DSRIP Meeting Agenda

PAGE 1

Date and Time 7/24/15

Meeting Title NYP PPS Clinical Operations

Committee

Location Milstein 1HN-151 Facilitator Dr. Emilio Carrillo, Angela

Martin

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Invitees

Chair: Angela Martin (VNSNY) Chair: Emilio Carrillo, MD (NYP)

Alissa Wassung (God’s Love We Deliver) Crystal Jordan (Harlem United)

David Pomeranz (Hebrew Home) Ana Garcia (NYC DOHMH) – Web

David Chan (City Drug & Surgical) Maria Lizardo (Northern Manhattan Improvement

Corporation)

Jean Marie Bradford, MD (NYPSI) Susan Wiviott (The Bridge)

Eva Eng (Arch Care)

Jonah Cardillo (St. Mary’s Hospital for Children)

Meeting Objectives Time

1. Review Action Items from Last Meeting 2. Review Project Successes and Challenges

a. Pediatric Ambulatory ICU – A. Matiz 3. Review/Finalize Other Committee Deliverables

a. Discuss Cultural Competency and Health Literacy Strategy b. Identify Approach to Performance Measurement / Rapid Cycle Eval.

4. Identify Action Items for Next Meeting

5 mins 15 mins

25 mins

5 mins

Action Items

Description Owner Start Date Due Date Status

Next Meeting:

- Review Approach to Performance Measurement / Rapid Cycle Evaluation

DSRIP Meeting Agenda

PAGE 1

Date and Time 7/24/15

Meeting Title NYP PPS Clinical Operations

Committee

Location Milstein 1HN-151 Facilitator Dr. Emilio Carrillo, Angela

Martin

Go to Meeting https://global.gotomeeting.com/

join/158738573 Conference Line Dial +1 (646) 749-3122

Access Code: 158-738-573

Invitees

Chair: Angela Martin (VNSNY) Chair: Emilio Carrillo, MD (NYP)

Alissa Wassung (God’s Love We Deliver) Crystal Jordan (Harlem United)

Susan Wiviott (The Bridge) Ana Garcia (NYC DOHMH) – Web

David Chan (City Drug & Surgical) Maura Frank (NYP)

Jean Marie Bradford, MD (NYPSI) Victor Carrillo (NYP)

Eva Eng (Arch Care) David Alge (NYP)

Jonah Cardillo (St. Mary’s Hospital for Children) Isaac Kastenbaum (NYP)

Action Items

Description Owner Start Date Due Date Status

Next Meeting:

- Review Approach to Performance Measurement / Rapid Cycle Evaluation Meeting Minutes:

A. Martin started the meeting with introductions and follow-up on previous action items.

Drs. Adriana Matiz and Maura Frank started a presentation on the Pediatric Ambulatory ICU. They provided an overview of the collaborator roles; overview of patient stratification and care bundles; also reviewed the role of CHWs and other care team members; concluded with review of metrics.

o E. Carrillo expanded on the importance of collaborators in working with these patients beyond the walls of the practice;

o E. Eng had questions about what resources were available for supporting the families of patients; o M. Frank mentioned that a significant challenge would be the geographic distribution of

patients/families; o A. Wassung had a question about how CHWs will assess food insecurity, who needs food pantry

access, and who needs medically tailored meals. GLWD provides many of these services/assessments.

o D. Chan mentioned bed-side delivery program with presence on the unit The main challenge is that MDs write prescriptions a few minutes prior to discharge CityDrug is considering a call center in pharmacy to do medication management / reminders

o A. Martin asked whether pharmaceuticals could be delivered to ambulatory setting. D. Chan suggested they might be able to.

VNSNY working on communication back to outpatient care managers E. Eng asked whether CityDrug does home delivery. D. Chan said yes to Manhattan, Bronx,

and Queens

E. Carrillo started the conversation on the Cultural Competency Deliverable(s). He provided an overview of the NYP approach (‘Culture of One’) of Cultural Competency.

A. Martin mentioned that VNSNY’s population is 20% Hispanic, 3% Russian, and 3% Asian. They do a number of orientations for staff and provide cultural and linguistically appropriate services.

