April 17, 2019 17 Why a Peer Support Certification? Process for acknowledging skills acquired by peers that qualify them to assist another in their recovery journey Includes standards for training and experience Promotes a skilled workforce Allows funding from new sources Establishes the qualifications for “professional” recognition for individuals working in the mental health system or addiction recovery system based on “The Shared Personal Experience” paradigm
April 17, 2019 18 What is a Certified Recovery Peer Advocate (CRPA)? Provides outreach, advocacy, mentoring and recovery support services to those seeking or sustaining recovery. In order to become a CRPA, the applicant must pass the International Certification and Reciprocity Consortium (ICRC) - An exam offered by an OASAS approved certification board. Hold a high school diploma or jurisdictionally certified high school equivalency and complete 46 hours of Complete 500 hours of volunteer required training-advocacy; mentoring & education; or paid work experience recovery & wellness; ethical responsibility CERTIFICATION REQUIREMENTS Receive 25 hours of supervision Pass the IC&RC Peer by an organization’s documented Advocate Exam and qualified supervisory staff
April 17, 2019 19 Resources for CRPA Training Friends of Recovery – NY (FOR-NY) FOR-NY in partnership with qualified trainers from throughout New York State, is pleased to offer first-rate trainings to peer professionals, treatment providers, prevention specialists, and anyone interested in addiction and recovery. Queensborough Community College-CUNY Josephine Troia , MS Ed., Program Coordinator 222-05 56 th Avenue Bayside, NY 11364 718-281-5535 , Fax: 718-281-5538 gtroia@qcc.cuny.edu Suffolk County Community College – COMING SOON Kathleen Ayers-Lanzillotta, MPA, CASAC Crooked Hill Road, Paumanok Hall P109A Brentwood, NY 11717 631-851-6594, ayersk@sunysuffolk.edu
April 17, 2019 20 FOR-NY BEST PRACTICE TRAINERS Best Practice Trainers provide comprehensive training and support to budding peer professionals. Trainers: • conduct a face-to-face screening interview • provide all 46 hours of NYCB-approved training (Both RCA + Ethics, or other approved curriculum) • mentor students through the CRPA certification process: * may assist with obtaining volunteer hours, * provide resources to prepare for the exam and * write a letter of recommendation. • host a monthly student learning collaborative • provide certification renewal training.
April 17, 2019 21 Long Island Recovery Association BEST PRACTICE TRAINERS Long Island (Nassau & Suffolk) Primary Richard Buckman Trainings Provided: Contact rbuckman@lirany.org CCAR Recovery Coach Academy 631-766-5664 CCAR Ethical Considerations for Recovery Coaches Trainer(s) Elsie Demers LIRA Ethics for Recovery Coaches edemersmetro@gmail.com Science of Addiction Recovery 516-903-1550 Our Stories Have Power-Recovery Messaging Richard Buckman Training rbuckman@lirany.org Legislative Issues and Addiction Recovery- 631-766-5664 Advocacy Training The Anonymous People Film and Discussion Generation Found Film and Discussion Multiple Pathways To Recovery
April 17, 2019 22 Principles for Peer Worker Core Competencies Recovery-Oriented Hope & Partnering; Building on Strengths Recognizing There are Multiple Pathways Person-Centered Voluntary Peer Choice Relationship Focused Trauma-Informed Strength based framework
April 17, 2019 23 Advantages for Providers Managed Care plans and other funders will look for peer integration New funding stream: Outpatient and OTP clinics - Peers & Continuing Care Being able to achieve the goal of integrating peers to bridge access points in the human services systems Increase the visibility of your organization Better: Engagement, Retention, Census
April 17, 2019 24 Advantages for Providers A cost-effective way to increase positive outcomes-Medicaid only needs to pay for the service (provider break even) for peer integration to be cost effective. The opportunity to have new perspectives on addressing behavioral health issues. Several studies document extensive evidence and research supporting the beneficial use of peer‐support and peer‐delivered services (e.g. Kyrouz, Humphreys, and Loomis, 2002; Bottomley, 1997; Davidson et al., 2006; Davidson et al., 1999).
