Post on 28-Jun-2020
“The Role of Primary Care”
Collaboration • Catalyst • Community
May, 2016
PRESENTED BY:
RuthAnn Craven, MS, PCMH CCEPractice Transformation Services Manager
• Project 2.a.ii – Advancing primary care
• Project 3.a.i – Integration of primary care & behavioral health
• Project 3.g.i – Integration of palliative care into primary care
The Role of Primary Care in DSRIP
An augmented patient-centered medical home (PCMH) that provides
patients with timely, well-organized and integrated care, and enhanced
access to teams of providers – as the foundation for a high performing
health system.
New York State Health Innovation Plan – December, 2013
Advanced Primary Care
• Ensure all primary care practices meet NCQA PCMH 2014 Level 3 and/or state-
determined criteria for Advanced Primary Care models
• Identify a physician champion
• Identify care coordinators at each practice who are responsible for care
connectivity
• Ensure providers are actively sharing health information (RHIO / SHIN-NY)
• Ensure EHR systems are certified and meet Meaningful Use and PCMH Level 3 or
APC standards
Project 2.a.ii – Advancing Primary Care
• Perform population health management
• Ensure all staff are trained on PCMH or APC, including evidence based
preventive and chronic disease management
• Implement preventive care screening protocols including behavioral health
screenings to identify unmet needs; assure referrals to appropriate care as
needed
• Implement open access scheduling
Project 2.a.ii – Advancing Primary Care (con’t)
Timeline: the last date to submit PCMH 2014 survey tools is 09/30/2017
• Patient Centered Access
• Team Based Care
• Population Health Management
• Care Management and Support
• Care Coordination and Care Transitions
• Performance Measurement and Quality Improvement
PCMH 2014 Level 3
• Outreach to patients for Population Management
• Measure performance improvement
Clinical quality performance
Resource use & care coordination
Patient/family experience
• Utilize clinical decision support / point of care reminders
PCMH Annual Requirements
• Practice transformation is a journey, not a destination.
• NCQA is looking for evidence of ongoing patient-centered activities; less
emphasis on form than substance
Practice Transformation
Milestones
• Co-locate behavioral health services at primary care sites (Model 1) or co-locate
primary care services at behavioral health sites (Model 2)
• Develop collaborative evidence-based standards of care, including medication
management & care engagement process
• Conduct preventive care screenings, including behavioral health screenings to
identify unmet needs
• Use EHRs to track patients engaged in this project
3.a.i Integration with Behavioral Health
Objectives
• Ensure coordination of care
• Identify behavioral health needs early
• Ensure treatments for medical and behavioral health conditions are compatible
and not counter-productive
• De-stigmatize treatment for behavioral health needs
• Care for all conditions delivered under one roof by known health care providers
3.a.i Integration with Behavioral Health (con’t)
Milestones
• Integrate palliative care into advanced primary care practices
• Develop partnerships with community and provider resources to bring palliative
care supports and services to the practice
• Develop and adopt clinical guidelines, including services and eligibility
• Engage staff in trainings to increase role-appropriate competence in palliative
care skills and protocols
• Engage with Medicaid managed care to address coverage
• Use EHRs to track patients engaged in this project
3.g.i Integration of Palliative Care
Objectives
• Ensure care and end of life planning needs are understood, addressed and met
prior to decisions to seek further aggressive care or enter hospice
• Pain and symptom management while patients pursue disease directed
treatment to maximize function, independence and quality of life for as long as
possible
• Maintain the trusted relationship with your patients; the primary care team is
accessible, has knowledge of the patient and family,
as well as psychosocial influences that may affect the patient’s
choices
3.g.i Integration of Palliative Care (con’t)
• Project 2.a.ii – Advancing Primary Care
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-2-a-ii/
• Project 3.a.i – Integration with Behavioral Health
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-i/
• Project 3.g.i – Integration of Palliative Care
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-g-i/
Additional Information
Questions
www.ahihealth.org | 518.480.0111
RuthAnn Craven, MS, PCMH CCErcraven@ahihealth.org
Community Based Behavioral Health
Collaboration • Catalyst • Community
May, 2016
• Project 3.a.ii – Community Crisis Stabilization Services
• Project 3.a.iv – Development of Withdrawal Management
Capabilities & Appropriate Enhanced Abstinence Services
Community Based Behavioral Health Projects
Objective
• To provide readily accessible behavioral health crisis services that
will allow access to appropriate level of service and providers,
supporting a rapid de-escalation of the crisis
Community Crisis Stabilization Services
• Providing readily accessible crisis services, supporting a rapid de-
escalation of the crisis
• Provide a single source of specialty care management for these
complex patients
Crisis Stabilization Program
• Observation monitoring and ready access to inpatient psychiatric
care if short term monitoring does not resolve the crisis
• Mobile crisis team to assist with moving patients safety from the
community to services, and follow up after stabilization
Crisis Stabilization Program (con’t)
• Implement a crisis intervention program, including outreach, mobile
crisis and intensive crisis services
• Establish linkages with Health Homes, ER and hospital services to
implement protocols for diversion of patients from emergency room
& inpatient services
• Establish agreements with Medicaid managed care organizations to