DSRIP Meeting Agenda

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J. Bradford mentioned that 50% of PI’s patients are monolingual Spanish. She has hired bilingual and bicultural staff.

D. Chan mentioned that he has recently hired a Russian staff person to be responsive to their Russian community.

E. Carrillo reviewed the NYP PPS Cultural Competency Strategy Document. He mentioned that the PPS should take a balanced approach of universal language vs. project-specific training.

A. Martin / E. Carrillo asked committee members to report on their organization’s cultural competency approach.

E. Carrillo closed meeting mentioning that the presentation and charter should be sent out and that the conversation would be continued at the next meeting.

Pediatric Ambulatory ICU Clinical Operations Committee – 7/24 Drs. Adriana Matiz, Maura Frank, and Connie Kostacos

1

2.b.i: Ambulatory ICU Model for Children with Special Health Care Needs (CSHCN)

Multi-provider team based visits for patients with complex medical,

behavioral and social morbidities and for community based non-

physician care for stable patients in need of chronic disease

monitoring.

Improve care for high-risk and high-cost pediatric populations with

specialized needs.

2

2.b.i Ambulatory ICU State Requirements

# Requirement

1 Ensure that Ambulatory ICU is staffed by or has access to a network of providers including medical, behavioral health, nutritional, rehabilitation and other necessary provider specialties that is sufficient to meet the needs of the target population

2 Ensure Ambulatory ICU is integrated with all relevant Health Homes in the community.

3 Use EHRs and other technical platforms to track all patients engaged in the project, including collecting community data and Health Home referrals

4 Establish care managers co-located at each Ambulatory ICU site

5 Ensure that all safety net project participants are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including Direct exchange (secure messaging), alerts and patient record look up.

6 Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of DY3.

7 Implementation of a secure patient portal that supports patient communication and engagement s well as provides assistance for self-management.

8 Establish a multi-disciplinary, team-based care review and planning process to ensure that all Ambulatory ICU patients benefit from the input of multiple providers.

9 Deploy a provider notification/secure messaging system to alert care managers and Health Homes of important developments in patient care and utilization

10 Use EHRs and other technical platforms to track all patients engaged in the project

3

2.b.i: Ambulatory ICU Model for Children with Special Health Care Needs (CSHCN)

Standardize the CSHCN medical home model (currently pilot phase)

to all NewYork-Presbyterian pediatric patient centered medical

homes (5)

Multidisciplinary teams and meetings

– Physicians and Nurse Practitioners

– RN Care Managers

– Community Health Workers

– Psychiatry nurse practitioner and/or psychologist

– Social workers

– Nutritionists

– Practice Ancillary staff

Partnership Opportunities

Enhanced community partnerships to service CSHCN

– Pharmacies, DME suppliers

– Long-term care facilities (Rehab)

– Schools

– Children’s hospitals

– Early Intervention service agencies

– Home Care agencies

– Mental Health facilities

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Ped Ambulatory ICU

Staffing

– Peds psychiatry providers (2 FTE)

– Peds RN Care Managers (4 FTE)

– Community Health Workers (5.5 FTE+ )

– Program Manager

– Physician Leaders

Community Health Workers (CHW)

Community-based partnership model

Collaborative training for CHWs

Intervention

– Home visits

– Goal setting

– Medication reconciliation

– Social service referrals

Screeners: Quality of Life, Social determinants of health (food

insecurity, violence, poverty)

Integration with Amb ICU team members (meetings, EMR)

Close collaboration with Care Manager and team

8

Practice-based RN Care Manager

Trained in the model and approach

Family and patient assessment

Identify obstacles to care and facilitate solutions to barriers

– Access

Appointments, transportation, system issues

– Care plan and associated documentation in the EMR

Population Health

– Registry ( CSHCN and asthma)

ED utilizers and inpatient admissions

– Care Bundles

– Support with system navigation

Collaborate with CHW

9

Population Health

Registry

Risk Stratification

– Level 1, 2, 3A and 3B

Care bundle

– CHW for all 3A and 3B

Process for registry management

– Influenza outreach

– Public health needs ( i.e. measles vaccination)