April 17, 2019 25 Early Implementation: Building the Foundation • Buy-in from executive level and bds. of directors • Means that all have been fully educated on best practices re: peer supports; analysis of impacts on current practices and changes needed; tolerance of uncertainty and challenges • Agency readiness self-assessment completed • Attitudes explored of existing staff-are we welcoming, do existing staff feel threatened peers will “take over”? • Forums held to listen to staff concerns/ideas • Anticipate questions about ADA, ethics • Identify idea champions at all levels of agency
April 17, 2019 26 OASAS Recovery Support Services on Long Island Recovery Community and Outreach Centers (Weekend & Evening hours- Strong Participatory Process) The centers provide health, wellness and other critical supports to people and families who are recovering from a substance use disorder or are seeking recovery services for a family member or friend. They provide a community-based, non-clinical setting that is safe, welcoming and alcohol/drug-free for any member of the community. The centers promote long-term recovery through skill-building, recreation, employment readiness and the opportunity to connect with other community services and peers facing similar challenges . 1324 Motor Parkway, Hauppauge, Family and Children's Association- 11501 516-746-0350 Suffolk THRIVE 1020 Old Country Road, Westbury, 11590 Opening soon Nassau Community based THRIVE Everywhere Lisa Ganz, LCSW, CASAC, CRPA Senior Director of Peer Recovery Services, FCA P: 631.822.3396 | C: 631.332.2065 lganz@fcali.org THRIVE Recovery Community & Outreach Center
April 17, 2019 27 Recovery Community and Outreach Centers on Long Island THRIVE Family & Children’s Association (FCA) leads the operations and oversight of THRIVE Recovery Community and Outreach Center in partnership with the Long Island Council on Alcoholism and Drug Dependence (LICADD), Long Island Recovery Association (LIRA), and Families in Support of Treatment (F.I.S.T.).
April 17, 2019 28 OASAS Recovery Support Services on Long Island Peer Engagement Specialist Services: The Peer Engagement Specialists use their “lived experience” to engage people on the street and in hospital emergency rooms, developing brief person centered service plans, providing referrals and linkages to needed services. PES provide support, encouragement and guidance in linking persons to appropriate services. PES are particularly effective with people who have been reluctant to participate in traditional behavioral health services. Peer Engagement Specialists Oceanside Counseling Center 71 Homecrest Court, Oceanside, NY 11572 516-766-6283 x14 Nassau Thomas Hope West Babylon, New York 11704 (631) 333-0871 Suffolk Easter Seals Linda Gomez (631) 335-1668 Suffolk
April 17, 2019 29 OASAS Recovery Support Services on Long Island Family Support Navigators: The primary goal of the Family Support Navigator is to assist families and individuals with gaining an increased understanding of the progression of addiction and how to navigate insurance and treatment systems. Family Support Navigators develop relationships with local substance use prevention, treatment, and recovery services; managed care organizations; area substance use disorder councils; and community stakeholders to assist families with accessing treatment and support services. New Horizon Counseling Center, Inc 50 W Hawthorne Avenue, Valley Stream, 516-872-9698 Nassau NY 11580 Family & Children's Association 110 E Old Country Road, Mineola, NY 516-746-0350 Nassau, (Sherpa) 11501 x2274 Suffolk Thomas Hope West Babylon, New York 11704 (631) 333-0871 Suffolk
April 17, 2019 30 OASAS Recovery Support Services on Long Island Hospital Diversion Services Hospital diversion services can be delivered by peers, case managers, or other specialized workers and are evidence-based recovery support services for people in need of detoxification, stabilization and/or crisis management. They offer choices or options to the individual other than a hospital admission . Wrap Around Services Wrap Around Services include case management services that address educational resources, legal services, financial services, social services, family services, child care services, peer to peer support groups or services, employment support and transportation assistance. Hospital Diversion Catholic Charities of the Diocese of Rockville Centre 155 Indian Head Rd, Commack, NY 20580 516-733-7099 Suffolk Nassau University Medical Center 2201 Hempstead Turnpike, NY 85020 516-572-0160 Nassau Wrap Around Catholic Charities of the Diocese of Rockville Centre 155 Indian Head Rd, Commack, NY 20580 516-733-7099 Suffolk Nassau University Medical Center 2201 Hempstead Turnpike, NY 85020 516-572-0160 Nassau Thomas Hope West Babylon, New York 11704 (631) 333-0871
