draft project plan application 141201 v2.docx · project resource needs and other initiatives...

DRAFT FOR PUBLIC COMMENT – NOT FINAL of 159

Finger Lakes Performing Provider System Draft DSRIP Project Plan Application

Posted for public comment: December 12, 2014 Public comment due: December 15, 2014 5:00 pm

DUE TO THE STATE ON MONDAY, DECEMBER 22, 2014 BY 5:00PM


Table of Contents

Contents Section 1 – Executive Summary ................................................................................................................. 3

Section 2 – Governance .............................................................................................................................. 6

Section 3 – Community Needs Assessment ............................................................................................ 18

Section 4 – DSRIP Projects ....................................................................................................................... 43

2.a.i Create integrated delivery systems .............................................................................................. 43

1. Project Justification, Assets, Challenges, and Needed Resources (1500 word limit, Total Possible Points – 20)......................................................................................................................... 43

2. System Transformation Vision and Governance (1500 word limit, Total Possible Points – 20) 46

3. Scale of Implementation (Total Possible Points - 20) ........................................................... 48

4. Speed of Implementation/Patient Engagement (Total Possible Points - 40): ..................... 49

5. Project Resource Needs and Other Initiatives (750 word limit, Not Scored) ...................... 50

2.b.iii ED Care Triage for At-Risk Populations ....................................................................................... 56

Project Justification, Assets, Challenges, and Needed Resources ........................................................ 56

2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions .............................................................................................................................................. 63

2.b.vi Transitional Supportive Housing ................................................................................................. 72

2.d.i “Project 11” ................................................................................................................................... 80

3.a.i Integration of Primary Care and Behavioral Health Services........................................................ 88

3.a.ii Behavioral health community crisis stabilization services ........................................................... 97

3.a.v Behavioral Interventions Paradigm ............................................................................................ 104

3.f.i Increase support programs for maternal and child health ......................................................... 109

4.a.iii Strengthen Mental Health and Substance Abuse Infrastructure across systems..................... 118

4.b.ii Increase access to high quality chronic disease preventive care and management in both clinical and community settings ......................................................................................................... 124

Section 5 – PPS Workforce Strategy ...................................................................................................... 130

Section 6 – Data-Sharing, Confidentiality & Rapid Cycle Evaluation ................................................... 140

Section 7 – PPS Cultural Competency/Health Literacy ......................................................................... 144

Section 8 – DSRIP Budget & Flow of Funds ........................................................................................... 146

Section 9 – Financial Sustainability Plan ............................................................................................... 149

Section 10 – Bonus Points ...................................................................................................................... 153

Section 11 – Attestation ......................................................................................................................... 155

Appendix A – Currently Known Scale & Speed ....................................................................................... 156


Section 1 – Executive Summary Description The PPS & Project Plan Application must include an executive summary clearly articulating how the PPS will evolve into a highly effective integrated delivery system. The executive summary should address the following: ● Succinctly explain the identified goals and objectives of the PPS.

PPS Response (1000 characters max): Current: 2,096 characters

Transformation from volume to value based payments, and from sick to wellness care, requires dramatic changes in the current health care delivery system. The Finger Lakes PPS (FLPPS) is committed to strong, systemized partnerships for health care delivery among a wide range of care providers with the purpose of creating a more integrated care delivery system that is accountable for some of the most vulnerable patient populations in our region. The specific changes required to ignite transformation vary widely across the diverse communities and geographies represented in the FLPPS. The variations include not only differences in currently available resources, the demographics and ethnography of the various urban and rural populations, available competencies and capacities of community based organizations (CBOs) throughout the PPS, but also the existing health care delivery infrastructure and the current flow of financial incentives to providers, as well as for patients based on contracts and benefit plans. The highly comprehensive network of roughly 130 home- and community-based partners ranging from acute health care, behavioral health, community service agencies, housing, health planning and FQHCs share the vision “to create an accountable, coordinated network of care that improves access, quality and efficiency of care for the safety net patient population across our participating counties.” This represents an unprecedented commitment to region-wide, cross-organizational, and cross-silo collaboration.

Based on the issues, needs, and resources identified in our CNA, the FLPPS has identified the following goals: - Improve access to care, quality of care, member safety and satisfaction, efficiency and cost-

effectiveness of care. - Improve long term financial stability of caregivers within the network. - Provide strong clinical leadership and resources to the network. - Drive advocacy and policy development to improve access to care. - Provide the best practice opportunities for physicians and other practitioners who want to treat

patients in underserved communities.

● Explain how the PPS has been formulated to meet the needs of the community and address identified health

care disparities.

PPS Response (1,200 characters max): Current: 917 characters

Throughout the development of the PPS, there has been a focus on engaging not only traditional health care providers and payers, but also community based organizations and other stakeholders. Additionally, there has been a focus on identifying, cultivating and engaging with leadership across the large number of communities within the 5 Naturally Occurring Care Networks (NOCNs). This has been facilitated in partnership with the Finger Lakes Health Services Agency (FLHSA), which also drove the development of the FLPPS CNA and deeper engagement with rural primary care providers. The proactive engagement with


CBOs and geographically diverse leaders from across the health and wellness continuum will ensure that in the long run FLPPS will have identified the highest priority health disparities and will be set up for success with addressing them and closing existing gaps in care, cultural competency and access.

● Provide the vision of what the delivery system will look like after 5 years and how the full PPS system will

be sustainable into the future.


The FLPPS performing providers are committing to a long-range and permanent transformation, starting with the five-year, multi-phase process of DSRIP-driven care transformation that requires ongoing collaboration, trial-and-error, and piloting innovative systems and concepts that will provide a strong, clinically integrated foundation. During this process, FLPPS will work with the local MCOs to establish commons systems and processes, along with risk sharing and value-based reimbursement that rewards improvements in quality of care, population health outcomes, member satisfaction, and overall annual per member cost savings.

We are confident that the initiatives taken on by FLPPS – in conjunction with partnerships with local, state and federal officials to attain the triple aim – will lead to integrated, coordinated patient-centered care that will ultimately improve the health of the population, and that will lead to long term financial sustainability.

Regulatory Relief Is the PPS applying for regulatory relief as part of this application? (Please see Regulatory Flexibility Guidance for Performing Provider Systems, available at: http://www.health.ny.gov/health_care/medicaid/redesign/docs/reg_flex_guidance.pdf). (Please mark the appropriate box below.)

Yes No

If yes, for each regulation for which a waiver is sought, identify in the response below the following information regarding regulatory relief: ● Identify the regulation that the PPS would like waived (please include specific citation); ● Identify the project or projects in the Project Plan for which a regulatory waiver is being requested and outline

the components of the various project(s) that are impacted; ● Set forth the reasons for the waiver request, including a description of how the waiver would facilitate

implementation of the identified project and why the regulation might otherwise impede the ability of the PPS to implement such project;

● Identify what, if any, alternatives the PPS considered prior to requesting regulatory relief; and ● Provide information to support why the cited regulatory provision does not pertain to patient safety and why

a waiver of the regulation(s) would not risk patient safety; include any conditions that could be imposed to ensure that no such risk exists, which may include submission of policies and procedures designed to mitigate the risk to persons or providers affected by the waiver, training of appropriate staff on the policies and procedures, monitoring of implementation to ensure adherence to the policies and procedures; and evaluation of the effectiveness of the policies and procedures in mitigating risk.

http://www.health.ny.gov/health_care/medicaid/redesign/docs/reg_flex_guidance.pdf


PPS Response (100 characters to list regulation; 3,000 to answer above questions for each regulation)

This will be developed over the next week as more of the detail related to project implementation and capital budget requests become clearer.

PPSs should be aware that the agencies may, in their discretion, determine to impose conditions upon the granting of waivers. If these conditions are not satisfied, the State may decline to approve the waiver or, if it has already approved the waiver, may withdraw its approval and require the applicant to maintain compliance with the regulations.


Section 2 – Governance Section 2 – Governance (25 percent of the Overall PPS Structure Score) Description An effective governance model is key to building a well-integrated and high functioning DSRIP PPS network. The PPS must include a detailed description of how the PPS will be governed and how the PPS system will progressively advance from a group of affiliated providers to a high performing integrated delivery system, including contracts with community based organizations. A successful PPS should be able to articulate the concrete steps the organization will implement to formulate a strong and effective governing infrastructure. The governance plan must address how the PPS proposes to address the management of lower performing members within the PPS network. The plan must include progressive sanctions prior to any action to remove a member from the PPS. Governance Organizational Structure (worth 20 percent of total points available for Section 2) Please provide a narrative that explains the organizational structure of the PPS. In the response, please address the following: ● Outline the organizational structure of the PPS, for example, please indicate whether the PPS has

implemented a Collaborative Contracting Model, Delegated Model, Incorporated Model, or any other formal organizational structure that supports a well-integrated and highly functioning network. Explain why the selected organizational structure will be critical to the success of the PPS. In addition, please attach a copy of the organizational chart of the PPS. Also, please reference the “Governance How to Guide” prepared by the DSRIP Support Team for helpful guidance on governance structural options the PPS should consider.

PPS Response (3,900 characters max): Current: 4,486 characters

FLPPS recognizes that the region it serves is both geographically large and diverse. From the beginning it was determined that Medicaid and uninsured members and providers would be best represented with a system of local governance which would be structured to allow for central services and vision informed by adaptable leadership and problem-solving at the local level. To accomplish this, five Naturally Occurring Care Networks (NOCNs) were formed based on geographic layout and patient flow: 1. Monroe County 2. Western Region (Genesee, Orleans, & Wyoming counties) 3. Southern Region (Allegany, Livingston, and northwestern Steuben counties) 4. Southeastern Region (Chemung, southeastern Steuben, & Schuyler counties) 5. Finger Lakes Region (Cayuga, Ontario, Seneca, Wayne, & Yates counties) In order to best facilitate broad governance representation from across the NOCNs, and the overall PPS, FLPPs has chosen to develop a hybrid model that is the combination of the delegated and hub models, including the development of a new 501(c)3 corporation. The lead applicant parent corporations, Rochester Regional Health System (RRHS) and University of Rochester (UR) Medicine, have provided the not only all of the initial capitalization and the bulk of the in-kind staffing and resource contributions during the start-up phase, but have committed to providing adequate ongoing capitalization, in-kind resources and operational support. As the entities taking primary accountability for initial development and financial viability of the FLPPS, URMC and RRHS are the sole corporate members of the new FLPPS corporation. FLPPS has a representative Board of Directors consisting of 19 individuals as follows: (i) 10 clinical or lay executives from each of the 2 corporate members; (ii) 5


clinician or lay executive leaders nominated by each of the five FLPPS NOCNs; (iii) 3 consist of one representative each from an FQHC, County Public Health and County Mental Health, and (iv) 1 is a Medicaid beneficiary who is served by the PPS and who does not have a conflict of interest (or an immediate family member with a conflict of interest) whether financial or otherwise with the PPS. The FLHSA provides a representative to serve as an ex oficio member of the Board. Under the auspices of the Board of Directors, and serving as the PAC executive body, is the Operations Steering Committee. The Operations Steering Committee has evolved from a pre-existing Organizing Committee that consisted of representatives from across the FLPPS and provided leadership during much of the initial planning activities. The Operations Steering Committee is accountable for: ● Coordination of the work of the operating committees and overall governance of the DSRIP

projects. ● Oversight of FLPPS Partners to ensure the performance targets established by NYS DOHS and the

Scale and Speed goals for the FLPPS are met. ● Advising on system issues that occur across the region (e.g. transportation).

The Operations Steering Committee includes the co-chairs of each of the Operating Committees, along with one representative per NOCN, a design that is meant to ensure both representation from across the broad FLPPS service area and also specific finance, clinical, workforce, cultural competency and IT expertise. The FLPPS PAC has 6 Operating committees that are responsible for developing and finalizing the key deliverables required to complete the DSRIP Project Plan Application. Each operating committee is overseen by two Co-Chairs, initially nominated by the FLPPS co-lead organizations and supported by Project Managers and Subject Matter Experts. Reporting to, and interfacing closely with the Operating Committees, are Project Teams consisting of subject matter experts helping to ensure successful design and implementation of each project across the NOCNs and the overall PPS. Finally, each of the 5 NOCNs are developing workgroups that will coordinated closely with the operating committees and project teams, identify regional-level needs and communicate key findings and anticipated regional challenges to project planning and implementation. They are tasked with leveraging existing relationships and developing new relationships to collect the provider-level information needed to ensure successful development of the IDS. The overall PAC is brought together in a variety of formats that specifically cater to a broad region with geographic spread and a mix of small rural and large urban providers.

● Specify how the selected governance structure and processes will ensure adequate governance and

management of the DSRIP program.


Within the FLPPS, the NOCN workgroups play a critical role in governance, interfacing via teams of project managers and subject matter experts with the operational committees and the Operational Steering Committee. The NOCNs will help to ensure that DSRIP project implementation and overall PPS transformation are successful in each unique FLPPS community, established based on its specific local needs. Foundational to the PPS success will also be the core principles of the FLPPS that do, and will,


drive every decision. Serving as motivating values, PPS leadership will focus on member and provider needs above all else. The FLPPS core principles are: Focus on the Member/Patient

All decisions are weighed against the question – “How will this impact the member/patient’s health care needs, cultural and linguistic preferences, enabling provision of the right care, at the right place, at the right time?”

Strong Physician and Provider Leadership

Physicians and other practitioners have representation and deep engagement in governance and leadership.

Accountability, Transparency and Trusting Partnerships

Clear and open partnerships with regular, proactive communication to support the design and implementation of truly cost-effective, best practice care delivery.

Adaptability

Develop the ability to continually transform based on patient needs and environmental changes. Recognize that there is no best, there is only better.

Capacity & Capability for Managed Care of a Population

Develop the ability to both manage members/patients across the continuum of care with varying disease states, health care and social needs

● Specify how the selected governance structure and processes will ensure adequate clinical governance at the

PPS level, including establishing quality standards and measurements, clinical care management processes, and the ability to be held accountable for realizing clinical outcomes.


The oversight of ongoing performance of FLPPS partners will balance a number of goals: 1) the requirements of strong accountability to individual and PPS performance improvement; 2) the need to provide structure, guidance and support to more resource-challenged PPS providers; 3) the importance of data driven 'dashboard' metrics and benchmarking; 4) the need to incorporate feedback from Medicaid beneficiaries. FLPPS will use clear contractual expectations, standardized consensus based performance metrics, improvement support, and consequences for continued poor performance as the processes by which the PPS will monitor performance. Dashboard metrics will continually evolve over the course of the initial DSRIP period to incorporate benchmarks, provider comparison and targeted areas for improvement. Clinical and Performance oversight will be the core responsibility of the Clinical Committee, which will coordinate with the Finance committee, NOCNs, Project Teams, Operational Steering Committee and the Board of Directors in ensuring overall quality across the FLPPS providers.

● When applicable, outline how the organization structure will evolve throughout the years of the DSRIP

program period to enable the PPS to become a highly performing organization.

PPS Response (2,000 words max): Current: 1,235 characters

Over time, as the FLPPS governance bodies will become more mature and there will be an enhanced understanding of delivery system integration for the transformation of clinical care and payment. This


transformation will be driven by FLPPS Central Office and integrated into the core strategies of each FLPPS partner provider. FLPPS will evolve from a collaborative group of providers working on projects into a true integrated delivery network with core systems and processes that support members and providers in achieving the triple aim and financial sustainability. It is expected that along the journey, an early evolution will include a transition from the interim Board of Directors and Committee members to a more formally nominated and elected slate of Directors and committee members. In parallel, the PPS will hire full time executive leadership. Over time, as the PPS is successful in modifying health plan contractual relationships away from traditional fee for service and toward pay for performance and risk-based contracts, it is expected that there may be a need to adapt the governance structure and recruitment of subject matter experts for various governing positions, as well as the staffing structure of the FLPPS.

Governing Processes (worth 30 percent of total points available for Section 2) Describe the governing process of the PPS. In the response, please address the following: ● Please outline the members (or the type of members if position is vacant) of the governing body, as well as

the roles and responsibilities of each member.

PPS Response (1,200 characters max): Current: 1,654 characteres

As previously stated, FLPPS has a representative Board of Directors consisting of 19 individuals as follows: (i) 10 clinical or lay executives from each of the 2 corporate members; (ii) 5 clinician or lay executive leaders nominated by each of the five FLPPS NOCNs; (iii) 3 consist of one representative each from an FQHC, County Public Health and County Mental Health, and (iv) 1 is a Medicaid beneficiary who is served by the PPS and who does not have a conflict of interest (or an immediate family member with a conflict of interest) whether financial or otherwise with the PPS. A full list of interim Board members is located on our website at www.flpps.org Roles & Responsibilities of Board of Directors

1. Prepare for Board and committee meetings by becoming well informed on subject to be discussed, in order to participate actively in Board/Committee discussions and decisions.

2. Attend and participate in regular/special meetings of the Board of Directors, providing subject matter expertise, participating in committees and generally supporting the mission and vision of the FLPPS 3. Be available to the CEO and Senior Management to provide advice, assistance or direction, as may be requested by the CEO. 4. Participate in establishing organization goals: approve annual operating budget, consistent with providing for the solvency and financial stability of the corporation. 5. Support the majority decisions of the Board of Directors. 6. Interpret and promote the philosophy of the FLPPS within and without, to increase understanding and support of FLPPS as its team and partners work to achieve their transformational care goals

● Please provide a description of the process the PPS implemented to select the members of the governing

body.


Members of the Interim Board of Directors were appointed via a nomination process in which the two corporate members (RRHS and UR) each nominated their 5 Directors and the Organizing Committee (just prior to transition to the Operations Steering Committee). PPS member representatives conducted

http://www.flpps.org/


extensive conversations with PPS partners and stakeholder organizations to generate the nominees for the remaining nine positions. The final slate of nominees was posted for public comment on the PPS website. For the Operations Steering Committee, the majority of the committee consists of the co-chairs of the operational committees, which were appointed for initial terms by the corporate members. Additionally, 5 members represent the 5 NOCNs and were nominated by the nascent NOCN workgroups.

● Please explain how the members included provide sufficient representation with respect to all of the providers

and community organizations included within the PPS network.


The process for nominating and selecting initial members of all governing body entities started with the submission of nominations via e-mail, followed by a survey with extensive participation by both PPS partners and other stakeholders across the PPS. These nominations were reviewed by project managers, subject matter experts, corporate member leaders, the organizing committee and the initial operations committee co-chairs depending on the governing body for which an individual was nominated. For each governing body, whether the Interim Board of Directors or an operational committee, a matrix was used in order to ensure both representation from each NOCN and from the various types of providers and CBOs engaged with the PPS.

● Please outline where coalition partners have been included into the organizational structure and the PPS

strategy to contract with community based organizations.


There is five percent set-aside in the funds flow to fund contracts with CBOs as the PPS engages them for their critical services provided as components of the new IDS. Initially, it is likely that the CBO services will be funded via a combination of current funding sources, grants and PPS contracts, as well as expansion as possible/appropriate of any existing MCO contracts. Over time the goal will be to completely integrate the CBOs into a PCMH based system of care in which they play a vital role in achieving and improving health for Medicaid and uninsured members and they are therefore contracted by MCOs based on actuarial estimates as to their value to the capitated dollar.

● Describe the decision making/voting process that will be implemented and adhered to by the governing team.


The Bylaws of the FLPPS corporation allow for clear criteria to arrive at major decisions, defining which decisions require a simple majority vote of the Board of Directors, a supermajority vote and which are held as reserve powers by the two members of the corporation. For DSRIP projects and IDS activities, recommendations will be developed at the NOCN, Project Work Team and Operating Committee level and these recommendations will be elevated via the committee structure for final decisions at the NOCN, Operations Committee, Operations Steering Committee, or Board of Directors as per the Bylaws and the Policies and Procedures of FLPPS that are being drafted.

● Explain how conflicts and/or issues will be resolved by the governing team.


