Embed Size (px)
Citation preview
NewYork-Presbyterian/Queens PPS Town Hall Delivery System Reform Incentive Payment (DSRIP) Program
March 14, 2016
DSRIP Program Overview
Delivery System Reform Incentive Payment (DSRIP) Program
• Health Transformation program being led by the NYS DOH
Infrastructure Development
System Redesign
Clinical Outcome
Improvements
Population Focused
Improvements
Goals of DSRIP:
• Reduce avoidable hospitalizations
& ED visits by 25% in 5 years
• Improve access and utilization of
primary care & preventative care
services
• Collaborate with community
providers to improve care for
patients
Why is this important to residents?
New York State ranks in the bottom 25% nationally for ‘Potentially Avoidable Hospital Use and Cost of Case’1
Shift to Value Based Payments (VBP) for Care
• Goal is to shift provider payments from MCOs from fee for service to value based payment (VBP)
Improved collaboration between providers
Improved access and quality to primary care and behavioral health services
1Source: Commonwealth Fund, October 2009 ‐”Aiming Higher: Results from a State Scorecard on Health System Performance, 2009”
DSRIP Opt-Out Letter
DOH is sending out letters to all Medicaid members about DSRIP
Letter allows patients to opt-out of sharing their health data with providers in the DSRIP system
• Opting out means the PPS will not have Medicaid information about that member and may not be able to direct services to that member
• Providers still share information with each other for patient treatment as they do today
NYP/Q PPS Overview
PPS has over 1400 partners from
130 organizations
• Contracting process underway
Collaborating with neighboring PPSs
Projects are focused on Primary
Care, Long Term Care, and
Behavioral Health
5
PPS Partner Network
NYP/Q PPS Clinical Projects
Clinical Projects
2.a.ii Increase certification of primary care practitioners with PCMH
certification and/or Advance Primary Care Models
2.b.v Care transitions intervention for skilled nursing facility residents
2.b.vii Implementing the INTERACT project for SNF
2.b.viii Hospital – Home Care Collaboration Solutions
3.a.i Integration of primary care and behavioral health services
3.b.i
Evidence-based strategies for disease management in high
risk/affected populations (Cardiovascular Disease – Adults
Only)
3.d.ii Expansion of asthma home-based self-management program
(Pediatric Only)
3.g.ii Integration of palliative care into nursing homes
4.c.ii Increase early access to, and retention in, HIV care
PPS is implementing 9
clinical projects
• Selected based on the
community needs assessment
completed in 2014
NYP/Q PPS Updates
PPS earning 100% of Achievement Values for DY1, Q2 Report
• This resulted in the PPS receiving the total amount of eligible funding
Engaging partners in project implementation
Capital Funding (CRFP)
• PPS submitted 17 applications for capital projects in 2015
• 1 partner received funding for expansion of Primary Care & Behavioral Health Services
• CC/HL Strategy Submission
Cultural Competency & Health Literacy Strategy
PPS has completed a CC/HL strategy for the PPS & submitted for IA approval
Strategy Highlights:
• Identifying factors to improve access to quality primary, behavioral, and preventive care
services
• Strategically inventory partners on current cultural competency and health literacy
trainings/ programs
• Enhancing communication with the community members on services available and
techniques to improve communication during interactions with healthcare providers
• Deploying assessments/tools to assist patients with compliance on self-management
goals
• Leveraging community-based interventions to reduce health disparities and improve
outcomes
ASTHMA COALITION OF QUEENS
1 in 12 adults 1 in 11 children
ASTHMA IN NYS
1.9 M
$262 M cost to NYS MMC
Prevalence highest in non-Hispanic Black children (15.4%)
Hispanic asthma mortality rate more than 3.5 times higher than non-Hispanic White mortality rate.
Compared to the nation, NYS
ED visit and hospitalization rates higher for all age groups
Non-Hispanic Black hospital discharge rates almost 5x higher than non-Hispanic White rate.
Non-Hispanic Black ED visit rate 6x times higher than non-Hispanic White rate.
(NYS DOH Asthma Surveillance Summary Report)
44% not well controlled or
very poorly controlled..
45% of above did not use asthma
controller
medications.
71% had never been given an
asthma action.
55% never been advised to
modify their environment.
ALANE
Whitney M. Young Jr. Family Health Center
ALANE NY Presbyterian Hospital
Woodhull Mental Health and Medical Center, HHC
Lincoln Mental Health and Medical Center, HHC
ALANE
ALANE
Hadi Jabbar, MD, Chair
Claudia Guglielmo, MPA, AE-C, Director
Cynthia Rosen, AE-C, Program Manager
Working together to improve the quality of life for people with asthma in the diverse county of Queens by engaging patients, families, healthcare providers, institutions and the community.
