PROJECT ADVISORY COMMITTEE (PAC) 9... · 10/1/2019 PROJECT ADVISORY COMMITTEE (PAC) Thursday,...
Transcript of PROJECT ADVISORY COMMITTEE (PAC) 9... · 10/1/2019 PROJECT ADVISORY COMMITTEE (PAC) Thursday,...
10/1/2019
PROJECT ADVISORY COMMITTEE (PAC)
Thursday, September 26, 2019
9:00 am - 12:00 pm
Hilton Garden Inn – Stony Brook
Hosted by the Office of Population Health at Stony Brook Medicine
10/1/2019 2
WELCOME REMARKS
Linda S. Efferen, MD, MBA
Executive Director & VP, Medical Director
Suffolk Care Collaborative
10/1/2019 3
MEETING AGENDA MODERATED BY:Sofia Gondal, MA, Project Manager, SCC
9:00 – 9:05 Welcome RemarksLinda S. Efferen, MD, MBA
Executive Director & VP Medical Director, SCC
9:05 – 9:30Catholic Health Services Physician Partners
Care Coordination, C3Catholic Health Services
9:30 – 9:55Northwell Health Transitional Care Management Northwell Health
9:55 – 10:20Stony Brook Medicine Community Transition of Care Stony Brook Medicine
10:20 – 10:35 Break
10:35 – 11:00
The Value of Virtual Medicine in Creating an Envelope of Care:
Lessons Learned with Roll-out and Implementation in a Federally Qualified Health CenterLong Island Select Healthcare, Inc.
11:00 – 11:30Performance Updates Suffolk Care Collaborative
11:30 – Noon Closing Remarks and Networking Suffolk Care Collaborative
Care Coordination
C3
Robert Fortini, PNP Vice President, Care Coordination
Transitions of Care – TOC
Chronic Condition Management – CM
Comprehensive Care for Joint Replacement – CJR
Comprehensive Medication Management
Integrating Behavioral Health in Primary Care
Post Acute Care Management/Advanced Illness Care
TOC IDENTIFICATION CRITERIA
Current admission or recent discharge
(less than 30 days)
Includes all Disease Registries
Risk stratification
CM HIGH RISK IDENTIFICATION CRITERIA
One chronic condition and one inpatient admission in the last 31-90 days
Chronic Conditions are:◦ COPD◦ CHF◦ Asthma◦ CAD/AMI◦ HTN◦ DM◦ Depression◦ ESRD◦ HIV◦ Cancer-Colon, Lung, Breast,
Ovary, Non-Hodgkin
ED Visits IP Admits
INCLUDING CJR
Improve Generic Utilization
Medication Therapy Management
Reduce poly-pharmacy in the Elderly
Prescription Assistance Services
Pharmaceutical Students and Residents
Generic/Formulary Utilization Outreach – 4970 Notifications
Medication Management/Outreach – 80 Patients
Medication Adherence Outreach – 595 Patients
Prior Authorization Program - 42
Charter adopted
Preferred Network based on specific criteria:
◦ LOS, Re-adm rate, Star rating, bi-directional communication
On-boarding meeting with preferred partners
Meetings with key Physicians
Process & Scripting Meetings with CM Departments
Data Metric Analytics and Reporting Plan Developed
Regular meetings with partners
Northwell Health Solutions
Transitional Care Management
Hallie Bleau, ACNP-BC, CCMAVP Transitional Care Management
NorthwellHealth Solutions
Northwell Health is aligning the organization to meet the objectives of value-based care delivery, including redesigning operational processes, investing in talent and technology, and educating physicians and staff.
