Clinical Integration Data Elements - CaresPPS network partners ... Cayuga Community Health Network,...

Welcome and Introductions Cayuga EPAC Representatives

Liz SmithKathleen Cuddy

Cayuga County Regional Project Advisory Committee

“Value Based Payment and the Year Ahead”

https://youtu.be/jqFipBmg2Rs

https://youtu.be/jqFipBmg2Rs

Promote community-level collaboration via performing provider systems (PPSs) that

support the formation of Integrated Delivery

Networks…

Improve health outcomes and reduce avoidable

hospital readmissions and emergency department

utilization by…

Preserve and transform the State’s fragile health care

safety net system and prepare providers for

success in Value Based Payment…

VBP 25%

Goals of DSRIPThere are Three Primary Objectives of the DSRIP Program

IDN

• 11 DSRIP Projects with required, at-risk Milestones, Provider, and Patient Targets

1. Integrated Delivery System2. DSRIP Care Management3. ED Care Triage4. Care Transitions5. Patient Activation6. Primary Care/Behavioral Health Integration7. Crisis Stabilization8. Cardiovascular Disease Management9. Palliative Care Integration10. Behavioral Health Infrastructure11. Reduce Preterm Births

• Organizational Workstreams, some with required, at-risk Milestones and Targets

• IT/PHM/Clinical Integration• Workforce & Primary Care Plan• Cultural Competency/Health Literacy• Governance & Performance Reporting• Financial Sustainability & VBP (new)Administer a Value Based Payments Needs

Assessment to the PPS network to identify opportunities to support transition to VBP

Develop a VBP support implementation plan to address the identified needs of the PPS network partners

Develop partner engagement schedule for partners for VBP education and trainings

State-Mandated PPS Requirements

Implementation of Evidence Based Best Practices

Standardized Protocols and Procedures of

Care

Care Coordination

and Care Management

Robust Data Analytics and Data Sharing

Collaborative PPS

GovernanceStructure

Communication Across the Network

Moving to an Integrated Service Delivery ModelINTEGRATED DELIVERY OF SERVICES ARE CHARACTERIZED BY A SYSTEM OF HEALTH CARE ORGANIZATIONS WORKINGTOGETHER TO DRIVE GREATER VALUE AND IMPROVE CARE

PPS Projects & Organization Worksteams

PHM InfrastructureCNYCC Functions

Value Based Payment Readiness

Required Capacities to Assume Clinical and Financial Accountability Through VBP Arrangements

Performance Management

QualityImprovement

Capacity to Accept and Distribute Payment

Financial Strategy for

Possible Short Falls

Care Management

& Care Coordination

Programs

Network Management

Data Analytics

PPS Focus Areas

ContractingEntities

Scope of responsibility based primarily on treatment episodes

Scope of responsibility based on defined population of assigned or attributed patients over time

Conventional Medical Care

Reactive: Address illness of presenting patient

Proactive: Care processes also emphasize outreach based on needs, including primary and secondary prevention

Care delivered primarily by individualprofessional contributors

Care delivered by multi-disciplinary teams, including patient and informal caregivers

Volume driven reimbursement primarily based on fee-for-service

Value driven reimbursement based at least partly on acceptance of responsibility and risk and delivery of value

Population Health Management

Value Based Payment And DSRIP Success

Success in DSRIP and Value Based Payment (VBP) Programs Requires a Transition from Conventional Medical Care to Population Health Management (PHM)

Presenter

Presentation Notes

What change do you or will you feel in your organization with population health? Focus on 1, 3, and 6 A move from episodic treatment to holistic treatment of the patient across their continuum of wellness and sickness. To provide value, practices will be more proactive and “own” the patient as a care team with accountability.

Development of New Funds Flow Policy

• Board of Directors charged CNYCC with the development of a plan for the next iteration of program funding

• CNYCC hired COPE Health Solutions to support the new funds flow policy development

• Creation of a Funds Flow Work Group (FFWG) comprised of a wide-range of CNYCC partner organizations

• FFWG work directly with the CNYCC (COPE) to provide oversight and recommendations for the successful development of the PPS’s next-phase funds flow model. CNYCC Funds Flow Work Group

CNYCC Phase I Funding

Approved by CNYCC BOD in November 2015Developed a process to distribute funding for participation

Fund Allocation

Distribution of approximately

$13 million

Activity Focus

Implementation Planning Actively Engaged PatientsReporting

Background – CNYCC Funds Flow

CNYCC Phase II Funding

Currently being finalized for BOD approval (June) Development of a formulaic process to distribute funding for participation

Fund Allocation

Distribution of approximately $49

millionBridge Payment

Phase II Project Agreement

Activity Focus

Actively Engaged PatientsReporting Performance ActivityTransition to VBPBridge Payment

