4ai Mental, Emotional, Behavioral Well being $ 322,096 4.12% 4bi Tobacco Use Cessation $ 313,540 4.01% $ 7,809,235 100.00%
CPWNY Cumulative Distributed Revenue by Project DY1 to DY2 Q2
CPWNY Cumulative Distributed Revenue by PPS Program Category* DY1 to DY2 Q2 PPS Program Category Sum of DY1-DY2Q2 Expense Percentage Case Management $ 1,591,288 20.38% Clinical Transformation $ 66,881 0.86% Community Based Organizations $ 1,937,690 24.81% Hospice $ 615,331 7.88% Hospital $ 1,341,019 17.17% Local Government Unit $ 217,774 2.79% Mental / Behavioral Health $ 173,995 2.23% Physician - Primary Care $ 1,862,838 23.85% Substance Abuse $ 2,420 0.03% Grand Total $ 7,809,236 100.00% May be different from NYS provider category on MAPP.
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