Central New York Care CollaborativePrimary Care Transformation Project Implementation Collaborative Kickoff MeetingFriday, February 26, 2016

Welcome and Introductions

CNYCC Team

Karen Joncas-Project Manager for Primary Care Transformation (and CVDM)PIC Moderator703-2981Karen.Joncas@cnycares.org

Lauren Wetterhahn-Director of Program OperationsPIC Facilitator

Liz Fowler-Operations CoordinatorScribe

Learning Objectives

Topics

What is the Delivery System Reform Payment Program(DSRIP) What is the Central New York Care Collaborative (CNYCC) Project Implementation Collaborative (PIC)-Who, What, When DSRIP Primary Care Transformation Requirements Overview Patient-Centered Medical Home (PCMH) Readiness Assessment Overview Getting Started with PCMH Transformation A Word about Advanced Primary Care (APC) A Word about PCMH 2017 Redesign CNYCC Partner Support Resources

Q & A and Next Steps

Learning Objectives

Introduction to DSRIP and the CNYCC

Goals of DSRIP

Reduce avoidable hospital readmissions and emergency department use by 25% over the next 5 years

Preserve and transform the State’s fragile health care safety net system

Created in 2014 allowing NYS to re-invest federal savings generated by the Medicaid Redesign Team (MRT)

Funding provided to support hospitals and other service provides to change how healthcare is provided to Medicaid beneficiaries

Provides incentives to promote community-level collaborations through Performing Provider Systems (PPSs)

$6.42 billion for payments to all state PPSs to meet DSRIP goals of system reform and cost reduction

DSRIP - Delivery System Reform Incentive Payment Program

Mission: Working together for better health

Vision: To improve the health of our community by coordinating services and building partnerships throughout the healthcare system

Guiding Principles:Better Integrate ServicesCollaborate on Patient CareImprove Healthcare QualityLower Cost of Healthcare

performance

CNYCC – Central New York Care Collaborative

6COUNTIES

9,700SQUARE MILES

CNYCC: At a Glance

Cayuga, Lewis, Madison, Oneida, Onondaga, and Oswego

New CorporationPPS Lead Agency

170 Partner Organizations

1,400HEALTHCARE AND COMMUNITY-

BASED SERVICE PROVIDERS

Nearly200,000

MEDICAID SUBSCRIBERS

Finance Committee

Nominating Committee

IT/Data Governance Committee

Corporate Members(4 Co-Leads)

Board of Directors(22 Members)

Board Committees

Clinical Governance Committee

Compliance Committee

Executive Committee

Executive Project Advisory Committee

(EPAC)

RPACMadison County

RPACOneida County

RPACOnondaga County

RPACCayuga County

RPACOswego County

RPACLewis County

CNYCC Governance

Partner Engagement Structures

Inform

Project Implementation Collaborative (PIC) Overview

Purpose

The PIC will develop, update, and guide the CNYCC’s project implementation plans over time with an eye toward meeting state project requirements, implementation of best practice, and broad system transformation

Project Implementation Collaborative (PIC)

Who-Roles and Responsibilities All partner organizations who have signed up to participate in projects are

encouraged to actively participate (Remember: Our joint success is based on individual partners meeting goal).

Participants will have a voice in the full PIC meetings and may volunteer to participate in smaller, targeted cohorts or work groups that meet more often and report back to full PIC

CNYCC Project Manager is the PIC facilitator ensuring that information flows between smaller groups and full PIC and monitors partner project plans against goals

Project Implementation Collaborative (PIC)

What

Primary Care Transformation is integral to the Integrated Delivery System project

Primary Care Transformation PIC purpose is to assist all eligible partners in achieving NCQA PCMH 2014 Recognition

Assist in identifying and sharing best practices

Support project monitoring and quality improvement processes

Promote/Celebrate project success and the system transformation

Project Implementation Collaborative (PIC)

When

Primary Care Transformation PIC will begin monthly meetings by Webinar

Primary Care Transformation PIC will periodically meet jointly with the Health Information Technology PIC to discuss common goals

Project Implementation Collaborative (PIC)

Actively Participate in the Meetings

Share expertise (best practices) with other Members

Share concerns or risks in meeting project goals

Achieve success in meeting project goals and deadlines

Primary Care Transformation PIC

PIC moderator ensuring that information flows between all partner members

Educate Partners in project requirements

Mitigate project risks

Monitor Partner Plans to ensure meeting NYS Project Implementation Plan Deadlines

