7/8/2019
PROJECT ADVISORY COMMITTEE (PAC)
Thursday, June 27, 2019
9:00 am - 12:00 pm
Hilton Garden Inn – Stony Brook
Hosted by the Office of Population Health at Stony Brook Medicine
7/8/2019 2
WELCOME REMARKS
Presented by
Linda S. Efferen, MD, MBA
Executive Director & VP, Medical Director
Suffolk Care Collaborative
7/8/2019 3
MEETING AGENDA MODERATED BY:Alyse Marotta, MPH, Administrative Manager, Behavioral Health Programs, SCC
9:05 – 9:50 Telemedicine Highlights Kimberly Noel, MD, MPHTelehealth Director and
Deputy Chief Medical Information OfficerStony Brook Medicine
9:50 – 10:05 Break
10:05 – 10:25 Telepsychiatry – Catholic CharitiesJohn P. Borrillo, MPAProgram EvaluatorCatholic Charities
10:25 – 10:45 Telepsychiatry – Stony Brook MedicineSusan Wilner, LCSWAssistant Director of
Behavioral Health Services OperationsStony Brook Medicine
10:45 – 11:05 Telepsychiatry – Catholic Health ServicesRonald Brenner, MD
Chief, Behavioral Health ServicesCatholic Health Services
11:05 – 11:20 Strategies to Implement & Sustain Value Based Payment Model Ankita Shah, MBAFinancial Operations Manager, SCC
11:20 – 11:30Building a Business Case for
Innovative Partnerships: Value Based Payments and Community Based Organizations
Amanda Chirco, M.Ed, PMPProject Manager, Community
Health Initiatives, SCC
11:30 – 11:35Prevention and Screening Resources Sofia Gondal, MA
Project Manager, SCC
11:35 – Noon Closing Remarks and Networking Linda S. Efferen, MD, MBAExecutive Director & VP Medical Director, SCC
Telemedicine Highlights
5
Kimberly Noel MD MPH
Telehealth Director
Deputy CMIO
Chief Quality Officer of PCMH
Family Medicine
Preventive Medicine Physician
BMI Researcher
Stony Brook Medicine
@DrKimNoel
HELLO!
No Financial Disclosures
6
7
Living Your Best Life
© History.Com Alexander Graham Bell: John Steele Gordon. The Reader’s Companion to American History. Eric Foner and John A. Garraty, Editors. https://www.history.com/topics/inventions/alexander-
graham-bell
Access Date March 20, 2019
January 17, 1960 edition of the Sunday comic strip Our New Age by Athelstan Spilhaus
11
© Copyright 1987 Hanna-Barbera Productions, Inc. All Rights Reserved
Telehealth
© Copyright 1987 Hanna-Barbera Productions, Inc. All Rights Reserved © 2019 All Rights Reserved Proteus Digital Health
Patient
Generated Health
Data
“
Artificial Intelligence at the Point of Care
Video
Sensors
Digital Apps
Personal Health
Technologies
A Doctor’s
Diagnosis and Evaluation
©2018 Advisory Board • All Rights Reserved • advisory.com
17
Telehealth Program Maturity, by Care Setting
REACH Health Survey, “2017 U.S. Telemedicine Industry Benchmarks”
Most Acute Care Providers Already Use Telehealth
Stroke, Mental Health, and Primary Care Expected to Remain Top Uses
Sources: “2017 U.S. Telemedicine Industry Benchmark Survey,” REACH Health, April 2017, http://reachhealth.com/wp-
content/uploads/2017-US-Telemedicine-Industry-Benchmark-Survey-REACH-Health.pdf, Service Line Strategy Advisor research and
analysis.