April 17, 2019 31 OASAS Recovery Support Services on Long Island Clubhouses Clubhouses offer services and supports to help young people progress in their recovery, and support at-risk young people who wish to live a substance-free life. Built on a core of peer-driven supports and services that encourage and promote a drug-free lifestyle, the clubhouse model provides a restorative safe, substance free space for youth and young adults in recovery, and those at-risk of substance use disorder, to participate in recovery programming as well as a variety of pro-social, recreational, educational, skill-building, and wellness programs. Clubhouses for youth are for people ages 12 to 17. Clubhouses for young adults are for people ages 18 to 21. Clubhouse HELP Services, Inc 46 Pine St, Freeport, NY 11520 516-378-1111 Nassau
April 17, 2019 32 OASAS Recovery Support Services on Long Island Centers of Treatment Innovation (COTIs) COTIs are OASAS Treatment providers focused on engaging people in their communities by offering mobile clinical services as well linking people to other appropriate levels of care. COTIs target un/underserved areas and expand access to tele practice, substance use treatment services, including linkage to Medication Assisted Treatment, as well as peer outreach and engagement within the community. Family Service League 1235 Montauk Hwy, Mastic, NY 11950 631-427- Suffolk. 3700 Tribal territories: Shinnecock, Poospatuck Central Nassau Guidance 950 South Oyster Bay Road, Hicksville, NY 11801 516-822- Nassau 4060
April 17, 2019 33 OASAS Recovery Support Services on Long Island Buprenorphine Induction OASAS has funded three hospitals on Long Island to support buprenorphine induction within the emergency department combined with peer connections through an outpatient provider. Hospital SUD Provider Partner Hospital Hospital Address Phone Northwell Health Central Nassau Guidance & Counseling Services (CNG) 516-465-2776 2000 Marcus Ave NY, 11042 Long Island Community Long Island Community Hospital SUD Program 101 Hospital Rd, Patchogue Hospital 516-377-5367 NY, 11772 South Nassau Oceanside Counseling Center (OCC) 516-822- One Healthy Way NY, Community Hospital 4060 11572
April 17, 2019 34 Recovery Bureau Functions • Management of Statewide Recovery Support Services (RCOCs, PES, FSN, HDWA) and Outcomes Reporting- http://cps.oasas.ny.gov • Peer Integration with Provider Agencies (COTIs and others) Recovery Bureau conducts TA site visits; Peer Learning Collaboratives; Readiness Assessments and Provide Resources • Management of FOR-NY- https://www.for-ny.org/ - Resource Guides; Training; Recovery Talks; Community Forums
PEER SUPERVISION COMPETENCIES April 17, 2019 35 Condensed SUD peer competencies adapted from SAMHSA: Appendix 3 (pages 32-34)
April 17, 2019 36 https://www.oasas.ny.gov/recovery/documents/PeerInte grationToolKit-DigitalFinal.pdf
April 17, 2019 37 IMPORTANT DATES: New York State Recovery Conference October 20-22, 2019
April 17, 2019 38 Contact Information: Susan Brandau, Director, Recovery Bureau Fredrick Hodges, LCSW, CASAC-MC-G Susan.Brandau@oasas.ny.gov (518) 485-2107 Assistant Director, Recovery Bureau Fredrick.Hodges@oasas.ny.gov (646)-728-4611 Marialice Ryan, MPA, Recovery Bureau Lureen McNeil, Recovery Bureau Marialice.Ryan@oasas.ny.gov Lureen.McNeil@oasas.ny.gov (518)-485-0506 (646)728-4578 Leslie Tabin, MS, ATR, CASAC-MC, Recovery Bureau Maureen Nguli, Recovery Bureau Leslie.Tabin@oasas.ny.gov Maureen.Nguli@oasas.ny.gov (585) 231-1695 (646)728-4672
We Can't 't do it it ALONE: ED + CBO = Success Sandeep Kapoor, MD, MS-HPPL Assistant Professor of Medicine & Emergency Medicine Zucker School of Medicine at Hofstra/Northwell Director, SBIRT Northwell Health Linda DeMasi, MBA Project Manager, SBIRT 39 Northwell Health
SUBSTANCE USE DISORDER TREATMENT & MANAGEMENT PROGRAM Gloria Mooney, MS, CSSGB CHS Project Manager – Facilities Based Projects Samantha Zeller, BS CHS Project Coordinator Amory Mowrey, CARC, CRPA, CASAC-T Sherpa Program Manager, FCA 4/4/2019
Program Objective: SUD Identification, Treatment and Management Combatting Opioid and Substance Use Disorder (SUD) through Community Collaborations The region served by CHS is faced with an alarming number of individuals addicted to opioids and other substances that present in the Emergency Departments. This population often has repeat visits to the ED, due to either noncompliance or lack of awareness of resources. To help individuals caught in this cycle CHS has adopted a collaborative approach to not just treat the short-term effects for the ED patient, but connect them with a community-based peer navigator to follow them through the recovery process. This unique approach has three parts: o 1) identify the patients in the ED through a specialized screening tool o 2) ensure medical stabilization and immediate support of the withdrawal process through Suboxone administration o 3) provide support beyond the ED through a community-based peer liaison. A Plan-Do-Study-Act approach was used to implement the program and included clinicians from the health system, religious agencies, and community agencies leaders with experience with addiction recovery. 41