PPS Response (1,000 characters max): Current: 741 characters Disagreements at the Board of Directors level will be achieved via the process outlined in the FLPPS bylaws, including specific guidelines as to what issues can be decided via a simple majority vote, a supermajority vote, or are reserved powers to the two sole corporate members. The corporate members have a long history of working together in an overlapping service area and have developed strong relationships across their respective corporate counsel that enable rapid problem-solving when conflicts arise. Provider and/or member conflicts and /or issues will be resolved via the FLPPS staff in coordination with the governance committees and Board of Directors, there will be a formal grievance process for both providers and members.

● Describe how the PPS governing body will ensure a transparent governing process, such as methodology in

which the governing body will transmit the outcomes of meetings.

PPS Response (1,000 characters max): Current: 461 characters All of the FLPPS governing bodies, from the Board of Directors to the various operational committees and NOCN workgroups, are populated with diverse and representative groups of providers, stakeholders and Medicaid members, thus ensuring that the process for decision making does not become opaque and/or hospital centric. The minutes of the meetings of all committees and Board meetings, with the exception of executive sessions, will be publically available.

● Describe how the PPS governing body will engage stakeholders, including Medicaid members, on key and

critical topics pertaining to the PPS over the life of the DSRIP program.

PPS Response (1,000 characters max): Current: 400 characters FLPPS feels that Medicaid member representation is a critical success factor in ensuring that member needs are met and that Medicaid members have input into the process of delivery and payment transformation. For this reason, there have been, and will continue to be, facilitated focus groups with Medicaid members, as well as a Medicaid member of the Board of Directors and on each NOCN committee.

The Project Advisory Committee (PAC) (worth 15 percent of total points available for Section 2) Describe the formation of the project advisory committee of the PPS. In the response, please address the following: ● Describe how the PAC was formed, the timing in which it was formed, along with its membership.


The PAC was formed as a collaborative effort between the co-leads and other stakeholder leaders during a process in which several nascent PPS leads came together to form FLPPS. During the development of the FLPPS project management office (PMO) between May and September, point persons from each of the co-lead organizations hosted general monthly PAC meetings with representation per the State’s guidance. Once the PMO launched in early October, the PMO leadership hosted a joint executive visioning session to outline the future-state vision for FLPPS. From this, a more structured PAC was born that now includes five operational committees (Clinical, IT, Workforce, Finance, Transportation, five NOCN workgroups (one for each NOCN) and 11 project teams (one for each FLPPS DSIP project). In addition, monthly - if not m - PPS-wide webinars were held to provide updates and detailed


next steps for DSRIP/FLPPS to the general FLPPS stakeholder audience. Throughout October, the PMO collected committee membership nominations from general PAC members and other representatives from interested providers. Internally identified operations committee co-chairs initially populated the committees with a handful of members who met in the beginning of October to review committee deliverables, roles & responsibilities, and committee purpose. By early November, oversight committees had been fully populated. Project Teams followed shortly after and began meeting in late November. We envision that NOCN workgroups will play a large role in project implementation plans have seen early success in a broad range of NOCN engagement already.

● Outline the role the PAC will serve within the PPS organization.

PPS Response (1,00 characters max): Current: 970 characters The operations committees have played a key role in developing the strategic content necessary to populate the DSRIP Organizational Application. Operations committees will continue to serve as the high level strategists for the FLPPS development during implementation and beyond. In the final weeks leading up to the Project Plan Application deadline, Project Teams worked diligently to ensure Project Plan applications were accurate and reflected the perspectives of the service area providers. Project Teams will continue to be a critical to developing patient engagement strategies and project implementation plans throughout the NOCNs. Beginning in December, NOCN workgroups identified regional-level leads & members. Overtime each NOCN will communicate key findings and anticipated regional challenges to the operations committees for consideration. They will receive input from the project teams to help understand how project implementation will impact their regions.

● Outline the role of the PAC in the development of the PPS organizational structure, as well as the input the

PPS had during the Community Needs Assessment (CNA).


Our initial PAC structure evolved into the newly established FLPPS governance structure. Since the launch of the FLPPS PMO, stakeholder engagement has been a priority in ensuring that the development of FLPPS and the Project Plan Application accurately reflected the perspectives of its stakeholders. Various drafts of the CNA were posted to the FLPPS website for review, and stakeholder comments were submitted to FLHSA for consideration.

● Please explain how the members included provide sufficient representation with respect to all of the providers

and community organizations included within the PPS network.

PPS Response (125 words max): Current: 783 characters

Committees were populated by nominations received from interested providers from across the FLPPS service area and by members of the Project Advisory Committee. In order to ensure each committee represented the cross-section of provider types and geographies across the FLPPS service area, each committee developed a matrix of provider type by NOCN. Co-chairs and initial committee members, along with project managers who orchestrated a number of NOCN-level planning days, reviewed nominations


and posed additional suggestions for membership to ensure that at membership represented at least one member from each of the five NOCNs and at least one member from each of the relevant provider types (i.e. behavioral health, hospital, post-acute, community-based organization, etc.).

● Identify the designated compliance official or individual and describe the individual’s organizational

relationship to the PPS governing team


The Finance Committees and Board of Directors, serving as the audit committee, will jointly vet and recommend a full time or contracted resources to serve as the Compliance Officer who will have a joint reporting relationship to the CEO and the Board of Directors.

The FLPPS Compliance Officer will periodically report on compliance activities to the FLPPS Board of Directors.

The Compliance Officer will attend all meetings of the Board of Directors and Executive Committee.

● Describe the mechanisms for identifying and addressing compliance problems related to the PPS’ operations

and performance

PPS Response (1,200 characters max): Current: 1,152 characters A standing Compliance Committee will be formed and chaired by the Compliance Officer.

The Compliance Committee and the Compliance Officer will jointly agree upon the DSRIP, State and Federal rules and regulations that will be included in this oversight role.

Written policies and procedures that define compliance, and describe compliance expectations, of all FLPPS staff, FLPPS providers and partners and their respective staffs will be developed and communicated. Executive Committee.

These will include guidance to all employees on how to deal with and report potential compliance issues and include the process by which compliance problems are investigated, reported and resolved.

An anonymous Compliance Integrity Hot Line will be implemented. The Compliance Officer will be responsible for reviewing the Hot Line and reporting the contents and actions taken to the Executive Team (CEO, CFO, COO) on a monthly basis.

All material agreements, contracts, policies and procedures require review by the Compliance Committee prior to execution.

The Compliance Officer will also report the compliance plan annually to NYS OMIG

● Describe the compliance training for all PPS members and coalition partners. Please distinguish those training

programs that are under development versus existing programs

PPS Response (1,200 character max): Current: 1,049 characters The Compliance Officer will be responsible for developing compliance education and training programs,

including a FLPPS-wide HIPAA program, along with establishing audit procedures. Disciplinary policies that encourage good faith participation will also be developed. In addition, included will be a policy of non-intimidation and non-retaliation that will be communicated to all affected persons.

Training and education will be provided to all existing and new FLPPS employees, Directors and all affected persons associated with FLPPS through a variety of communicative options.

A FLPPS Compliance Website will be developed with an easily accessible link for partners and members to submit complaints.


The Compliance Officer will review code of conduct and compliance policies and programs of all FLPPS partners and how they relate to DSRIP. Any deficiencies will be addressed through the FLPPS compliance program.

A schedule will be developed to review and monitor the compliance programs of all FLPPS partners.

● Please describe how community members, Medicaid beneficiaries and uninsured community members

attributed to the PPS will know how to file a compliance complaint and what is appropriate for such a process

PPS Response (1,200 characters max): Current: 410 characters Complaints can be filed through the FLPPS Compliance Integrity Hot Line.

Awareness of the Hot Line and instructions on how to file a complaint will be communicated to attributed members through various communications including mailings, notices on billing statements, blast e-mails, etc.

FLPPS will also work with the various Medicaid Managed Care plans to help make their members aware of the Hot Line.

PPS Financial Organizational Structure (worth 10 percent of total points available for Section 2) Please provide a narrative on the planned financial structure for the PPS, including a description of the financial controls that will be established. This narrative should include, at a minimum: ● Description of the processes that will be implemented to support the financial success of the PPS and the

decision making of the PPS’ governance structure.

PPS Response (1,200 characters max): Current: 897 characters The FLPPS Finance Committee has been in place since October 2015. The specific tasks for the Finance Committee include:

Develop and approve policies and procedures for funds flow.

Implement mechanisms for financial accountability and oversight including internal control and cash management policies.

Bring material exceptions/questions/issues and variances to budget to the attention of the FLPPS Board of Directors.

Introduce action plans for any variances over established benchmarks.

Monitor financial performance of FLPPS and all Partners and report to the Board of Directors monthly.

Review and approve annual FLPPS operating and capital budgets.

Work with the Clinical Committee, Operations Oversight Committee and area Health Plans to develop recommendations for a transition from the current mainly fee for service provider contracts to specific pay-for-performance initiatives that push more financial risk for Medicaid down to the PPS and providers.

● Description of the key finance functions to be established within the PPS.

PPS Response (1,200 characters max): Current: 987 characters The financial structure for FLPPS has three components:

The FLPPS corporate Board of Directors

The Finance Committee

The FLPPS CFO and finance staff


As the fiduciary to DOH, FLPPS will be receiving and distributing DSRIP funds beginning on April 1, 2015. - The Finance Committee and the FLPPS CFO have principle accountability for and oversight of all financial matters for FLPPS. - The Finance Committee will work with the CFO and the Board of Directors to finalize the financial policies and procedures to be used by FLPPS, including but not limited to:

Spending authority limits

Completing the design and implementation of DSRIP fund distribution

Developing the annual budget process

Defining the financial metrics that Partner organizations are expected to meet

Developing the financial compliance program in conjunction with the Compliance Officer and the Board of Directors

Identify Medicaid & Medicare sanctioned providers and evaluate their further participation in FLPPS

● Identify the planned use of internal and/or external auditors.

PPS Response (1,200 characters max): Current: 821 characters The Board of Directors will serve as the audit committee, and as such, will coordinate with the Finance Committee, CFO, CEO and Compliance Officer to determine if a single audit firm can meet the needs of both financial and general compliance. Irrespective of this decision, the Board of Directors will issue an RFP and select a qualified external auditor for a contract that will be reviewed annually for renewal or re-bid. The auditor contract will be re-bid at a minimum every 3 years. Should a separate contract be required for a general compliance auditor, the RFP and selection for this will be undertaken by the Finance committee in coordination with the Board, as the audit, CFO and Compliance Officer. When complete, the FLPPS compliance program will meet all requirements of New York State Social Services Law 363-d.

● Description of the PPS’ plan to establish a compliance program in accordance with New York State Social

Services Law 363-d.

PPS Response (1,200 characters max): Current: 185 characters The Finance Committee will work jointly with the Compliance Officer in order to draft a compliance program for the review and approval of the Compliance Officer and the Governing Board.

Oversight and Member Removal (worth 15 percent of total points available for Section 2) Please describe the oversight process the PPS will establish and include in the response the following: ● Describe the process in which the PPS will monitor performance.

PPS Response (1,200 characters max): Current: 823 characters Performance data, collected and reported via dashboards developed based on a “balanced scorecard” framework, will be monitored through a series of “tollgates,” starting with review by the FLPPS staff; then by the Clinical and Finance committees; followed by the Operational Steering Committee and finally reviewed and discussed quarterly at the meetings of the FLPPS Board of Directors. As described earlier in the Governance sub-section, FLPPS will use clear contractual expectations, standardized consensus based performance metrics, improvement support, and consequences for continued poor performance as the processes by which the PPS will monitor performance. Dashboard metrics will continually evolve over the


course of the PPS period to incorporate benchmarks, provider comparison and targeted areas for improvement.

● Outline on how the PPS will address lower performing members within the PPS network.

PPS Response (1,200 characters max): Current: 679 characters FLPPS will have a proactive process involving engagement with PPS partners from planning and into the execution stages by FLPPS project managers, other staff, Project Team SMEs and members of the Operational Committees. An Office of Advanced Performance Improvement will be led by an expert in performance excellence and will have staff resources available to partner with providers for both the initial design of projects and improvement efforts when performance issues arise. Lower performing members will receive feedback as to their performance deficits and technical assistance, as resources allow, to assist and support the provider in gaining performance improvement.

● Describe the process for the sanctioning or removing a poor performing member of the PPS network who fails

to sufficiently remedy their poor performance. Please ensure the methodology proposed for member removal is consistent and compliant with the standard terms and conditions of the waiver.

PPS Response (1,200 characters max): Current: 1,127 characters As discussed earlier, FLPPS will use clear contractual expectations, standardized consensus based performance metrics and improvement support to monitor and attempt to improve performance when necessary. Performance data will be transparently shared and discussed on a regular basis such that a poorly performing provider will have early indications and interventions when performance has begun to suffer, or appears at risk. These providers will be placed on a Corrective Action Plan (CAP). Providers on a CAP who are either unable to engage in performance improvement activities to change performance and/or are unwilling to do so will undergo a process of peer review overseen by the Clinical and Operational Steering Committees in coordination with the FLPPS assigned staff and the Compliance Officer. After a prescribed amount of time and set of attempted interventions as per the policies and procedures of FLPPS, which will be compliant with the standard terms and conditions of the Waiver, the Board of Directors may be recommended by the Clinical Committee and Compliance officer to remove the poorly performing member.

● Indicate how Medicaid beneficiaries and their advocates can provide feedback about providers to inform the

member renewal and removal processes.


The PPS will incorporate into its own policies and procedures Medicaid beneficiaries' existing complaint and appeal processes that will reflect concerns regarding dissatisfaction, appointment scheduling, denied referrals. Lower-performing providers will be subject to Corrective Action Plans (CAPs), which will provide a critical focus on improving performance over time. However, it is essential that there is accountability to the entire PPS for continuing failure to improve performance by removing Members after a reasonable period.

● Describe the process for notifying Medicaid beneficiaries and their advocates when providers are removed

from the PPS.


PPS Response (1,200 characters max): Current: 346 characters Medicaid beneficiaries will receive advance notice, as per FLPPS policies and procedures, of an action to remove their provider from the PPS and will be provided with information on how this may impact Medicaid members and their options for seeking ongoing care if there is a risk that ongoing care may not be available with the removed provider.

Domain 1 - Governance Milestones Progress towards achieving the project goals and core requirements specified above will be assessed by specific milestones for the DSRIP program, which are measured by particular metrics. Investments in technology, tools, and human resources that will strengthen the ability of the Performing Provider Systems to serve target populations and pursue DSRIP project goals. Domain 1 process milestones and measures will allow DOH to effectively monitor DSRIP program progress and sustainability. The following outlines the milestones that will be required and expected of the PPS to earn DSRIP payments. The milestone is presented for informational purposes only, however, the PPS will be expected to develop a work plan to outline the steps and timeframes in which these milestones will be achieved. - Implementation plan outlining the PPS’ commitment achieving its proposed governance structure (Due March 1, 2015). - Periodic reports, at a minimum semi-annually and available to PPS members and the community, providing progress updates on PPS and DSRIP governance structure.. - Supporting documentation to validate and verify progress reported on governance, such as copies of PPS bylaws or other policy and procedures documenting the formal development of governance processes or other documentation requested by the Independent Assessor.


Section 3 – Community Needs Assessment Section 3 – Community Needs Assessment (25 percent of the Overall PPS Structure Score) Description All successful DSRIP projects will be derived from a comprehensive community needs assessment (CNA). Since DSRIP is about system transformation, the structure of a DSRIP CNA will be different from the usual public health format. The CNA should be a comprehensive assessment of the health care resources and community based service resources currently available in the service area and the demographics and health needs of the population to be served. This will lead to the identification of excesses and gaps in services that will need to be corrected in order to transform the system to one that meets the goals of DSRIP. The CNA will be evaluated based upon the PPS’ comprehensive and data-driven understanding of its service delivery system and the community it intends to serve. Please note, the PPS will need to reference in Section 4, DSRIP Projects, how the results of the CNA informed the selection of a particular DSRIP project and how the choice of projects combine to result in the envisioned transformed system. The CNA shall be properly researched and sourced, shall effectively incorporate the stakeholder engagement in its formation, and shall identify current community resources, including community based organizations, as well as existing assets that will be enhanced or eliminated as a result of the PPS’ CNA. Lastly, the CNA should include documentation, as necessary, to support the PPS’ community engagement methodology, outreach and decision-making process. For more information on DOH’s expectations to ensure a successful completion of the CNA, please refer to the document, Guidance for Conducting Community Needs Assessment required for DSRIP Planning Grants and Final Project Plan Applications, and the DSRIP Population Health Assessment Webinars, Part 1 and, particularly 2, located on the DSRIP Community Needs Assessment page: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip_community_needs_assessment.htm Health data will be required to further understand the complexity of the health care delivery system and how it is currently functioning. The data collected during the CNA should enable the evaluator to understand how the health care delivery system functions, the community the PPS seeks to serve and the key populations where service gaps are identified. The CNA must include the appropriate data that will support the CNA conclusions that drive the overall PPS strategy. Data provided to support the CNA must be valid, reliable and reproducible. In addition, the data collection methodology presented to conduct this assessment should be done with consideration that future community assessments will be required. DOH has provided a significant amount of relevant data that should inform and be leveraged to complete the CNA process. This data, in addition to other relevant data sources produced other state agencies, can be found on the DSRIP Performance Data, found here: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip_performance_data/. It is critical that the PPS leverage the data sources available on the DSRIP Performance Data page to ensure the successful completion of the CNA. Overview on the Completion of the CNA (worth 5 percent of total points available for Section 3) Please describe the completion of the CNA process and include in the response the following: Describe the process and methodology in which the CNA was completed.


PPS Response (2,000 characters max): Current: 1,787 characters Finger Lakes PPS worked collaboratively with Finger Lakes Health Systems Agency, a regional health planning group, to compile and finalize the CNA. In-depth quantitative analyses and extensive qualitative feedback were intertwined – each guiding the other – throughout the six-month process.

- The groundwork for the CNA was laid by reaching out to a diverse group of stakeholders to discuss the DSRIP opportunity, ascertain level of interest, initiate an assessment of perceived community needs, and explore PPS/provider/organization potential roles in addressing those needs.

- Preliminary local health status data (general population demographics, demographics and description of Medicaid population, description of current inpatient and outpatient hospital use in Medicaid population, avoidable hospital use metrics, population health outcomes) was shared with service providers, community partners, and interested community members, who began to identify perceived gaps in service, and to prioritize focus areas for the community. This provided the basis for planning subsequent data analyses.

- Additional quantitative analyses provided a better understanding of the potential factors contributing to healthcare challenges for Medicaid/uninsured populations. Methods included the combining of multiple datasets, geographic variation analyses, bivariate analyses, and multivariate modeling techniques.

- Input on the results of these additional quantitative analyses was sought from an even broader cross-section of the community.

- A more complete CNA and potential project list was then sent to the full list of potential FLPPS providers and stakeholders, and was posted on the FLPPS website for public comment. These comments were incorporated into the final CNA document.

Outline the information and data sources that were leveraged to conduct the CNA, specifically citing specific resources that informed the CNA process.