– Medication administration forms

– Annual appointments

– Social Work appointments

10

Community Partners in PPS

Transition of Care

– Discharge process for long term care agency patients

– Early intervention referrals

– IT enhancement for communication (RHIO or Care Director)

Communication

– Enhanced with pharmacies and DME suppliers

Integration into Amb ICU meetings as invited speakers

Identify opportunities for partner billable services

11

Access

Extended hours for primary care to reduce preventable ED visits

Extended time visits and reserved appointments for CSHCN

Build QA performance to the system

– Ensure it is properly utilized

Alerts from in-patient admissions (NYP and community)

– RHIO and EMR

Partner need – through the care manager

12

Metrics

The Pediatric ICU will provide 2+

services to 12,674 distinct

pediatric patients annually by

the end of DY4.

Approximately 9000 patients at

Columbia and 3674 patients at

Cornell

System transformation

– Reduction in avoidable ED

visits

– Reduction in avoidable

Readmissions

– CG-CAHPS measures in

primary care

– NCQA PCMH metrics

– RHIO participation by

providers

– HEDIS

– PQI (Prevention Quality

Indicators)

13

Challenges/Concerns

Who are the patients on our attribution list from NYS?

– How many will be patients at NYP primary care practices?

Expansion in primary care access/hours

Pediatric psychiatry resources - limited

Access to subspecialty care for the population

Capacity for new patients in NYP practices

Health Home in Peds

What is truly preventable for this population?

15

Cultural Competency / Health Literacy Strategy

DRAFT - PAGE 1

Background: Much the NYP PPS service area is comprised of linguistically isolated and culturally diverse ethnic and

racial minorities. In response, the NYP PPS has adopted a patient-centered approach to cultural competency, known as

the “Culture of One,” which is aligned with the National Quality Forum’s (NQF) Cultural Competency framework

(Reference: A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency,

NQF, April 2009). As part of the Culture of One, the NYP PPS realizes that the burden of clear communication and

understanding is placed on the provider, not the patient. A patient’s unique culture defines the illness experience and

the target of effective treatment and care. On the other hand, the culture of a population determines the

characteristics of successful public health and community health interventions

Cultural Competency / Health Literacy Goal: The goal of the NewYork-Presbyterian Performing Provider Cultural

Competency and Health Literacy Strategy is to develop a PPS-wide approach that acknowledges that the burden of

clear communication and understanding is placed on the provider, not the patient. A patient’s unique culture defines

the illness experience and the target of effective treatment and care. As such the Strategy will specifically focus on: (a)

identifying key priority groups experiencing health disparities through a community needs assessment, (b) identifying

factors to improve access to quality primary, behavioral, and preventive care, (c) enhancing communication with the

attributed population, (d) deploying assessments/tools to assist patients with self-mangemenent, (e) improving

provider and community-based organization’s cultural competency, and (f) leveraging community-based interventions

to reduce health disparities and improve outcomes.

Strategy: For Medicaid beneficiaries attributed to the NYP PPS and collaborators participating in the network, the NYP

PPS will focus on:

a. Identifying key priority groups experiencing health disparities through a community needs assessment

i. The PPS will conduct a formal community needs assessment every three years, as required by New

York State and/or the Attorney General.

ii. The Clinical Operations Committee (and ratified by the Executive Committee) will make

recommendations on the re-allocation of programmatic resources to address identified populations.

iii. The PPS will collaborate with longstanding CBOs in communities to enhance understanding of

community needs.

b. Identifying factors to improve access to quality primary, behavioral, and preventive care

i. The PPS Clinical Operations Committee (and ratified by the Executive Committee) will make

recommendations on enhancing access to quality care.

ii. The PPS will capture the necessary data to refine cultural competency and health literacy strategies,

including (1) disparity sensitive outcomes, (2) measures associated with cultural competency, and (3)

participation in relevant training.

c. Enhancing communicating with the attributed population

d. Deploying assessments and tools to assist patients with self-management

i. The PPS will develop patient portal content, including specialized, relevant, multi-lingual content to

improve health literacy such as asthma-related materials for parents of asthmatic children and

information about managing multiple chronic diseases for adults.

e. Improving provider and community-based organization’s cultural competency

i. The PPS will adopt the “Culture of One” program to meet the distinct needs of the community and

attributed beneficiaries.