Mission
Purpose
“Empower patients, families, and providers to improve patient-
important outcomes through a focus on access, coordination, activation,
integration and alignment”
“Helping the people who need it most”
CMS CJRCMS STARFollow Your
HeartDCTBPCI-A
Beneficiaries:
Medicare FFS
Five clinical episodes:
CABG, CHF, COPD,
bronchitis, asthma, G.I.
hemorrhage, Simple
PNA and respiratory
infections
Navigated for 90 days
post discharge
Beneficiaries: Medicare
FFS
65 Years +
Seven measures:
AMI, Stroke,
CABG, THA/TKA
COPD, Pneumonia
Heart Failure
Navigated for 30 days
post discharge
Beneficiaries:
Medicare FFS
Procedures:
Major Joint
Replacements
(MS-DRG 469, 470)
Navigated for 90
days post discharge
Beneficiaries:
All Payer
Procedures:
Cardiac Surgery
Navigated for 30
days post
discharge
Beneficiaries:
Northwell
Employees
Qualifications:
Any qualifying
admission
Navigated for 30
days post
discharge
Employee
Health Plan
Beneficiaries:
Medicaid
Qualifications:
Any qualifying
admission
Navigated for 30
days post
discharge
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
TRANSITIONAL CARE MANAGEMENTCurrent Programs
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
In-Person Visit during hospital stayAccess to 24/7 Call CenterEnroll in Conversa
Inpatient
24hr D/C
Every Patient called within 24hrs of discharge
Covered: Discharge InstructionsMedicationsFacility/Home DischargesHomecare Visit
Community Connections
Community Based Care MgmtBehavioral Health Care MgmtHealth HomeHealthy LivingTobacco Cessation
Real-Time Notification for ED PresentationsClinical Note entered into ED chartHospital team takes action to meet patient in the ED
ED Action Team
High Risk patients receive a home or SNF visitPost Acute Analytics used for SNF LOS management
Community Visits
Care Across the Care Continuum
Transitional Care ManagementCare Navigation Model
CONVERSA HEALTHPERSONALIZED AUTOMATED CONVERSATIONS
PATIENT FOCUSED EDUCATIONProvide sequence of education that is
appropriate for patient’s health
CLINICAL EFFICIENCYCollect patient generated health data while
improving clinical efficiency and optimizing
resources
DIAGNOSIS SPECIFICAMI, HF, PNA, COPD, Stroke, CABG VERSATILE USAGE
Utilization possible across a wide
spectrum from primary care, chronic
disease management, transitional care
management, and preventive lifestyle
support
TARGETED POPULATIONValue based programs for readmission
and cost reduction at 14 hospitals: Star,
BPCI-A, Follow Your Heart, Health
Home at Risk, DSRIP, Next Gen ACO,
Employee Health
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
5.3Additional Touches
Per Patient
2,800+Patients enrolled in
Health Chats
“I find these chats very helpful and encouraging.
I feel much more confident about my recovery as a result of these
interactive guides. The fact that assistance is only a telephone call
away is very reassuring.”
Bundled Payments Patient
5%
8%
12%
18%
21%23%
Q2 2018 Q3 2018 Q4 2018 Q1 2019 Q2 2019 Q3 2019
Star Conversa Enrollment Rate
12%
19%
27%
32%
Q4 2018 Q1 2019 Q2 2019 Q3 2019
BPCI-A Conversa Enrollment Rate
CONVERSA HEALTHNORTHWELL HEALTH CHATS DEPLOYMENT
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
Benefits of PAA Dashboard Integration
Patient tracking in Real Time utilizing
the Post Acute Dashboard (CTM)
Provides alerts via CTM dashboard for
patients who are “off track” for
quality/cost and readmission.
Creates continuity of patient care utilizing SNF,
Northwell Home Care and TCM
Navigators to view and work
collaboratively
Helps with reduction in readmissions
Post Acute Analytics:
PAA provides a platform called Care Transition Management (CTM) to monitor, coordinate,
and intervene on patients’ health in real time outside the
four walls of a hospital– i.e. post acute setting.
Northwell, SNFs and PAA will share data via an extract or
HL7 feed.
Northwell and SNFs will be able to access the PAA data and any alerts that CTM is
tracking on patients through CTM’s cloud based portal via a
web browser.
Overview SNF Benefits
Comprehensive patient
management with the ability to demonstrate
clinical excellence.
Effective communication
and cross network
collaborative alignment with
Northwell.
Increases STAR
rating.
Efficient patient
management across
network.