PPS Response (2,000 characters max): Current: 2,151 characters Quantitative information and data resources leveraged in the initial, preliminary analyses included state-provided data and additional data sources for more in-depth exploration and subgroup analyses, including: 2010 US Census data (US Census Bureau) Vital Statistics of New York State (NYS DOH) Salient non-PHI Medicaid Claims Database Statewide Planning and Research Cooperative System Inpatient and Outpatient Hospital Claims Database (NYS DOH) Behavioral Risk Factor Surveillance Survey NY State Open Data Subsequent, more in-depth analyses utilized data from: Western Region Behavioral Health Organization’s quarterly progress reports 2012 American Community Survey (US Census Bureau) Hospital and nursing home cost reports Directories of community-based service providers obtained from three regional 2-1-1 centers. Finger Lakes Health Systems Agency Health Disparity Reports


Finger Lakes Health Systems Agency Regional Chart Books Finger Lakes Health Systems Agency Regional Profiles Sage Commission Report New York State Health Foundation CCSI BH Resource Database Catholic Family Center records Community Health Care Association of New York State reports In addition, qualitative information was gathered through: - (5) Meetings with workgroups of service providers – needs/priorities in geographic sub-areas - (1) Community partner survey – additional input on projects - (3) Community partner engagement meetings – overall consensus on initial project selection - (2) Project Advisory Committee meetings – feedback from partner organizations and interested community members - (6) Naturally Occurring Care Network planning meetings – regional-level needs and geographical disparities - (1) Regional Commission on Community Health Improvement meeting – broad dissemination of preliminary CNA results - FLPPS website – feedback on CNA draft - (1) Public webinar – key issues - (15) Focus groups – challenges and barriers for specific at-risk populations - (30) Key informant interviews – complex issues facing these at-risk populations - (1) Community services survey – additional information on supply, distribution, and utilization of community services

Healthcare Provider Infrastructure (worth 15 percent of total points available for Section 3) Each PPS should do a complete assessment of the health care resources that are available within its service area, whether they are part of the PPS or not. For each of these providers, there should be an assessment of capacity, service area, Medicaid status, as well as any particular areas of expertise. Please address the following in the response: Describe in an aggregate level the existing healthcare infrastructure and environment, including the number and types of healthcare providers available to the PPS to serve the needs of the community.

PPS Response (Table): Convert to table The FLPPS region includes 23 acute care hospitals with a total of 3,843 acute care beds. Beds per 100,000 population by county range from zero to 524.12. The combined occupancy rate for hospitals in the region is 61.1 percent, but site-specific rates range from 15 to 80 percent, with lower rates in rural hospitals. There are a total of 9,521 nursing home beds, and average occupancy rate for the region is 91.4 percent, with a range of 39.5 to 109.4 percent by facility. There are 32 ambulatory surgical centers, one freestanding emergency department, and 46 urgent care centers in the region. However, 24 percent of the urgent care centers do not accept Medicaid, and only 58 percent


accept all types of Medicaid. There is no hospital or ambulatory surgical center in Seneca County, and no sources of urgent care (outside of the hospital emergency department) in Wayne, Wyoming or Yates Counties. There are 63 Federally Qualified Health Centers in the FLPPS region, nearly 60 percent of which are located in Monroe County, and five mobile FQHCs that serve multiple counties Health Homes of Upstate New York (HHUNY), serves 11 of 14 FLPPS counties. Seven other health homes provide services only in specific counties, few of which are rural. County health departments provide services to the Medicaid and uninsured populations in all FLPPS counties, but the availability of services varies by county. PCP FTE per 100,000 population data show that only Monroe County exceeds the state average, with several FLPPS counties demonstrating less than half of the PCP workforce than the state per capita ratio. The entire counties of Allegany, Livingston, Orleans, Schuyler, Seneca, Wayne, Wyoming and Yates Counties are primary care Health Professional Shortage Areas, and portions of Cayuga, Genesee, Monroe, Ontario and Steuben Counties are designated as well. Dentists are underrepresented in every FLPPS county compared to the state per capita ratio, and numerous areas are designated as dental HPSAs. Pharmacists are underrepresented in 12 of the 14 FLPPS counties. Every county in the FLPPS region measures below the New York State average rate – in some cases significantly – for psychiatrists and psychologists. Allegany, Chemung, Orleans, Schuyler, Seneca, Steuben, Wyoming, and Yates counties are identified in their entirety as mental health HPSAs, and Cayuga, Genesee, Livingston, Monroe, Ontario, and Wayne counties have specific subsets of mental health HPSAs.

Outline how the composition of the providers needs to be modified to meet the needs of the community.

PPS Response (3,200 characters max): Current: 2,135 characters While the FLPPS region as a whole has a large number of healthcare resources covering the full spectrum of acute, primary, long term, specialty and behavioral health care resources, there remain significant shortages in providers of primary care, dental care, behavioral health services, and substance abuse treatment services, and access and availability vary -- particularly for Medicaid recipients -- from one sub-area of the FLPPS region to another. Many services are geographically spread out, so they are less accessible to patients and less likely to be coordinated by providers, and communication tends to be siloed. At the county level, data suggest that there is significant variation in the quality of or access to primary care provided to persons with chronic disease. There is very limited penetration of integrated models of care, such as accountable care organizations and health homes, in the FLPPS region, and much of the service capacity of currently existing integrated delivery systems are concentrated in Monroe County. Given the fact that a coordinated and integrated healthcare delivery system has been shown to provide highly efficient and effective care to complex patients with chronic disease, we need to significantly expand the penetration of integrated models of care throughout the FLPPS region. At the same time, in all but two of the region’s fourteen counties, nurse staffing remains higher than the state average per 100,000 population. At least in the case of primary care services, additional PCMH


certification efforts could serve to rebalance work flow in primary care practices so that patient needs are better met using the resource of nurse staffing. Within many of these counties, correctional facilities are identified as needing additional mental health services, and half of the 14 counties specifically identify the Medicaid population as being in need of additional mental health services. The lack of access to adequate primary care or urgent care other than through an Emergency Department -- particularly for the Medicaid population -- suggests the need for care triage at EDs.

Community Resources Supporting PPS Approach (worth 10 percent of total points available for Section 3) Community based resources take many forms. This wide spectrum will include those that provide basic life needs to fragile populations as well as those specialty services such as educational services for high risk children. There is literature that supports the role of these agencies in stabilizing and improving the health of fragile populations. (Extensive list) Please address the following in the response: Describe in an aggregate level the existing community resources, including the number and types of resources available to the PPS to serve the needs of the community.

PPS Response (Table): Convert to table

The total number of community programs providing services to the residents of the FLPPS region is nearly 5,600. Of these, 1,137 are for individual and family life, 1,085 are for health care, 1,082 are for basic needs, 878 are for organizational/community/international services, and 754 are for mental health and substance abuse services, with significantly fewer programs for consumer services, criminal justice and legal services, education, environment and public health/safety, and income support and employment. Thirty-six percent of these programs are located in Monroe County, 13 percent are located in Steuben County, and 10 percent are located in Chemung County. Only one percent of these resources are located in Wyoming County, one percent in Orleans County, two percent in Genesee County, two percent in Seneca County, and three percent in Livingston. The remaining six counties have between four and nine percent of community program services. Of the total of 278 transportation programs in the FLPPS region, there are none in Orleans County; one in each of Livingston, Seneca and Wyoming Counties; and three in each of Cayuga, Ontario, and Wayne Counties. There are 21 in Monroe County and 30 in Steuben County. Safe and stable housing is essential particularly for individuals with severe and persistent mental illness, and a review of the number of housing programs by county again shows significant disparity between counties: Five counties (Livingston, Orleans, Seneca, Wayne, and Wyoming) have fewer than 10 housing programs, while most have between 12 and 33 programs. Monroe County has 75 programs, but also contains nearly half of the FLPPS population. There are a total of 146 libraries and 832 religious organizations throughout the FLPPS region. Collaborative partnerships with community organizations such as libraries and religious organizations have been illustrated


as a strategy to improve community success. For example, Rochester has successfully utilized partnerships with primarily African-American faith-based organizations, which are frequently located in neighborhoods with high rates of poverty, to address disparities in high blood pressure and encourage health habits at the community level. Libraries can serve as a resource for individuals to access information about health and to communicate with providers.

Outline how the composition of the community resources needs to be modified to meet the needs of the community .Analysis of potentially preventable visit rates and distance to emergency rooms identified that proximity was associated with PPV utilization in the FLPPS region.

PPS Response (3,200 characters max): Current, 1,160 characters While there are many community-based resources in the FLPPS region, the majority of these services are clustered in Monroe, Steuben, and Chemung Counties, and significant service gaps persist throughout the region. Given the size and rurality of much of the FLPPS region, and the fact that the lack of transportation services was identified by community-based organizations and behavioral health survey respondents as the leading barrier to residents needing services, transportation is clearly an area that should be addressed. In fact, analysis of potentially preventable visit rates and distance to emergency rooms identified that proximity was associated with PPV utilization in the FLPPS region. Even in the counties with larger numbers of supportive housing programs, taking into account certain characteristic of these counties (for example the concentration of the region’s population in Monroe County), all counties in the FLPPS area would benefit from additional housing programs. Additional leveraging of libraries and religious organizations within a patient-centered model could have far-reaching positive impacts on health care in the FLPPS region.

Community Demographics (worth 15 percent of total points for Section 3) Demographic data is important to understanding the full array of factors contributing to disease and health. Please address the following in the response: Provide detailed demographic information, including: (1000 max characters each bullet point) o Age statistics of the population; o Race/ethnicity/language statistics of the population, including identified literacy and health literacy limitations; o Income levels; o Poverty levels; o Disability levels; o Education levels; and o Employment levels. Please note, demographic information should also include those who are institutionalized, as well as those involved in the criminal justice system. *As necessary, please include relevant attachments supporting the findings.


PPS Response (1000 characters max): The FLPPS is comprised of 14 counties: Allegany, Cayuga, Chemung, Genesee, Livingston, Monroe, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, and Yates). The city of Rochester, located in Monroe County, serves as the primary urban center in the region, and nearly half of the region’s 1.5 million people reside in Monroe County. As is the case with many cities, the farther one travels from the urban center of Rochester, the more progressively rural the area becomes. Given the size of the Finger Lakes PPS region and the significant variation of urban versus rural areas, while there are some demographic factors that are consistent across the region, there are a number that differ by geographic area:

- In the last twenty years, the region’s population has increased only 1.3 percent; however, the number

of persons over the age of 65 has increased by 40,000, and they now account for 15.4 percent of the total population.

- Ranging from 11.4 percent in Livingston County to 15.5 percent in Steuben County, all counties in the FLPPS have higher rates of disabilities in non-institutionalized population than New York State as a whole. This may be related to the aging of the region’s population.

- Ranging from $42,000 to $54,000, the median household income for all FLPPS counties falls below the New York State average of $57,683.

- Twelve of the 14 counties have greater than 10 percent of their population living below the poverty threshold; however, only four of these counties have a poverty rate above the statewide average.

- The percent of the population with a high school degree or less ranges from over 52 percent in Allegany County to about 36 percent in Monroe County; only two counties (Monroe and Ontario) have a rate that is less than the New York State average.

- Racial and ethnic diversity are concentrated in Monroe County, where the population identify as 62 percent white, 22 percent African American, and 6 percent Hispanic; the remaining thirteen counties identify as 62 percent white, 4 percent African American, and 3 percent Hispanic.

- Roughly 13 percent of the population aged 5 and older in Monroe County speak a language other than English at home, but only about 5 percent of the total Monroe County population report speaking English “less than very well.” At an aggregate level, however, the population of non-English speakers in the FLPPS is much lower than New York State rates.

- Unemployment rates vary from 5.5 percent to 9.9 percent, with three counties having a rate higher than the statewide average.

- In 2013 twenty percent of the region’s population was enrolled in Medicaid. While the Medicaid population is centralized in the City of Rochester, all counties in the region have significant numbers of Medicaid enrollees. The race and ethnicity of Medicaid enrollees closely mirror that of the region’s population as a whole.

- The number of Medicaid enrollees increased by 32 percent from 2011 to 2013, and as a result of the Affordable Care Act, that number is anticipated to continue to increase over the life of the DSRIP program.

The FLPPS region is also home to a number of populations with special health needs: - Rochester and the Finger Lakes region has a significant deaf community, supported by the presence of

the National Institute for the Deaf (NTID) and the Rochester School for the Deaf (RSD). At a national level, these individuals are poorer on average than other Americans and are more likely to have public assistance (Medicare or Medicaid). This community experiences language and communication barriers, especially among individuals deafened before the age of three.


- The FLPPS region has over 25,000 OPWDD consumers, and almost 4,500 OPWDD consumers in community-based residential care. These consumers are individuals with developmental disabilities, defined as a diverse group of severe chronic conditions that are due to mental and/or physical impairments, and they represent a disproportionate approximately 12 percent of OPWDD consumers statewide. Access to dental care is a high need for this population.

- Across the FLPPS region, 2.0 percent of the population is institutionalized in prisons, juvenile facilities, nursing homes, psychiatric facilities, hospices, and residential schools for individuals with developmental disabilities. People in institutionalized settings often have unique health challenges such as dental needs, diabetes and depression.

- The FLPPS region is home to over 11,000 individuals who identify as at least partially Native American, and Genesee County is home to the Tonawanda reservation, where more than 500 Native Americans reside. A national study indicates that up to 30 percent of American Indian and Alaska Native adults suffer from depression, and are at higher risk for both diabetes and cardiovascular disease. The study also indicated that the current health care system has difficulty recognizing this population and addressing their issues.

- There are over 5,200 refugees living in the FLPPS region, mainly in the city of Rochester. These refugees are enrolled in Medicaid upon their arrival in this country, and most remain on Medicaid until they are able to secure employment or transition to other coverage. Forty-three percent of refugees in the region are from Bhutan, 19 percent from Burma, 9 percent from Cuba, 9 percent from Iraq, 9 percent from Somalia, 3 percent from Congo, and the remaining 8 percent from a variety of countries. Language and cultural differences can present challenges as these individuals access health care here.

- The rural areas of the FLPPS region are home to a very large population migrant workers, some of whom are uninsured, and some of whom are covered, at least for the time they are here in New York State, by Medicaid. However, these individuals are transitory, which presents unique challenges in managing their health care.

Community Population Health & Identified Health Challenges (worth 15 percent of total points for Section 3) Please describe the health of the population to be served by the PPS. At a minimum, the PPS should address the following in the response: Identify the leading causes of death and premature death by demographic groups.

PPS Response (1,200 characters max): Current: 863 characters Leading causes of death in the FLPPS region are cancer and heart disease, regardless of race or ethnicity; they are also the leading causes of premature death, or years of potential life lost (YPLL), for deaths before the age of 75. Unintentional injury is also one of the top five causes of premature death for all demographic groups. However, there are a number of top five causes of premature death that are unique to specific demographic groups: homicide is in the top five for both African American and Latino populations; suicide is in the top five for whites and Latinos; and COPD and stroke are in the top five for whites and African Americans respectively. In general, African Americans and Latinos in the region have consistently higher rates of premature death than whites, with African Americans having a rate that is almost twice that of whites.

Leading causes of hospitalization and preventable hospitalizations by demographic groupings.

PPS Response (1,200 characters max): Current: 978 characters Combined, diseases of the circulatory, respiratory, digestive and endocrine systems account for almost 20


percent of Medicaid hospital admissions. People of color have substantially higher rates of PQIs, regardless of type of condition, within the FLPPS. It is unclear if these differences are related to disparities in the quality of or access to primary care, differences in the utilization of primary care services, differences in disease prevalence, or some combination of these factors. Data also shows that end-of-life care contributes to a sizable number of inpatient admissions. Conditions of the circulatory and respiratory system are the two primary diagnoses related to Medicaid readmissions. However, aggregating mental illness and substance use disorders accounts for over 17 percent of all readmissions, the highest percentage of Medicaid readmissions. The presence of multiple conditions also appears to be an important contributor to the risk for readmission.

Disease prevalence such as diabetes, asthma, cardiovascular disease, depression and other behavioral health conditions, HIV and STDs, etc.

PPS Response (3,200 characters max): Current: 793 characters There are a substantial number of Medicaid recipients in the FLPPS region living with chronic conditions. Topping this list are: 45,159 Medicaid beneficiaries with hypertension, 37,880 with depression, 22,251 with asthma, 21,462 with diabetes, and 17,680 with chronic stress and anxiety diagnoses. Rates of mental diseases and disorders and substance abuse are higher in the FLPPS than the state as a whole: across the state, 51.5 percent of Medicaid beneficiaries have received OMH or OASAS services in their lifetime, while 58.0 percent of FLPPS Medicaid beneficiaries have. Overall, conditions related to mental illness and substance use disorders, diabetes, respiratory illness, and heart disease appear to be major contributors to the overall chronic disease prevalence in the region.

Maternal and child health outcomes including infant mortality, low birth weight, high risk pregnancies, birth defects, as well as access and quality of prenatal care.

PPS Response (1,200 characters max): Current: 698 characters Five of the FLPPS counties have a higher rate of infant mortality than the state. Explanations for this phenomenon have been difficult to ascertain, as the region demonstrates relatively low rates of teen pregnancy (except in Monroe and Chemung counties) and higher percentages of parents receiving prenatal care. In Monroe County infant mortality rates for African Americans and Latinos were between three and four times higher than for white residents; these disparities are virtually non-existent in rural areas of FLPPS. Of the 11 counties where data is available, seven demonstrate a drug-related newborn discharge rate higher than the New York state average, particularly in Monroe County.

Health risk factors such as obesity, smoking, drinking, drug overdose, physical inactivity, etc.

PPS Response (1,200 characters max): Current: 477 characters Throughout the FLPPS region data show consistently higher rates of tobacco use (current smoking), overweight and obesity, binge drinking, and poor mental health (14 or more of the past 30 days) than the state overall. Nearly 9,000 beneficiaries chronically abuse alcohol and 7,400 are listed as having drug abuse as chronic issue.


The FLPPS rate of chronic alcohol abuse and chronic drug abuse are much higher than the state’s rate (28.1 vs 20.4 and 23.3 vs 16.9, respectively).

Any additional challenges:

PPS Response (1200 characters max): Current: 0 characters

Healthcare Provider and Community Resources Identified Gaps (worth 15 percent of total points for Section 3) Please describe the PPS’ capacity compared to community needs. In the response please address the following: Identify the health and behavioral health service gaps and/or excess capacity that exist in the community, specifically outlining excess hospital and nursing home beds.

PPS Response (3,200 characters max): Current: 1,777 characters Chronic diseases account for one of the leading causes of death in the FLPPS region, demonstrating a need for more chronic disease management. Entire counties in the FLPPS region are health professional shortage areas for primary care providers, who could provide needed management of diseases that can be managed in a primary care office rather than an acute care facility. There is a shortage of providers with more than one licensure type in 7 of the 14 FLPPS counties, showing that providers aren’t equipped to managed complex care and coordinate within their facilities. A lack of coordination between behavioral health providers and primary care providers is also an issue. Furthermore, only 44 percent of psychiatrists nationally are willing to accept Medicaid patients, which reduces the access for underserved patients with these needs. Across 10 of the 14 counties in FLPPS, there is a shortage of behavioral health providers. For both medical and mental health conditions, prevention often begins in the community and with the influencing of other social determinants. In FLPPS, most of the resources are located in three counties. The remaining counties’ residents lack access to crucial social services which can help prevent the exacerbation of chronic diseases and other conditions. Particularly the FLPPS region is in need of more housing, transportation, and services for women and children. Most of the counties in the FLPPS area have bed shortages, rather than excesses. Nursing home beds are less than the state average in 9 of the 14 counties and hospital beds are less than the state average in 12 of our 14 counties. Assuming a 25 percent improvement in the NYS rate of hospitalization, the FLPPS region would still have shortages in 10 of the 14 counties.

Include data supporting the causes for the identified gaps, such as the availability, accessibility, affordability, acceptability and quality of health services and what issues may influence utilization of services, such as hours of operation, and transportation that are contributing to the identified needs of the community. PPS Response (300 words max):

PPS Response (2,400 characters max): Current: 1,176 characters Much of the data supporting the causes for identified gaps and community needs are found in the CNA. Some supporting facts include:


1. The availability of PCP FTE per 100,000 population is significantly lower than the state rate in 11 counties in FLPPS. One county, Orleans County, has about ⅓ of the PCP FTE than the state rate. Every single one of the counties in FLPPS has less dentists per 100,00 population than the state.

2. The state has an average of 36 psychiatrists per 100,00 population. However, every single one of the FLPPS counties has less than that per 100,000. The lowest are Allegany, Schuyler and Livingston.

3. The FLPPS region has an average of 3.7 support services per 100,000 population for behavioral health patients.

4. The most common causes of death and premature mortality are heart disease and cancer, followed by COPD, stroke and unintentional injury.