New – CNYCC Funds Flow Policy

Bridge Payment

• Above Target Patient Reporting – Retroactive funding provided to partner organizations that reported actively engaged patients over the identified targets ($1.5 Million)

• Performance Activity Funding – All CNYCC contracted partner organizations will be provided the opportunity to complete as many as seven performance activities to receive funding ($8.5 Million)

• A small cohort of contracted partners (approximately 40 partner organizations) will have the opportunity to participate in an additional activity focused on the implementation of the Population Health Management (PHM) system

• Flow funds to partners immediately for completed, in-process and near-term activities to advance DSRIP objectives

• Gather important information that will inform future contracting• “Bridge” the network activities from previous payment policies to upcoming Phase II contracts

Goals of the Bridge Payment:

Bridge Payment: Funding Opportunities

Proposed Allocation of CY17 Baseline Partner Share w/ Rollover

Copyright © 2017 COPE Health Solutions. All rights reserved. 14

$34M

$15M

0

$10M

$20M

$30M

$40M

$50M

$60M

CY17/FY17Baseline Rollover

$10M

$3.4M

$1.6M

InnovationFunds andProject RFPsRevenue Loss

Total Partner Share for CY17/FY17: approx. $49M

Phase II Contracting Funds

Phase II Contracting

• $34 Million Dollars to be allocated to Partner Organizations • Formula to Determine Potential Funding Possible per Individual Partner Organization• Greater Emphasis on Performance Measurement • “Bridge” the network activities from previous payment policies to upcoming Phase II contracts

Phase II Funding:

Next Steps:

• FFWG Recommendation of Phase II Funds Flow Policies• BOD Approval (June Board Meeting)• Development & Distribution of Phase II (Amended) Project Agreements• Friday Webinar – Overview of Bridge Payment and Phase II Contracting Process

Performance Activities Finalization Process Efforts

Estimated over 12 weeksdedicated to the process from

contributors

Over 15 PAWG Sessions with CNYCC to brainstorm,

iterate, revise activity language

6 Sessions with FFWG for Review and Discussion, including “Homework” reviews and revisions

3 Drafts of Performance Activities, 2 Gap

Analyses, and 1 QA

120 Final Performance

Activities Developed

Copyright © 2017 All Rights Reserved

FFWG: FundsFlow Work GroupPAWG: CNYCC PerformanceActivity Workgroup

13

• 120 Performance Activities approvedby FFWG

• 84 general Performance Activities• 36 Patient Engagement reporting

activities

• 92 activities directly linked to oneor more outcome measures

• 19 foundational activities addressall outcome measures


Total 120

14

Performance Activities SummaryProject # of Performance

Activities2.a.i 51

2.a.iii 72.b.iii 62.b.iv 72.d.i 143.a.ii 7

3.a.iM1 73.a.iM2 8

3.b.i 103.g.i 7

Multi Project 1Total 120

Contracting PeriodQuarter

# of PerformanceActivities

Quarter 1 24Quarter 2 21Quarter 3 43Quarter 4 32

Phase II Timeline Proposed Updates – Remediation Period

• Review outputs andconduct reasonablenesstests

Contract Input Validation Remediation Period Output Analysis Production and QA

• Produce individualized partner project agreements

• Conduct full QA processto ensure accuracy andcompleteness of eachindividual contract

• Roll out final project agreements to partners

• Revise inputs and runmodel for baseline allocations

• Produce preliminaryoutputs (without dollars) for partner remediationprocess

• QA initial outputs before distribution to partners

• 2 week data remediationperiod for service type and project selection

• Provide technical assistance to support partner decision making

• Clean up Data ValidationTools received frompartners

• Provide to CNYCC toinput into salesforce tocreate a single source oftruth

• Finalize partnercontracting list

• Run model withvalidated project andservice type selection

Today – June 30 July 5 – July 26 July 31 - August 3

BoD

Appr

oval

of fi

nala

naly

sisou

tput

s

August 11 – August 21


*August 10 36

10-minute break

Cayuga County Community Forum

Cayuga Community Health Network

Jessica Soule

Partner Spotlight

Listening SessionsLearning from our residents and consumers

Cayuga Community Health Network, Inc.• Rural Health Network of Cayuga County

• 501(c)3 non-profit organization

• Focus on chronic disease prevention and maintenance

• Chronic Disease Self-Management

• National Diabetes Prevention Program

Community Engagement Forums

• Implementation of patient activation activities to engage, educate, and integrate the uninsured and low/non-utilizing Medicaid populations into community-based care