36%
ACUTE CARE
27%
37%
Greater than 3 years
Less than 3 years
No telehealth program
14%
16%
70%
4%
6%
90%
PRIMARY CARE SKILLED NURSING
Top Specialty Applications
Stroke Psychiatry RadiologyNeurology Pediatrics
©2018 Advisory Board • All Rights Reserved • advisory.com
18
Interest and Investment Show No Signs of Slowing
Telehealth Continues to Be a Top Priority for Health Care Professionals
Sources: “2017 U.S. Telemedicine Industry Benchmark Survey,” REACH Health, April 2017, http://reachhealth.com/wp-
content/uploads/2017-US-Telemedicine-Industry-Benchmark-Survey-REACH-Health.pdf; ATA, “Executive Leadership Survey,” March
2017, http://thesource.americantelemed.org/resources/telemedicine-executive-leadership-survey, Service Line Strategy Advisor
research and analysis.1) ATA, “Executive Leadership Survey”; n=168.
Telemedicine as a Strategic Priority
REACH Health, “2017 U.S. Telemedicine Industry Benchmark Survey”
n=436
Health care executives
responding that they were likely
to invest in telehealth in 20171
83%
©2018 Advisory Board • All Rights Reserved • advisory.com
19
Medicare Imposes Restrictive Eligibility Criteria
Most Favorable for Virtual Visits Between Rural Health Care Facilities
Sources: CMS, “Telehealth Services Fact Sheet,” Nov. 2016, https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf;
Service Line Strategy Advisor research and analysis.
Eligibility Criteria for Telehealth Reimbursement Under FFS Medicare
21
3 4
Modality1
Distant Provider2
Patient Location
health care professional shortage area (HPSA),
3
Care Site4Is your organization eligible for reimbursement? HRSA has a
Medicare Telehealth Payment Eligibility Analyzer Tool.
2
NYS Medicaid
╺ HPSA Geographic
Restrictions for Video
Chat: Except Mobile
Stroke and ESRD
╺ Virtual Check-Ins
╺ Remote evaluation of
pre-recorded data
╺ Interprofessional
Internet Consultation
╺ Chronic Care Remote
Patient Monitoring
╺ Can see Patients in the
Home, Schools, Day
Cares, Dentist Offices,
Article 28 Nursing
Homes
╺ Store and Forward
Reimbursed
╺ Remote Patient
Monitoring
2019 CMS
Physician Fee
Schedule
21
Stony Brook Is Committed
to High Quality Virtual
Care
╺ Evidence Based
╺ Responsible
╺ Well Coordinated
╺ Appropriate
╺ Accessible
23
Core Competencies of Telehealth at Stony
Brook Medicine
Communication
Clinical JudgementImage Based
Diagnosis
Interprofessional
Collaborative
Education
25
Simulation Center
Telehealth Training
26
OUR PROCESS IS EASY
27
Pilot ScaleRefine
Telehealth Pilots
Tele-Psychiatry
Enhancing
Mental Health
Access to
Eastern Long
Island
Tele-Neurology
Providing
Specialist
Consultation to
Partnered
Hospitals
Tele-Transport
Using Video to
Improve
Specialist
Access, Early
Diagnosis and
Patient Safety
28
Collaborate with Us at
Stony Brook
Clinical Trials
Education
New Technologies
Clinical Simulations
30
BIG CONCEPTTelehealth is Here to Stay
32
THANKS!
Any questions?
You can find me at
╺ Email: [email protected]
╺ Linkedin:
Kimberly Noel
╺ Twitter:
@DrKimNoel
References
Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. New
England Journal of Medicine. 2017;377(16):1585-1592.
Advisory Board. 2018 Telehealth Industry Trends.
CMS, “Telehealth Services Fact Sheet,” Nov. 2016,
https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-
MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf;
Service Line Strategy Advisor research and analysis.
: “2017 U.S. Telemedicine Industry Benchmark Survey,” REACH
Health, April 2017, http://reachhealth.com/wp-
content/uploads/2017-US-Telemedicine-Industry-Benchmark-
Survey-REACH-Health.pdf; ATA, “Executive Leadership
Survey,” March 2017,
http://thesource.americantelemed.org/resources/telemedicine-
executive-leadership-survey, Service Line Strategy Advisor
research and analysis.
https://vavmc.com/media
7/8/2019 34
BREAK15 minutes
7/8/2019 35
John P. Borrillo, MPA
Program Evaluator
Catholic Charities Brooklyn and Queens
Telepsychiatry
Presented by
Telepsychiatry
Catholic Charities Brooklyn and Queens
Who We Are
• CCBQ is one of the largest human and social service providers in New
York City. In operation since 1899, we currently provide mental health,
behavioral health and related services to over 7,000 individuals annually at
our network of Article 31 outpatient clinics and school-based satellites.