5. Suicide is the fifth leading cause of premature mortality. 6. The top chronic conditions for Medicaid beneficiaries in FLPPS are hypertension (45,159 beneficiaries),

depression (37,880), asthma (22,251), diabetes (21,462), chronic stress and anxiety diagnoses (17,680) and schizophrenia (15,298).

Identify the strategy and plan to sufficiently address the identified gaps in order to meet the needs of the community. For example, please identify the approach to develop new or expand current resources or alternatively to repurpose existing resources (e.g. bed reduction) to meet the needs of the community.

PPS Response (2,400 characters max): Current: 1,200 characters Overall, population in the region has fallen has been relatively stable over the past several decades, with a 1.3 percent increase from 1992 to 2012. We would expect this to result in some excess bed capacity. But, that inappropriate utilization of hospital and ED, has prevented us from taking advantage of this excess capacity. Presumably, we would repurpose excess capacity in counties that are “richer” in the resource, such as Chemung, Ontario, Monroe, and Steuben. Many opportunities for overall quality improvement were identified in the CNA:

➢ Over utilization of ED due to close proximity and ease of access. Resolved through ED triage, and things like expanded hours at PCMH locations

➢ Opportunities to impact super users (behavioral health and health comorbidities) While the needs of the population in the FLPPS region -- and the service gaps in meeting those needs -- are not homogeneously distributed, there are four primary opportunities that are consistent throughout much of the region:

1. Integrated delivery system to address chronic conditions 2. Integration between physical and behavioral health care systems 3. Address social determinants of health 4. Support women and children

Stakeholder & Community Engagement (worth 5 percent of total points for Section 3) It is critically important the PPS strategy be developed through collaboration and discussions to collect input from the community the PPS seeks to serve. Please address the following in regards to stakeholder and community engagement: Describe, in detail, the stakeholder and community engagement process undertaken in developing the CNA (public engagement strategy/sessions, use of focus groups, social media, website, and consumer interviews).


PPS Response (2,400 characters max): Current: 2,170 characters After the announcement of the DSRIP program opportunity in the spring of 2014, the four emerging PPSs in the Finger Lakes region convened numerous informational meetings with community stakeholders, including insurers, the Regional Commission on Community Health Improvement, FQHC representatives, public health officials, self-organized groups of providers, and a school of nursing. Subsequently, the emerging PPSs engaged the community (through 5 workgroups of service providers in geographic sub-areas, 3 Community Partner Engagement Meetings with over 240 attendees from interested organizations and providers, and a survey of 100 potential community partners) to examine preliminary data, identify perceived gaps in service, and begin to prioritize focus areas for the community. After additional quantitative data analyses were conducted, data and results were shared with, and input was sought from, an even broader cross-section of the community through: two Project Advisory Committee meetings with a total of over 400 representatives from partner organizations and interested community members; six regional Naturally Occurring Care Network meetings with more than 170 potential participating staff from health care providers, community service providers, hospital/health system leadership, subject matter experts, patient advocates, and interested community members; a meeting with the Regional Commission on Community Health Improvement to broadly disseminate findings with community representatives; a Finger Lakes PPS website that provided background, updates, milestones, upcoming events, and the most recent version of the CNA for public comment; a public webinar on Updates and Next Steps; 15 focus groups; 30 key informant interviews; and a web-based Community Services Survey to all known community service providers in the region, to identify resources, capacity, and barriers to utilization of services. A more complete CNA and potential project list was then sent to the full list of potential FLPPS providers and stakeholders, and was posted on the FLPPS website for public comment. These comments were incorporated into the final CNA document.

Describe the number and types of focus groups that have been conducted.

PPS Response (1,200 characters max): Current: 1,036 characters In collaboration with FLPPS partner organizations, qualitative research was conducted in community settings with 15 focus groups of Medicaid recipients, Medicaid providers, and at-risk individuals. Guided by preliminary findings of quantitative data analysis and stakeholder input, the general themes included:

➔ Currently pregnant, first-time mothers ➔ Mothers of young children ➔ Individuals with behavioral health condition and history of hospital use ➔ Individuals with chronic disease and history of hospital use ➔ Individuals with substance use disorders and history of hospital use ➔ Individuals readmitted to hospital within 30 days of discharge ➔ Individuals with history of frequent emergency department use (not related to behavioral health

condition) ➔ Migrant workers in rural counties

Focus groups for each theme were conducted in different counties to capture differences between urban and rural populations, and focused on challenges faced by the group, underlying causes of hospital use, and barriers to receiving needed care.


Summarize the key findings, insights, and conclusions that were identified through the stakeholder and community engagement process.

PPS Response (1,200 characters max): Current: 764 characters The FLPSS’s broad-based stakeholder and community engagement process provided invaluable insight into, and perspective on, a number of health issues, especially for at-risk populations in our community. These findings included:

- Physical and mental health must be simultaneously addressed. - It is difficult for individuals to find specialized mental health and/or substance use treatment

throughout the area, and primary care physicians are ill-equipped to provide such comprehensive care. - Socioeconomic factors are a driving force behind mental and physical wellbeing struggles with chronic

conditions. - Individuals with chronic conditions are not receiving care that is integrated throughout the healthcare

system, and this is negatively impacting outcomes.

Please complete the following stakeholder & community engagement exhibit. Please list the organizations engaged in the development of the PPS strategy, a brief description of the organization, and why each organization is important to the PPS strategy.

Organization Brief Description Rationale

Naturally Occurring Care Networks (NOCNs)

Geographically based networks of FLPPS partners based on shared utilization patterns

Because of the size of the FLPPS region, and the distinct needs of certain sub-areas within it, NOCNs provided feedback specific to their geographic areas.

Regional Commission on Community Health Improvement (RCCHI)

The RCCHI aims to improve health outcomes by facilitating the integration and coordination of programs and activities across nine of the FLPPS counties.

This is a large and very diverse group of community leaders whose endorsement and feedback were essential. They were also able to assist with broad dissemination of the preliminary CNA results.

County Health Departments

Provide a variety of services to Medicaid and uninsured populations

County Health Departments work in tandem with other health care providers and community agencies; FLPPS focus and activities will benefit from collaboration with them.

FLPPS Participant Advisory Committee

The structure and purpose of this committee was based on guidance given in DSRIP documentation from NYSDOH.

Partner organizations should be kept informed about, and have a say in, FLPPS strategies and developments.


Healthcare and Community Service Organizations

Over [xx] healthcare and community service organizations who were interested in the initial planning and strategizing related to DSRIP in our community (through meetings and surveys).

Involvement of community service organizations in planning is crucial in order to reach consensus on community needs, and to fully understand the supply, distribution and utilization of community resources and how they might be best utilized.

Greater Rochester Health Home of NY

Provide health home services in Monroe County

GRHHN can serve as a resource for providing coordinated and integrated health care.

Health Home of Upstate NY

Provide health home services in 11 out of 14 FLPPS counties

HHUNY can serve as a resource for providing coordinated and integrated health care.

Workgroups of service providers

Service provider groups who self-organized early in the DSRIP process

These groups self-organized in an effort to understand the DSRIP opportunity and risks, and to identify shared needs and concerns to be communicated to the FLPPS leads.

Finger Lakes Health Systems Agency

Regional health planning organization

FLHSA brings extensive experience in data analysis related to population, health care utilization, and health system capacity to FLPPS.

Focus groups Medicaid recipients, Medicaid providers, and at-risk individuals

Understanding the health needs and perspectives of at-risk populations in our region is essential in developing a strategy that will address the health care needs, challenges and barriers of those populations.

Key Informants To better understand the systematic perspective on the issues discussed in focus groups

Summary of CNA Findings (worth 20 percent of total points available for Section 3) In the chart below, please complete the summary of community needs identified, summarizing at a high level the unique needs of the community. Each need should be designated with a unique community need identification number. The needs should be those that the PPS is intending to address through the DSRIP program and projects. Each of the needs outlined below should be appropriately referenced in the DSRIP project section of the application re-enforcing the rational for project selection. Finally, please attach the CNA report completed by the PPS during the DSRIP design grant phase of the project.


CNA Number

CNA Title Brief Description Primary Data Source

1 Non-urgent ED Use

The most frequently seen diagnosis category among Medicaid ED treat & release visits are non-definitive symptoms. This may suggest that significant volume is being driven by potentially non-urgent conditions, and that Medicaid recipients may be using the ED to screen for and/or diagnoses serious conditions. 23% of ED visits in the region coded for signs and symptoms

NY State SPARCS Database

2 Overuse of the ED

Patients feel that ED care was preferable for reasons including difficulty in selecting and maintaining a primary care physician, a perceived superiority of EDs in diagnosing conditions, and the belief that they would be seen faster in the ED. Patients who are close to the ED tend to use it more.

Distance data is calculated using geo-coding software to assign latitude and longitudes to ED addresses and ZIP code centroids. Straight line distances are then calculated between the ZIP code centroid and all hospitals, and the minimum among these distance is used for graph creation. PPV rates are obtained from the state-provided PPV by ZIP code file.

3 Pediatric ED use The ED visit rate for individuals less than one year old on Medicaid is approximately .49. Indicating that there is nearly an ED visit for every 2 Medicaid recipients under the age of one

Salient No PHI Medicaid Claims Database

4 Avoidable ED use

The use of the emergency department for the treatment of conditions which could have been potentially treated in a more effective and lower cost setting such as a primary care office or an urgent care center is a driver of avoidable hospital use in the Finger Lakes region. Furthermore, when compared to all counties in New York State, 9 of the 14 counties in the PPS have PPV rates that fall below the 80th percentile, meaning that only 5 of the counties in the region are among the top 20% of performers with regards to preventing avoidable ED use.

NY State Open Data

5 Avoidable ED use

PPV rates are above NYS average with data supporting an over-reliance on ED for primary care level needs; increasing outpatient capacity

NY State Open Data


and assuring linkages from ED to PC should decrease PPV rates

6 All-cause readmissions

All-cause readmissions are a significant portion of total Medicaid hospital use, accounting for almost 8,000 hospitalizations in 2012


7 High PPR rate FLPPS has an unadjusted PPR that similar to the statewide rate (6.26 vs. 6.75), with 18 of the 22 facilities in the FLPPS having a PPR rate that is worse than the top 20% of NYS performing hospitals, suggesting substantial room for improvement in the area of PPRs

NY State Open Data

8 High readmissions for chronic diseases

Chronic diseases, particularly those related to circulatory, respiratory, and behavioral health conditions are the conditions most frequently associated with a readmission, suggesting a need to focus on individuals with these diagnoses. Statistically significant higher risk for readmission - by disease type: COPD, CHF, Diabetes, CVD as primary; HTN, SMI, heart disease as secondary; co-morbities. Prevention Quality Indicators (PQIs) which are attributable to chronic disease (diabetes, respiratory, and heart) account for 85 percent of all the potentially preventable inpatient hospitalizations in the FLPPS in 2012. (CNA). A patient with 3 comorbid conditions would have between 18 and 24 percent greater risk of being readmitted within 30 days of discharge compared to a patient with no comorbid diagnoses, holding all else constant (CNA) High-risk)


9 SNF readmission rates

Discharges to a SNF that resulted in a subsequent readmission within 30 days accounted for a significant number of the overall Medicaid all-cause readmissions in 2012 (1,216 readmissions; ~15% of total readmissions), suggesting that particular attention may need to be given to SNF patients to reduce readmission rates in the FLPPS. The all-cause readmission rate among the Medicaid population discharged to a SNF was 21.2%. This rate is higher than the 15.6% readmission rate seen in individuals discharged to self-care, suggesting that patients with a SNF disposition are at greater risk for being readmitted (Table 40).-Readmissions to a acute care bed



following a discharge to a SNF account for about 16% of all Medicaid readmissions with behavioral health symptoms among the top 11 most frequent

10 Heart attacks The PPS has a higher rate of hospitalization for AMI than the NY State Average

???

11 Diabetes complications

The PPS has a higher hospitalization for PQI 01 - ST Diabetes complications than the NY State Average


12 Pediatric readmissions

Overall, FLPPS performance on this metric suggests that this is an area of strength for the 14 county region as both its unadjusted and adjusted rates are well below the statewide average (151 PDI admissions per 100,000 population and 194 vs. 323). When examining where the individuals counties rank relative to the other counties in NYS, there appears to be greater room for improvement. Namely, 9 of the 13 counties for which data were available rank in the bottom 80% of performers.

NYSDOH

13 Avoidable readmissions

While both the unadjusted and adjusted rates of composite PQI admissions in the FLPPS are slightly below the statewide rate (1,624 PQIs per 100,000 population and 1,757 vs. 1,847), many of the counties in the PPS lag behind the highest performing communities. Namely, 11 of the 14 counties in the PPS have an adjusted or unadjusted overall PQI rate that is below the top 20% of counties in the state.

NY State Open Data

14 PQIs The PQIs which are attributable to chronic disease (diabetes, respiratory, and heart) account for 85 percent of all potentially preventable inpatient hospitalizations in the FLPPS in 2012


15 ED revisit 30 day Revisit to ED rates higher for Medicaid than overall population (24% vs 18%)

???

16 Need for care transitions

Patient complexity appears to be an important independent predictor of a patient's readmission risk, suggesting a need to improve transitional care for these challenging individuals


17 Lack of preventive care for children

The PPS does slightly worse than the state average for Well Care Child Visits in the first 15 months, and Lead Screening in Children.

???


18 Transportation for care

Focus group participants identified the difficulty of traveling with infants. Providing in-home care would alleviate the stress associated with traveling regionally with infants to receive care.

Focus group

19 Transportation for care

#1 barrier to care is transportation Focus group

20 Lack of PCP Overall, 62.45 PCP FTE per 100,000 in FLPPS vs. 84.5% in the State

Center for Health Workforce Studies

21 PCP wait times Wait times to get PCP appts versus immediate access to ED; limited operating hours of PCP versus ED open 24/7

Focus group

22 Prevention services

*Community-based prevention services are often grant funded and unsustainable over the long term.

NOCN meetings

23 CBO access *PCPs and Hospitals lack good information about the availability of community-based programs and resources. Community-based services are currently siloed from the wider health system, including those programs delivered by Public Health Departments and Offices of the Aging. (NOCN Meetings)

NOCN meetings

24 Delay of care Across the FLPPS region, 10% of the population has delayed or failed to seek care due to cost. This is contrary to the long-term commitment required for effective chronic disease management. – (2008-2012 American Community Survey) (High Risk: Poverty)

2008-2012 American Community Surve

25 Socioeconomic factors

Socioeconomic factors to prevent readmissions

26 Homelessness Data from the WRBHO shows that about 15% of inpatient mental health or substance abuse admissions in the WRBHO 18 county region were for individuals who were homeless at the time of admission. Having an inadequate income affects many aspects of health: access to care, ability to buy and eat a healthy diet, adequacy of housing.

WRBHO

27 Poverty The number and proportion of the population living below the federally defined poverty threshold has increased in the past decade. Poverty rates are highest in the city of Rochester

FLHSA Regional charbook


but poor and near-poor live in all areas of the region. Racial and ethnic populations in Rochester are especially affected by poverty. Almost two-thirds (65%) of African Americans and 69% of Latinos in Rochester live in households with incomes below 200% of the poverty threshold. Over three-quarters (76%) of all children ages six and under in Rochester live in or near poverty (FLHSA Regional Chart book) (High-risk: Poverty), Whether from lifestyle (behaviors), disadvantages from where one lives (social circumstances and environment) or disadvantages in access to medical care, residents of areas of lower socio-economic

status tend to have less favorable measures of health compared to those living in higher SES areas. For example, regional cancer mortality is 30% higher among those with Low SES compared to those with high SES (FLHSA Regional Chart book)

28 FQHC Homeless * In 2013 FQHCs in the FLPPS region reported between 0.8% (rural counties) and 5.5% (Monroe County) of their patients as homeless or receiving public housing support (HRSA) . *National Data from the FQHC homeless program illustrates that 56% of homeless patients have mental health and substance abuse conditions are primary diagnoses. These patients also averaged over 4 visits in 2013, compared with twice the average visit per patient as homeless patients with other primary diagnoses.

HRSA; FQHC homeless program

29 Lack of housing resources

More of the CNA needs should address the issue of homelessness, not just chronic disease prevalence

211 Resource Directories

30 Homelessness for patients with BH conditions

Housing was the top capacity priority identified by the 14 county mental hygiene directors, indicating that there is consensus that the current available resources for the BH population is insufficient

31

32 High rates of behavioral health incidence

Eight of the 14 counties had higher rates of reported poor mental health over the past month that the statewide average. Among the Medicaid

NY State Advanced BRFSS, 2009; NY State Open Data


population the FLPPS has a much higher rate of mental diseases and disorders and a higher rate of substance use disorders relative to the NYS rates. 5 of the top 10 chronic disease diagnoses are behavioral health. Our region is at 142% of the NYS rate for prevalence of 16 categories of mental diseases/disorders. The FLPPS region has a significantly higher prevalence of Mental Illness among Medicaid beneficiaries (411.2/1000 pop.) when compared to the New York State (NYS) average (289.4/1000 pop.). (CNA)

33 Substance abuse In Monroe county nearly 11.8% of Medicaid recipients have a SUD. The prevalence of substance abuse disorders in the FLPPS region is also higher than the NYS average, with rates of 99.5/1000 population compared to 86.8/1000 population. CNA)

NY State Open Data

34 Hospitalizations for BH

They are the most frequent primary diagnosis cluster among Medicaid hospital admissions, the third most frequent diagnosis cluster among Medicaid ED treat and release visits, and one of the most frequent primary diagnostic groups among hospital readmissions.

???

35 High incidence of dual diagnoses

In 2012, 65 percent of Medicaid or uninsured adults admitted to an inpatient medical or surgical bed in the FLPPS (presumably for a primary physical health need) had a co-occurring behavioral health diagnosis documented. The WRBHO found that 77 percent of inpatient mental health or substance abuse admissions (in an 18 county region that includes the 14 counties of the FLPPS) had a physical health need identified during the inpatient stay (p. 63).

SPARCS database, WRBHO

36 Coordination between BH and physical health

Only 42 percent of these discharges had an appointment scheduled with an outpatient physical health care provider at the time of discharge, suggesting inadequate integration of care.

WRBHO

Most of the county mental hygiene directors have identified a need to transition to a more integrated delivery system that address both


behavioral and physical health care needs

37 Dual diagnoses *In the FLPPS region, 50% of Medicaid recipients have a behavioral health + chronic disease diagnosis. (Salient/High Risk)

Salient database

38 Readmissions for dual diagnoses

77% of inpatient mental health or substance abuse readmissions had a co-occurring physical need identified. Psych bed admissions with co-occurring diabetes or heart disease had 31% and 48% higher likelihood of being re-admitted

DSRIP Chartbook

39 High BH admissions for Medicaid

17% of all hospital readmissions are associated with an individual having a mental health or substance abuse diagnosis

NYS SPARCS

40 Inappropriate ED use for BH patients

Over 50 percent of active behavioral health super-utilizers were seen in the ED for general signs and symptoms at some point during 2013, while 44 percent were seen for injuries. Over 50% of all treat and release visits for chronic conditions are attributable to MDD’s and SUD’s

Salient non-PHI Medicaid Claims Database; NY State SPARCS database

41 Lack of outpatient BH services

There is a mild and statistically significant negative association between distance from a hospital and the percent of active BH users in a ZIP code who received a hospital-based BH service in 2013. Those who live further from a hospital might be less likely to use hospital-based BH services, indicating a potential need for increased geographic availability of outpatient BH resources.

Distance data is calculated using geo-coding software to assign latitude and longitudes to hospital addresses and ZIP code centroids. Straight line distances are then calculated between the ZIP code centroid and all hospitals, and the minimum among these distance is used for graph creation.