Partner Member Role Project Manager Role

Purpose

Work together to ensure the success of the collaborative integrated delivery system and all eligible partners achieve transformation validated by NCQA PCMH 2014 Recognition

What

• Collaborative venue for sharing best practices across the partner network• Communication link for updates/issues to partner organizations

Who

• Partner organization’s Project Leadership, Clinical Leadership, HIT Leadership, Quality Leadership, Administrative Leadership

• Partner organization’s DSRIP Coordinator

Primary Care Transformation PIC

Relationship Between PICs

HIT PIC

Project & Primary Care

Transformation PICs

Clinical & OperationalRequirementsDevelopment

Exploration, Vetting and Development

Of Technical Solutions

PCMH and DSRIP

PCMH required across multiple DSRIP projects including:

Integrated Delivery System (2ai)

DSRIP Care Management (2aiii)

ED Care Triage (2biii)

Primary Care/Behavioral Health Integration (3ai)

Cardiovascular Disease Management (3bi)

Palliative Care PCMH Integration (3gi)

PCMH and DSRIP

Implement strategies for contracted projects into your PCMH plan.

Introduction to PCMH

Patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.

The evidence indicates how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.

What is PCMH?

Readiness Assessment & Planning Process Overview

Goals Identified current state including PCMH recognition, MU attestation, readiness to

transform practice to PCMH

Final Reports

On-site or telephone assessments of each practice

Summary of PPS Partner recognition status and EMR platform

Cohort strategy for small workgroups and learning collaborative sessions

PPS PCMH and MU Readiness Assessment

PPS PCMH Readiness Assessment

Planning for Transformation

Educate

Practice Eligibility

Practice provides coordinated, team-based whole-person care at outpatient primary care sites https://www.youtube.com/embed/ZC4YCLG4h5k

Personal clinician (MD, DO, APRN, PA) with their own patient panel and provides first contact, continuous, comprehensive care for at least 75% of its patients

Does not include urgent care clinics or those offering seasonal care

Provides scheduled routine and urgent care appointments

http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/BeforeLearnItPCMH/PCMHEligibility.aspx

Educate

Determine Type of Submission

Single Site(s) submission

Confirm Eligibility for submitting a multi site application

Three or more eligible sites

Use same EMR system

Operate under the same policies and procedures

Telephone Consultation with NCQA Project Leader for mulit-site application

http://www.ncqa.org/Programs/Recognition/RecognitionProgramsMultisiteProcess.aspx

Educate

NCQA PCMH 2014 Standards

Obtain a copy of PCMH 2014 Recognition Standards and Guidelines (www.ncqa.org)

NCQA offers recorded trainings

http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/RecognitionTraining/RecordedTrainings.aspx

Community Health Care Association of NYS (CHCANYS) PCMH resources http://www.chcanys.org/index.php?src=gendocs&ref=2013%20Presentation%20HCNN-QI%20FORUM&category=NYS_HCCN

Patient Centered Primary Care Collaborative (http://www.pcdcny.org/)

Download the PCMH 2014 Self- Assessment tool

http://www.pcdc.org/performance-improvement/special-content/pcmh-2014-self-assessment.html

Educate

Already PCMH 2011 Recognized?Conversion vs Renewal

Conversion to PCMH 2014

Documentation required for six standards

Must complete the full survey tool

All positive survey responses subject to audit

Submission of Record Review not Required-Sample care plan only

Does not extend recognition expiration date

Must have achieved PCMH 2011 Level 3

Option if 2 years of quality data is not available

Educate

Renewal to PCMH 2014

Documentation required for eleven standards

Must complete the full survey tool

All positive survey responses subject to audit

Extends recognition expiration date for three years

Must have achieved PCMH 2011 Level 2 or 3

Educate

Plan

Payment Policy Planning

Develop and Submit a Project Charter including Names and Contact Information and Defined roles of Project Team Members

Complete Project Plan Documentation Template (Under Development)

Complete and Submit Planning Questions in Appendix B/Payment Mechanism 3

Complete Provided Excel Template with Provider Information

Project Planning

Components of a Project Charter

Suggested Components

Determine the Project Mission and Objectives

Determine the Project Deliverables and Timeline

Develop a Project Team

Determine a communication plan and decision making process

Determine Frequency and Location of Project Meetings

Determine if outside resources will be used

Determine where project documentation will be kept

Project Charter

Establish a Project Team

Suggested Team Members

Physician Champion

Project Leader

Clinical Leader

Administrative Leader

Quality Leader

HIT Leader Scribe

PCMH Project Team

Some team members could take on multiple roles or share roles with multiple staff.