Program Objective: SUD Identification, Treatment and Management Top Three Outcomes Achieved SBIRT was implemented on 1/1/2017. The eligible population is 12+. As of 2/28/2019, CHS has identified 1,525 patients to date in need of a brief intervention with 97% of them receiving an intervention. o Across GSH, SCH and SJH, ED utilization of this population after the intervention decreased by approx. 60% out 90 days, and approx. 47% out 180 days. As of 2/28/2019, 266 patients have been referred to the “ SHERPA ” program . Sherpa represents a community collaboration which provides two navigators: one to guide the patient through treatment and the second focuses on support for the family members or caregivers impacted. 96% of the ED physicians at the original pilot hospitals and about 60% of newly on-boarded hospitals have been trained in Suboxone administration, providing them the medical tools to support the start of the withdrawal process. Top Three Lessons Learned As a collaborative effort, lessons learned spanned multiple disciplines and beyond the health system: The data showed that opioid addicted ED patients were less likely to consent for the peer navigator support versus alcohol or other substances. Efforts will be made to revise the referral process and consider expanding the navigator program to better capture this population. The community agency providing the peer navigators to follow the patients discovered the need for alcohol related abuse and dependency was greater than expected. The program was originally intended for opioid abusers only, but was expanded to other substances based on the need. The Emergency Medicine Service Line physician leader of the system shared that while the ED physicians have completed training on Suboxone medication administration, there is hesitancy in administering the drug due to lack of confidence in the connection with longitudinal outpatient care. 42
Program Scope: SBIRT/SHERPA Program Scope: - Enterprise Collaboration, Establish Best-Practices using Evidence Based SUD Screening Tool, Standardize Process and Resources, Use Objective Data for Outcomes GOOD SAM ST. CHARLES ST. JOSEPH MERCY ST. CATHERINE ST. FRANCIS Pre-Screen Implemented Full SBIRT Implemented TBD 4/17/2019 INPATIENT PYSCH INPATIENT PYSCH TBD TBD EMERGENCY EMERGENCY EMERGENCY EMERGENCY ROOM ROOM EMERGENCY ER/IP TRAUMA ROOM ROOM ROOM SHERPA Implemented TBD TBD TBD SUBOXONE ADMIN NARCAN 43
Performance Improvement Plan: Decrease in SHERPA Referrals What the Data Showed: The number of referrals to Family and Children’s Association decreased. The Identified Cause: Education and workflow related. Action: Identified gaps in workflow and technology; Retrained Staff. Reanalysis of Data Showed: Improved referrals; Identified new gap in referrals of opioid population. PEER NAVIGATORS ON-SITE: EPIC Enhancement: New SHERPA Column and Icon EPIC Enhancement & Change in workflow: Live 6/20, added Opioid Questions to SBIRT Pre-Screen 44
Performance Improvement Plan: SHERPA Enrollment of Opioid Population What the Data Showed: Low SHERPA enrollment in the population of patients self-reporting opioid use. The Identified Cause: Technology and workflow related: inactivated trigger in Pre-Screen and the inability to differentiate and prioritize opioid population. Action: Activated trigger and added new SHERPA column and icon on the ED Whiteboard and on the SW SBIRT. Reanalysis of Data Showed: TBD 31 32 27 26 27 40 23 23 18 7 3 3 15 2 2 3 1 1 1 20 0 June July August September October November December January February Answered Yes… Referred to SHERPA Answered Yes Referred to SHERPA to Opioids June 18 2 11% July 27 1 4% August 31 3 10% September 26 1 4% October 27 2 7% November 32 3 9% December 23 1 4% January 15 7 47% February 23 3 13% 45 222 23 10%
System Enhancement: Pre-Screen Workflow to incl. Opioid Question 46
System Enhancement: SW SBIRT Worklist and ED Tracking Board 47
System Enhancement: Referral Workflow to incl. SHERPA Questions 48
A Collaboration with CHS Amory Mowrey, CARC, CRPA, CASAC-T Sherpa Program Manager, FCA 4/4/2019
What is is it it? ● Sherpa is a collaboration between CHS and FCA that delivers on-call peer services to several CHS emergency departments. ● Peers are dispatched based on positive SBIRT screenings and arrive within 30 minutes of being called. ● Peers meet bedside with patients to assist in linkage to care ● Peers remain engaged with patients post-discharge in the community to decrease preventable emergency department readmissions, and improve quality of life. ● Peers provide non-clinical services that supplement the clinical services provided by hospital staff.