42 High BH incidence

2012 Medicaid beneficiaries with depression (37,880), chronic stress/anxiety (17,680), schizophrenia (15,298), depressive/other psychoses (13,654), ADHD (12,755), chronic alcohol abuse (8,919), bipolar disorder (8,328), drug abuse – cannabis/NOS/NEC (7,410), minor chronic MH diagnoses (6,082), moderate chronic MH diagnoses (4,961), opioid abuse (4,551), disruptive behavior disorders (5,430), PTSD (4,094), cocaine abuse (3,614), other significant drug abuse (3,404), severe depressive psychoses (2,776), major personality disorders (1,221)

NY State Open Data


43 ED visits among BH patients

7% of Medicaid inpatient ED visits are associated with BH; major diagnostic categories associated with 30 day re-admits -11.39% for mental diseases/disorders & 5.91% for alcohol/drug use or induced mental disorders


44 Homelessness and BH

WRBHO survey data suggests that 15% of inpatient MH or SA admissions were from homeless individuals

WRBHO

45 Adherence to anti-psychotic medications

DSRIP chartbook data reveals that our FLPPS PPS is below the NYS average for adherence to antipsychotic use and for effective treatment for acute depression with Wayne, Monroe and Chemung sig. below the NYS average.

DSRIP Chartbook

46 High incidence of BH

Findings from the initial FLHSA CNA indicate that 8 of the 14 counties in our proposed PPS are >10% worse than the NYS average for these health concerns and that overall, Behavioral Health is an important issue throughout our region in terms of prevalence and utilization. Seven percent of all ED admissions in have a primary diagnosis of Behavioral health, the highest of all disease states.

NY State Open Data

47 BH in SNFs The lack of accessible Psychiatric expertise coupled with the lack of access to acute geriatric psychiatric services is the cause of safety concerns for residents and staff when BH symptoms exceed the skill set of SNF staff.

???

48 Mental health incidence

The number rate of beneficiaries identified with mental disease and disorders is twice that of the overall NYS.

NY State Open Data

49 High rates of infant mortality

The PPS has a higher infant mortality rate than NY State, with Monroe, Allegany, Orleans and Yates counties being exceptionally high

NY State VITAL Statistics

50 Premature mortality

* African Americans and Latinos consistently experience higher rates of premature mortality relative to Whites. (CNA/High Risk). The most common causes of premature death across all population types are Cancer, Heart Disease COPD and Stroke. These illnesses share a number of conditional risk factors including smoking, physical inactivity and unhealthy diet. (CNA)

51 Unhealthy Regional rates of Poor Mental Health for 14 or Domain 3 metrics


behaviors More Days in the Last Month (10% Adult Binge Drinking (16.1%), and Suicide (9.31/100,000 pop.) are higher than NYS Prevention Agenda goals. (CNA)

52 Ned for more chronic disease self-management

Focus group findings suggest that many frequent utilizers of the hospital struggle with independent management of their chronic conditions, particularly in the area of medication adherence. As such, it may be important to address patient health literacy and self-efficacy in adhering to discharge instructions

Focus group

53 Ned for more chronic disease self-management

In the past, acute disease was the primary cause of illness and patients were generally inexperienced and passive recipients of care. Today, chronic diseases management is ultimately the responsibility of the person with the chronic disease. Most skills required for disease management are not disease specific, but life and behavior change skills. This is a significant paradigm shift. (Plumb et.al)

Plumb et. Al (see attached document)

54 Disparities in infant mortality

There are racial / ethnic disparities in infant mortality in Monroe county. African Americans and Latinos were between three and four times higher than for white residents. Generally, infant mortality rates in the FLPPS are higher than the New York State average, particularly in Allegany, Monroe, Orleans, and Yates Counties.

FLHSA ‘What’s Goin On’ 2014

55 High rates of obesity

The PPS has a higher percentage of adults who are obese than the NY State Average

NY State Advanced BRFSS, 2009

56 High smoking rates

The PPS has a higher percentage of current smokers than the NY State Average


57 Lack of colorectal cancer screening

The PPS has a lower percentage of individuals who receive appropriate colorectal cancer screening than the NY State Average

Table 45 - Domain 3 and 4 Metrics

58 Substance abuse Medicaid recipient Monroe County substance abuse diagnosis rate is 11.8%

NY State Open Data.

59 Low-birth weight

Three counties have higher rates of low birth weight than state average. CDC states that infants weighing less than 2500g are almost 40x more likely to die than infants of normal weight. Allegany, Monroe and Seneca Counties have

Table 45 - Domain 3 and 4 Metrics


higher low birth weight rates than the New York State average, with Wyoming County close behind.

60 Access to care for rural mothers

Heard across all 5 NOCNs that access to care is difficult both in terms of transportation to care providers as well as outreach to high risk moms. Amongst the mothers in our rural focus group, 9 out of 12 identified transportation as a major barrier to accessing care for their children.

Focus group

61 High-risk behavioral factors

FLPPS has a high incidence of substance abuse, tobacco use, binge drinking, poor mental health and other behavioral risk factors that impact mothers and the health of infants.


62 Binge drinking The FLPPS region has higher rates of binge drinking than NYS, overall.


63 Suicide Suicide is the only cause of YPLL that has been trending upward since 2002


64 Poor performance in domain 4 indicators

Significant disparities by race/ethnicity; >10% Prevention Agenda Goals. FLPPS region falls short of Prevention Agenda objectives: Adult Obesity (29.9 percent vs. 23.2 percent statewide); Adult Smoking (21.1 percent vs. 15 percent statewide); Age-Adjusted Heart Attack Hospitalizations/ 10,000 pop. (17.3 vs. 14 statewide); and Rate of Hospitalizations for Short-Term Complications of Diabetes/10,000 pop. ((7.21 vs. 4.86 statewide) (CNA)

???

65 Perinatal conditions

Perinatal conditions are the fourth highest leading cause of years of potential life lost in the FLPPS region at nearly 400 per 100,000 persons and higher than the New York State average


66 Pediatric quality 65.1 percent of children in the PPS are receiving the appropriate lead screening and only 53 percent of children (in the nine counties where data is available) complete the 4:3:1:3:3:1:4 vaccination series

Domain 3 metrics

67 Risky prenatal behaviors

21 percent of women reported smoking during or within three months prior to pregnancy, a rate that has changed only one percent in four years, and of the 11 counties where data is available, seven FLPPS counties – Cayuga, Chemung,

???


Genesee, Monroe, Ontario, Wayne, Wyoming – have a higher incidence of newborn drug-related hospitalization than the state average (no data available in Orleans, Schuyler, and Yates).

68 Lack of HIT interoperability

In FLPPS · 33 different EMRs without

interoperability • 3 RHIOS cannot communicate • 60% of providers do not participate

in the RHIO

FLPPS Surveys

69 Lack of insurance

8% of FLPPS region is uninsured ???

70 Non-utilizers 1.5% of FLPSS attributed population are non-utilizers (Salient data)

Salient database

71 Poverty Between 2008 - 2012, approximately 29% of the FLPPS region population were classed as belonging to a low income grouping UDS Mapper Data Source (higher than the state average of 14.9% below poverty level CNA), with ≈ 66% of these being unserved by the various health care centers serving these zip codes, with specifically 18% of the low income population indicating that had no usual source of care or delayed care due to high cost (non or low utilizers). The need for tailored outreach and patient activation strategies in this region cannot be underscored.

UDS Mapper

72 Lack of insurance

While Monroe County, an urban area has the highest number of uninsured (56, 095 persons, 7% of the county population), rural areas such as Steuben County have cities like Perkinsville and Woodhull uninsurance rates of 36% and 35% respectively UDS Mapper Data Source (greater than twice US national average of 15.1% CNA) pointing to even larger barriers to care in FLPPS region rural settings than urban areas such as transportation and cultural and/ or language barriers (CNA). Note also that in rural counties, like Steuben, 15.1% of the population are living below the federal poverty level as compared to 14.9% in NYS, increasing the likelihood that uninsured also fall within this category and require particular attention for activation.

UDS Mapper


Section 4 – DSRIP Projects 2.a.i Create integrated delivery systems 1. Project Justification, Assets, Challenges, and Needed Resources (1500 word limit, Total Possible Points – 20)

a. Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps this project will fill in order to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community.

PPS Response (4,000 characters max): Current: 4,247 characters The Finger Lakes Performing Provider System (FLPPS) region covers 14 counties in Upstate/Western New York and approximately 330,000 Medicaid beneficiaries. Across the 14 county-region, chronic conditions are a leading cause of mortality and years of potential life lost (YPLL). Numerous metrics of integration, including Prevention Quality Indicator (PQI) admissions and Potentially Preventable Emergency Department Visits (PPV) indicate that these chronic conditions could be more appropriately addressed by a system that better integrates primary care and preventative medicine into the treatment plans for individuals with asthma, COPD, cardiovascular conditions, and diabetes. The PQIs which are attributable to chronic disease (diabetes, respiratory, and heart) account for 85 percent of all potentially preventable inpatient hospitalizations in the FLPPS in 2012. A review of the available literature suggests that a coordinated and integrated health care delivery system is well-positioned to provide efficient and effective care to complex patients with chronic disease. When multiple conditions are present in a patient, as is often the case, the complexity of treating that individual rises. The CNA indicates that having three comorbidities on a hospital admission results in an 18 to 24 percent increased risk of readmission within 30 days. Addressing these conditions through an integrated delivery system should result in improved outcomes for these individuals and reductions in preventable utilization.

The FLPPS region separates physical and behavioral healthcare into two separate, non- integrated systems. The need to integrate these networks in the FLPPS region is especially critical because of the higher-than-average prevalence of behavioral health conditions. The fragmentation of the two systems leads to poor outcomes for individuals. Not only do these individuals’ behavioral health conditions influence their mental health, but these conditions have consequences for their physical health as well. In fact, suicide was found to be the fifth leading cause of premature mortality in the FLPPS. Additionally, 24 percent of all Medicaid- only hospital discharges in 2012 were for a primary behavioral health diagnosis compared to just 8 percent and 3 percent of private insurance and Medicare discharges, respectively. Developing links between the behavioral and physical health care systems may ensure that Medicaid patients are seen in the appropriate setting and receive the most appropriate care for their conditions. Addressing these individuals holistically will not only improve their wellbeing, but will also reduce costly care that might otherwise be avoided. Infant mortality rates in the FLPPS region are generally higher than the New York state average, particularly in Allegany, Monroe, Orleans, and Yates Counties. Substance use admissions among newborns also appears to be unexpectedly high in several PPS counties. While infant mortality does appear to be a serious concern in the FLPPS region, other measures of perinatal health generally match New York state trends, including low birth weight, initiation of prenatal care, and birth defect rates. It is likely that social determinants of health, not captured in the data, are driving that statistic, which is evidenced by the disparity in health outcomes of African Americans and Latinos in Monroe County. Supporting women and children will have long term positive impacts


on the health of the FLPPS population. There is also a need to increase interoperability between providers’ IT systems. There are 33 different EMRs with interoperability and 3 of the RHIOs cannot communicate. Transportation is also a key issue because the region is so large and separated by lakes -- as a result, fragmentation is often the system status quo. The EMS often transports patients to hospitals with no history of care for that patient. IT solutions will be key to overcoming some of these geographic barriers. Overall, it is important to drive reform so the delivery system aligns with the payment system to ensure sustainability. This system needs to reward outcomes and standardized patient care, and be able to track progress through NYDOH and PPS established metrics.

b. Please provide a succinct summary of the current assets and resources that can be mobilized and employed to help achieve this DSRIP Project. In addition, identify any needed community resources to be developed or repurposed.

PPS Response (4,000 characters max): Current: 2,701 characters The FLPPS service area has a longstanding culture of collaboration that will be mobilized to develop a comprehensive, coordinated system of care. One key example is the creation of the FLPPS by the collaboration two competing healthcare organizations for the purpose of improving the care of the safety net population. The collaboration of the two largest healthcare systems allows FLPPS to leverage the systems’ profound expertise and experience in healthcare delivery, IT, and interoperability. As co-leads, these organizations recognize value in sharing their resources for the betterment of the PPS providers and patients. Providers across the FLPPS region carefully selected DSRIP projects that not only addressed the needs of the community, but that provide the framework and resources needed to build upon existing expertise and infrastructure. Project Teams, with representation from the cross-section of provider types and geographies in the region, have begun sharing best practices and lessons learned from programs that promote similar objectives to that of DSRIP. These best practices and lessons learned will be mobilized and employed across the region to ensure successful DSRIP project outcomes. From a technological standpoint, the FLPPS service area has connectivity to the RHIO. Over 70 health care organizations in the service area are already sending patient data for more than one million patients who have given consent to share their health information. Further, the RHIO can provide Direct Electronic addresses that allow secure notification/messaging between providers and patients. The PPS will develop an IT hub managed by the FLPPS office. It will include a centralized IT database and care management software to serve as EMR lite and facilitate interoperability among PPS providers enhances partners’ ability to engage patients in appropriate levels of care, perform population health management and ensure all partners are actively sharing data with HIE and each other A number of Accountable Care Organizations (ACOs) already in place that can be leveraged and built upon to develop an integrated delivery system. Our existing Health Homes are experienced with Health Home Care Management training, implementation and capitated payment structure. These organizations can be expanded to include additional care managers and to embed care managers within provider clinics who have sustainable HH Care Management eligible patients. The PPS will support navigation of fragmented systems by offering


guidance and support resources in the form of HH care management, care navigators, and resource experts that present information to individuals in a preferred format.

c. Describe anticipated project challenges or anticipated issues the PPS will encounter while implementing this project, and describe how these challenges will be addressed. Examples include issues with patient barriers to care, provider availability, coordination challenges, language and cultural challenges, etc. Please include plans to individually address each challenge identified.

PPS Response (2,400 characters max): Current: 2,987 characters There are several challenges to the successful implementation of an integrated delivery system that were identified by both the Community Needs Assessment and via engagement of the providers who intend to participate in FLPPS. Major barriers to achieving project metrics include patient access to care, workforce availability, and a lack of adequate resources for providers. In order to successfully address these challenges, FLPPS will develop a centralized infrastructure that will provide the resource management, workforce training, data reporting and program oversight.

Improving access to care will be a top priority for FLPPS. Discussions with regional stakeholders have identified social determinants of health as a key influence in the health of the Medicaid population. Nationally, these health factors have recently come to prominence as researchers identify that these issues are significant contributors to population health. Availability of transportation was noted as a barrier to health, both by focus group participants and health care and community service workers throughout the region. A regression analysis comparing PPV rates and distance to emergency rooms identified that proximity was associated with PPV utilization in the FLPPS region. Housing resources were also identified throughout this process as a need throughout the region. For example, of individuals who were homeless at the time of admission to a hospital, only 62 percent were connected with housing before their discharge. Addressing social determinants of health will be critical to the long term success of any programmatic efforts. Because of the region’s transportation needs, in addition to its shortage of healthcare providers [xx], FLPPS will explore the development of a comprehensive telemedicine network and a robust, integrated transportation network with linkage to the FLPPS health information exchange in order to ensure patients in the network can physically and digitally – where appropriate – access care.

Providers have reported that they do not have sufficient resources to implement electronic medical records and to achieve NCQA PCMH Level 3 standards, Meaningful Use Level 2, and connectivity to the RHIO. Providers/practices with existing IT systems may need to upgrade to newer versions of the existing application, they may need to purchase, implement, and install new software, or they may pay a third party vendor to install the tools required for this purpose. Either of these issues will require considerable financial and human resources to implement. FLPPS, in partnership with the Finger Lakes Health System Agency, is exploring the availability of CMMI grants that provide the support providers need to upgrade their practices to meet the standards under DSRIP. The centralized FLPPS infrastructure will be able to coordinate and manage the grant across the 14-county region in order to ensure providers have the support needed to meet the project’s metrics.

d. Please outline how the PPS plans to coordinate on the DSRIP project with other PPSs that serve an overlapping service area. If there are no other PPS within the same service area, then no response is required.


PPS Response (4,000 characters max): Current: 0 characters PPS is currently drafting

2. System Transformation Vision and Governance (1500 word limit, Total Possible Points – 20)

a. Please describe the comprehensive strategy and action plan for reducing the number of unnecessary

acute care or long-term care beds in parallel with developing community-based healthcare services, such as ambulatory, primary care, behavioral health and long term care (e.g. reduction to hospital beds, recruitment of specialty providers, recruitment of additional primary care physicians, hiring of case managers, etc.). The response must include specific IDS strategy milestones indicating the commitment to achieving an integrated, collaborative, and accountable service delivery structure.

PPS Response (8,000 characters max): Current: 6,788 characters FLPPS is targeting to reduce hospital utilization by 20 percent over the next five years. One of the FLPPS participating partner organizations, currently receiving IAAF funds, has discussed a specific project with NYSDOH and the FLPPS leadership team to reduce over 100 inpatient beds in one of our IDS communities. Consistent with the CNA, it is proposed that these beds be replaced with a robust ambulatory off-campus ED, an urgent care center, an FQHC with primary care, outpatient dental and behavioral health services, and outpatient procedures. In addition, telemedicine will support access to specialty services. It is anticipated that this project will serve as a model for further efforts to re-balance the healthcare delivery system in ways that are consistent with the healthcare needs of communities served by the FLPPS. To reduce nursing home beds, the FLPPS is proposing the replacement of a certain number of LTC beds with Medicaid assisted living beds providing safe housing, primary care, and supportive care management services for patients in an environment that has a lower per diem cost than LTC. It is the ultimate goal of FLPPS to create an Integrated Delivery System (IDS) under the governance of the major stakeholders and build the infrastructure required to integrate and coordinate care. By creating such a structure, FLPPS will provide care at the most appropriate level of care in the community. By providers working together to coordinate a patient's care, we will achieve, healthier happier and more satisfied patients, faster recovery by those who are ill or hospitalized, improved quality of life and lower health care costs. The keys to reducing hospitalization and long-term care are keeping individuals healthier longer, avoiding the acute crises through monitoring and proactively managing the individual’s physical and behavioral health, and coordination of the social services they require. An effective system will integrate all of these elements. We know that in the absence of addressing and coordinating the physical (including dental), behavioral, and social the cost of medical care dramatically increase. The medical cost of care for patients with chronic medical comorbidities doubles if the patient also has a chronic mental diagnosis. FLPPS will coordinate all these patient issues. Behavior health professions will be integrated into the care teams. In the current system a person with a chronic mental health condition can end up associating “feeling bad” with their depression when the major cause is their uncontrolled diabetes that is making the feel poorly. The current system emphasizes inpatient care but does not do a good job of providing primacy care, medications, or transportation to get to the doctor that would have prevented the admission. FLPPS strategies to reduce healthcare costs is to reduce the need for hospitalization and need for long-term


care beds, primarily by avoiding the healthcare crises that initiate the need for these services. Other strategies will focus on reducing readmissions, shortening the length of stay, avoiding admissions, and transitioning the patient to community based care options by building a system that will eventually not only coordinate care, but also align the financial incentives for providing the care.

Coordinated Care Strategy. The centerpiece of this strategy is a proactive coordinated care model that expands Health Home (HH) Care Management and establishes the PPS as a point of contact for individuals looking to be connected with services.

o HHs monitor and guide individuals through the current fragmented healthcare, behavioral, and social systems, partnering with enrollees to improve quality of care, improve social outcomes reduce mental health costs, and lower mental and physical health costs. HH Care Management has demonstrated 46% decrease in ER visits per enrollee, 53% reduction in days spent in hospital, and 78% of enrollees reported “dealing more effectively with problems” according to the CNA. PPS will establish the number of HH enrolled patients as a metric tracked across time, anticipating an increase of HH Care Management services of 400% over five years.

o A PPS call center will serve to connect patients with appropriate services, staffed by staff trained to triage calls appropriately

Hospital Discharge Care Transition Strategy. To reduce readmissions in the Medicaid patient population, in addition to current readmission reduction strategies, FLPPS will implement programs to obtain patient information on the social determinants of health and arrange for post discharge, community services during the patient’s hospitalization. This will include referrals for appropriate levels of housing based on social and health factors of the patient to determine the lowest cost, safe level of housing appropriate for the patient consistent with a patient’s cultural values and wishes to maximize adherence to treatment and outcomes for patients.

Hospitalist Strategy. To reduce hospital length of stay, FLPPS will work with hospitals that do not currently use hospitalists to implement hospitalist programs as a core strategy to create efficiencies and improve quality of care.