CCHN proposed 2 listening sessions within Cayuga County in February

Subsidized Housing• For residents

• Thursday morning

• $10 gift cards

• Onsite at housing campus

• Questions related to expectations of care levels, barriers

Rural Community• Community leaders by

invite

• Friday over lunch

• Host Lifespan Therapies, King Ferry

• Questions focused on challenges faced by rural population

Listening Sessions’ Audiences

Forum Results• Identified themes,

ideas, suggestions, surprises

• Created report for stakeholders

• Conduct additional information gathering

• Find solutions to address issues

Population Demographics

Auburn Housing Authority

• Consists of three complexes within City of Auburn

• 326 housing units

• All subsidized housing

• 25% of residents racial minority (12% city of Auburn)

King Ferry

• Town of Genoa 1,935 people

• Very rural community

• Many diary farms (migrant workers)

• 6.7% of people don’t speak English at home

• 2% of population is Guatemalan

HealtheCNY.org

A snapshot of the economic conditions for zip code for King Ferry.

Demographics for the groupsAuburn Housing

• 11 people attended (registered)• 81% has specific health condition

– Asthma, Diabetes, High blood pressure, Depression/anxiety

• 100% had Medicaid, primary dr.• 90% taking medication• 82% smoke• 63% use public transport, 18% have a car,

9% have no transportation• 9% Native, 9% Hispanic, 9% multiracial• Barriers to keeping appt.

– Cost/co-pays– Transportation– Prior experience with dr

King Ferry

• 8 people attended (invited)

• 37% had specific health conditions– Thyroid, diabetes and hypertension

• 88% have private insurance

• 63% take medication

• 12% smoke

• 100% have vehicles

• Multiple people spoke about migrant workers in farming area

• 88% said healthcare was fairly affordable

ThemesTransportation, low health literacy, lack of respect, lack of options

Auburn Housing Authority• Lack of transportation. Most medical offices don’t ask, even

if a note is needed. Call too early, can be rejected.• Lack of respect. Many won’t accept their insurance. Many

referrals out of county but can’t get there.• This culture caused many to feel pushed aside or not valued. • Other challenges to getting quality health care include long

wait times and insufficient time with doctors, issues communicating with doctors –Providers with English as second language, doctors hard

to understand

Auburn Housing Authority continued• Doctors urge clients to make changes. People with success were given

clear directions. Overarching statements don’t work such as lose weight, stop smoking.

• Insurance coverage: Surprised to receive medical bills for procedures and lab work that they didn’t know wasn’t covered. Would have made different choices.

• Preference for healthcare sites for doctors office, urgent care or emergency department:– Urgent care sites are preferred. They see people quicker and are

nicer– ER is challenging because of long waits. It’s uncomfortable and not

clean– Would go to primary care if could get appointments when needed

• Participants provided positive feedback regarding working with insurance navigators

Quotes from Auburn• “They were snotty.” “I never saw my doctor.”

• “Being pushed aside, or not being heard.”

• “They went to college – we have to listen to them.”

• “Don’t look at us like we are stupid because you see we have Medicaid or Medicare.”

• “(Doctors) treat us like we are nothing.”

• “I have a high risk pregnancy and I can’t get an appointment for three months.”

King Ferry• Lack of public transportation. Medical

transport may not pick people up, few buses and no taxi services. Some people have to travel elsewhere to get to care, but can’t physically there.

• Copays and deductibles are a major factor in deciding when and what medical services to seek. Some reject recommended procedures and therapies based on high copays and timing related to insurance.

Town of Genoa = 1,935 people

King Ferry continued• Rural populations are aging. This leads to lack

of volunteers, attrition for those who are involved or donate their time to community efforts.

• Aging in place for residents is limited to those who can afford care. Even then, finding aides willing to come to rural is difficult and inconsistent.

• Internet and cellular service is unreliable and causes major issues. Besides issues with communication to public, and causes difficulty in employee recruitment to small community.

Quotes from King Ferry• “Transportation is a big issue for our families. We’re trying constantly to meet (that need).

There are three of us who offer transportation to the southern end of the county. That’s not enough.”

• “Six months is not acceptable to wait (for dental appointment).”

• “I would say the majority of the people we see here – if we weren’t here (in King Ferry), would not be going to physical therapy and they should. They just can’t drive to Cortland or Auburn. Transportation is an issue.”

Quotes from King Ferry• “All this effort to get people signed up for WIC is almost a waste of time because they will

never get to the appointment.”

• “If our aide can’t come, that’s it. One of us has to be home.” (Isaac has gotten so big that his mom can’t lift him.)

• Immigrants and non-English speakers “are not always welcome at other agencies.”

• “I have a mom coming in today to help her with her taxes, and I’ve been thinking all day with my fingers crossed, ‘I hope the internet works at school’ because for us, it’s hit or miss.”

Next StepsWhat to do with the results

Future Forums • Focus on aging in place, find proposed solutions to seek funding

• Gather more information regarding prediabetes/risk factors

• Referral process survey to healthcare providers

https://www.surveymonkey.com/r/lifestylechangeprogramsurvey

Contact Me

Jessica Soule• Cayuga Community Health Network, Inc.