There will be no cost for this service for our high value network of providers
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
Post Acute Analytics: Dashboard Overview
PAA will have the capabilities to flag patients who are included in our bundles – i.e. Stars, CJR etc.
EMERGENCY DEPARTMENT STRATEGYREAL-TIME UPDATES
Patient belonging to Star has
Emergency Registration at Lenox
Hill Hospital
Information Summary:
Patient:
Date of Birth:
EPI:
MRN:
Member ID:
Visit Number:
Hospital Service:
Encounter Type:
Admit Time:
Admitting Doctor:
Chief Complaint:
Last Admission History
Type:
Facility:
Admission Date
Discharge Date:
Final Billing Dx
Please do not reply to this email.
Smith, John
06/21/1954
3542958
1258270
LXHH9104810
184401888
EMR/L
Emergency
06/21/2019 00:00:00
DOCTOR, SMITH
SOB
Inpatient
Lenox Hill Hospital
6/1/2019 00:00:00
6/5/2019 00:00:00
Pneumonia
2 REAL-TIME ALERTvia SMS or
ED Clerical Note
1 ED REGISTRATIONPatient returns to the ED
3PLAN OF CARECollaborate and
coordinate care to allow
for safe ED discharge
ED ACTION TEAMStrategic mobilization of
entire hospital at the
moment a patient returns
the ED
BLACK PHONE
Icon on ED dashboard
populated once ED Clerical
Note is entered by
navigation team
Clerical Note Content
TCM program
information
24/7 contact information
Contact information for
inpatient team
Relevant ambulatory clinical information
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
ED Provider
Navigation Team
Inpatient Team
Population: Medicaid patients
discharged from SIUH
139% improvement in readmission rates since
2017 for both 30d and 60d
readmission rates for pps
population
TCM Model OUTCOMES
Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.
Population: Medicare FFS Joint patients
28% improvement in
readmission rates since
2016 to 2018 for 30 day
readmissions
Population: STAR Medicare FFS
population
9.5% improvement in readmission rates since
2017 to 2018 for 30 day
readmission rates
Thank You
Stony Brook Medicine
Community Transition of Care
Highlights of Continuity of Care
Department of Care Management and Social Work Services
Care Management Team:
Jere’ Freeman, Assistant Director of Operations and Analytics
Susan McCarthy, Director of Social Work
Mary Ann Lind, Director of Case Management
Maura Shovlin, RN Clinical Educator
Care Management at Stony Brook Medicine
Overview:
• History of Transitions of Care (TOC)
• How ongoing data drives changes to transition planning and project initiatives
• Current Projects
• Future State Goals
History of Transitions of Care (TOC)
History of Transition of Care (TOC)
Together - Strengthening Transitions Avoiding
Readmissions (T-Star) Committee, 2009:
An initiative to reduce avoidable hospital readmissions. This
project consists of a collaborative of local skilled nursing
facilities, home care agencies and DME suppliers working
together to improve patient care and reduce avoidable
readmissions.