• We have embraced telepsychiatry as a mode of therapy, not as replacement
for traditional in-person treatment, but as a valuable and value-based addition,
adjunct, and complement to it.
How Did We Get Here?
Like other mental-health providers, we have struggled with the challenge of
meeting our clients’ psychiatric needs amid:
A severe and growing shortage of psychiatrists.
The need to demonstrate reduced mental health-related emergency room
(ER) visits, hospitalizations and other value-based outcomes.
Institutional resistance to telepsychiatry as a mode of treatment.
Meeting the Resistance
• When we did the research, we discovered that many of the objections against
telepsychiatry rested on false or tenuous assumptions that were either
contradicted or unsupported by the evidence.
• To address concerns about safety, we put specially designed policies and
protocols in place to meet concerns relating to high-risk clients. To address
concerns about privacy and confidentiality, we augmented our informed-
consent and privacy policies to ensure that our clients and practitioners
understand and sign off on them.
How Is It Working?
• In 2018, we received approval from the New York State Office of Mental
Health (OMH) to provide telepsychiatry (medication management) services
at our outpatient clinics, the first such approval in the New York City area.
• Our ability to provide these services by telemedicine has meant that our
practitioners are part of a supportive network and see themselves as part of
a team. Clients are never turned away because of a missing psychiatrist. “The
Doctor will see you now” is a reality.
Outcomes
0
10
20
30
40
50
60
70
80
90
100
April May June July August September October November December
CLIENT HOSPITALIZATIONS OVER A 9-MONTH PERIOD (2018)
Data Source: PSYCKES and
Internal Hospitalization
Logs
7/8/2019 43
QUESTIONS
TelepsychiatrySusan Wilner, LCSW
Assistant Director, Behavioral Health OperationsStony Brook Medicine
DRIVERS OF ADMISSION / HEALTH CARE COSTS
SUFFOLK COUNTY
4,040
3,3783,180
1,858
1,226
848702 683 673 644 598 555
450 421 372 345173
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
SUFFOLK COUNTY BEHAVIORAL
HEALTH PROVIDERS
47
STONY BROOK TELEHEALTH
49
ELIH
SBUH/HSC
Satellite Sites/
Partners
Out -Patient SB
Clinics
South Hampton Hospital
MARKETING
• Meeting House Lane is a not-for-profit organization that
was created in 2008 under the umbrella of SHH/SBUH
• Presently there are 65 providers in over 25 sites,
stretching from Montauk to Westhampton, and expanding
to Riverhead and Greenport
• They provide multi-specialty care to patients on the East
End as a Patient Centered Medical Home
• Presently the Behavioral Health Team consists of one
Psychiatrist, one Psychiatric NP and 2 Social Workers
MEET OUR PARTNER: MEETING HOUSE LANE
51
OUR PROCESS IS EASY
Pilot ScaleRefine
MEASURING SUCCESS
53
Metrics for Success
• Number of Consults
• Volume of Patients
• Timeliness of Appointments
• No Show Rates
• Patient Satisfaction Metrics
• Patient Adherence Metrics
• Patient Safety Metrics
• No denied claims for Tele-Psychiatry Services
• High Patient Satisfaction for Telehealth
Services
• High Physician Satisfaction
• Increase in Patient Portal Enrollment
• Formal Credentialing Process for Telehealth
Privileges
LESSONS LEARNED FROM
TELEPSYCHIATRY
“We are so excited about this! Our patient from
yesterday actually just stopped in the office and
thanked me for yesterday, saying that she is
very excited for this new option to assist in
improving her mental health. She also said that
she spoke with her brother and sister and they
are both interested in giving TeleHealth a try.”