• (315) 252-4212

• [email protected]

Management DashboardsPerformance & Outcomes Measures (Measurement Year 2, (MY2))July 2015 to June 2016

Actively Engaged Patients (Demonstration Year 3, (DY3))May 2017

Performance & Outcomes Measures (Measurement Year 2, - MY2 -)July 2015 to June 2016

Performance and Outcomes Measures – Measure SummaryCNYCC Performance Measure Summary Total

Total Measures 52

# of Measures with Data Available 24# of Measures with No Data Available 28

# of Measures on Target 10# of Measures off Target 14

# of Measures with Unknown Performance 28

# of Measures currently Pay for Reporting 39# of Measures currently Pay for Performance 13

Performance & Outcomes Measures – Goals & Results(Performance Period: July 2015 – June 2016 [Measurement Year 2])

The Performance and Outcomes Measures below apply to the following projects:

• Integrated Delivery System (2.a.i)

• DSRIP Care Management (2.a.iii)

• ED Care Triage (2.b.iii)

• Care Transitions (2.b.iv)

85.15 90.37 88.78 95.24 91.55 157.14

37.02 95.30 96.47

645.55

85.06 90.19 88.00 95.23 90.93 154.80

44.77 95.67 96.76

619.98

-

100.00

200.00

300.00

400.00

500.00

600.00

700.00

Adult Access toPreventative or

Ambulatory Care- 20 to 44 (%)


Ambulatory Care- 45 to 64 (%)


Ambulatory Care- 65 and older (%)

Children's accessto Primary Care -12 to 19 years (%)

Children's accessto Primary Care -25 months to 6

years (%)

PDI 90 -Composite of allmeasures (Rate

Per 100,000)

PotentiallyAvoidable ER

Vists (Rate Per100)

Children's accessto Primary Care -12 to 24 months

(%)

Children's accessto Primary Care -7 to 11 years (%)

PotentiallyAvoidable

Readmissions(Rate Per100,000)

Most Recent Data Goal

(2.34)

(0.37) (0.29)

(25.57)

Performance & Outcomes Measures – Goals & ResultsPay for Reporting Measures(Performance Period: July 2015 – June 2016 [Measurement Year 2])

On or Above GoalNot on Target to Goal – Indicates which direction and how much improvement is needed for CNYCC to meet goal



• Behavioral Health/Primary Care Integration (3.a.i)

• Behavioral Health Crisis Stabilization (3.a.ii)

Performance & Outcomes Measures – Goals & ResultsPay for Reporting & Pay for Performance Measures(Performance Period: July 2015 – June 2016 [Measurement Year 2])

On or Above Goal

P4R Currently Pay for Reporting Measure

78.3

8

69.9

4 78.6

0 95.4

0

51.5

5

48.4

1

33.5

1

19.4

1

57.8

1

40.1

7

62.4

6

58.2

5

43.0

6

80.7

6

67.4

8 77.9

7

114.

21

51.0

0

49.2

1

34.8

7

21.7

4

61.5

9

43.6

0

65.7

4

61.3

4

45.9

1

-

20.00

40.00

60.00

80.00

100.00

120.00

CardiovascularMonitoring for

People withCardiovascular

Disease andSchizophrenia (%)

Diabetes Monitoringfor People with

Diabetes andSchizophrenia (%)

Diabetes Screeningfor People with

Schizophrenia orBipolar Disease who

are UsingAntipsychotic

Medication (%)

PotentiallyPreventable

Emergency RoomVisits (for persons

with BH diagnosis) ±(Rate Per 100)

Adherence toAntipsychotic

Medications forPeople with

Schizophrenia (%)

Antidepressant Medication

Management –Effective Acute

Phase Treatment (%)

Antidepressant Medication

Management –Effective

Continuation Phase Treatment (%)

Engagement ofAlcohol and OtherDrug Dependence

Treatment(Initiation and 2visits within 44

days) (%)

Follow-up after hospitalization for

Mental Illness –within 30 days (%)

Follow-up after hospitalization for

Mental Illness –within 7 days (%)

Follow-up care forChildren PrescribedADHD Medications -Continuation Phase

(%)

Follow-up care for Children Prescribed ADHD Medications – Initiation Phase

(%)

Initiation of Alcoholand Other Drug

DependenceTreatment (1 visit

within 14 days) (%)


(.80)

(1.36)

(2.33)

(3.78)

(3.43)

(3.28) (3.09)

(2.38)

(2.85)

P4R P4R

Not on Target to Goal – Indicates which direction and how much improvement is needed for CNYCC to meet goal



• Cardiovascular Disease Management (3.b.i)