History of Transition of Care (TOC)
SNF Transfer Form (2010):
• Form initially created by SBM in 2010 that was
shared and utilized with community facilities
History of Transition of Care (TOC)
Skilled Nursing Facility (SNF) Leadership
Meetings:
• Quarterly meetings began in 2011 with
communities SNFs
• Quarterly meeting with community SNF
Leadership
• Engagement and Process improvement initiatives
are discussed
• Home Care one on one meetings (2014)
Analytics Drive Change
How ongoing data drives changes to transition planning and project initiatives
• Information Technology Initiatives to drive TOC Projects:
• Discharge Disposition Data
• Blind reports for SNF Partners
• Quality Improvement Measures
Analytics Drive Change
Largest Discharge Dispo
per month is Home
Care Services
Followed by AR/SNF
Discharges
Approximately 950 Discharges
per Month to AR/SNF/Home Care
Approximately 35,000 inpatient discharges in 2018
32% (11,346) required Acute Rehab (AR), SNF, Home Care arranged by Care Management
Analytics Drive Change
This TOC data does not include:
• Hospice
• Acute Care Psychiatric Hospitals
• Hospital Transfers
• DME
• Group Home
• Supported/Supportive Housing
• Home with Services (Early Intervention, Case Management, Health Homes, Day Programs)
Analytics Drive Change
Top 15 Facilities by Bookings January 2018 - December 2018
CodesTotal Referrals # Accepts % Accepts
Total Bookings
30 Day Readmit % Readmit
S3 914 455 50% 452 36 8%
S6 1,607 609 38% 384 50 13%
S1 1,119 279 25% 281 60 21%
S14 1,339 710 53% 280 35 13%
S4 1,325 465 35% 240 46 19%
S2 1502 469 31% 249 40 16%
S8 1,422 338 24% 224 47 21%
S11 1,381 330 24% 217 47 22%
S13 1,147 306 27% 173 16 9%
S21 1,449 219 15% 161 19 12%
S9 986 445 45% 146 26 18%
S15 983 522 53% 143 24 17%
S33 1,066 446 42% 131 26 20%
S16 1,010 362 36% 116 18 16%
S5 1,089 411 38% 113 18 16%
S42 1,147 109 10% 111 18 16%
16.9%
14.9%15.9% 16.0%
14.1% 14.0%
15.7%14.7%
17.3%
14.9% 15.3%
Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018
SNF/Rehab Readmission Rate
• Anonymous Reporting is provided to our top 15 Facilities at each of our Quarterly SNF Meetings
• Currently expanding this reporting ability to our Certified Home Health Agencies
Analytics Drive Change
Quality Improvement Measures:
• naviHealth reporting function is utilized for quality
improvement measures
• naviHealth Reporting feature provides reports that includes:
• Number of discharges by disposition per unit, financial
class, and specific timeframes (monthly, quarterly, yearly)
• Number of readmissions per unit
• Staff Productivity
• Provider Productivity
Analytics Drive Change
Analytical Review:
• Reviewed Quantitative Measures
• Drilled down to encounters for qualitative measures and for feedback from providers
• Identified barriers and opportunities on the Inpatient Medicine Units: Behavioral Health
~50% of SBM Patients admitted to non-behavioral health units have a comorbidity of behavioral
health/SUD diagnosis
Behavioral Health TOC
Approximately 50%-60% of SBM Patients admitted to non-behavioral health units have a comorbidity of behavioral health diagnosis
• Depression
• Anxiety
• Substance Use Disorder
• Suicide Attempt/Overdose
• Geriatric Psych/Neuro
• Chronic Mental Illness/Medical Diagnosis
• Psychosis/Delusion
1. Behavioral Health patients in non behavioral health units
2. Behavioral Health patients in behavioral health units
• Depression
• Anxiety
• Substance Use Disorder
• Suicide Attempt/Overdose
• Geriatric Psych/Neuro
• Chronic Mental Illness/Medical Diagnosis
• Psychosis/Delusion
Psych Social Work Merge 2016
Prior to 2016, CPEP, and Adult/Child Psych Social Work was a separate entity to Inpatient Social Work
In 2016, the Social Work Teams combined which offered improved TOC for integrated health and opportunity for:
• Improvement of Transition to SNF/Home care for behavioral health patients
• Screening, Brief Intervention, and Referral to Treatment (SBIRT)
• Float Social Work to multiple behavioral health units
• Enhanced Coverage- Social Work training for all behavioral health areas
• Psych Social Work coverage on weekends
• Enhanced Psychiatric Social Work Competencies
• Consult Liaison Team Social Work
• CASAC Consult in Inpatient Adult Units
Behavioral Health Care Transitions
Mobile Crisis Outreach Overview:
• 4 Mobile Behavioral Health Specialists
• Operating since October 2018
• Coverage 7 days a week from 8:00AM – 8:00PM
• See patients in the community recently discharged from Stony Brook