TESTIMONIAL
55
ACTUAL PATIENT STORY
56
“I’m so grateful for telehealth. It’s
convenient, accessible, and has been
super beneficial to me. The staff is very
accommodating and understanding. I
highly recommend telehealth, as it is
much needed on the east end.” - Patient
Thank You!!!
Questions??
57
Tele-Psychiatry Presented by
Ronald Brenner, MD
Chief of Behavioral Health Services, Catholic Health Systems
What is Tele-Psychiatry?
Tele-Psychiatry is the use of Telemedicine in the Psychiatric setting
The service is delivered through a telecommunication cart located in the
Emergency Room of OMH approved hospitals
A Psychiatrist can provide care to multiple locations from one “hub” in lieu of
a physician being called in for a physical consultation
CHS Tele-Psychiatry Program
In 2016, OMH approved a pilot program for 3 systems, Columbia University,
Northwell Health and Catholic Health System. The 3 hospitals at CHS
participated, Mercy Medical Center, St. Catherine's of Sienna, and Good
Samaritan Hospital.
Coverage at the CHS hospitals is Friday, Saturday, and Sunday night, 6pm-7am
Tele-Psychiatry
Between 2016 and 2017 there were 341 Tele-Psychiatry consultations
For the year 2018, there were 345 Tele-Psychiatry consultations
There is a significant benefit with Tele-psychiatry services
Expedited admissions
Cost savings from reduction of 1 to 1 safety watches
LOS reductions in the Emergency Departments
Tele-Psychiatry
One of the most significant benefits from the use of the Tele-Psychiatry
service was the reduction in turnaround time from the time the psychiatric
consult was requested to completed disposition by
Without Tele-Psychiatry it was 12 hours and with Tele-Psychiatry, 1:55 mins
Expedited safe discharge for over 181 patients, and approximately 150
patient admissions, enabling overnight admits, that were not happening in our
system
Positive Impacts of Tele-Psychiatry
Improves patient safety through decreased elopements and falls due to less
time the patient spends in the ED
Reduction in patients leaving the ED without a Psychiatric Consultation
Decreases an inpatient length of stay through an expedited admission
Direct impact on patient satisfaction through expedited care
Tele-Psychiatry Today
In May 2019, we presented a poster to the American Psychiatric Association
called “A Comparison Study of the Turnaround Time for Tele-Psychiatry versus
face-to-face Consultations in General Hospital Non-Psychiatric Emergency
Rooms) was presented at the APA conference in San Francisco, California
It found an 84% reduction in the time to consult for Tele-psychiatry compared to
the face-to-face consultation.
The time reduction went from 11.4 hours for face-to-face to 1.9 hours for Tele-
Psychiatry
Tele-Psychiatry services offered in general hospital Emergency Rooms can decrease
the turnaround time, which directly results in better patient care
Tele-Psychiatry Patient Satisfaction
For the year 2018, out of the 345 patients seen, 239 surveys were collected
and the following satisfaction results were recorded:
Question #1
98% of Patients feel they
received an explanation of
their treatment options
I received and explanation of my treatment options
Agree Strongly Agree Neither
79%
19%
2%
Question #2
98% of Patients felt that
the time spent on the
Telesession was sufficient
The amount of time on Telesession was sufficient
Agree Strongly Agree Neither
82%
16%
2%
Tele-Psychiatry Patient Satisfaction
Question #3
Telepsychiatry made it easier to get Psychiatric Care
Agree Strongly Agree Disagree Neither
75%
6%
1%
18%
82% of Patients felt
Telepsychiatry made it
easier to get Psychiatric
Care
Question #4
The care I received through Telepsychiatry was as good as a regular
in-person visit
Agree Strongly Agree Disagree Neither
71%9%
2%
18%
80% of Patients felt the care they
received was as good as an in-
person visit
Tele-Psychiatry Patient Satisfaction
Question #5
I would chose a Telepsychiatry session over a face-to-face session with a person
Agree Strongly Agree Disagree Strongly Disagree Neither
33%20%
3%20%3%
36% of Patients agree that
they would chose a Tele-
Psychiatry session over face-
to-face
Question #6
I was satisfied with today's appointment
Agree Strongly Agree Neither
78%
19%
3%
97% of Patients were
satisfied with their Tele-
Psychiatry appointment
7/8/2019 69
QUESTIONS
7/8/2019 70
Presented by
Ankita Shah, MBA
Financial Operations Manager, SCC
Strategies to Implement & Sustain Value Based
Payment Model
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
VALUE BASED PAYMENT (VBP) EDUCATION SERIES #6
Strategies to Implement & Sustain
Value Based Payment Model
Part 1
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
LEARNING OBJECTIVES
• Identify steps to prepare for value-based care
and effective identification and management
of high risk/high need patients
• Evaluate effective Transitions of Care