Performance & Outcomes Measures – Goals & ResultsPay for Performance Measure(Performance Period: July 2015 – June 2016 [Measurement Year 2])

36.11 32.39

0

10

20

30

40

Prevention Quality Indicator # 7 (Hypertension) ±


(3.72)

On or Above Goal

Not on Target to Goal – Indicates which direction and how much improvement is needed for CNYCC to meet goal

Total Available FundingDY2, Q3 and Q4 Reporting Period

Available Funding for AEP & Performance and Outcomes (Total Available Funding for DY2, Q3 and Q4 - $5,405,492.52)

Performance and Outcomes Measures

$4,617,291.73

Actively Engaged Patients (AEP) $788,200.79

Performance & Outcome Measures: Projected FundingJuly 2015 - June 2016 (Measurement Year 2)

Performance and Outcomes – Projected Funding Summary• Dollar Values reflected in the Dashboards are based on the available funds for DY2,

Quarters 3 and 4. Total available to CNYCC is $4,617,291.73

• Performance Measures are broken into 4 Tiers based on measure worth• Tier 1 – 15 Performance and Outcomes Measures worth $2,624,748.34

• Includes Potentially Avoidable Readmissions and Potentially Avoidable ER Visits Measures

• Tier 2 – 13 Performance and Outcomes Measures worth $1,204,171.27• Includes Follow-up after Hospitalization (7 & 30 Days) & Antidepressant Medication

Management

• Tier 3 – 12 Performance and Outcomes Measures worth $633,986.46• Includes Adult and Children’s Access Measures

• Tier 4 – 12 Performance and Outcomes Measures worth $154,385.66• Includes Cardiovascular Measures

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY2, Q3 and Q4 Performance Measures - $4,617,291.73)

Tier 1, $2,624,748.34

Tier 2, $1,204,171.27

Tier 3, $633,986.46Tier 4, $154,385.66

MEASURE TIERS BASED ON TOTAL FUNDING FOR ALL PROJECTS

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY2, Q3 and Q4 Tier 1 Performance Measures - $2,624,748.34)

$615,926.64

$1,390,132.73

$386,335.31

$232,353.65

Projected NOT to Receive Payment

Pay for Reporting – Guaranteed Funds

Performance Unknown – Pay for Performance

Projected to Receive Payment

Performance and Outcomes – Projected Funding Summary(Total Funding Available for DY2, Q3 and Q4 Performance Measures - $4,617,291.73)

Projected NOT to Receive Payment

Pay for Reporting – Guaranteed Funds

Performance Unknown – Pay for Performance

$232,353.65$232,353.65

$205,309.00$169,260.53$169,260.53$169,260.53$169,260.53$169,260.53$169,260.53$169,260.53

$153,981.66$153,981.66$153,981.66$153,981.66$153,981.66

$0.00 $50,000.00 $100,000.00 $150,000.00 $200,000.00 $250,000.00

Prevention Quality Indicator # 7 (Hypertension) ±Prevention Quality Indicator # 8 (Heart Failure) ±

Screening for Clinical Depression and follow-upPQI 90 - Composite of all Measures

Potentially Avoidable ReadmissionsCare Coordination (Q13, 17 and 20)

Getting Timely Appointments, Care and Information (Q6, Q8 and Q10)HCAHPS - Care Transistion Metrics (Q23 to Q25)

Potentially Avoidable ER VistsPDI 90 - Composite of all measures

Diabetes Screening for People with Schizophrenia or Bipolar Disease who…Potentially Preventable Emergency Room Visits (for persons with BH…

Cardiovascular Monitoring for People with Cardiovascular Disease and…Diabetes Monitoring for People with Diabetes and Schizophrenia

Adherence to Antipsychotic Medications for People with Schizophrenia

Tier 1 Measure Payments (Total $2,624,748.34)

Projected to Receive Payment

Actively Engaged PatientsMay 2017 (Demonstration Year 3)

Actively Engaged Patients: May 1 – May 31, 2017

58

ProjectDY3Q2 Target Actual

Gap to DY2Q4 Target Status

DSRIP Care Management (2aiii) 5,600 8 5,592

ED Care Triage (2biii) 7,200 1,402 5,798

Care Transitions (2biv) 2,970 180 2,790

Patient Activation (2di) 11,100 875 10,225

Primary Care/Behavioral Health Integration (3ai) 16,490 6,123 10,367

Behavioral Health Crisis Stabilization (3aii) 10,800 1,520 9,280

Cardiovascular Disease Management (3bi) 6,460 1,822 4,638

Palliative Care PCMH Integration (3gi) 1,980 1 1,979

Indicates that 80% of the Q4 target has been reached and the AV should therefore be achieved