Team Members should always strive for sustainable change with the goal to improve care for all patients.

Project Team Roles

Physician Champion

Should have passion for and be able to define organizational values and facilitate culture change to patient-centered team based care.

Develop the strategic vision and drive the necessary investment in infrastructure change in people, process and technology.

Manage resistance and set a positive tone for the project

Embrace performance measurement and partner with project team to communicate quality initiatives and evidence best practices to providers and staff

Project Team Members

Project Leader

Responsible for the facilitation of the project plan development and project management.

Communicates status throughout the team and organization.

Ensures the project team and staff completes all aspects of transformation and submission

Makes sure that success is continually celebrated with the team and all staff.

Communicates with CNYCC Project Manager regarding status of the project and any risks or issues to meeting project goals.

Project Team Members

Clinical Leader

Responsible for managing and overseeing all clinical functions within the practice including: clinical advice, team based care, population health management, evidence-based decision support, care management and support, medication management.

This role is typically held by a physician or mid-level provider. The functions may be assisted by a Clinical Nurse Manager.

Project Team Members

Administrative Leader

Responsible for supervising and directing all administrative functions within the practice including policy and workflow updates for PCMH topics such as patient access and scheduling, patient orientation and transitions, collecting demographic information, communicating medical home responsibilities, language services and care coordination.

A practice manager or administrative director is ideal for this role

Project Team Members

Quality Team Leader

Leads the practice or organization’s Quality Improvement(QI) Team.Works with the QI team to assign roles and responsibilities for quality

improvement for all functions in the practice and all QI committee roles

Works with the practice/organization to identify performance measures and quality improvement initiatives

Project Team Members

HIT Leader

Responsible for all Health Information Technology requirements including assessment of capability of systems to meet PCMH (including Meaningful Use) requirements, building of required EMR templates to facilitate the delivery of consistent evidence based medicine; building and running reports (and/or training others). Interfaces with EMR Vendor as required.

Interfaces with CNYCC on interoperability capabilites

Project Team Members

Scribe

Responsible for taking notes at all scheduled and ad-hoc planning meetings. The organization can decide how these will be distributed or stored for easy access by all team members.

Project Team Members

Implement

Early Steps

Begin with the steps (standards) that will have multiple impact on culture and where focus will enhance sustainability

These should be implemented with buy-in from staff and with the support of practice/organizational leadership

Prepare PCMH self-assessment to identify opportunities Develop Care Team Strategy Develop communication strategy to include all team members in

PCMH transformation and all quality initiatives Develop Quality Improvement Strategy

NCQA Focus: Standard 2D and 6

Implementation

Early Steps

Assess where new policies, documented processes will be needed

Assess PCMH standard alignment with planning strategies Training Strategy Health Information Technology Strategy

Prepare Baseline Reporting for QI and Gaps in Care (when available)

NCQA Focus: Multiple standards, Standards 2D, 6 and 3D

Implementation

Early Steps

Determine Patient Engagement Strategy Patient experience measurement Patient Advisory Council; Patients on QI team Care management strategy and workflows Shared decision making aids Self-management support Home monitoring for chronic conditions

NCQA Focus: Multiple standards, Standard 2D, 4B, 4E, 6C

Implementation

Patient Access

Develop understanding of patient access supply and demand Provider patient panels Demand vs. Supply of Same Day Access Appointments Develop minimum standards for wait times for appointments Determine how supply and demand of appointments will be

monitored Consider alternative visits Determine baseline no-show rates and review policies to mitigate this

affect on patient access

NCQA Focus: Standard 1

Implementation

Integrated and Coordinated Care

Develop/update/tighten strategies for care coordination and care transitions Tracking and follow-up on all tests and referrals Manage all care transitions (hospitals, palliative care, referrals, new

patients) Behavioral Health Strategy Co-management agreements with specialty care providers Build relationships with community based organizations Engage in the RHIO