Support for Families ● In addition to offering peer support for individuals, the Sherpa Program offers support for family members and loved ones. ● Families that are present in the hospital can receive support regardless of whether or not their loved one enrolls in the program. ● Family members may be outreached with the patient’s permission when not present at the hospital.
Why Peer Services? ● Peer services have been successfully utilized within several vulnerable populations (veterans, mental health, HIV) and are now widely recognized as an integral component of working with these groups. ● Mutual aid (12 step) groups have been using a peer model successfully to address substance use disorder for decades. ● Peer services is now being integrated into the treatment of substance use disorder as a method for improving engagement and retention.
Wrap Around Services ● The Sherpa Program works closely with THRIVE Recovery Center. ● THRIVE is an OASAS funded Recovery Community and Outreach Center, the first of its kind on Long Island. ● THRIVE offers FREE peer-lead services 7 days a week, and is staffed by Certified Recovery Peer Advocates and driven by dedicated volunteers and community members. ● Sherpa is a 90-day program, therefore participants of the program are linked to THRIVE for ongoing long-term peer support when appropriate .
Success Story ● Individual presented to GSH ED and reported using multiple substances. As a result of engaging with Sherpa Peers, the individual agreed to attend Mercy New Hope crisis respite. While in Mercy New Hope, Sherpa maintained engagement and helped facilitate transfer to Phelps Memorial where she remained for 21 days. The day after she was discharged, Sherpa facilitated linkage to THRIVE where she attended her first peer support meeting. At last follow up, she is still engaged in THRIVE services. ● This demonstrates a continuum of care: Sherpa remained engaged with her as she moved through 4 different “systems”: a hospital, a crisis respite, a residential facility, and community supports.
Other Considerations / Lessons Learned ● MAT induction in Emergency Rooms and transition to community-based follow-up. ● Tracking participants through multiple health care systems. ● Access to care and overcoming barriers; partnering with CHAMP ● Open Access Centers - FCA and Family Service League’s DASH program.
Impact on Community For any providers in the room who are not part of CHS... ● THRIVE accepts referrals from providers and community members interested in receiving non- clinical, recovery-based peer services. ● ALL of our services are free. Further questions or want to know more? Please reach out at...