SNF Strategy. To reduce nursing home length of stay, FLPPS will work with nursing homes that do not currently use dedicated providers (MDs, NPs, PA) with geriatric training to provide residents with healthcare services. Creating capacity to provide Primary care by trained geriatric providers is a goal for nursing homes in the FLPPS.

Information Technology Strategy. To be able to coordinate the care for those most in need FLPPS will continue to support the implementation of the Health Information Exchange (HIE) and Care Management Enterprise System with supporting analytics to monitor NYSDOH and PPS established metrics.

Increase Primary Care Access Strategy: To maximize access to primary care the PPS, in addition to primary care physician recruitment, FLPPS will focus on efforts to increase the number of nurse practitioners and physician assistants to increase the availability of primary care especially in community clinics, and rural clinics. Furthermore the PPS will reduce barriers to utilization of existing primary care resources in the region:

o Expanding the use of telehealth services to mitigate geographic barriers.


o Contracting with transportation companies to facilitate transportation to and from primary care appointments.

Assessment of the Patients’ Physical Health, Behavioral Health, and Social Needs. FLPPS will gather and update a Comprehensive Patient Health and Social Needs Assessment with the goal of eventually populating the assessment for 80 percent of all individuals in its target population.

b. Please describe how this project’s governance strategy will evolve participants into an integrated healthcare delivery system. The response must include specific governance strategy milestones indicating the commitment to achieving true system integration (e.g., metrics to exhibit changes in aligning provider compensation and performance systems, increasing clinical interoperability, etc.).

PPS Response (6,00 characters max): Current: 0 characters PPS currently drafting

3. Scale of Implementation (Total Possible Points - 20) DSRIP projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale, please complete the following information:

a. Please indicate the total number of sites, programs and/or providers the PPS intends to include in the project by the end of Demonstration Year (DY), or sooner as applicable. These numbers should be entered in the table as Total Committed.

PPS Response: PPS currently drafting finalizing provider and patient scale and speed. Work will continue to be done until application is submitted. PPS committees, board members, and DSRIP project teams are informing and guiding final decisions on scale and speed. You may refer to Appendix A for a high-level overview of the nine FLPPS projects current scale and speed information.

b. Please identify the number of committed providers who are a part of the local Safety Net.

PPS Response: PPS currently drafting finalizing provider and patient scale and speed. Work will continue to be done until application is submitted. PPS committees, board members, and DSRIP project teams are informing and guiding final decisions on scale and speed.


You may refer to Appendix A for a high-level overview of the nine FLPPS projects current scale and speed information.

*Based on Department of Health Safety Net Provider designation

c. Please indicate the total expected volume of patients the PPS intends to engage throughout this project by the end of Demonstration Year (DY) 4. This will become the Expected # of Actively Engaged Patients. Patient scale is measured by the total number of patients that are expected to be actively engaged by the end of Demonstration Year 4.


4. Speed of Implementation/Patient Engagement (Total Possible Points - 40): DSRIP projects will be evaluated based upon the proposed speed of implementation and timeline for patient engagement. The projects with accelerated achievement of project requirements and active engagement of patients will receive more funding than those taking longer to meet goals. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess speed and patient engagement, please complete the following information:

a. Please indicate the Demonstration Year (DY) and Quarter by which all participating providers will achieve project requirements. Project speed is measured by how fast all the project requirements for all chosen locations are met. PPSs will be expected to meet these requirements for all of the providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.


b. Please indicate the expected timeline for achieving 100 percent engagement of total expected number

of actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent by the end of DY 3.



For this project, Actively Engaged is defined as patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent). Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column.

5. Project Resource Needs and Other Initiatives (750 word limit, Not Scored)

a. Will this project require Capital Budget funding? (Please mark the appropriate box below)

Yes No

X

If yes: Please describe why capital funding is necessary for the Project to be successful.

PPS Response (3,00 characters max): Current: 0 Characters PPS Currently Drafting

b. Are any of the providers within the PPS and included in the Project Plan PPS currently involved in any

Medicaid or other relevant delivery system reform initiative or are expected to be involved in during the life of the DSRIP program related to this project’s objective?

Yes No

X

If yes: Please identify the current or expected initiatives in which the provider is (or may be) participating within the table below, which are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.

Name of Entity (200 characters max)

Medicaid/Other Initiative

(100 characters max)

Project Dates (25 characters max start; 25 characters max end)

Description of Initiatives (500 characters max)

Al Jordan Health Corporation/GRHHN

CMMI Ends Dec. 2014. Provides care coordination and funds for primary care redesign

Arbor Housing and Development

Health Homes Care Management

now we are adding care management to our housing programs


Arnot Health (3 hospitals, 2 SNFs)

VAP---Southern Tier Mental Health Project

April 2014-March 31, 2017 Operating and systems change, professional psychiatric capacity, mental health/substance abuse assessment and management, behavioral health in primary care

Blossom View Nursing Home Inc.

Greater Rochester Nursing Home Quality Consortium

2009 and no end date Grant programs associated with reducing healthcare costs through projects like reducing hospital readmissions, decrease UTIs and other Lean Six Sigma programs to reduce overall costs.

Catholic Charities Community Services

Health Homes of Upstate NY

#N/A Health Homes and Care Management

Finger Lakes Addiction Counseling and Referral Agency

Health Homes of Upstate New York

7/1/2013 to present Health Homes and Care Management

Genesee County Mental Health Services

PSYKES 2008-present Provide data to help improve and adopt psychiatric medications and quality concerns

Genesee County Office for the Aging

Balancing Incentive Program

1/1/15 to 9/30/15 The Balancing Incentive Program (BIP) is a federal initiative authorizing grants to States to increase access to non-institutional community-based long-term services and supports. New York was awarded $598.7 million through BIP, a portion of which will be used to strengthen and expand NY Connects, an information and referral service mostly operated by local offices for aging. With the expansion, New Yorkers will come to know NY Connects as the one-stop shop for long-term services and supports. Through outreach activities to identify potential Medicaid eligible, "No Wrong Door" single point of entry, "Level 1" screen to identify Medicaid eligibility and need for/linkages to ltc services and supports


Greater Rochester Health Home Network LLC

Medicaid Health Home 4/1/12 - no end date Care Management for high risk Medicaid enrollees

Hillside Children's Center Meaningful Use 2012-ongoing EMR implementation

Jewish Home & Infirmary of Rochester

Certificate of Need - Jewish Senior Life Master Campus Plan

6/1/16 to 10/1/18 New build of 14 Green House Project Home for long term care, reducing the total number of long term care beds by 34. Renovation of legacy building to increase and serve Transitional Care (post-acute).

LDA Life and Learning Services

Supportive and Supervised Certified Residential Services

1990's and ongoing 24/7 and as needed life skills, medical and behavioral supports

Lifespan BIP Innovation Grant 10/1/14 - 9/30/15 Health Care Coordination

Lifetime Care Home Health and Hospice

Teleheatlh Rate Demonstration Project

July 23 2008-july 2009 Telehealth services were given to patients who were at risk for ED visits and hospitalizations

Medical Solutions, Inc. Consumer Directed Personal Assistance Service (CDPAS)

Since 2009, ongoing long term homecare service

CDPAS is a self-directed home care option that allows providers to operationalize the independent living philosophy. It's an extraordinarily successful and heavily preferred program that improves healthcare quality and outcomes while saving significant sums of healthcare dollars. The consumer has the control of hiring their aides and controlling the delivery of their health care plan. Medical Solutions is actively serving a Medicaid census of 130 consumers throughout FLPPS, a census too large to be transitioned to traditional home care services without care disruption. Selected by Monroe County Department of Human Services, we have maintained compliance, broadening and growing service to consumers since 2009. Furthermore, we are contracted with MCOs, MLTCs


across the FLPPS area and Upstate New York, providing flexibility to serve metro and urban consumers. We maintain operation 7 days a week with an office staff having over 100 years of combined experience in providing community based services. To ensure performance standards and quality assurance, our customer support is uniquely established with orientations, 90 day home visits, evaluations, annual in-services, list of active status employees to connect the consumer to aides, and regular contact with aides and consumers through weekly payroll processing and support staff.

Monroe County Arc, NYSARC Inc

Regional Workforce Development

9/1/2014 to 8/30/2016 Development of Core Competencies for Direct Support Professionals

Monroe County Office for the Aging

Balanced Incentive Program (Still in planning phase at state level)

April 1,2014 - September 30, 2015 (in process of trying to get reappropriated)

Expansion of Long Term Care Information and Assistance Line (NY Connects) to include persons under age 60 that have disabilities and information and referral to agencies that serve those populations in addition to our existing directory of services for individuals age 60+

Oak Orchard Community Health Center

HRSA 330 grant; HRSA O/E grant

Annual HRSA grant facilitates access to care for Medicaid populations/uninsured/underinsured populations; O/E grant facilitates registering patients for insurance using enrollers and navigators

Orleans Community Health Integration Primary Care/Behavioral health

41773 #N/A

Perinatal Network of Monroe County

Healthy Start September 1, 2014 to May 31, 2019

Improving the health of women and infants.


Planned Parenthood of Central and Western New York

VAP 1/12 - 12/14 Funding to assist us reaching meaningful use with EHR systems

Rochester RHIO Perinatal Network of Monroe County/HIT for Perinatal Health

1/1/2014-3/30/2015 This project will enhance the coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and case management system, and the existing relationships among the medical systems, the health plans, and perinatal support services. The goal is to share both medical and psychosocial information efficiently with all the providers who form the system of care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women with complex medical and/or psychosocial needs.

Steuben Co Office for the Aging

ADRC- NYCONNECTS/ BIPP

2007 and ongoing Single POE for LTC to streamline access

Syracuse Brick House, Inc. d/b/a Syracuse Behavioral Healthcare

E2 Began 10/1/14 Medicaid Incentive Program to encourage prescribers to serve Medicaid populations

Trillium Health Health Homes 11/2012 - present Integrated Care Management Model focused on preventing avoidable ER visits and avoidable Hospitalizations by coordinating

Visiting Nurse Service of Rochester and Monroe Co., Inc/SHCG

Health Homes Sept 2013 to present We are a care management agency of GRHHN, we are also a service provider for the GRHHN and HHUNY.

Al Jordan Health Corporation/GRHHN

Vital Access Provider Fund

NO FUNDS CURRENTLY AVAILABLE

Will provide funds for primary care redesign and management development

Blossom View Nursing Home Rural Health Network continuous Provide services and training for


Inc. healthcare facilities to improve long-term care treatments and reduces costs. Plans and initiates innovative projects that one provider could not undertake

Finger Lakes Addiction Counseling and Referral Agency

Ambulatory Patient Group

#N/A Medicaid Reimbursement Program

Genesee County Mental Health Services

Meaningful Use Stage 1

2014 Better information sharing for coordination of care


Extended Supported Employment

Long term support to maintain competitive employment and career advancement

1980's and ongoing


CMMI grant 2013-2015 Facilitates practice transformation and provides an RN Care Manager

Orleans Community Health Care Coordination #N/A #N/A

Perinatal Network of Monroe County

New York State Maternal and Infant Community Health Collaborative

October 1, 2013 until October 1, 2018

Statewide initiative to increase women's access to insurance and healthcare, and to increase the percentage of families engaging in healthful behaviors.

Trillium Health Adult Day Health 1/2011 - present A group based Self-Management program for individuals diagnosed with a Chronic Health Disease

Visiting Nurse Service of Rochester and Monroe Co., Inc/SHCG

MLTC 2012 to present We are a provider of services and care management for Elderplan/Home First MLTC.

Blossom View Nursing Home Inc.

ECHO 2014 and no end date Provides training and development of mental health programs and skills for the nursing home staff


Day Habilitation Employment Track

1990's and ongoing Providing community based volunteer activities to build transferable skills for employment


HRSA New Access Point grant - Hornell, NY

2015 - Annually HRSA decision to be made in May 2015

Orleans Community Health ED Utilization #N/A #N/A

Perinatal Network of New York State January 1, 2014 to March Improving linkage among health


Monroe County Medicaid Redesign team Health Information Technology

31, 2015 information systems

c. Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the

current Medicaid initiative(s) identified above. A PPS may pursue a DSRIP project that exists as part of another effort if the PPS can demonstrate a significant enhancement to the existing project.

PPS Response (3,00 characters max): Current: 780 characters The proposed IDS project typically serves to expand upon many of the initiatives mentioned above by

leveraging the model workflows and infrastructure created in those projects to be expanded throughout the PPS. Examples of this include several grants related to care coordination (Consumer Directed Personal Assistance Service, Health Homes, PSYKES), workflow transformations (CMMI, MU, Home Quality Consortium), and increasing access of care (Balancing Incentive Program, E2, HMH), and interoperability (MU) across EHR systems. The IDS serves to expand upon the fragmentation of initiatives by incorporating pieces from each and establishing one overarching initiative that combines the efforts of all to recognize a collective benefit that is more than the sum of its parts.

2.b.iii ED Care Triage for At-Risk Populations

Project Justification, Assets, Challenges, and Needed Resources 1a Community Needs Assessment

PPS Response (4,000 characters max): Current: 3,645 characters The CNA found that in our service area, nearly 39 percent of the regional Medicaid Emergency Department (ED) visits are Potentially Preventable Visits (PPV), with both higher adjusted and unadjusted rates than the New York State average rate of 36.43 percent); nine of the fourteen counties representing all five of the Naturally Occurring Care Networks in the PPS fall in the bottom 80th percentile. The data shows that in 2011, 18 percent of people seen and released in the ED had another ED visit within 30 days and 24 percent had another visit within 60 days; the 30 day re-visit rates were even higher in the Medicaid population than the general population, at 24 percent. A large portion of ED visits resulted in a non-definitive diagnosis, with 23 percent simply coded for signs and symptoms. Community Health Improvement Plans in all five of the NOCNs identified priorities that would be positively impacted by implementing this project, including access to chronic disease prevention and management in community settings and improving access to care for those of low socioeconomic status. Reasons for use of the ED rather than ambulatory care for treatment of non-emergency and minor medical conditions were demonstrated through the CNA to relate to both real barriers to accessing ambulatory care, such as transportation and inadequate Primary Care Provider capacity, as well as perceived barriers, including a lack of understanding of available levels of care. Of the 46 Urgent Care Centers in the region, only 58% accept all types of Medicaid; three counties (Wayne, Wyoming, Yates) have no Urgent Care centers. Three counties in the PPS - Chemung, Genesee, and Schulyer -lack an FQHC, and eleven of the fourteen counties have a lower than state average of 84.5 primary care physicians per 100,000 residents. Eight counties are entirely designated as Primary Care Health Provider Shortage Areas, while portions of an additional five counties are designated as such, totaling thirteen of the fourteen counties as fully or partially Primary Care HPSAs. The CNA notes a relationship between proximity to an ED and more frequent use of the ED; those who


live closest are more likely to utilize it. This finding is particularly relevant in the context of regional variations found in the PPS, ranging from Monroe County with 48% of the entire population of the PPS and a density of 1132 residents per square mile, to the other thirteen counties collectively having the remaining 52% of the PPS population and density as low as 48 residents per square mile in Alleghany County. The CNA conducted focus groups and cited participants’ comments on receiving referrals to PCPs while in ED but simply not following through, as well as choosing to go the ED over their PCP even when they had a PCP due to convenience of location, continuous operating hours of the ED, immediate access versus waiting days to get appointments, and habit. There are several traditional and non-traditional transportation services throughout the PPS however these cannot often be accessed on short notice and were cited as the leading barrier to service access by community based and behavioral health organizations; increased options including alternatives to ambulances for short notice transportation is a need. This project intends to address both real and perceived access challenges by placing patient navigators into EDs who will facilitate timely appointments to community based primary care providers, ensuring successful linkage, while also educated patients on availability of services appropriate use of lower levels of care for non-emergencies.

1b Target Population:


To address these gaps we will meet all project requirements, establishing ED care triage program the key element. This will be implemented throughout the PPS; all patients who present to the ED and have no PCP are a priority focus area, to insure linkage to primary care both for preventive interventions and chronic disease management. There will be standard triage protocols and workflows wherein all patients who present to ED for non-emergency conditions, whether they have a PCP or not, will also be referred to an ED based patient navigator, to schedule a timely appointment with primary care, to whom all necessary and available patient information will be communicated, and to educate on available levels of care and appropriate utilization of care for non-emergencies. Partner PCPs and FQHCs will increase open access scheduling. Patient navigators will by protocol ascertain if a patient is eligible for or has a health home care coordinator; will refer if eligible and not linked or will notify health home care coordinator if applicable, to insure all members of patients’ treatment team are aware of: services utilized, follow up care needed/ scheduled, opportunities for reinforcement of alternatives to ED usage. Navigators will review with patients any barriers to keeping appointments with PC/make a specific plans to overcome barriers. Navigators will be staffed through retraining/redeployment of existing hospital staff such as insurance liaisons/navigators and social workers. Repurposing space to increase non-emergency level urgent or primary care capacity will occur throughout the project implementation phase as ED volumes decrease, which will allow for smoother triage to non-emergency care in real time. Project will be implemented throughout the entire PPS, as the rates for PPVs are above average across the NOCNs. Monroe County will be a high priority focus area, as with the largest population and the largest hospitals, located in densely populated neighborhoods, this county accounts for the largest number of ED visits. Priority focus will also be EDs located in Southeastern Western NOCNs, as all of the counties that make up these NOCNs have above NYS average PPV rates; all of the counties in the PPS that lack a Federally Qualified Health Center are in these regions as well, highlighting potential opportunities to improve access to primary care.

1c Current Assets and Resources:



This PPS contains a broad depth and scope of partner agencies with a history of successful collaboration and communication; though the PPS being co-lead by two large and historically competitive health care systems can present as both an asset and a challenge. All PPS partner hospitals have committed to participation in this project as have several primary care practice and FQHCs; of these, several hospital partners own primary care practices, many with PCMH certifications; these hospitals and owned practices usually utilize a shared EMR platform which will be crucial to communication of patient information. Partner hospitals have a large number of existing staff who can be retrained to provide a focused navigator role within the ED, or where volumes are lower in smaller hospitals to function in dual roles. In addition to hospital owned practices there are regional FQHC partners who are committed to supporting the work of patient navigation by expanding open and timely new patient access. Fall meetings held at the regional NOCNs validated that partner agencies are truly invested in making necessary transitions away from acute care, as the ED utilization for non-emergent conditions is a strain on limited human and fiscal resources for all hospitals. The region has a RHIO which interfaces with 23 different EMR systems which will be an asset in providing real time notifications when patients are seen in ED and delivery of ED discharge summaries to receiving providers, as well as for required patient tracking and milestone reporting. There are large health home care coordination programs which are well known and utilized in Monroe County, with a need for increased awareness of and referral to this service in several partner counties. Scattered throughout the PPS there are pockets of unique services and assets. This includes Monroe County EMS administrator with proposal to add transportation triage system for ED diversion by allowing allow ambulance transport to Urgent or primary care centers rather than EDs, programming for on-call RNs to provide immediate home visits to chronically ill patients 24/7, a hospital ED director from another state who has brought experience in reducing Medicaid ED usage, programming for palliative care managers deployment to EDs, behavioral health care managers and outreach workers placed in EDs, and a program training the developmentally disabled population on when to use or not use the ED. The PPS will provide an opportunity for knowledge sharing and expansion of small scale and localized innovative initiatives. In October of this year, St. James Mercy Hospital, located in Steuben County, announced plans to close as an acute care hospital, and to transition delivery of care services to a co-located ED/Urgent Care/Primary Care model, to insure adequate community based care, in concert with Oak Orchard, which is an FQHC with PCMH Level 3 certification. This evolving repurposing and partnership will provide a model for the PPS in designing co-location of tiered services allowing for better utilization of appropriate levels of care. Co-location of services may be of particular importance for rural, low population density areas that cover much of the region to realize true efficiencies in operational costs and insure fiscal viability. Some hospital partners have identified intention to co-locate their primary care practices, or if already co-located to increase access and extend hours of operation, increasing the likelihood of successful linkage to primary car through real time warm hand offs. Arnot-Ogden Medical Center has an ED fast track program in place which allows for triage in the ED; this model of triage will provide a springboard for transition to providing primary care on-site through real time triage and diversion.