NCQA Focus: Standards 5 and 2A

Implementation

Communication Plan

Develop strategy to communicate the roles and responsibilities of a medical home

Develop strategy to Communicate Performance Results externally Develop strategy to effectively communicate to patients with

consideration to cultural competency and health literacy. Develop strategy for patient education and self-management support Internal communication plans- team huddles, practice process,

quality performance results

NCQA Focus: Standards: Multiple including 1B, 1C, 2, 4B, 4E,6F

Implementation

Evidence-Based Medicine

Develop patient safety strategies including: Consistent evidence-based medicine Implement Clinical Decision Support tools Care Coordination

NCQA Focus: Standards 3E, 5

Implementation

Documentation Gaps

Complete Mock Audit-Chart Review using NCQA Record Review Workbook to identify documentation gaps Complete health assessments Medication Care plan

Revise workflows as needed

NCQA Focus: Standards 3C, 4B, 4C

Implementation

Execute

Policy, Documented Process, Workflow and Procedure Evidence-based Medicine Clinical Decision Support Quality Initiative Action Plan Population Health Management- Gaps in Care Patient Engagement Plan Internal and External Communication Plans Integrated and Coordinated Care Training Strategies

NCQA Focus: Standards: Multiple and 1, 2B, 2D,3D,3E,5, 6

Implementation

Execute

Care Management Strategy Patient Identification Workflows Care Team Members-Internal Resources vs. External Resources Care Plan Templates Motivational Interviewing Self-Management Support Care Coordination Community Based Resources

NCQA Focus: Standards 4B and 5

Implementation

Execution of NCQA Application and Survey

Final Report Run Complete final Record Review Complete Quality Improvement Worksheet Complete NCQA On-line Application (and fees) Prepare Final Survey tool Final Quality Check of all Documents to be Submitted Upload Documents to NCQA Document Library Submit NCQA ISS Tool and Document Library CELEBRATE

Implementation

A Word on Sustaining the Transformation

Build process audits into policies Maintain accountability to patients Maintain quality improvement team with continued measurement CONTINUE to CELEBRATE SUCCESS

Sustain

PCMH Suggested Timeline

Current PCMH Recognition Status and Expiration Date EMR Implementation or Upgrade Readiness Multi-site vs. Single Site submissions Organization Mission and Objectives Transformation Process could take 1 year or more PPS to have Staggered Timelines

No NCQA submissions in PPS after October 1, 2017

Timeline Considerations

Assessment and Planning Process Timeline

31-Mar-16 30-May-16 31-Jul-16 30-Sep-16 30-Nov-16 31-Jan-17 31-Mar-17 31-May-17 31-May-17 31-Jul-17 30-Sep-17Educate, Assess, PlanCare Team StrategyBehavioral Health Strategy and implementationQuality Improvement Strategy

Communication Plan-Internal and External

HIT Cohort Assistance/Baseline ReportingTraining Strategy and Implementation

Patient Engagement StrategyDetermine and communicate QI planExecute population health and other QI action plansPatient Access Strategy and ImplementationExecute Internal and External CommunicationsUpdate and Implement Policies and Procedures and workflowsCare Coordination and Transitions MonitoringExecute Care Management StrategyFinalize Documentation for Submission Complete On-Line NCQA applicationFinal Document Audit and Sign offLoad documents to Document Library and Submit NCQA Survey Tool

This graphic display is a sample project plan meant to show how educate, assess, plan and implement are often not linear. Also, in order for transformation to be sustainable, transformation and quality improvement continue.

NYS Advance Primary Care Model

New York State Innovation Model:

Comprehensive, patient-centered care

Coordinated care between primary care and other clinical care and community-based services

Greater usage of HIT including EHR, Population Health and data analytics

Financial support for primary care practices for transformation

A shift from encounter based payment to alternative payments supporting services and infrastructure

Multi-payer participation and alignment

Advanced Primary Care Model

New York State Innovation Model:

Meaningful Performance Measures consistent with existing standards and measures (NCQA, CPCI, etc.)-Measured on improvement in Core Measures

Requires ability to identify high-risk patients and have plan for care coordination

Drive change over time instead of one-time certification

Be tied to outcomes and facilitated by innovative payment systems

State goal is for 80% of care to be paid under a value-based financial arrangement within 5 years

Timeline fluid – Preliminary Launch scheduled January 2017

Advanced Primary Care Model

PCMH or APC?