DSRIP Care Management Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

St. Joseph's Health Center Oneida Health Systems, Inc. Regional Primary Care NetworkApr-17 7 1

Mar-17 6

Feb-17 14

Jan-17 4 1

Dec-16 5

Nov-16 5

Oct-16 2

Sep-16 10

Aug-16 6

Jul-16 5

Jun-16 1 14

May-16 132

020406080

100120140

2aiii DSRIP Care Management - Monthly

DY Target Actual AEP / Month (*) $ At-Risk

DY3Q2 (9/17) 5,600 8 747 x 6 months $167,000

DY3Q4 (3/18) 16,700 - 1112 x 12 months $144,000Action Steps

• To increase partnership between Health Homes, down stream providers and medical entities, a finalized sample Service Agreement and Care Coordination communication work flow will be disseminated to partner organizations to assist with implementation strategies.

DSRIP Care Management Actively Engaged Patient Targets

* 80% AEP needed to meet target

ED Care Triage Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

RomeMemorialHospital

St. ElizabethMedical Center

St. Joseph'sHealth Center

Faxton-StLuke's

Healthcare

UpstateUniversityHospital

Oneida HealthSystems, Inc.

OswegoHospital Crouse Hospital

Lewis CountyGeneralHospital

AuburnCommunity

Hospital

CommunityMemorialHospital

May-17 62 138 123 156 47 53 62 14 5 1

Apr-17 71 202 105 152 47 63 41 23 36 1

Mar-17 79 233 124 94 41 46 32 38 6 3

Feb-17 77 241 123 88 58 57 45 33 10 4 4

Jan-17 74 246 124 92 63 52 50 44 15 4 5

Dec-16 73 213 94 56 85 55 12 41 7 4

Nov-16 102 131 80 32 95 55 31 43 29 2

Oct-16 135 99 136 17 74 59 33 17 16

Sep-16 63 63 94 42 44 42 36 21 5 2

Aug-16 184 44 160 36 34 51 27 7 9

Jul-16 71 40 93 2 29 40 85 16 13

Jun-16 726 111 18 36 133 22 6

0200400600800

1,0001,2001,4001,6001,8002,000 2biii ED Care Triage - Monthly


DY3Q2 (9/17) 7,200 1,402 960 x 6 months $157,000

DY3Q4 (3/18) 14,490 - 966 x 12 months $134,000Action StepsRecent change (4/19) to expand AEP Definition by suspending the 2 day business notification of PCP or HH CM appointment. The expanded AEP Definition is:

• Had either a PCP or Health Home Care Manager appointment scheduled within 30 Days of the ED discharge date OR• A PCP or Health Home Care Manager appointment scheduled outside of the 30 Days following the ED discharge

BUT had been notified of the appointment within 30 Days of the ED discharge

ED Care Triage Actively Engaged Patients


Care Transitions Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

Upstate UniversityHospital

St. Joseph's HealthCenter

St. Elizabeth MedicalCenter

Auburn CommunityHospital

Oneida HealthSystems, Inc.

Rome MemorialHospital

Faxton-St Luke'sHealthcare Oswego Hospital Lewis County General

Hospital Crouse Hospital

May-17 73 15

Apr-17 67 17 2 6

Mar-17 308 10 83 11 4 5

Feb-17 292 20 58 12 7 1

Jan-17 320 14 29 15 19 1

Dec-16 314 188 72 10 43 57 37 1 2

Nov-16 267 178 61 43 53 34 17 15 5

Oct-16 281 212 82 50 54 43 15 11 4 1

Sep-16 274 219 83 65 66 47 17 13

Aug-16 266 185 114 60 38 56 12 12 1

Jul-16 236 193 110 13 60 46 23 23 7 1

Jun-16 281 222 113 54 38 45 21 21 10 4

0

500

1,000

1,500

2,000

2,500

3,000

2biv Care Transitions - Monthly


DY3Q2 (9/17) 2,970 180 396 x 6 months $156,000

DY3Q4 (3/18) 5,940 - 396 x 12 months $134,000

Action Steps

• Actively Engaged Patient definition is undergoing review and revision that will include a consideration of timing based on the new DY.

Care Transitions Actively Engaged Patients


Patient Activation Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

TheSalvation Army

LewisCountyGeneralHospital

OneidaHealth

Systems, Inc.

PlannedParenthood of

Mohawk

Hudson, Inc.

CatholicCharitie

s ofOnonda

gaCounty

CrouseHospital

FingerLakes

Community

Health

RescueMissionof Utica

AuburnCommu

nityHospital

ACRHealth

Faxton-St

Luke'sHealthc

are

PlannedParenthood ofCentral

andWester

n NY

CatholicCharitie

s ofOswegoCounty

St.Elizabet

hMedicalCenter

Regional

PrimaryCare

Network

NOCHSI

Resource

Centerfor

IndependentLiving

NorthCountryPrenata

lPerinat

alCouncil

LewisCountyHealthAgency

Arise,Inc.