1d Project Challenges and Issues (max 300 words)


There is a need to significantly expand both the overall capacity of primary care providers as well as their ability to provide open access scheduling. There are several committed partners willing to increase primary capacity however recruitment of qualified medical staff is an on-going challenge. While there is intention to offer extended primary care hours, because much of the PPS is rural with low population density this along with staffing challenges may make it more difficult to financially support expanded PCP hours in some areas; thus there might be shifts in hours of operation to offer more evening/weekend hours rather than a net increase of hours of operation. In this project, PCPs will need to become PCMH level 3 certified providers. This in part requires use of an EMR which not all PCPs currently use; also one ED does not currently use an EMR. There are


33 different EMRs in use in our PPS, only 23 of which interface with the RHIO. PCMH certification, EMR implementation, and consistent use of the RHIO will be supported in coordinated efforts with other DSRIP projects, particularly Projects 2.a.1 and 3.a.1. Significant efforts and expenses for investment in IT infrastructure and equipment will be required and is being managed through an active IT committee that the PPS has formed. Other challenges include lack of adequate transportation in rural areas and a very limited number of Urgent Care centers that accept Medicaid and resistance to change in established behavior patterns. The PPS has developed an active transportation committee that is developing a number of strategies to address these challenges including establishing a partnership with the County 911 centers to develop and operate a local nurse triage call center and efforts to negotiate to increase the reimbursement rate for Medicaid so that more urgent care settings will be willing to take Medicaid patients. Linkage to Health Home Care Coordinators will also provide another resource for transportation assistance. In order to address challenges in changing in well-established behavior patterns, community education efforts on accessing appropriate level of care will be developed with patient input and completed in conjunction with Project 4.b.ii; the PPS cultural competency committee is focusing on health literacy efforts in support of all projects.

1e. PPS Coordination: Are there other PPSs that serve an overlapping service area

PPS Response (4,000 characters max): Current: 952 characters The three counties of the Western NOCN, Genesee, Orleans, and Wyoming, are also in a PPS with the Western region of NYS, and that PPS also intends to implement project 2.b.iii. Due to the location of these three counties, their patients often receive medical services in both Buffalo and/or Rochester, and there have been some partners concerns expressed about the use of different RHIOs in Rochester and Buffalo. However, given that there are EDs located within each of the partner counties, and given that people generally use an ED that is closest to them, if anything the overlap in this project should only serve to be a support to implementation, as there will be more community resources available to these partner hospitals. There are additional overlapping PPS service areas to the East and Southeast, however in the initial design applications submitted by those PPSs they did not express intention to implement this particular project.

Scale of Implementation

a. Please indicate the total number of Emergency Department sites where Care Triage will be established by the Demonstration Year 4, or sooner as applicable.


b. Please indicate the total expected volume of patients the PPS intends to target throughout this project by the end of Demonstration Year 4.

PPS Response: PPS currently drafting finalizing provider and patient scale and speed. Work will continue to be done until


application is submitted. PPS committees, board members, and DSRIP project teams are informing and guiding final decisions on scale and speed. You may refer to Appendix A for a high-level overview of the nine FLPPS projects current scale and speed information.

Speed of Implementation/ Patient Engagement

a. Please indicate the Demonstration Year and Quarter by which all participating EDs with Care Triage will achieve all project requirements.


b. Please indicate the expected timeline for engagement of patients within the project. For example, the PPS may indicate that 25 percent of targeted patients will be actively engaged by the end of Demonstration year 1, 50 percent by the end of Demonstration year 2, etc.

c.


*For this project, Actively Engaged is defined as number of participating patients presented at the ED and appropriately referred for medical screening examination and successfully redirected to PCP as demonstrated by a connection with their Health Home care manager or a scheduled appointment. Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column.

Project Resource Needs and other Initiatives

a. Will this project require Capital Budget funding? (Yes/No) YES

a. If Yes, describe why capital funding is necessary for the Project to be successful.

PPS Response (3,000 characters max): Current: 638 characters Capital funding will be needed for renovation, repurposing, and expansion of existing space in order to allow


for offices for navigators, triaging, and co-location of services, as well as expansion of primary care capacity. Office furnishings will also be needed. Significant capital will be needed for HIT, both in establishing EMRs where they are not currently in use, as well as enhancing those that are, in order to allow for information sharing in real time. Related computer equipment will require capital funds. Small partner hospitals do not have cash on hand to support physical renovations and equipment purchases upfront.

b. Are any of the providers within the PPS and included in the Project Plan PPS currently involved in any

Medicaid or other relevant delivery system reform initiative related to this project’s objective? (Yes/No) a. If yes: Please identify the initiatives in which the provider is participating in the table below, which

are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.


Medicaid/Other Initiative (100 characters max)



Arnot Health VAP Southern Tier Mental Health Project

April 1, 2014 to March 31, 2017

Operating and systems change, professional psychiatric workforce, behavioral health and substance abuse assessment and management in EDs, mental health providers in primary care

Greater Rochester Health Home Network Finger Lakes Addiction Counseling and Referral Agency

NYS DOH Health Homes Care Management

2012-ongoing NYS DOH Health Homes Care Management

Finger Lakes United Cerebral Palsy

Medicaid Redesign Funds - Housing

Community Affordable Housing

Lifespan BIP Innovation Grant

10/1/14 - 9/30/15

Health Care Coordination

Monroe County ARC Regional Workforce

Development 9/14-8/16 Deployment of Core Competencies

for Direct Support Professionals

Rochester RHIO Perinatal Network of

Monroe County/HIT for Perinatal Health

1/1/2014-3/30/2015

Enhance the coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and


case management system, and the existing relationships among the medical systems/services. Goal: share medical and psychosocial information efficiently for coordination of care. With all the providers who form the system of care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women with complex medical and/or psychosocial needs

Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the current Medicaid initiative(s) identified above. A PPS may pursue a DSRIP project that exists as part of another effort if the PPS can demonstrate a significant enhancement to the existing project.

PPS Response (3,00 characters max): Current 677 characters These initiatives do not overlap with DSRIP programming or initiatives though in some cases they will support or enhance the work of this project. For example Health Home care coordination supports this project, through providing support to patients to better link with primary care and decrease ED utilization. Health Homes also provide another referral option for eligible patients, through the patient navigators working in the EDs. Several of these programs support medical assessment and interventions which could prevent ED utilizations and support receipt of care within the community. Workforce Development will enhance the skill sets of direct support professionals.

Domain 1 DSRIP Project Requirements Milestones & Metrics

Progress towards achieving the project goals and project requirements specified above will be assessed by specific milestones for each project, measured by particular metrics as presented int the attachment Domain 1 DSRIP Project Requirements Milestones & Metrics. Domain 1 Project Milestones & Metrics are based largely on investments in technology, provider capacity and training, and human resources that will strengthen the ability of the PPS to serve its target populations and successfully meet DSRIP project goals. PPS project reporting will be conducted in two phases: detailed Implementation Plan due in April 1, 2015 and ongoing Quarterly Reports throughout the entire DSRIP period. Both the initial Implementation Plan and Quarterly Reports shall demonstrate achievement towards completion of project requirements, scale of project implementation, and patient engagement progress in the project.

b. Detailed Implementation Plan: By April 1, 2015, PPS will submit a detailed Implementation Plan

to the State for approval. The format and content of the Implementation Plan will be developed by the Independent Assessor and the Department of Health for the purpose of driving project


payment upon completion of project milestones as indicated in the project application. c. Quarterly Reports: PPS will submit quarterly reports on progress towards achievement of project

requirements as defined in Domain 1 DSRIP Project Requirements Milestones & Metrics. Quarterly reports to the Independent Assessor will include project status and challenges as well as implementation progress. The format and content of the quarterly reports will be developed by the Independent Assessor and the Department of Health for the purpose of driving project payment upon completion of project milestones as indicated in the project application.

2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions Project Justification, Assets, Challenges, and Needed Resources (1500 word limit, Total Possible) 1a Community Needs Assessment/Gaps:

PPS Response (4,000 characters max): Current: 4,136 characters Review of hospitalization use data in the CNA finds that while our PPS as a whole has a Potentially Preventable Readmission (PPR) rate comparable to NYS average of 6.75, 18 of the 22 hospitals in the network’s counties are in the bottom 80th percentile. The CNA notes that readmission rates within the region are consistently higher for Medicaid patients than the non-Medicaid population (15.1 percent), highest for those with Fee for Service Medicaid (18.9 percent) and those who are Medicare/Medicaid dually eligible (22.2 percent). St. James Mercy, Soldiers and Sailors, Clifton Springs, Medina and Strong Memorial Hospitals, spread throughout four of the five NOCNs, all have unadjusted potentially preventable re-admission rates that are at least 10 percent worse than NYS average. By Major disease category, circulatory conditions and respiratory conditions account for 15 percent and 14 percent of all cause readmissions. The CNA identified a number of statistically significant variables within the Medicaid population of the PPS that increase risk of all cause readmission. Diagnostically, primary diagnosis of Chronic Obstructive Pulmonary Disorder, Diabetes, Congestive Heart Failure, Cardiovascular disease, ischemic heart disease, and pneumonia are all linked to higher risk for readmission; as are having secondary diagnoses of hypertension, serious mental illness and heart disease. Multiple medical comorbidities of any type increase risk for readmission. Dispositions to home care, leaving against medical advice and discharge to skilled nursing facilities also represent significant increase risk for readmission. Based on volume, discharge to self-care represents the largest number of all cause readmission. 85 percent of potentially preventable admissions within the PPS were found to be related to chronic Prevention Quality Indicators, representing 20 percent of all Medicaid admissions in 2013. 12 of 14 counties are above NYS average rate of 17.0 percent for smoking and 59.3 percent for overweight/obesity, which are often contributing factors to many of the conditions that are associated with higher risks for readmission risks. The CNA focus groups found that lack of health literacy particularly around understanding the role of medications in disease management is a gap within the PPS, with specific concerns cited as confusion around multiple medications and being given unfilled prescriptions rather than actual medications; as well as general responses about feeling overwhelmed with inadequate resources or support networks to attend to complex health needs. The needs assessment also identified provider shortages throughout the region, with rates of providers per population below state average (84.5 per 100,000) in eleven of the fourteen counties in the PPS. Eight counties are entirely designated as Primary care HPSAs with an additional five counties partially designated as such (13/14 counties thus full or partial PCP HPSA). Supplemental CNA data provided by Care Coordination Services Incorporated of Monroe County shows lower rates of utilization of acute services by patients who have higher rates of medication adherence and for those receiving Health Homes Care Coordination services. Awareness, capacity, and use of Health Home Care coordination services is limited particularly outside of Monroe County. The CNA


highlights differences in counties that comprise the PPS; Monroe County with a population density of 1132 residents per square mile accounts for 48 percent of all attributed lives within the PPS; the other thirteen counties have smaller populations with more rural areas; Alleghany County has fewer than 48 residents per square mile. Population density allows for more efficient delivery of home and community based care management versus phone outreach; care manager facilitated linkage to community based services for ongoing support of chronic disease management is a key component of reducing readmissions and to date there has not been a region wide approach for consistent management of patient care post-hospitalization which is a gap this project will close.

1b

PPS Response (2,400 characters max): Current: 2,453 characters Community care agencies will partner with hospitals to develop protocols and staffing to provide 30 day

post-acute transition care management to targeted Medicaid patients to reduce readmissions by insuring understanding of/adherence to discharge plans. Barriers to adherence such as inadequate access to care, limited health literacy and basic needs will be addressed by care managers (CMs). While inpatient, eligible patients will be identified/referrals made and CMs will meet with patients pre-discharge and review discharge plans verifying patient understanding through teachback. CMs will insure needed home based resources are in place such as home care, medical equipment, food service and medications. Post-discharge, CMs will work with patients for 30 days to insure adherence to plans such as appointment attendance and medication compliance, and work through any barriers. Standard discharge protocols will be developed to include real time record transmission from inpatient to outpatient teams. We will meet all project requirements and implement in the whole PPS. Monroe County has almost half of attributed lives and the highest Medicaid PPR rate of the PPS; thus patients being discharged from hospitals in this county will be highest priority. Existing partnerships in Southeast and Finger Lakes NOCNs support regional implementation. Western NOCN has high PPR rates and also above average rates of COPD and heart disease; patients in this area will also be a priority. Services will be phased in to allow for building of workforce; initial priority population is Medicaid patients being discharged to home care or self-care following admissions for diabetes, respiratory diseases, cardiac and circulatory conditions; within those groups additional priority focus will be patients with: medical co-morbidities, limited social supports, secondary behavioral health conditions, and/or those with more than one recent admission. Workforce of transition CMs who can manage small dynamic caseloads and follow clear protocols of 30 day post-acute transition care management will be grown from small base of existing staff with training in care transitions. Project will promote wide use of the care transitions model with Medicaid patients with chronic conditions to address all factors that lead to preventable re-admissions. PPS will work with Medicaid Managed Care organizations to obtain reimbursement to insure program sustainability.

1c. Current assets (500 word limit)

PPS Response (4,000 characters max): Current: 3,676 characters The PPS has a solid basis to build off of in terms of existing well-functioning professional collaborations between partner hospitals and community based providers to treat the needs of the region, including good relationships between several post-hospitalization service providers and many of the PPS’s large hospitals; though the PPS being co-lead by two large and historically competitive health care systems can present as both an asset and a


challenge. Care transitions pilot projects completed in the recent past provide existing relationships and specific protocols for the identification and referral of patients from hospital inpatient units to care transitions managers, prior to pt discharge. Among partner agencies in this project are community based Home Care agencies with care transitions model trained workforces who have already successfully implemented the Coleman Care Transitions Model with targeted Medicare populations, in collaboration with several of the PPS partner hospitals, resulting in 30-50 percent reductions in readmission rates; those who have experience in providing care transitions services will expand their staffing and target populations to work with Medicaid patients with chronic conditions/high readmission risk. Additional assets include PPS partner experienced with care transitions in a palliative care program, partner agency providing home delivery of medications and medical equipment in less densely populated parts of the region, and experience health home care coordination partner. These assets will be leveraged to develop a PPS wide team of care transitions staff with appropriate knowledge and training to achieve the outcomes for this project, to insure care managers have access to a wide range of community based medical and non-medical supports and services for their clients, and increase capacity of Health Home care coordination provider agencies and outpatient medical services to provide continuity of care post hospitalization. There are strong current workforces through the PPS including social workers, LPNs, RNs, medical technicians, and Home Health care providers, among other disciplines, who are currently employed within partner agencies. This along with anticipated workforce additions will allow for the development of a large team that is skilled to provide focused, time limited care transitions management with a variety of targeted patient populations. The need to establish both clear workflows and adequate payment agreements with Medicaid Managed Care plans as project deliverables will build upon the existing relationships between home care, health homes, Medicaid managed care, and hospital systems, to insure that there is adequate payment to support financial viability of this model long term. Some regional Medicaid managed care plans have already agreed to pay for this service, which will be leveraged to insure that all such plans cover this. The past successes of partner agencies in significantly reducing readmissions through the provision of care transition management services with the Medicare population will also be an asset in payment agreement planning, and in addition the PPS has established a solid working finance oversight committee experienced with contract negotiations with payers. Work on this project will be completed in concert with other projects being proposed by the PPS, including Project 3.a.i Integration of primary and behavioral health care, Project 3.a.ii Community based crisis stabilization services, Project 2.b.iii ED care triage, and Project 2.b.vi Transitional supportive housing, as well as Project 2.a.i Integrated Delivery Systems.

1d. Project challenges:

PPS Response (2,400 characters max): Current: 2,483 characters Ownership of the Care Transitions CM positions may be a challenge; there are many partners in the project representing several different types of service providers. Development of strong referral processes, explicit workflows, and role delineation will be top priority in the implementation planning process, to ensure that there is a fidelity to the care transitions model and that this is a time limited and specific intervention. Consistent/timely communication between inpatient units, Health Home providers, home care services providers, transition care managers, and community based medical practitioners is key, which may be a challenge as there are 33 EMRs in use throughout the PPS, while some programs still use paper charts, which will be addressed in part through development of standardized discharge notification processes and also through the work of IDS Project 2.a.i. The PPS’s IT committee and Project 2.a.i will be active in insuring that there are technical platforms to meet project requirements for patient tracking and reporting. Regional challenges include the need to increase primary care capacity, which the PPS is working on through several selected projects including 2.a.i, with several practices and FQHCs committed to increasing capacity and access; linkage with primary care is needed to address risks for admission beyond the 30 days. Other challenges include


economically depressed areas, sparsely populated regions with limited transportation, and workforce recruitment/retention especially in rural regions. Workforce efficiency is limited when providing home based care in thinly populated areas, requiring long periods of travel between client home, which impacts on number of patients who can be served. Transportation is being addressed project wide through transportation committee that is actively working in PPS; there is a partner agency signed on for this project that has had success in running a volunteer transportation program. Cultural competency, language and literacy have been identified as key to several projects, thus the formulation of a cultural competency committee; there is a partner agency with expertise in work with non-English speakers through migrant worker program that will be an asset. Challenge of financing sustainability of services will be addressed by PPS in conjunction with partner organizations through dedicated resources to complete Medicaid Managed Care contracting requirements of the project.

1e. PPS coordination - Are there other PPSs that serve an overlapping service area?

PPS Response (4,000 characters max): Current: 1,421 characters There are overlapping PPSs in the West, Central and Southern Tier regions which intend to do this project. In the West, Orleans, Genesee and Wyoming Counties will be working both with this PPS and the Erie County Medical Center led PPS; in addition Orleans county is also working with the Niagara Falls led PPS. To the southeast, Schulyer County and Steuben Counties will be working with the Southern Tier Rural Integrated PPS. All of these PPS’s intend to implement project 2.b.iv. Likely one of the bigger challenges arising from this is that there will be different RHIOs in use, and communication of information is critical to project success. However this is not unique to this project, therefore Project 2.a.i will address RHIO and communication issues both within and across PPSs. While overlap can pose challenges, it is likely that ultimately this can be beneficial to the providers and residents of the border counties, by expanding their partner networks and thus allowing for best matching of patients and transition care managers based on individual patient needs. Addressing regional issues such as transportation and community service needs will also receive more attention and input through involvement of not one but two provider networks. The necessary development of clear workflows and referral processes will need to include careful considerations for management of PPS and project overlap.

Scale of Implantation

Please indicate the total number of sites, programs, and/or providers the PPS intends to include in the project by the end of DY or sooner as applicable. The numbers should be entered in the table as total committed.


Please identify the number of committed providers who are part of the local safety net.

PPS Response: PPS currently drafting finalizing provider and patient scale and speed. Work will continue to be done until


application is submitted. PPS committees, board members, and DSRIP project teams are informing and guiding final decisions on scale and speed. You may refer to Appendix A for a high-level overview of the nine FLPPS projects current scale and speed information.

a. Please indicate the total expected volume of patients the PPS intends to engage throughout this

project by the end of Demonstration Year 4.



a. Please indicate the Demonstration Year and Quarter by which all participating hospitals will achieve project requirements.


BELOW WILL NEED REVISION AS PROVIDERS HAVE SUBMITTED REVISED ATTRIBUTION – CANNOT CHANGE SPREADSHEETS D/T CHANGE CONTROL PROCESS SO WILL RE-CALCULATE ONCE SPREADSHEETS ARE UPDATED

b. Please indicate the expected timeline for achieving 100 percent engagement of total expected number of actively engaged patients identified. For example, the PPS may indicate that 25 percent of targeted patients will be actively engaged by the end of Demonstration year 1, 50 percent by the end of Demonstration year 2, etc.


*For this project, Actively Engaged is defined as the number of participating patients with a care transition


plan developed prior to discharge who are not readmitted within that 30-day period. Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column.