Contact Information ● Sherpa Program: 516-592-7385 ● THRIVE: 631-822-3396 | www.thriveli.org ● Amory Mowrey, Program Manager : 516- 592-2817 | amowrey@fcali.org
Outcomes Update: SHERPA Referral Status DY4Q2: DY4Q3: DY4Q4: DY4Q1: 4/01/2018-6/30/2018 3/19/2018-9/30/2018 3/19/2018-12/31/2018 3/19/2018-2/28/2019 Patients Served = 73 Patients Served = 124 Patients Served = 196 Patients Served = 266 58 Yes/No = whether or not the patient accepted the PEER Navigator’s referral; Unknown/Attended/Engaged/etc. = Referral Outcome
Outcomes Update: SHERPA Referral Engagement Status Patients Served = 188 # of Referrals Accepted by Patients: 133 (~71% of Patients Served) 03/19/2018-12/31/2018 Referral Rates 30 Days 60 Days 90 Days Engaged in Engaged Engaged in Engaged Engaged in Engaged Treatment with Peers Treatment with Peers Treatment with Peers Yes 38% 48% 11% 17% 6% 11% No 18% 8% 11% 5% 11% 6% N/A 26% 26% 42% 42% 50% 50% Unable to Reach 50% 50% 72% 71% 72% 71% Unkown 8% 8% 4% 4% 2% 2% 59
Outcomes Update: SBIRT and SHERPA ED Utilization 60
Questions 61
BREAK 15 minutes 4/17/2019 62
Building Community Partnerships to Improve Medication Adherence Presented by Juan C. Espinoza, MD Alexandra Kranidis, MPH, CPH, CHES, AE-C Project Manager, SCC Pediatrician, Brentwood Pediatrics & Adolescent Associates Alyse Marotta, MPH Administrative Manager, Behavioral Health Tomas Diaz, RPh Programs, SCC President, Salumed Pharmacy 4/17/2019 63
WHY THE PHARMACY INITIATIVE Overarching Goal: Impact the 3ai/3bi/3dii medication adherence measures to meet/exceed performance goals Objectives: 1. Understand breakdown of communication channels between pharmacies and prescribers 2. Establish meaningful lines of communication between pharmacies and prescribers 3. Identify patients at risk for not picking up/receiving prescribed medications 4. Outreach to patients to understand barriers around receiving medications 5. Address barriers reported by patients 64
PHARMACY & PCP SELECTION METHODOLOGY • Total Medicaid Rx fill volume • Rx fill volume for each type of medication (Antidepressants, Antipsychotics, Statin, Asthma) •Volume by PCP practice’s attributed population (identify practices that have most prescriptions filled at Pharmacies each pharmacy) • Total number of Medicaid Rx filled by their attributed population SCC leveraged • Total number of medication adherence performance gaps PCP the DOH Salient •Top Pharmacies where practice’s attributed population is filling prescriptions Practices Database to analyze claims to inform the selection Example Example Total Medication Total Medication Gaps Rx Filled Gaps Rx Filled (10/1/16-9/30/17) (5/1/2017-4/30/2018) (10/1/16-9/30/17) (5/1/2017-4/30/2018) PCP Practice 1 219 22,055 Pharmacy 1 24.4 44,446 Pharmacy 1 219 10,595 PCP 1 219.0 10,595 Pharmacy 2 219 4,032 PCP 2 115.0 6,985 65
PILOT DYADS Dyad Brentwood Pediatrics + Salumed Suffolk Pediatrics + Salumed Allied – Peconic Peds + Barths HRHCare – Patchogue + Brookhaven Pharmacy HRHCare – Wyandanch + New Island Pharmacy 66
PILOT TIMELINE 4/17/2019 67
DATA COLLECTION 1. Percentage of prescriptions not picked up, sent from PCP to partnered pharmacy for all medications over a retrospective six month period (Baseline data) 2. Number of successfully transmitted and received patient reports between pharmacy and PCP 3. Excel log utilized to document barriers to receiving medications reported by patients during outreach calls 4. Percentage of missed prescriptions sent from PCP to partnered pharmacy for selected medications over the course of the pilot project (Outcome measure) 68
PHARMACY-PCP DYAD • Tomas Diaz, Pharmacist, SaluMed Pharmacy SaluMed Bay Shore SaluMed Brentwood 1805 5 th Ave 753 Commack Rd Bayshore, NY 11706 Brentwood, NY 11717 • Dr. Juan C. Espinoza, Pediatrician, Brentwood Pediatric & Adolescent Associates Brentwood Pediatric & Adolescent Associates 1464 5 th Ave Bayshore, NY 11706 69
PHARMACY & PCP WORKFLOW PCP Pharmacy o PCP follow-up priority o Vendor o Receiving the report o Current outreach approach o Workflow adaptations o Building the report (fields included) o Outreaching to patients/staffing o Uploading the report/ transmission of o Logging patient responses (data collection) report o Home care program referrals 70
EMERGING PROCESS TRENDS • Independent pharmacies have varied platforms and capabilities to generate and transmit reports. At this time, all dyads have been successfully transmitting patient level reports. • To generate reports needed for pilot, Pharmacists needed to outreach to information technology vendors to build reports with specific fields. Technical assistance from each vendor varied. • HIPPA compliant report transmission was the most challenging consideration due to technology limitations and the capabilities of the pharmacy and PCP office. • Staff selected at PCP sites to receive reports and make outreach calls varied based on the population served. • Language barriers, cultural competence and health literacy was considered at PCP office to operationalize plan. 71