410 General Pediatric Clinic Addabbo Family Health Center Aerocrine American Cancer Society American Lung Association of the Northeast Asthma Coalition of Erie County Asthma Coalition of Long Island Astra Zeneca Boys Club of NY Campaign for Tobacco Free Kids Chinese American Planning Council Clergy United for Community Empowerment Cohen Children’s Medical Center Committee for Early Childhood Development East Harlem Asthma Center Emblem Health Excelsior IPA
First Presbyterian Church in Jamaica GlaxoSmithKline Health4Youths Health First HealthPlus Amerigroup Hudson Valley Asthma coalition Jamaica Hospital Medical Center Jamaica Hospital SBHC Make the Road NY Meda Pharmaceuticals Merck Pharmaceuticals Mount Sinai Medical Center Neighborhood Hunger Network NSLIJ Health System NY Hospital – Queens NYC Department of Health NYC Human Resources Administration NYC Office of School Health
NYS Department of Health NYU Langone Medical Center Pediatric Asthma Center -NYHQ Queens Comprehensive Perinatal Council Queens Hospital Center Queens Smoke-Free Partnership Riis Settlement House, LIC SBHC- Far Rockaway St Albans Medisys ACC St. John’s University Sunovion Sutphin Medisys ACC Take Care NY Thermo Fisher Scientific Visiting Nurse Assoc. of Long Island Wyckoff Hospital YMCA of Greater NY
COALITION PARTNERS
people with asthma and families of people with asthma
especially those disproportionately affected by asthma, such as children and low income minority populations
in geographic areas with high asthma-related hospitalization rates and emergency department visit rates.
WHO DO WE WORK WITH?
the # of hospitalizations
the # of emergency department visits
the # of school/work days lost
the # of clinic/provider office urgent care visits
the quality of life among people living with asthma
WHAT WE WORK TO DO
Measures of assessment
and monitoring
Education for a partnership in asthma care
Control of environmental conditions and
comorbid conditions
Pharmacologic therapy
HOW DO WE DO IT ?
DSRIP 3DII Expansion of Asthma Home-Based Self-Management
Objective – Implement an asthma self-management program to reduce avoidable ED and hospital care
Home environmental trigger reduction Self-monitoring Medication use Medical follow-up
An overview of
St. Mary’s Healthcare
System for Children
Care is at the heart of everything we do
St. Mary’s Healthcare System for Children St. Mary’s a national leader in intensive
rehabilitation, specialized care, and education
for children with special needs and life-limiting
conditions.
St. Mary’s opened the first medical facility for
children in New York City in the 1870s, and
today remains the City’s only pediatric post-
acute care hospital – and one of the State’s
largest providers of long-term care services to
children with medical complexity.
Pioneers in Care
St. Mary’s is internationally recognized for introducing innovative
new treatment strategies that have revolutionized care for kids:
• Pediatric Traumatic Brain Injury and Neuro-Rehabilitation
– The first in the NY Metropolitan area
• Interdisciplinary Feeding Disorders Program – The only
program in NY State
• Pediatric Home Care – The first in NY State and the only
program designed specifically for children and young
adults with medically complex conditions
• Pediatric Palliative Care – The first of its kind in the US
• Pediatric AIDS Home Care – The first program in NY
State
Our Network of Care
• St. Mary’s Hospital for Children – 97 Beds
• St. Mary’s Pediatric Day Healthcare Program
• St. Mary’s Early Education Center
• St. Mary’s Home Care, a special needs Certified
Home Health Agency (CHHA)
• St. Mary’s Kids at Roslyn, a community-based
therapy center
• St. Mary’s Community Care Professionals, a
licensed home care services agency
St. Mary’s cares for 2,000 children every day. We provide care
wherever it’s needed – at home, in the community, and at St.
Mary’s Hospital for Children.
New York City’s One and Only
St. Mary's is the only pediatric post-acute facility in New York
City, operating at nearly 100% capacity every day.
St. Mary’s Healthcare System for Children
www.stmaryskids.org
St. Mary’s Telehealth Program for
the Medically Complex Population
Elvira F. Roveto, FNP B-C Home Care Administrator, DPS
Donna Mapp-Reid, RNC, CCM Telehealth Supervisor
St. Mary’s Telehealth Program
• In July 2014, St. Mary’s was awarded $928,668 from
the NYS Balancing Incentive Program Innovation Fund
(BIP)
• Grant allows St. Mary’s to enhance its home care
services through the use of an Interactive Voice
Response System (IVR)
• Original BIP contract period August 1, 2014 to
September 30, 2015. DOH extension through 2017
Background
St. Mary’s Telehealth Program
1. Decrease the risk of re-hospitalizations
2. Increase medication adherence
3. Increase patient/family satisfaction
Goals
Telehealth Targets
The program targets children with medical complexity, with
diagnoses including but not limited to:
Seizure Disorder
Asthma
Respiratory (non-asthma)
Dehydration
St. Mary’s Telehealth Program
How IVR works • Patients / Caregivers sign consent to participate in the program
• Patients / Caregivers agree to accept calls and they specify
day/time/frequency that is most convenient for them
• Automated calls are scheduled and monitored
• Alerts are triggered based upon responses
• Action is taken based on the type of alert
St. Mary’s Telehealth Program
Actions Taken When Alerts are Received
• Each family that has triggered an alert receives a call by a
Registered Nurse with extensive pediatric experience to determine
appropriate interventions.