processes across the care continuum
• Support closing gaps in care by increasing
access to community-based services
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Start by using your Electronic Health Record or payer data to
identify:
• Patients at high risk for hospitalization
• Multiple visits to the emergency department
These are the populations that may increase healthcare
costs and are at risk for fragmented care
STEPS TO PREPARE FOR VALUE-BASED CARE
Identify your target population
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Consider the following elements in the development of a VBP model
• Identify the target patient population(s)
• Identify which payers will be involved
• Estimate how the type and volume of services will change
• Identify the benefits expected for patients and payers
• Design the workflows required to provide the desired care to the selected patient population
• Determine details including:
• Staff who will support the new model
• Roles and responsibilities of providers and support team
• Frequency of patient contact and visits to the practice
• Identify measurable success metrics for each population and determine your baseline in
order to quantify your impact in the future
• Identify the people, process and technology to monitor progress toward achieving metric
goals
• Identify transition costs (revenue & risk-stratification)
STEPS TO PREPARE FOR VALUE-BASED CARE
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Avoid fragmented care with communication and collaboration across the
continuum of care
• Partner with local hospitals, practices, urgent care centers and other
organizations to enhance your ability to offer better transitional care and
outpatient care management to your patients
• Partner with home health agencies, skilled nursing facilities, pharmacies
and other community resources
• Consider partnering with other entities for potential resource sharing
STEPS TO PREPARE FOR VALUE-BASED CARE
Care fragmentation effects patient safety and leads to patient
dissatisfaction and disengagement
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
• Identify opportunities to reduce
unnecessary costs or variances
• Use a team-based approach to
care
• Utilize provider resources
efficiently
• Empower staff to help patients
manage and improve chronic
conditions
STEPS TO PREPARE FOR VALUE-BASED CARE
http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
Move toward a lower-cost, highest-quality approach with The Triple Aim as a goal
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
• Monitor progress to determine impact on your target patient
population
• Reassess how well your practice is accomplishing the
predetermined goals and make adjustments
• Reevaluate your care model at least annually to ensure achievement
of desired impact
• Regularly measure patient, provider and staff satisfaction, which are
key indicators of your model’s success
• Review negotiated contracts annually to ensure use of latest
evidence-based metrics and that financial compensation is aligned
STEPS TO PREPARE FOR VALUE-BASED CARE
Continuously review impact in order to continuously improve
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
27
EFFECTIVE TRANSITIONS OF CARE ACROSS THE
CARE CONTINUUM
• Transitions of care involves the coordination and continuity of health care as patients transfer between different settings
• The transition between inpatient and community settings in particular is prone to medication errors
• Inconsistent care coordination contributes to the readmission of 20% of patients within 30 days of discharge
• Interest in preventing readmissions has grown since Center for Medicare and Medicaid Services (CMS) imposed financial penalties on hospitals with high 30-day readmission rates
Source: Jencks SF, Williams MV, Coleman EAN. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–1428 [PubMed]
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
27
EFFECTIVE TRANSITIONS OF CARE ACROSS THE
CARE CONTINUUM
Communication and collaboration across the care continuum is
necessary to avoid care fragmentation and support patient
engagement
• The transitions of care plan should promote shared accountability
between the sending provider/facility and the receiving
provider/facility
• Facilities, Providers and Community-based Organizations should
assure they have a mechanism in place to support the plan of
care timely, using effective information technology (IT) solutions
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Leverage systems to create new and effective processes to identify
and manage assigned patients
Utilize your Electronic Health Record (EHR) and Payer Portals to:
• Identify and monitor your existing patients/attributed members
• Assist patients in scheduling appointments to close gaps in care, such as
annual wellness visits, screenings, etc.