Cultural Competency / Health Literacy Strategy

DRAFT - PAGE 2

ii. The PPS will conduct a three-year project to develop, and make training available for frontline staff

and physicians involved in DSRIP projects to provide care that respects patients’ “Culture of One.” This

approach treats patients as individuals whose culture is unique and a result of multiple social, cultural

and environmental factors and avoids racial or ethnic stereotyping.

a. The first year - core team will engage leadership and “cultural competency champions” in all

clinical components of the NYP PPS in the exploration of topics and training modalities that

may be used to address and develop cultural competency within programs.

b. The second year - the modalities developed in year 1 will be implemented among a number of

representative training programs to determine their ability to adopt and adapt these

modalities within their training curricula.

c. A cultural competency curriculum will be fully available for all NYP PPS participants.

f. Leveraging community-based interventions to reduce health disparities and improve outcomes

i. The PPS will co-invest in an ASCNYC-hosted Peer Training Institute, which will be a PPS center for

CHW, Patient Navigator, Health Educator and Interpreter training serving all NYP PPS projects and

Network Members. Providers will learn to avoid the pitfalls of “false fluency” and of using family

interpreters or bilingual providers as ad hoc interpreters.

ii. Culturally competent CHWs will serve as a link between patients and medical/social services. The

CHWs will see patients in their homes and document their findings, e.g., psychosocial issues that may

be hurdles to the delivery of optimal care and recommendations for referrals to community-based

organizations

NYP PPS Organizational Committments

July 2015

[As taken from NYS Implementation Plan]

Tab Requirement Type MilestoneTarget Completion

DatesDocumentation Owner Reviewer Status

Cultural

ComptencyDomain 1 Process Measure

Finalize cultural competency / health literacy

strategy.DY1, Q3

Cultural competency / health literacy strategy signed off by PPS Board. The

strategy should:

-- Identify priority groups experiencing health disparities (based on your CNA

and other analyses);

-- Identify key factors to improve access to quality primary, behavioral health,

and preventive health care

-- Define plans for two-way communication with the population and

community groups through specific community forums

-- Identify assessments and tools to assist patients with self-management of

conditions (considering cultural, linguistic and literacy factors); and

-- Identify community-based interventions to reduce health disparities and

improve outcomes.

Subsequent quarterly reports will require updates on the implementation of

your cultural competency / health literacy strategy.

Cult Competency

WorkgroupExecutive

Performance

ReportingKey Issue

Establish reporting structure for PPS-wide

performance reporting and communicationDY1, Q4

Performance reporting and communications strategy, signed off by PPS Board.

This should include:

-- The identification of individuals responsible for clinical and financial

outcomes of specific patient pathways;

-- Your plans for the creation and use of clinical quality & performance

dashboards

-- Your approach to Rapid Cycle Evaluation

Subsequent quarterly reports will require updates on your progress on

implementing this strategy and evidence of the flow of performance reporting

information (both reporting 'up' to the PPS Lead and 'down' to the providers

throughout the network)

PMO Executive

Performance

ReportingKey Issue

Develop training program for organizations and

individuals throughout the network, focused on

clinical quality and performance reporting

DY1, Q4

Finalized performance reporting training program.

Subsequent quarterly reports will need to demonstrate up-take of training.

PPSs will need to provide: a description of training programs delivered and

participant-level data, including training outcomes.

