PROJECT ADVISORY COMMITTEE (PAC) 9... · 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

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


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



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


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


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


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


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.


SNF Transfer Form (2010):

• Form initially created by SBM in 2010 that was

shared and utilized with community facilities


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


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


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)


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


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


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


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


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


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


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:

[email protected]

(631) 650-2111

JANET PEPPER CONTACT INFO

[email protected]

(631) 650-2084

LINDSAY FUDIM CONTACT INFO

[email protected]

(631) 650 - 2278

mailto:[email protected]



10/1/2019 72

Kevin Bozza, MPA, FACHE, CPHQ, RHIT

Chief of Operations & Vice President, Population Health Management Services


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)


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


SCC PERFORMANCE


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


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)✅


CHRONIC DISEASE PROGRAM

Measures


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


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


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


MY4

ED Use by uninsured✅

Non-use of primary and preventative care services x

PAM Level Not Eligible


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


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)✅


HIGH PERFORMANCE FUND (HPF)


“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


STATEWIDE ACCOUNTABILITY MILESTONES

(SWAM)


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


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


MY4 Target: 489.85 MY4 Target: 27.36 MY4 Target: 98.89


% point change since baseline: +4.17% % point change since baseline: +2.25% % point change since baseline: +3.60%

Behavioral Health Medication Measures



% point change since baseline: +5.91% % point change since baseline: +4.46%

Diabetes Measures



% point change since baseline: +8.51% % point change since baseline: +7.22%

Asthma Medication Measures


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


10/1/2019 92

QUESTIONS

10/1/2019 93

Linda S. Efferen, MD, MBA

Executive Director & VP, Medical Director


CLOSING REMARKS

Documents

PROJECT ADVISORY COMMITTEE (PAC) 9... · 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