• Provides assessment, crisis intervention, counseling, and referral to care for persons with severe and
persistent mental illness
Behavioral Health Care Transitions
Mobile Crisis Outreach
August 2018:
Project Kickoff
October 2018:
First MCT Referral
January 2019:
Successful Insurance Billing
0
5
10
15
20
25
30
35
40
45
50
Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19
Mobile Crisis Referrals
Behavioral Health Care Transitions
Suffolk Care Collaborative Embedded Care Manager:
• Embedded Care Manager to providing additional community supports for psychiatric patients
• CPEP and inpatient adult psychiatry
• HARP
• Health Homes
• Transportation to appointments
Behavioral Health Care Transitions
Consult and Liaison Team:
• Social Work Services and Psychiatry Collaboration
• Caseload throughout the hospital for psychiatric intervention and safe discharge planning
• Enhanced psychiatric intervention and assessment in Medical ED and Units
• Interdisciplinary Approach for difficult cases on medical floors (MD, NP, LCP, LMSW)
• Enhanced collaboration for medical team and psychiatric team
• Patient centered approach to SNF and homecare transitions
Behavioral Health Care Transitions
Care Restructuring Enhancement Pilot Program (CREP)
• Intensive 2yr Education and training for Care Management Staff
• Psychiatric Services Clinical Knowledge Enhancement System (PSYCKES)
• Health And Recovery Plans (HARP)
• Peer Support
• Home and Community Based Services
SBIRT Expansion- Screening, Brief Intervention, and Referral to Treatment
• Designed to screen and respond to every patient at Stony Brook Medicine
• Addiction Counselors for house-wide Consults for Medicine Units
• Ongoing education and documentation improvement with Nursing and Physicians
Current Projects
Enhancements of Resources and Confirmation
of Resources at Depart:
• Substance Use Disorder (SUD)
• Alcohol use disorder (AUD)
• Mental Health
• Domestic, Family Violence, Human
Trafficking
• Homeless and Indigent Resources
• Oncology
• Stroke
• Heart Failure
• LVAD
Current Projects
New Hospital Network Alliance
• Patient Transfer Tracking
• Increase in Patient Transfers
• Acceptance of High-Risk Medical Patients
• EMR Connectivity
• Care Management Collaboration
• Joint Commission Readiness
• Palliative Care Program Enhancement
Current Projects
Continuing Community Partner Enhancements:
• On-going Quarterly SNF Leadership Meetings now includes representation from:
• 26 SNFs
• 9 Certified Home Health Agencies
• 12 Assisted Living Facilities
• SNF to ED Form Audit Data
• Anonymous Reports provided to SNFs and CHHAs
• One on One Meetings with SNFs
• One on One Meetings with CHHAs
• One on One Meetings with Assisted Livings
Technology and Analytics
Stroke Monitor Dashboard:
• Tableau dashboard of patients with a stroke dx
• Emailed daily to all interdisciplinary team members
Technology and Analytics
Diabetes Tracking:
• Tableau dashboard of all current high A1C patients
• Updated daily to show new admits
• Available to all interdisciplinary team members
Future State Goals
Future State Goals
Hospital to SNF Transfer Form:
• Internal Coordination to begin 1st Quarter 2020
Emergency Department Consults:
52
Future State Goals
Diagnosis Specific Assessment, Psycho-Social, and Discharge Planning:
• Disease Specific Joint Commission Standard
• Stroke
• LVAD
• Heart Failure
• Palliative Care
Future State:
• Oncology
• Psychiatry – Behavioral Areas
• Psychiatry – Non-Behavioral Areas
Future State Goals
Medication Assisted Treatment (MAT) in ED:
• Patients interested in MAT from the ED will now receive their first
dose of suboxone in the ED and a three day prescription.
• The four types of patients that would benefit are:
• Those coming in with active opioid withdrawal
• Those coming in with other medical issues who state that they
are active opioid users (dependent)
• Those coming in not identified with opioid use and who then
start to withdraw while they are in the ED
• Those coming in with an overdose
Next day appointments will be secured for these patients
Future State Goals
Enhanced High Risk Assessment:
• Suicide Risk Reduction
• Substance Use Disorder (SUD)
• Family Violence
• Human trafficking
• Distress Tool
Future State Goals
Beta Projects with naviHealth
Future State Goals
Care Management Stony Brook Medicine
Outcomes and Future Goals:
• Advanced innovation and analytics
• Analysis of Disposition Types
• Enhancement in mobile engagement and psych follow-up
• Increase outpatient SW/CM
• Implementation of Community Workgroups
Questions?