Workforce Sub-

CommitteeExecutive

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NYP PPS Organizational Committments

July 2015

[As taken from NYS Implementation Plan]

Tab Requirement Type MilestoneTarget Completion

DatesDocumentation Owner Reviewer Status

Practitioner

EngagementKey Issue

Develop practitioner communication and

engagement planDY1, Q4

Practitioner communication and engagement plan. This should include:

-- Your plans for creating PPS-wide professional groups / communities and

their role in the PPS structure

-- The development of standard performance reports to professional groups

--The identification of profession / peer-group representatives for relevant

governing bodies, including (but not limited to) Clinical Quality Committee

Subsequent quarterly reports will require evidence of ongoing communication

and engagement, in line with plan, evidence of active professional peer groups

and performance reporting to these groups.

Clinical Operations Executive

Cultural

ComptencyDomain 1 Process Measure

Develop a training strategy focused on

addressing the drivers of health disparities

(beyond the availability of language-appropriate

material).

DY2, Q1

Cultural competency training strategy, signed off by PPS Board. The strategy

should include:

-- Training plans for clinicians, focused on available evidence-based research

addressing health disparities for particular groups identified in your cultural

competency strategy

-- Training plans for other segments of your workforce (and others as

appropriate) regarding specific population needs and effective patient

engagement approaches

Subsequent quarterly reports will require evidence of training programs

delivered. PPSs will need to provide: a description of training programs

delivered and participant-level data, including training outcomes.

Cult Competency

WorkgroupExecutive

Practitioner

EngagementKey Issue

Develop training / education plan targeting

practitioners and other professional groups,

designed to educate them about the DSRIP

program and your PPS-specific quality

improvement agenda

DY2, Q1

Practitioner training / education plan.

Subsequent quarterly reports will require evidence of training. PPSs will need

to provide: a description of training programs delivered and participant-level

data, including training outcomes.

Clinical Operations Clinical Operations

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NYP PPS Organizational Committments

July 2015

[As taken from NYS Implementation Plan]

Tab Requirement Type MilestoneTarget Completion

DatesDocumentation Owner Reviewer Status

Pop Health Key IssueDevelop population health management

roadmapDY2, Q2

Population health roadmap, signed off by PPS Board, including:

-- The IT infrastructure required to support a population health management

approach

-- Your overarching plans for achieving PCMH 2014 Level 3 certification in

relevant provider organizations

--Defined priority target populations and define plans for addressing their

health disparities.

Subsequent quarterly reports will require an update on the implementation of

this roadmap.

PMO-PCMH Team Clinical Operations

Clinical

IntegrationKey Issue

Perform a clincial integration 'needs

assessment'DY2, Q2

Clinical integration 'needs assessment' document, signed off by the Clinical

Quality Committee, including:

-- Mapping the providers in the network and their requirements for clinical

integration (including clinical providers, care management and other providers

impacting on social determinants of health)

-- Identifying key data points for shared access and the key interfaces that will

have an impact on clinical integration

-- Identify other potential mechanisms to be used for driving clinical

integration

PMO Clinical Operations

Pop Health Key Issue Finalize PPS-wide bed reduction plan DY3, Q1

PPS Bed Reduction plan, signed off by PPS Board. This should set out your plan

for bed reductions across your network, including behavioral health

units/facilities, in line with planned reductions in avoidable admissions and the

shift of activity from inpatient to outpatient settings.

Subsequent quarterly reports will require updates on bed reductions across

the network and updates on the delivery of your bed reduction plan.

PMO NYP

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NYP PPS Organizational Committments

July 2015

[As taken from NYS Implementation Plan]

Tab Requirement Type MilestoneTarget Completion

DatesDocumentation Owner Reviewer Status

Clinical

IntegrationKey Issue Develop a Clinical Integration Strategy DY3, Q1

Clinical Integration Strategy, signed off by Clinical Quality Committee,

including:

-- Clinical and other info for sharing

-- Data sharing systems and interoperability

-- A specific Care Transitions Strategy, including: hospital admission and

discharge coordination; and care transitions and coordination and

communication among primary care, mental health and substance use

providers

-- Training for providers across settings (inc. ED, inpatient, outpatient)

regarding clinical integration, tools and communication for coordination

-- Training for operations staff on care coordination and communication tools

Subsequent quarterly reports will require an update on the implementation of

this strategy.

PMO Clinical Operations

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