• Establish a pre-visit plan to coordinate tests/services
• Manage patient alerts through patient portals and Regional Health
Information Organization (RHIO) alerts
CLOSING GAPS IN CARE BY INCREASING
ACCESS TO COMMUNITY-BASED SERVICES
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Addressing Social Determinants of Health (SDH) is necessary to care for the whole person and important in removing barriers that prevent patients from managing their health.
• The Centers for Disease Control and Prevention (CDC) describes SDH as “the complex integrated and overlapping social structures and economic systems that are responsible for most health inequities”
• Many of the factors that comprise SDH such as access to and availability of healthy foods, transportation and the physical environment where people live, are outside the control of Primary Care (PC) and Behavioral Health (BH) Providers and Hospital Staff
• Partnering with Community-based Organizations becomes critical to mitigating SDH
Source: https://www.cdc.gov/socialdeterminants/
CLOSING GAPS IN CARE BY INCREASING
ACCESS TO COMMUNITY-BASED SERVICES
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
27
CLOSING GAPS IN CARE BY INCREASING ACCESS TO
COMMUNITY-BASED SERVICES
Community
Health Home
PC/BHSocial Services
Home Care
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
27
CLOSING GAPS IN CARE BY INCREASING ACCESS TO
COMMUNITY-BASED SERVICES
Online resources such as HITE (Health Information Tool for Empowerment): a directory that lists over
5,000 free and low-cost health and social services across NYC and Long Island to address social
determinants of health. This user-friendly directory is available at www.hitesite.org and can be utilized by
providers to connect patients to vital resources that can assist in addressing gaps in care.
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
VALUE BASED PAYMENT (VBP) EDUCATION SERIES #6
Strategies to Implement & Sustain
Value Based Payment Model
Part 2
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
LEARNING OBJECTIVES
• Recognize opportunities to optimize care
management and care coordination services across
all provider types, including Community Based
Organizations (tiers 1, 2 and 3)
• Promote cultural competency/health literacy
• Demonstrate compliance
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
OPTIMIZING CARE MANAGEMENT THROUGH
COMMUNITY BASED ORGANIZATIONS
Non-profit, non-Medicaid billing, community based social and human service organizations (e.g. housing, social services, religious organizations, food banks)
Non-profit, Medicaid billing, non-clinical service providers (e.g. transportation, care coordination)
Non-profit, Medicaid-billing, clinical and clinical support service providers
Tier
1
Tier
2
Tier
3
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Addressing Social Determinants of Health (SDH) aim to improve outcomes
and reduce overall healthcare costs
• Utilize Care Management/Coordination to impact members’ health and
wellness by:
• Implementing screening such as Social Determinants of Health Screen
(SDH)
• Helping patients to schedule and keep appointments – address medical,
transportation, behavioral health needs
• Assisting patients with self-management goals and adherence to
care/treatment plan
• Connecting patients to community based organizations, such as faith-
based organizations, shelters, food banks, etc. to mitigate SDH
OPTIMIZING CARE MANAGEMENT/COORDINATION
THROUGH COMMUNITY BASED ORGANIZATIONS
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
CARE MANAGEMENT/COORDINATION CONTINUUM
Identify and Screen
Enroll and Engage
Care Management
and Coordination
Case closure when goals are
met
• Provide patient education and reinforce education provided by primary care
or behavioral health practice
• Coordinate care with primary care providers and specialists
• Share suggestions and observations with provider to support patient’s care
and improve outcomes
• As risks are lowered, patients may “graduate” from care management and
new patients may start care management program
• Warm hand off to community based supports such as Health Home for on-
going care management as warranted
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
PROMOTING CULTURAL COMPETENCY/HEALTH LITERACY
Through the partnership between Suffolk Care Collaborative, Nassau Queens
Performing Provider System, Long Island Health Collaborative (LIHC) and Martine
Hackett Ph.D, MPH, Associate Professor, Department of Health Professionals,
Hofstra University, Cultural Competency and Health Literacy (CCHL) Master
Training was developed. This program is an interactive training program
designed to give hands-on learning experience to build better communities.