10/1/2019 60
BREAK15 minutes
THE VALUE OF VIRTUAL MEDICINE IN CREATING AN ENVELOPE OF CARE LESSONS LEARNED WITH ROLL OUT AND IMPLEMENTATION IN A FEDERALLY QUALIFIED HEALTH CENTER
JAMES POWELL, MD
JANET PEPPER, MBA
LINDSAY FUDIM, MHA
WHY DID LONG ISLAND SELECT HEALTHCARE (LISH) CHOOSE TELEMEDICINE?
BRIDGE ACCESS GAP
LOWER ER RATES
EASIER ON DEVELOPMENTALLY DISABLED PATIENTS
BIP GRANT 2014-2017
THE FLAWS OF TELEMEDICINE INTEGRATION
What happened from 2017 until now…..
* Insurance
* Partnerships
* Reimbursement, or lack there of
* Once grant ended, telemedicine ended.
Wasn’t sustainable.
However….
THANK THE TELEMEDICINE GODS FOR ANOTHER GRANT!!!!!!!
LISH received a $655,000 grant in 2019…
2019 PREPARATION
• Selecting the sites
• When it is site to site, put appointment on site patient will be at so robo call selects right
location.
• Add consent form and connectivity survey to registration packets.
• Create new visit types: On-site Telemedicine & Off-Site Telemedicine (for primary care &
mental health)
• Assign a few point people to make appts and remind patients of upcoming appts.
• Train patients/caregivers & LISH staff.
• I.T. -take inventory, deploy Samsung 10.5” tablets, test wifi, disable apps, download chrome,
make sure no PHI is on tablets.
• Create logins and passwords per provider rather than using a blanket one.
• Keep a list of providers that have been trained so that schedulers do not accidently make an
appointment for untrained providers (training is quick).
• Include a point person & back-up person per site that locks the equipment at night and knows
where equipment is stored.
• Remote Patient Monitoring equip. if needed.
• Create Standard Operating Procedures/Policies
PROVIDER VIEW
PATIENT VIEW
LESSONS LEARNED
• In-servicing for staff needed greater
detail
• Turn volume up.
• Show providers how to keep
themselves on “available” status.
• Manipulating screen to show
appropriate backdrop if at home.
THANK YOU!
DR. POWELL CONTACT INFO:
(631) 650-2111
JANET PEPPER CONTACT INFO
(631) 650-2084
LINDSAY FUDIM CONTACT INFO
(631) 650 - 2278
10/1/2019 72
Kevin Bozza, MPA, FACHE, CPHQ, RHIT
Chief of Operations & Vice President, Population Health Management Services
Suffolk Care Collaborative
Performance Updates
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
SCC P4P MEASURE CONVERSION
0
10
20
30
40
50
60
MY1 MY2 MY3 MY4 MY5
0 P4P Measures
14 P4P Measures
41 P4P Measures
56 P4P Measures 56 P4P Measures
P4P Measures in Each Measurement Year (MY)
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
MEASURE / ATTRIBUTION CHANGES
Measure Issue Identified MY Impact
PPV & PPV BH Discrepancies in PPV / PPV BH logic identified in December
2018 after the new Encounter Intake System (EIS) was
implemented. ED visits were being undercounted.
MY0 – MY4
PPR & PQI 90 One MCO reporting duplicate claims instead of adjustments to
original claims. Led to an increase in PPRs for several PPSs.
PQI 90 was impacted to a lesser degree.
MY4 month 7 - 11
Asthma Measures
AMR, MMA50,
MMA75
Improper value set label provided by AHRQ for Antibody
Inhibitors.
MY3 month 6 thru MY4
month 5
Children’s Access
to Primary Care
Members were placed in the incorrect age bracket. Impacted
the 12-24 months and 25 months to 6 years measures.
MY0 – MY4
All Measures Changes in health home billing policy, practices and rate codes
resulted in unintended shifts of Health Home attribution from
and to a subset of PPSs over time.