Syracuse

Recovery

Services

HillsideChildre

n'sCenter

ElderChoice,Inc.

FingerLakes

MigrantHealthCare

ProjectInc.

Hutchings

Psychiatric

Center

UpstateUniversi

tyHospital

Northern

Regional Center

forIndepen

dentLiving

May-17 4 89 54 35 77 7 30 49 9 12 5 12 8 3 3 2 1 1

Apr-17 5 101 35 50 46 20 23 74 12 23 36 9 14 5 4 2 1 7 4 2 1

Mar-17 136 53 27 14 4 15 2 25 14 15 4 2 3 8 7 4 3 6

Feb-17 52 33 32 12 32 27 3 6 34 1 26 7 1 4 4 1 3 1

Jan-17 5 59 41 32 23 31 35 4 8 14 12 1 6 1 1

Dec-16 21 37 19 16 26 9 7 2 4 8 3 2 7

Nov-16 109 70 20 24 10 6 13 4 9 1 3 3

Oct-16 5 27 38 31 27 12 8 1 4 1 8 7

Sep-16 26 35 3 12 2 16 10 1 6 1 2

Aug-16 62 37 12 8 6 2 11 11 5 3 4

Jul-16 136 13 90 18 12 40 5 6 9 5 4 5

Jun-16 74 31 20 22 3 8 4 6 5 13

050

100150200250300350400450500

2di Patient Activation - Monthly


DY3Q2 (9/17) 11,100 875 1480 x 6 months $135,000

DY3Q4 (3/18) 22,300 - 1,487 x 12 months $116,000Action Steps• Continuing outreach to engage new organizations to partner with CNYCC to

implement project

Patient Activation Actively Engaged Patients


Primary Care/Behavioral Health Integration Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

St.ElizabethMedicalCenter

St.Joseph'sHealthCenter

Faxton-StLuke's

Healthcare

NOCHSIUpstateUniversity Hospital

PlannedParentho

od ofMohawkHudson,

Inc.

SyracuseBrick

House

FamilyCare

MedicalGroup

Community

MemorialHospital

RegionalPrimary

CareNetwork

OswegoHospital

SyracuseCommunity HealthCenter,

Inc.

CrouseHospital

LibertyResource

s, Inc.

LewisCountyGeneralHospital

MohawkValley

Psychiatric Services

OneidaHealth

Systems,Inc.

UnitedCerebral

Palsy

FarnhamInc.

FingerLakes

Community Health

AuburnCommuni

tyHospital

HarborLights Arise, Inc.

May-17 915 370 528 399 113 105 214 67 80 42 8

Apr-17 796 444 569 445 175 124 97 100 186 99 46 98 76 19 8

Mar-17 491 269 179 314 148 275 226 72 39 69 39 59 51 10 9 7 18 18

Feb-17 471 210 176 315 103 249 208 92 36 92 100 46 48 22 58 12 3 16 21 15

Jan-17 577 252 197 417 164 244 205 49 42 55 132 46 41 24 68 18 7 19 25 30 2

Dec-16 439 254 170 468 235 263 164 63 38 76 51 28 19 26 28 11 16 23

Nov-16 308 316 186 530 347 275 178 59 512 59 71 23 42 8 29 14 10 24 40

Oct-16 240 378 237 321 460 153 69 71 73 75 20 42 8 13 13 38 1

Sep-16 458 283 247 322 690 315 30 48 77 3 1 7 2

Aug-16 723 474 351 249 629 213 211 62 91 134 42 15 32 26

Jul-16 14 169 315 71 513 337 196 226 18 100 179 32 27 6 28 21

Jun-16 254 265 515 14 50 183 209 415 57 115 1 52 39 8 89 38 26 25 12 1

0

1,000

2,000

3,000

4,000

5,000

6,0003ai Primary Care/Behavioral Health Integration - Monthly

DY Target Actual AEP x Month (*) $ At-Risk

DY3Q2 (9/17) 16,490 6,123 2,199 x 6 months $142,000

DY3Q4 (3/18) 39,865 - 2,658 x 12 months $122,000Action Steps

• Actively Engaged Patient Reporting Criteria narrows starting April 1st to align with the 3ai Standards of Care

Primary Care/Behavioral Health Integration Actively Engaged Patients


Behavioral Health Crisis Stabilization Actively Engaged PatientsActively Engaged Patient Contribution by Organization by Month

OnondagaCase

Management

OswegoHospital

SyracuseBrick House

LibertyResources,

Inc.

St. Joseph'sHealthCenter

Arise, Inc.

CayugaCounty

CommunityMentalHealthCenter

TheNeighborhoo

d Center,Inc.