State Project Implementation Plan requires one or the other

Recommendation is for PPS practices to pursue PCMH

State APC Model has delayed launch date

Those with PCMH Recognition with demonstrated transformation will be eligible for earlier access to care coordination payments and/or outcome based payments

Measure metrics to be aligned with PCMH and other quality initiatives

Existing Medicaid PMPM payments

Additional information forthcoming

Advanced Primary Care Model

NCQA PCMH 2017 Re-design

NCQA PCMH Redesign

Role out Spring 2017. PCMH 2014 Retires December 2017. Earlier for corporate application. No survey tool purchases after June 2017.

Overarching objective is to enhance the value of the recognition for all stakeholders

Reduce the burden of non-value added work

More focus on outcomes instead of structure and process

More support for transforming practices

NCQA PCMH 2017

NCQA PCMH Redesign

Two pathways

Those with first time recognition will complete an assessment to determine readiness. If more work is needed practice would be directed to additional educational materials.

Second pathway-Engagement phase-Match practice with a facilitator and reviewer, identify education needed, facilitate check-ins with a reviewer where practice would know where they stand during process.

Engaging practices in a streamlined annual check-in rather than three year documentation burden

Watch for more information on NCQA blog

NCQA PCMH 2017

CNYCC Partner Support ResourcesLearning Collaborative Sessions

CNYCC Learning Collaborative Sessions

CNYCC Learning Collaborative Sessions

CNYCC Partner Support ResourcesHealth Information Technology Support

Goals

Identify current state of health information technology availability and capability including: Access to RHIO and usage of Direct Messaging EMR certification for Stage 2 Meaningful Use Provide Clinical Decision Support to facilitate evidence based care Access to reporting required for PCMH and other quality performance measurements

Format

Series of surveys indicating technology capability of each organization

Summary of PPS Partner status

Readiness Assessment-Health Information Technology

Goals

Vendor Engagement to Implement/Optimize EMR Platforms EMR Vendor Selection Toolkit Create clinically integrated networks Build the technical infrastructure including a shared platform to enable care

coordination and population health management Develop Project/Reporting Specific HIT requirements Technical Assistance Technical Cohort Development

Integrated Delivery Network-HIT Support

CNYCC Partner Support ResourcesFunds Flow

Project Activity Description EligiblePartners

DY1 Payments

2.a.i Category 1. Regional Health Information Organization (RHIO)

Payment 1: Payment for signing a participation agreement and implementing a consent management policy/procedure

All Partners Total: $870,349Per Partner: $2,500Assumption: 350 responding partner sites

2.a.i Category 2. Electronic Medical Records (EMR)

Payment 1: Current State Assessment (Documented plan for upgrading to, or implementing new MU Certified EMR that meets DSRIP requirements; documented plan for making required system changes to meet DSRIP requirements)

MU eligible; BH Providers; SNFs; Non-PCPs

Total: $1,450,582Per EMR: $10,000Assumption: 145 completed assessments

2.a.i Category 3. Patient-Centered Medical Home

Payment 1: Per practice site payment for PMCH 2014 Level 3 recognition plan

PCPs Total: $1,740,699Per PCP Site: $10,000Assumption: 145 responding PCP sites

CNYCC Integrated Delivery System Funds Flow

Questions & Answers

Do you feel you have a good understanding of the goals of Primary Care Transformation? What type of support would be most useful to you? What topics would you like to see brought to this PIC or learning collaborative sessions?

What success stories do you have to share?How have you celebrated success with your staff?

CNYCC Primary Care Transformation PIC: Feedback

Next Steps & Wrap Up

Next Steps

Complete Project Planning Templates

Assist CNYCC IT Team in identification of needed IT reports and other technology upgrades to meet NCQA PCMH 2014

Site visits with Project Leaders to review planning process, assess needed support

Learning collaborative sessions plan

Next Steps & Wrap Up

Next Meeting

PIC meeting 3/25/16, 10:00 AM – 12:00 PM

Joint meeting with HIT PIC with DSRIP IT leads and other PCMH Project Team Leaders and DSRIP Coordinators

Next Steps & Wrap Up