MY3 – MY4
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
SCC PERFORMANCE
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
0%
20%
40%
60%
MY1 MY2 MY3 MY4
36.4% (12/33)
46.9%(23/49)
*Pending
50.0%(28/56)
Measurement Year Results
MY1 MY2 MY3 MY4
% M
easure
s M
et
*Pending release of “Report 11” from NYS DOH
BEHAVIORAL HEALTH PROGRAM
PPS Target 10% Gap-to Goal
Measures MY4
Adherence to Antipsychotic Medications for People with Schizophrenia ✅
Antidepressant Medication Management - Effective Acute Phase Treatment ✅
Antidepressant Medication Management - Effective Continuation Phase Treatment ✅
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia x
Diabetes Monitoring for People with Diabetes and Schizophrenia x
Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication x
Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) x
Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) x
Follow-up after hospitalization for Mental Illness - within 30 days x
Follow-up after hospitalization for Mental Illness - within 7 days x
Follow-up care for Children Prescribed ADHD Medications - Continuation Phase x
Follow-up care for Children Prescribed ADHD Medications - Initiation Phase x
Screening for Clinical Depression and Follow-up ✅
Potentially Preventable Emergency Department Visits (for persons with BH diagnosis) +/- (per 100) x
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
CARE TRANSITIONS PROGRAM
Measures
PPS Target 10% Gap-to-Goal
MY4
Adult Access to Preventive or Ambulatory Care - 20 to 44 yearsx
Adult Access to Preventive or Ambulatory Care - 45 to 64 yearsx
Adult Access to Preventive or Ambulatory Care - 65 and olderx
Children's Access to Primary Care - 12 to 19 years x
Children's Access to Primary Care - 12 to 24 Monthsx
Children's Access to Primary Care - 25 months to 6 yearsx
Children's Access to Primary Care - 7 to 11 yearsx
PDI 90 - Composite of all measures +/- (per 100,000) ✅
PQI 90 - Composite of all measures +/- (per 100,000)✅
Potentially Preventable Emergency Room Visits +/- (per 100)x
Potentially Preventable Readmissions +/- (per 100,000)✅
© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
CHRONIC DISEASE PROGRAM
Measures
PPS Target 10% Gap-to-Goal
MY4
Asthma Medication Ratio (5 - 64 Years)x
Medication Management for People with Asthma (5 - 64 Years) - 50% of Treatment Days Covered ✅
Medication Management for People with Asthma (5 - 64 Years) - 75% of Treatment Days Covered ✅
Pediatric Quality Indicator # 14 Pediatric Asthma +/- (per 100,000) ✅
Prevention Quality Indicator # 15 Younger Adult Asthma +/- (per 100,000) ✅
Controlling High Blood Pressure ✅
Prevention Quality Indicator # 7 (HTN) +/- (per 100,000)x
Prevention Quality Indicator # 8 (Heart Failure) +/- (per 100,000)x
Statin Therapy for Patients with Cardiovascular Disease –Received Statin Therapy ✅
Statin Therapy for Patients with Cardiovascular Disease –Statin Adherence 80%x
Comprehensive Diabetes Care- Hemoglobin A1c (HbA1c) Poor Control (>9.0%) +/- ✅Comprehensive Diabetes screening - All Three Tests (HbA1c, dilated eye exam, nephropathy monitor) ✅
Prevention Quality Indicator # 1 (DM Short term complication) +/- (per 100,000) ✅© Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC
and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC.