provide coverage for the services under this project
Crisis Stabilization Project Milestones
• Develop written treatment protocols
• Include at least one hospital with specialty psychiatry services and
crisis oriented services
• Expand access to observation for stabilization monitoring (up to 48
hours)
• Deploy a mobile crisis team to provide stabilization using evidence
based protocols
Crisis Stabilization Project Milestones (con’t)
• Ensure all providers are actively sharing health information among
clinical partners (RHIO/SHIN-NY)
• Establish central triage service
• Ensure a quality committee is established for oversight and
surveillance of compliance with protocols and quality of care
• Use EHRs or other platforms to track patients engaged in this project
Crisis Stabilization Project Milestones (con’t)
Objective
• To develop withdrawal management services for substance use
disorders (ambulatory detoxification) within community based
addiction treatment programs that provide medical supervision and
allow transfer of stabilized patients into treatment, and to provide
link with care management services to assist with addressing related
life disruption related to substance abuse
Withdrawal Management Services
• Outpatient monitoring programs, with a primary care integrated
team
• Care management services to support abstinence and improved
function within the community
• Programs to address alcohol, sedative and opioid dependency, and
access to ongoing medication management treatment
Withdrawal Management Program
• Develop community based addition treatment programs that include
PCP integration teams, stabilization services, and social services
• Establish referral relationships between community treatment
programs and inpatient detox services
Withdrawal Management Project Milestones
• Identify a medical director, board certified in addiction medicine,
with training for use of buprenorphine, and other withdrawal
management agents
• Link to providers approved for outpatient medication management
of opioid addiction, for continued maintenance therapy
• Collaborate with treatment program(s)/care manager(s)
Withdrawal Mgmt Project Milestones (con’t)
• Develop community based withdrawal management (ambulatory
detoxification) protocols based on evidence-based best practice
• Develop care management services within the SUD treatment
program
Withdrawal Mgmt Project Milestones (con’t)
• Form agreements with Medicaid managed care organizations to
provide coverage for the services under this project
• Use EHRs or other platforms to track patients engaged in this project
Withdrawal Mgmt Project Milestones (con’t)
Project 3.a.ii – Community Crisis Stabilization Services
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-ii/
Project 3.a.iv – Development of Withdrawal Management Capabilities
& Appropriate Enhanced Abstinence Services
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-iv/
Additional Information
Questions
“Prevention Projects”
Collaboration • Catalyst • Community
May, 2016
PRESENTED BY:
• Project 4.a.Iii – Strengthen Mental Health & Substance Abuse
Infrastructure Across Systems
• Project 4.b.ii – Increase Access to High-Quality Chronic Disease
Preventive Care and Management (COPD)
Prevention Projects
Objective
• To collaborate with traditional and non-traditional providers to
promote mental, emotional, behavioral (MEB) wellbeing
Strengthen Infrastructure
• Participate in MEB health promotion and disorder prevention
partnerships
• Provide cultural and linguistic training on MEB health promotion,
prevention and treatment
• Offer poverty training, trauma informed care training, SEDL (social,
emotional, developmental learning) training and cross training of
medical & behavioral health providers
Program Services
• Participate in MEB health promotion and MEB disorder prevention
partnerships
• Obtain evidence-based MEB promotion and prevention resources
• Have an MEB integration plan
Project Milestones
• Provide MEB health promotion and disorder prevention trainings
• Share data and information on MEB health promotion and MEB
disorder prevention and treatment
Project Milestones
Objective
• Increase access to high quality chronic disease preventative care and
management in both clinical and community settings for COPD
Chronic Disease Preventive Care (COPD)
• Deliver high-quality chronic disease preventative care to lessen the
burden of chronic disease or avoid related complications
• Provide cost-effective care including screening tests, counseling or
medications used to prevent disease, detect health problems early
and prevent disease progression and complications
Program Services
• Print media campaign to build public awareness about COPD
prevention and programs
• Care teams are staffed/trained and have necessary patient education
tools & materials in place
• Home monitoring equipment is acquired and fully deployed
Project Milestones
• Adoption of primary care evidence-based diagnosis and treatment
guidelines for COPD
• Embedded clinical decision supports for evidence based care are in
place in EHRs and/or population health management tools are
utilized as applicable
Project Milestones (con’t)
• Adoption by skilled nursing facilities of evidence-based guidelines for
COPD
• Supportive resources are established or enhanced
Project Milestones (con’t)
• Primary care sites are equipped with adequate spirometry testing
• Opportunity to bring additional COPD services to more patients
• Current pulmonary fitness programs are expanded or developed, as
necessary
Project Milestones (con’t)
Project 4.a.iii – Strengthen Mental Health & Substance Abuse
Infrastructure Across Systems
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-4-a-iii/
Project 4.b.ii – Increase Access to High-Quality Chronic Disease
Preventative Care and Management (COPD)
http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-4-b-ii/
Additional Information
Questions
www.ahihealth.org | 518.480.0111
@ahihealth.org