The program’s mission is to advance cultural and linguistic competence, promote
effective communication to eliminate health disparities and enhance patient
outcomes.
Communities on Long Island are growing in cultural
and linguistic diversity and, therefore, there is a
need to inspire cultural change within organizations.
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
PROMOTING CULTURAL COMPETENCY/HEALTH LITERACY
To learn about
the different
training
options and to
register for
upcoming
training, visit
the Long
Island Health
Collaborative
CCHL
webpage
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
• Moving from conventional / fee-for-service arrangements to a
value-based payment structure will require commitment and a
change in mindset and workflows
• What doesn’t change is the requirement to operate ethically
and follow the law
• Having an organizational compliance program gives
employees guidance and outlines their responsibility to follow
organizational rules/policies and the law
COMPLIANCE
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Staff should:
• Know their responsibility to detect and prevent fraud, waste and
abuse of Medicare/Medicaid funds
• Know the right thing to do, and what to do if they see others not
doing the right thing
• Understand their obligations to report non-compliance
• Know that retaliation against good faith reporting is prohibited
Compliance education for staff helps to build an organizational
culture of ethical integrity and compliance
COMPLIANCE
Copyright © 2019 Suffolk Care Collaborative, All rights reserved.
Are qualities that frame ethical behavior and ensures compliance
in an organization
Visit the Office of the Medicaid Inspector General website or SCC’s
Compliance Webpage to review the 8 Required Elements of a compliance
program and for resources to assist you in developing your compliance
program and training.
COMPLIANCE
•Honesty
•Integrity
•Accountability
7/8/2019 94
QUESTIONS
7/8/2019 95
Presented by
Amanda Chirco, MEd, PMP
Project Manager Community Health Initiatives, SCC
Building a Business Case for Innovative Partnerships:Value Based Payments and Community Based Organizations
Innovative Trends in Community Partnerships
October 11, 2018
• Event held in response to feedback received from CBO VBP Survey
• Panel presentation featured HealthFirst, Northwell Health, and God’s Love We
Deliver
• Focused on:
o How health needs and social determinants of health are addressed
o Engagement of CBOs in Value Based Payment (VBP)
CBO VBP EDUCATION SERIES
Building a Business Case for Innovative Partnerships
May 23, 2019
• Presentations from NYS DOH and NYS Bureau of Social Determinants of Health
• Focused on:
o Innovative projects addressing the Social Determinants of Health throughout New York
o VBP contracting strategies for CBOs
o Creating a Value Proposition
• Value Proposition Workshop
CBO VBP EDUCATION SERIES
CBO VBP EDUCATION SERIES
UPCOMING OPPORTUNITIES
• Suffolk Care Collaborative is available to assist CBOs as they develop their Value Proposition
• CBOs with completed value propositions are encouraged to share them with SCC
Interested CBOs should contact Amanda Chirco [email protected]
7/8/2019 100
QUESTIONS
7/8/2019 101
Presented by
Sofia Gondal, MA
Project Manager, SCC
Prevention and Screening Resources
7/8/2019 102
PREVENTION AND SCREENING RESOURCES WEBPAGE
FREE disease specific resource guide covering:
• Breast Cancer
• Colorectal Cancer
• Lung Cancer
• Obesity Prevention
Click here to access the Prevention and Screening Resources
7/8/2019 103
Presented by
Linda S. Efferen, MD, MBA
Executive Director & VP, Medical Director
Suffolk Care Collaborative
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