IMMEDIATE NEXT STEPS • Continue to work with pharmacies and PCP site representatives to ensure successful transmission of reports. • Document patient identified barriers for not receiving medications and explore resources to mitigate barriers. • This information will inform pro-active workflow strategies at the PCP practice to improve medication pick up and adherence • Expand program to additional dyads once best process is identified. 72
Localizing the MAX Methodology through a Community-Based Approach Presented by Ashlee McGlone, MA, Provider Relations Manager, SCC For Harbor View Medical Services, PC and Michael Quartier, Regional Practice Manager Carlos Ortiz, VP, Operations Diana Velez, Operations Manager Jillian Annunziata, Sr. Project Manager, Strategy Hudson River HealthCare’s Elsie Owens Health Center 4/17/2019 73
MEDICAID ACCELERATED EXCHANGE (MAX) SERIES • NYS DOH launched the Medicaid Accelerated eXchange (MAX) Series to support DSRIP efforts • Leverages rapid cycle continuous improvement (RCCI) methodology • Largely deployed as a hospital-centric program • SCC transformed this program into a community-based approach • SCC facilitated the program with three community-based partners • Federation of Organizations • Harbor View Medical Services, PC • Elsie Owens Health Center, HRH Care 74
METHODOLOGY • Brainstorm and operationalize community-level solutions to engage patients at the practice site/community instead of the ED when avoidable Patie tient Presents ts • Engage an interdisciplinary team who share care of target patient population Man anage Ide dentify ify • Identify the most vulnerable population • Assess the drivers of utilization • Strengthen linkages with community partners who can support patients with identified drivers of utilization Li Link Assess/P /Plan • “Do something different” 75
TIMELINE 76
WORKSHOP AGENDAS • Workshops 1 and 2 focus on segments of the care pathway • Modules include brainstorming and improvement idea generation for each stage of the care pathway • Workshop 3 focuses on consistent implementation • Modules aimed at achieving high reliability and ongoing improvement idea generation • Each workshop includes a module on change management • Prioritization of improvement ideas • Action plan building • The SCC facilitator conducts bi-weekly status calls with the action team 77
CONTINUOUS IMPROVEMENT • Team builds a Continuous Improvement Plan • Long-term goals • Ongoing measurement • Reporting • Meeting agenda • Frequency • SCC facilitator provides ongoing support 78
Harbor View Medical Services, PC Pharmacy MAX Project
HARBOR VIEW MEDICAL SERVICES, PC • Affiliated with J.T. Mather Memorial Hospital and Northwell Health • Multi-site medical practice with locations in Stony Brook, Port Jefferson, Port Jefferson Station and Rocky Point • Medical services include cardiology, endocrinology, family medicine, internal medicine, neurology and vascular surgery • Staff of more than 40 physicians and six nurse practitioners 80
DEVELOPING A GOAL STATEMENT What are your goals for your target population? Your action team? Provider: “Understand who hasn’t picked up their medications and why?” Population Health Manager: “Improve continuity of care” Administrator: “Ensure that patients are properly cared for and managed” Care Coordinator: “Understand what I can do to ensure the patient can get their prescriptions” Goal Statement: Work collaboratively with a community pharmacy to improve the quality of care provided to our patients. 81
ACTION TEAM Action Team Member Role Dawn DiGregorio, LPN Population Health Manager Robert Giacobbe, DO Chief Medical Director Andrea Fucci Assistant Practice Administrator Sunshine Guarino Care Coordinator Bryan McCutcheon Pharmacist 82
30 DAY ACTION PERIOD Gaps Identified: • No early warning process in place alerting providers of prescriptions that have not been picked up / received (informed by the patient at the next scheduled visit) • Link to care coordination occurs only after provider becomes aware that patient has not picked up / received medication 30 Day Action Period Outcomes: • Explored registries to identify a cohort of patients at risk for medication non-adherence • Social determinants (living and eating alone) and PHQ9 >15 • Identified a community pharmacy to collaborate with • Selected Echo Pharmacy based on volume and location • Explored ways that care coordinator workflows can be adjusted to support project goal 83
INITIAL 60 DAY ACTION PERIOD Improvement Ideas: • Pharmacy sends to Harbor View patients who have not picked up prescriptions • Care coordinator contacts patient and assesses why prescription has not been pick up • Care coordinator supports patient with barriers to picking up the prescription 84