SyracuseCommunity

HealthCenter, Inc.

Central NewYork Services

MohawkValley

PsychiatricServices

HutchingsPsychiatric

Center

NorthCountry

TransitionalLiving

Services


Unity Houseof Cayuga

County, Inc.Farnham Inc.

OswegoCounty

Opportunities

May-17 168 319 127 24 29 24 23 1 4

Apr-17 239 149 242 110 18 20 21 2

Mar-17 172 235 95 35 20 24 3 2

Feb-17 668 257 157 132 109 22 20 15 21 16

Jan-17 745 268 161 133 156 47 25 27 32 31 13 2 2 1

Dec-16 610 259 163 113 136 35 24 13 39 9 2 3

Nov-16 591 252 150 137 141 31 19 16 24 4 7 1 4 1

Oct-16 547 153 163 163 125 40 21 15 27 4 4 1 2

Sep-16 528 175 157 131 32 20 12 3 4 2

Aug-16 184 189 80 12 32 13 2 10 8 5 3 1

Jul-16 526 159 155 31 92 10 22 11 5 28 2 3 1 1

0500

1,0001,5002,0002,5003,0003,5004,0004,5005,000

3aii Behavioral Health Crisis Stabilization - Monthly


DY3Q2 (9/17) 10,800 1,520 1,440 x 6 months $135,000

DY3Q4 (3/18) 24,480 - 1,632 x 12 months $116,000

Action Steps• Convening partner-led discussion about Open Access scheduling as a strategy to

improve access to services. • Workgroup meeting to develop protocols around mobile crisis, peer respite and

warm line. • Work of the group will continue, but at the county level; exploring overlap with

the Care Transition Coalitions and other forums.

Behavioral Health Crisis Stabilization Actively Engaged Patients


Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

St. ElizabethMedicalCenter

Faxton-StLuke's

Healthcare


RomeMemorialHospital

Family CareMedicalGroup

Lewis CountyGeneralHospital

SyracuseCommunity

HealthCenter, Inc.

RegionalPrimary Care

Network

CommunityMemorialHospital

NOCHSI PhysicianCare, PC

OneidaHealth

Systems, Inc.

OswegoHospital

AuburnCommunity

Hospital

St. Joseph'sHealth Center

Port CityFamily

Medicine

May-17 368 258 89 50 10 81 17 32 17 16 23

Apr-17 235 93 118 54 81 21 54 43 48 60 8 17 29

Mar-17 218 150 65 31 47 82 24 29 26 3 4 23

Feb-17 218 133 24 26 31 62 14 23 15 29 30 17 10 13

Jan-17 65 166 10 25 65 61 14 32 22 31 32 17 9

Dec-16 46 150 15 21 39 31 4 23 25 30 34 12 10 1

Nov-16 38 136 218 52 70 48 20 10 35 27 16 7

Oct-16 32 19 263 63 69 80 41 9 33 21 16 8 5

Sep-16 42 19 393 75 26 50 28 19 15 11 6

Aug-16 19 26 49 82 62 91 31 21 5 13 29 5

Jul-16 43 41 75 158 33 46 35 19 4 5 22 4

Jun-16 65 63 128 140 46 5 2 42 50 3 4 56 5

0

200

400

600

800

1,000

1,200

1,400

1,600

3bi Cardiovascular Disease Management - Monthly


DY3Q2 (9/17) 6,460 1,822 861 x 6 months $104,000

DY3Q4 (3/18) 12,730 - 849 x 12 months $89,000Action Steps• Supporting partner implementation of Standards of Care.• Working with HealtheConnections and other community partners to increase Self-Measured

Blood Pressure opportunities to improve patient blood pressure control.• Continuing work with Central New York Regional Center for Tobacco Health Systems to

support smoking cessation training, 5A’s implementation and connections with the NYS Smoker’s Quitline.

• DY3 focus on promotion of community resources and population health management particularly for high risk patients.

Cardiovascular Disease Management Actively Engaged Patients


Palliative Care IntegrationActively Engaged Patient Contribution by Organization by Month

St. Elizabeth Medical CenterMay-17 1Mar-17 6

5

6

6

6

6

6

7

7

7

7

3gI Palliative PCMH Integration - Monthly


DY3Q2 (9/17) 1,980 1 264 x 6 months $80,000

DY3Q4 (3/18) 3,960 - 264 x 12 months $69,000Action Steps• Exploring alignment with PCMH and working with Karen Joncas to develop a

model for delivery within practices to support implementation.• Continued outreach to partner organizations considering the Palliative Care

project to help eliminate barriers to engagement• IPOS training date and registration disseminated to all current and

prospective partners• Developing repository for IPOS for contracted partners to be able to report

Palliative Care Integration Actively Engaged Patients


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October 5, 2017

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