CG CAHPS - MEDICAID
Measures
PPS Target 10% Gap-to-Goal
MY4
Care Coordination with provider up-to-date about care received
from other providers x
Flu Shots for Adults Ages 18 - 64 ✅Getting Timely Appointments, Care and information (Q6, 8, 10,
and 12) ✅
Health Literacy - Describing How to Follow Instructions ✅
Health Literacy - Explained What To Do If Illness Got Worse x
Health Literacy - Instructions Easy to Understand ✅Medical Assistance with Smoking and Tobacco Use Cessation -
Advised to Quit x
Medical Assistance with Smoking and Tobacco Use Cessation -
Discussed Cessation Medication ✅
Medical Assistance with Smoking and Tobacco Use Cessation -
Discussed Cessation Strategies ✅
Primary Care - Length of Relationship - Q3 ✅Primary Care - Usual Source of Care - Q2 x
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CAHPS Clinician and Group Adult 3.0 core survey
Distributed by: NYS DOH
11 measures
Sampling Frame:
o Adults ages 18-64
o Current Medicaid members, enrolled
continuously for six months
o Patients who have had at least one qualifying
outpatient visit in the last six months as of July
Administration Period: September – December
COMMUNITY AND PATIENT ENGAGEMENT
Measures
PPS Target 10% Gap-to-Goal
MY4
ED Use by uninsured✅
Non-use of primary and preventative care services x
PAM Level Not Eligible
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CG-CAHPS – UNINSURED
• Partnered with Press Ganey to coordinate
and distribute the CG-CAHPS mail patient
satisfaction survey.
• Annual DOH requirement for the 2.d.i
Project – Community Health Activation
Program.
• Patients targeted for survey included
adults 18 years or older, self-identified and
provider identified as uninsured, and
patients who have had at least one
qualifying visit (such as primary care or
preventive care) within the PPS during the
measurement period.
• As of MY3 Pay-for-Performance Measure.
Measures
PPS Target 10% Gap-to-Goal
MY4
Getting timely appointments, care and information✅
How well providers (or doctors) communicate with
patients ✅
Helpful, courteous, and respectful office staff✅
Patients’ rating of the provider (or doctor)✅
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HIGH PERFORMANCE FUND (HPF)
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“Supplemental” DSRIP program
Awards additional funds to PPSs that achieve a 20% gap-to-goal closure and/or exceeds NYS performance goal in HPF-eligible measures
HPF pool increases as PPSs across the state fail to achieve payments linked to projects and/or HPF
Met High Performance Targets (20% improvement)
Antidepressant Medication Management – Effective Acute Phase Treatment
Antidepressant Medication Management – Effective Continuation Phase Treatment
SCC PERFORMANCE
MY4 FINAL RESULTS
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STATEWIDE ACCOUNTABILITY MILESTONES
(SWAM)
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Statewide Milestone Pass Criteria Current Status
Statewide metrics performance More metrics are improving on a statewide level than are
worsening
PASS
Success of projects statewide More metrics achieving an award than not PASS
Managed care plan Achieving VBP roadmap goals related to value-based
payment transition
PASS
Total Medicaid spending 1) The growth in total Medicaid spending is at or below
the target trend rate (DY4-5 only) - and -
2) The growth in statewide IP & ED spending is at or
below the target trend rate (DY3-5)
PENDING
STATEWIDE PERFORMANCE TRENDS
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SCC PERFORMANCE TRENDS
Rate of change since baseline: -20.36% Rate of change since baseline: -13.84% Rate of change since baseline: -6.61%
Reductions in Preventable Hospital Use
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MY4 Target: 489.85 MY4 Target: 27.36 MY4 Target: 98.89
SCC PERFORMANCE TRENDS
% point change since baseline: +4.17% % point change since baseline: +2.25% % point change since baseline: +3.60%
Behavioral Health Medication Measures
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SCC PERFORMANCE TRENDS
% point change since baseline: +5.91% % point change since baseline: +4.46%
Diabetes Measures
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SCC PERFORMANCE TRENDS
% point change since baseline: +8.51% % point change since baseline: +7.22%
Asthma Medication Measures
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MEASUREMENT YEAR 5
DELIVERABLE REPORTINGRESPONSIBILITY
EXPECTEDCOMPLETION DATE
Patient Activation Measure (PAM) SCC DY5 Q2
CG CAHPS Survey - Uninsured SCC DY5 Q3
CG CAHPS Survey - Medicaid DOH DY5 Q3
Medical Record Abstraction DOH Vendor DY5 Q4
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10/1/2019 92
QUESTIONS
10/1/2019 93
Linda S. Efferen, MD, MBA
Executive Director & VP, Medical Director
Suffolk Care Collaborative
CLOSING REMARKS