• Common interventions resulting from the follow-up calls include:
• Educating about the disease process, complications, and when
to contact healthcare provider or seek emergency treatment
• Providing education regarding medications and treatments
• Identifying the need for an unscheduled home visit from their
primary care Nurse.
• Contacting the physician, pharmacy or vendor
General Interactive Call Demonstration
St. Mary’s Telehealth Program
Interactive Voice Response (IVR) allows
patients to have St. Mary’s “eyes & ears” in
the home in addition to regular scheduled
in-person visits.
Sample Template (Asthma) Asthma Program: Is the patient having any of the following:
If yes for any above, alert triggered:
- Yes: Alert Level: High
» We will let the nurse know
- No: Alert Level: None
St. Mary’s Telehealth Program
• Coughing at night?
• Fast breathing?
• Noisy breathing or wheezing?
• Less physical activity?
• Using the rescue inhaler more
than usual
• Signs of a cold or flu?
837
474 348
100 54
1844 45%
26%
19% 5% 3%
0%5%10%15%20%25%30%35%40%45%50%
0200400600800
100012001400160018002000
Number of Alerts Percent of Total
St. Mary’s Telehealth Program October, 2014 – October, 2015
Medication Adherence • St. Mary’s recognizes the correlation between medication
adherence and positive patient outcomes:
• increased patient satisfaction
• fewer hospitalizations and ED usage
• reduced costs
• Medication teaching and monitoring is a key component of patient
care.
• This program is an opportunity to influence medication adherence
more consistently.
• All patients in the Telehealth program are asked questions about
medication.
8.6
6.4 6 4.9
0
1
2
3
4
5
6
7
8
9
10
Hospitalizations Per Patient Percent of Patients Hosptialized
266 Patients in Cohort 1 BEFORE TH enrollment, First Qtr., 2014
Same 266 Patients in Cohort 1 ACTIVE TH , First Qtr., 2015
St. Mary’s Telehealth Program
St. Mary’s Telehealth Program
Program Achievements 500 patients enrolled
Successful DOH onsite survey - March 30, 2015
Patient and staff satisfaction has improved
Decrease in avoidable hospitalizations & medication issues
Testimonials “The Telehealth program has helped so much, I am able to explain problems to the Nurse and the
interventions on the phone help and prevent me from going to the ER. Having the Nurse come out
to visit after the phone call is also very helpful. I love the fact that someone always calls back and
I am not alone.”
“The program helps me, once I took him to Urgicenter but he was still not better. The call came
and it was helpful to speak to the Nurse on the phone and then have another nurse visit. This
stopped me from having to take him back to the ER. My child is not normal so the additional
expert advice benefits him.”
“ The program makes me feel safe.”
“I have come to rely on the program, knowing I am not alone and have help even when life gets
so busy.”
St. Mary’s Telehealth Program
The Future • Use the data from this grant to help develop a care management model
that will allow us to provide those services under managed care in the
future for our children.
• Currently grant funded- Our ultimate goal is to work with Managed
Medicaid and insurers to recognize the importance of the program in
reducing hospitalizations and costs - and make this a reimbursable
service.
• Our goal is to continue to innovate and find cost effective ways to better
serve our medically complex children.
St. Mary’s Telehealth Program
A costly ER visit or hospitalization can
be avoided by the push of a button.
St. Mary’s at your fingertips is the
solution….
St. Mary’s Telehealth Program
St. Mary’s Healthcare System for Children
Elvira Fardella-Roveto, FNP B-C
718-281-8723
Donna Mapp-Reid, RNC, CCM
718-281-8935
www.stmaryskids.org BIP Transformation Grant utilizes “Federal funding” per section G, page 20 of 26 of the Master Contract for Grants.
42
NYS DOH Key Upcoming Dates
March 16 Revised PPS Third Quarterly Report due from PPS
March 31 Approval of PPS Third Quarter Report
April 1 DSRIP Year 2 Begins
April 8 DOH Holds All PPS Meeting
April 30 PPS Fourth Quarter Report due from PPS
Mid May DOH All PPS Learning Symposium
43
Contact Us!
Executive Leadership:
• Maureen Buglino, RN, MPH
Vice President, Community Medicine
• Maria D’Urso, RN, MSN
Administrative Director, Community Medicine
• Amanda Simmons
Executive Director
PMO Staff:
• Sarah Kalinowski
DSRIP Director
skalinowski@nexer
ainc.com
• Coleen Dunkley
DSRIP Program
Coordinator
• Crystal Cheng
Sr. Data Analyst
44
PPS Website: http://www.nyp.org/queens/dsrippps
PMO Office: 718-670-1968