INITIAL 60 DAY ACTION PERIOD • Established a weekly workflow for prescription communications Echo Pharmacy Echo Pharmacy efaxes Harbor View Care Harbor View efaxes confirms match of report of patients Coordinator contacts updated patient PCP and updates who have not picked patients on the report cohort to Echo satellite with new up medications to and provides support Pharmacy information Harbor View as needed • Harbor View cohort included anyone who had Echo pharmacy listed as their primary pharmacy and had a visit within the past 18 months • Carried out workflow with Rocky Point location site first • Site selected because volume of Medicaid and proximity to homeless shelter • Relatively low numbers of patients who did not pick up prescriptions in a week span (~5) • No barriers identified by care coordinator 85
SECOND 60 DAY ACTION PERIOD • Scaled project to include all Harbor View patients whose primary pharmacy is listed as Echo Pharmacy • Echo Pharmacy generated a weekly report of anyone in their software with a Harbor View PCP and included these patients in the satellite report • Care Coordinator began to notice providers and prescriptions unknown to the care team • Project focus shifted from improving medication adherence to improving continuity of care • Update care team records and reach out to unknown providers for consult notes # of individuals with missed # of patient with providers unknown Month prescriptions to the practice December 2018 53 37 (69.8%) January 2019 66 39 (59%) February 2019 67 45 (67.2%) March 2019 45 25 (55.6%) 86
UNEXPECTED OUTCOMES & LESSONS LEARNED • Echo Pharmacy notified Harbor View of specialty providers improving continuity of care • Echo Pharmacy notified Harbor View of new medications prescribed by providers other than PCP • Provided the opportunity to medication reconciliation from pharmacy report • Presented an opportunity to reconnect with patients who have not been seen in the office for over a year • Helped care coordinator build stronger relationships with patients 87
NEXT STEPS • Pharmacy continues to send weekly reports to Harbor View of patients who have not picked up / received a prescription • Harbor View continues to provide pharmacy with weekly cohort updates and care coordinator continues to support patients who have not picked up / received their prescriptions • Project included on Harbor View’s Quality Improvement Meeting as a standing agenda item • The team is beginning to explore ways that Harbor View can improve continuity of care through care plans with specialty practices • Action Team outlined a plan to continue to meet quarterly • Discuss ways that Echo Pharmacy and Harbor View can continue to collaborate • Review data collected and continue to generate improvement ideas 88
Medicaid Accelerated eXchange New York (MAXny) Series HRHCare Community Health Elsie Owens Health Center 2019
HRHCare, Community Health ✚ Largest FQHC in New York State ✚ 3 regions Long Island Hudson Valley New York City ✚ 43 community health centers ✚ 2k employees ✚ 200k patients served
Only 10- 20% of factors affecting health outcomes are related to clinical care… Systems of Community Health Centers like HRHCare are an important link between potentially preventable hospitalizations and the Social, Physical, Environmental, Institutional, Racial, Determinants of Health
Goal Identify patients who are likely to have preventable hospitalizations and/or ED visits and address the causative factors in an effort to prevent such visits Methods for Identifying Patients ✚ Pre-visit planning ✚ Reports Frequent (2+ in 6 months) visits to hospitals / ED’s for PPVs Patients with 2+ chronic diseases of interest / behavioral health Dx, and/or substance use Dx Patients without a regular primary care visits in 2+ years
Patients At-Risk of potentially preventable TOC visits are referred to: ✚ Primary Care Provider for Medical Evaluation ✚ HRHCare Outreach staff for coaching: pts. without a primary care visit in 24+ months ✚ DSRIP Care Manager: Medicaid patients ✚ Health Home: Qualified patients
Which EOHC patients may fall into the target population? Action Team Discussion: • Chronic diseases • Behavioral health • Bi-lingual/ language • Lack of education on additional healthcare options (i.e. urgent care, after hours) • Low-Utilizers - no visit in last 2 years • High-Utilizers of hospitals/ EDs
Reports HRHCare TOC & TOC At-Risk | Stonybrook University TOC HRHCare TOC At-Risk (cont.) + Outreach – No visit in 24+ months
Target Population TOC & TOC At- Risk
The Evolution of our MAX Workflow Current State (see handout)
Script
Documentation TOC template in eCW + MAX subgroup
Current Workflow
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