Project Resource Needs and Other Initiatives

a. Will this project require Capital Budget funding? YES a. If Yes, describe why capital funding is necessary for the Project to be successful (limited to 375

words)

PPS Response (3,000 characters max): Current: 475 characters Implementation of this project will require dedicated staffing who are working in the community and thus will need equipment including laptops, phones, and vehicles. There are workforce training costs for both existing and new staff. Office space including renovations to existing space and furnishings are necessary to accommodate staffs of care transitions managers. IT costs including EMR, interfaces, database development and equipment are identified as capital needs.

Are any of the providers within the PPS and included in the Project Plan PPS currently involved in any Medicaid or other relevant delivery system reform initiative related to this project’s objective? (Yes/No)

b. If yes: Please identify the initiatives in which the provider is participating in the table below, which are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.





Visiting Nurse Service of Rochester and Monroe Co. Rochester Regional Health System Greater Rochester Health Home Network LLC Finger Lakes Addiction Counseling and Referral Agency URMC STRONG

Health Homes 2012 - ongoing

NYS DOH Health Homes Care Management

URMC STRONG AQUA agreement Present Excellus agreement


with primary care aka the AQUA agreement that provides enhanced reimbursement for HEDIS measure based outcome measures targeting health care maintenance and chronic disease management


1/1/2014-3/30/2015

enhance the coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and case management system, and the existing relationships among the medical systems/services. Goal: share medical and psychosocial information efficiently for coordination of care. with all the providers who form the system of care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women


with complex medical and/or psychosocial needs.

Monroe County Chapter, NYSARC Inc

Regional Workforce Development

9/1/2014 to 8/30/2016

Deployment of Core Competencies for Direct Support Professionals

Lifespan, in partnership with Lifetime Care, Visting Nurse Service, URMC, RRHS

Community Care Transitions Promotion, CMS

2013-2015

CMS demonstration project focused on reducing readmissions for Medicare patients through use of Coleman care transitions coaching model



1/1/15 to 9/30/15

Federal initiative authorizing grants to states to increase access to non-institutional community-based long-term services and supports. NY was awarded $598.7 million through BIP, a portion of which will be used to strengthen and expand NY Connects, an information and referral service mostly operated by local offices for aging.

b. Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the


PPS Response (3,00 characters max): Current: 1,730 characters The Community Care Transitions Promotion CMS demonstration project is in alignment with this project though it is only for Medicare patients. Any overlap would be found within the dually eligible population, who will be covered through the demonstration project and not counted toward scale for this project for the duration of the CMS project. The benefit of participation in the CCTP program is that as a result there are a number of staff


already trained in the Coleman model, referral processes and relationships have already been established, and implementation protocols including lessons learned can be applied to the whole. Thus our new project has opportunity for greater success and will not be duplicative in that currently Medicaid only patients are not eligible. Other programming such as Health Homes are an enhancement or asset but not an overlapping project, because the role of the post-acute transition care manager is a very specific and time limited role, which is a different role than that of a health home care manager. For patients who are not eligible for or not yet linked to health home care coordination, transition care management can fill a void, and it is supplement to the health home care coordinator role during a very high needs time for those who are already receiving care coordination services. Care transitions managers can also facilitate referrals to health home care coordination for eligible patients, which is beneficial as health homes are effective and cost effective yet have been underutilized in several areas. This project would enhance the BIP project by helping to prevent institutional levels of care and thus is in alignment with but not overlapping with this project.


2.b.vi Transitional Supportive Housing Project Justification, Assets, Challenges, and Needed Resources: 1a. Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps this project will fill in order to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community (500 words).

PPS Response (4,000 characters max): Current: 3,764 characters Chronic medical conditions, mental health (MH) and substance abuse (SA) disorders were the top diagnoses among the more than 11,000 super-utilizers in the FLPPS region who used the ED 4 or more times in 2013; 57,000 patients had co-existing BH and chronic medical conditions (Salient). Data linking housing status with diagnosis is scarce. FQHCs in the region report that 1% (rural areas) to 5.5% of their patients in 2013 were homeless or receiving public support; national 2013 FQHC data illustrates cites 56% of homeless patients with MH or SA, and averaging twice as many visits in a year as homeless patients with other primary diagnoses (HRSA). The Western Region Behavioral Health Organization found that 15% of patients with mental and behavioral health conditions were homeless at the time of admission, yet only 62% of these had improved their housing status at the time of discharge (CNA pg 69). In NYS in 2013, SAMSHA’s Projects for Assistance in Transition from Homelessness (PATH) cited 57% of its clients as having co-occurring MH and SA disorder. Yet homelessness is only one indicator of housing instability. County Mental Hygiene Directors across the region confirm: affordable supportive housing is the number one area of need for additional capacity (CAN pg 59). In a NYS DOH survey, health home providers reflected a similar perspective, citing affordable housing and permanent supportive housing in a single site as priority options needed by their patients (89.5% and 84.2%, respectively)[1]. With a higher prevalence of mental diseases and disorders in FLPPS compared to the NYS average (411.2 vs 289.4 per 1,000 beneficiaries, respectively), delivering a relevant and appropriate mix of housing and supportive services for super-utilizer and BH-chronic condition co-morbid patients is clearly critical to achieve DSRIP goals (CNA pg 39). Stakeholders attending Naturally Occurring Care Networks (NOCN) meetings indicated that coordination between hospitals and care management providers (health homes and home care services) lack formalized processes, leading to inconsistencies across the region. Care managers are often notified less than 24 to 48 hours prior to discharge, leaving little time to assess a patient’s needs and arrange appropriate housing or home care services. In response to these gaps, FLPPS will meet all project requirements with a focus on strengthening care transitions so housing unstable patients are identified early after admission to a hospital. Formalized protocols will ensure hospitals link patients with both a community housing provider and an appropriate care manager or patient navigator, providing adequate lead time to assess needs and secure appropriate affordable or supportive housing upon discharge. Partnerships between community-based housing providers, health homes and home care services, and hospitals will leverage 272 transitional supportive beds in scattered site and multi-unit single site complexes across each of the five NOCN regions. The majority of housing providers also provide mental health and substance abuse support services, and medical care management will be wrapped around or pushed into sites using telemedicine and home care providers. Community housing providers will strengthen their institutional capacity to provide the range of support services demanded by various patient profiles, ensuring relevant and culturally competent service provision. FLPPS will explore the use of vouchers to ensure adequate transportation is available for patients requiring access to relevant support services that cannot be


pushed in or delivered via telemedicine.

[1]https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/hh_supportive_housing_survey_summary.pdf

1b. Please define the patient population expected to be engaged through the implementation of this project. The definition of patient population be specific and could be based on geography, disease type, demographics, social need or other criteria. This patient population that the PPS expects to actively engage over the course of the project will be a subset of the total attributed population.

PPS Response (2,400 characters max): Current: 610 characters Transitional supportive housing will target patients in FLPPS region who face housing instability and are either super-utilizers (defined as patients with 4+ hospitalizations per year or face mental health or chronic conditions that make them eligible for enrollment in a health home (total figure data pending salient data pull). Evidence based criteria examining housing status will be incorporated into hospital risk assessment practices, including for example screening for health home eligibility; this will ensure that the appropriate housing is included early in the patient discharge planning process.

1c. Please provide a succinct summary of the current assets and resources that can be mobilized and employed to help achieve this DSRIP Project. In addition, identify any needed community - resources to be developed or repurposed.

PPS Response (4,000 characters max): Current: 1,725 characters PPS partners that have committed to this project have a wide range of complementary expertise and decades of experience in care management, support services and housing provision across several key population segments at high risk for becoming chronically ill super-utilizers due to housing instability and/or their behavioral and medical health conditions. The majority of committed community based housing partners already offer mental and behavioral health support services, and many are contracted health home providers and/or are engaging with projects in Domain 3a to support BH and primary care integration and crisis stabilization. This is particularly valuable in rural NOCNs that are behavioral health personnel shortage areas (HPSA), and facilitate economies of scale to enable a smooth continuum of care transition and BH service delivery across the region. Other care management service providers offer a complementary range of services that will enable the PPS to make an array of service options available to patients based on their individual needs. In addition to transition coaches and health home care managers to assist clients in their transition, partner providers offer consumer-directed personal assistance, a workforce of home health aides, nursing and rehab services, as well as telehealth biometric monitoring and Meals on Wheels. PPS-level operational committees for Transportation and Housing will include network partners from all NOCNs as well as other key players in each sector including Housing Authorities and County EMS agencies, to improve coordination, maximize the range of housing options available to patients and secure transportation is adequate to access relevant support services.

https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/hh_supportive_housing_survey_summary.pdf



1d. Describe anticipated project challenges or anticipated issues the PPS will encounter while implementing this project and describe how these challenges will be addressed. Examples include issues with patient barriers to care, provider availability, coordination challenges, language and cultural challenges, etc. Please include plans to individually address each challenge identified.

PPS Response (2,400 characters max): Current: 3,484 characters The top three barriers and challenges identified by partners and stakeholders identified through engagement meetings and participation surveys were information technology, regulatory inconsistencies and limitations, and capital resources for actual housing space (bricks and mortar). Information technology is considered a barrier because of inconsistent processes and data management tools utilized across the range of partners involved in meeting project deliverables. The majority of partners offering housing options and/or supportive services (particularly for mental/behavioral health patients) do not use EHR technology. This will need to be addressed in order to effectively track and report on actively engaged patients per the project definition. Among key regulatory barriers identified as a challenge: NYCRR Section 7-1.3 and 7-1.11; NYCRR Chapter 14 Mental Hygiene Law, PHL 2802; allow Article 28 clinics to provide short term rehabilitative services in the individual’s home; and Adult Care regulations 487. In particular housing providers and hospitals cite the regulatory restrictions that severely restrict eligibility and make a wide range of patients almost impossible to place post discharge. As a result the majority of new and repurposed housing options that will be created under the project will be unlicensed and leverage partnerships with home care providers and telemedicine to push in support services. This will greatly improve the availability of flexible housing options for BH patients, particularly in the more rural NOCNs. Segmentation across housing initiatives funded by OASAS, OMH, HUD, DSS, DOH and regulatory inconsistencies across different housing providers create disincentives and significant barriers, particularly for hospitals, to seek less restrictive and lower cost housing options that might be more appropriate for a patient’s condition and more effective at reducing their likelihood of readmission. Doing so is costly, from the hospital’s perspective: the lack of familiarity with regulations and documentation takes more time away from other patients, and is riskier because the outcome seems less certain. There is a need to streamline data on available housing inventories, access eligibility requirements a Health home agencies will be a key partner for short and long term care management, yet less than 30% of those responding from upstate NY to a DOH survey reported ever placing its members in housing[1]. Both HH agencies and HH providers (GRHHN and HHUNY) expressed grave concerns about current reimbursement rates and methodologies, suggesting that without serious and prompt reform many providers were likely to cease offering HH services. Furthermore, knowledge and understanding of HH remains very low among other key project partners including housing providers and even hospitals, particularly in the Southern and Southeastern NOCN regions. By requiring MOUs and formalized partnership agreements between hospitals, health home, home care and community based housing and supportive service providers, the project will overcome these challenges to ensure that HH care management is integrated in the menu of support service models utilized in order to offer an adequate array of options to high risk patients as part of long term care management that includes stable and appropriate housing. [1]https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/hh_supportive_housing_survey_summary.pdf




1e. Please outline how the PPS plans to coordinate on the DSRIP project with other PPSs that serve an overlapping service area. If there are no other PPS within the same service area, then no response is required.(300 words)

PPS Response (4,000 characters max): Current: 71 characters There are no PPS in the same service area targeting the same project.

Scale of Implementation DSRIP projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale, please complete the following information. 2a. DSRIP Projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale please complete the following information.

a. Please indicate the total number of transitional beds for high-risk patients the PPS intends develop through project by Demonstration Year (DY) 4, or sooner as applicable. This number should be entered in the table as Total Committed.


Please identify the number of committed providers who are a part of the local Safety Net.




b. Please indicate the total expected volume of patients the PPS intends to engage throughout this project by the end of Demonstration Year (DY) 4. This will become the Expected # of Actively Engaged Patients. Patient scale is measured by the total number of patients that are expected to be actively engaged by the end of Demonstration Year 4


Speed of Implementation/ Patient Engagement (Total points 40) DSRIP projects will be evaluated based upon the proposed speed of implementation and timeline for patient engagement. The projects with accelerated achievement of project requirements and active engagement of patients will receive more funding than those taking longer to meet goals. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess speed and patient engagement, please complete the following information

a. Please indicate the Demonstration Year (DY) and Quarter by which all project requirements will be met. Project speed is measured by how fast all the project requirements for all chosen locations are met.

PPSs will be expected to meet these requirements for all of the participating providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.


b. Please indicate the expected timeline for achieving 100 percent engagement of total expected

number of actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent by the end of DY 3.




For this project, Actively Engaged is defined as the number of participating patients who utilized transitional supportive housing and were appropriately monitored via telephonic or face-to-face contact throughout a 90-day transition period to address a specific housing-related need. Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 Project Resource Needs and Other Initiatives (750 word limit, not scored)

a. Will this project require Capital Budget funding? (Yes/No) a. If Yes, describe why capital funding is necessary for the Project to be successful.

PPS Response (3,000 characters max): Current: 740 characters Implementation of this project will require dedicated staffing who are working in the community and thus

will need equipment including laptops, phones, and vehicles. There are workforce training costs for both existing and new staff. Office space including renovations to existing space and furnishings are necessary to accommodate staffs of care transitions managers. IT costs including EMR, interfaces,

database and telemedicine development and equipment are identified as capital needs. Several community housing providers request capital to support renovation, secure additional scattered multi-unit sites, and/or as a small percent of matching funds for new large scale multi-unit complex construction projects already in progress.

b. Are any of the providers within the PPS and included in the Project Plan currently involved in any Medicaid

or other relevant delivery system reform initiative or are expected to be involved in during the life of the DSRIP program related to this project’s objective? (Yes/No)




Project Dates (25 characters max start; 25 characters end)


Rochester RHIO Perinatal Network of Monroe County/ HIT for Perinatal Health

1/1/14 - 3/30/15

This project will enhance the coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and case management system, and the existing relationships among the medical systems, the health plans, and perinatal support services. The goal is to share both medical and psychosocial information efficiently with all the providers who


form the system of care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women with complex medical and/or psychosocial needs.

FLACRA, GRHHN, Visiting Nurse Service (VNS), HHUNY VNS, UCP Association of Rochester, Finger Lakes UCP Hillside Children’s Center, Chemung County Dept of Aging and Long Term Care Medical Solutions, Inc

Health Homes of Upstate New York MLTC Balancing Incentive Program Consumer Directed Personal Assistance Service

4/1/12 - present Fall 2012 - present 8/1/2014-9/30/15 2009 - present

Health homes and Care Management Providing services and care management for Elderplan/Home First MLTC and iCircle MLTC Community-based respite care for youth experiencing behavioral/emotional issues CDPAS is a self-directed home care option that allows providers to operationalize the independent living philosophy. It's a heavily preferred program improves healthcare quality and outcomes while saving significant sums of healthcare dollars. The program gives the consumer the control of hiring their caregivers and controlling the delivery of their health plan. Medical Solutions is actively serving a Medicaid census of 130 consumers throughout the Finger Lakes Region, a census too large to be transitioned to traditional home care services without care disruption. Selected by Monroe County Department of Human Services, we have maintained compliance, broadening and growing service to consumers in the FLPPS territory. We are contracted with MLTCs and MCOs across FLPPS and upstate New York providing flexibility to serve both metro and rural consumers while promoting efficient FLPPS project implementation.

c. Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the


PPS Response (3,00 characters max): Current: 975 characters This project and DSRIP will enhance the HIT initiative by enabling all providers to view both medical and


psychosocial information in a patient centered rather than facility based record, including by ensuring that relevant supportive services such as housing are captured in a patient’s electronic health record (EHR). It would enhance the MLTC initiative by offering structured housing options for those that need an enhanced level of support that cannot be provided in their own homes. The project will enhance the Consumer Driven Personal Assistance Services initiative by expanding the use of these services among underserved populations across PPS regions in Western and Central NY. Medical Solutions is a home care provider with the unique capacity to serve the entire region with a successful long term home care solution that is affordable and helps overcome workforce gaps, while also offering opportunities for operational efficiencies and inter-PPS coordination.


2.d.i “Project 11” 1. Project Justification, Assets, Challenges, and Needed Resources

d. Identified Gaps.

PPS Response (4000 characters max): Current: 3,985 characters Across the FLPPS region, 8% of the population remains uninsured (UI). In 33 zip codes, over 15% of the population are UI, including six zip codes where over 30% lack health insurance. All of these zip codes are rural areas, and those with the highest percentage of UI have large Mennonite populations. While Monroe County, an urban area has the highest number of UI, 56, 095 persons, (7% of the county population), rural areas such as Steuben County have cities like Perkinsville and Woodhull with UI rates of 36% and 35% respectively, (greater than twice US national average of 15.1% for the UI), pointing to even larger barriers to care in FLPPS region rural settings than urban areas such as transportation and cultural and/ or language barriers. The need to engage and activate the uninsured who are responsible for 11.59 percent of all hospital readmissions in the region cannot be underscored. A recent analysis by the Health Resources and Services Administration (HRSA) found that 8% of the region’s population identified as having no usual source of care, 26% lacked a dental visit in the last year and 10% consistently delayed or did not seek care on a regular basis, due to cost. Again the top 50 zip codes where access to care is lowest are located in rural areas, with the exception of 14621 (ranked 45th), which is located in the city of Rochester. In addition, approximately 2% and 17% of FLPSS Medicaid population are non-utilizers (NU) and low utilizers (LU) respectively pointing to significant barriers to care and/or utilization of health services in the region. The largest barriers to care in the PPS are transportation to healthcare resources, low motivation to seek services, financial constraints and insurance coverage limitations. Additionally low health literacy, inadequate numbers of culturally responsive healthcare and social support staff, languages barriers and lack of collaboration between the wider health system and primary and preventive care services also serve to stymie individuals’ efforts in our region to gain full access to available healthcare resources. Improper utilization of the emergency department (ED) is also of great concern, with the PPS region having a higher (adjusted and unadjusted) potentially preventable emergency department visit (PPV) rate, 38.83 and 37.56 per 100 population respectively than the statewide statistic of 36.43, emphasizing the need to educate both our patients and healthcare providers of proper utilization of healthcare resources and provide patients with greater access to PCPs in our region. Through implementation of this project, the FLPPS will address these needs and stated barriers by: A) Establishing multiple community based organization (CBO)/PPS partnerships, to - i. Leverage needed expertise in patient activation (PA) techniques as premised on the collective of the greater than 6000 sociobehavorial, dental and social support service programs in the PPS region, ii. Offer widespread training to key community penetration staff (e.g. community health workers, social workers, faith leaders) on coaching modalities to improve PA, Health Literacy and appropriate utilization of the health system in identified hot-spots utilized by the target populations, such as EDs, colleges and universities, jails, places of worship, social service agencies and CBOs, iii. Conduct widespread measurement around levels of Patient Activation and Health Literacy, B) Develop and execute multifaceted media driven and/or marketing strategies to educate and engage target populations on key health messages, available healthcare resources and importance of a proactive health approach, C) Develop multilingual health promotion education materials and approaches specific to our LU, NU and UI populations, largely characterized by having low income and 19 - 34 years old, and D) Facilitating targeted expansion of Federally Qualified Health Centers (FQHCs) who are already poised to serve the uninsured.


a. Project Target Population (300 words)

PPS Response (2400 characters max) Current: 2,390 characters Uninsured (UI): There are currently 123,073 uninsured living the FLPPS region. Of those, 56,095 live in urban Monroe County. Other counties with high numbers of UI include rural areas such Steuben (9,168), Wayne (8,080), Ontario (7,656) and Chemung (6,647). HRSA has also cited that during 2008 - 2012, approximately 29% of the FLPPS region population belonged to a low income grouping (state average is 14.9% below poverty level), with approximately 66% of these being unserved by the available health care centers. In addition, Enroll America indicates that, across the PPS, the age groups with the highest number of uninsured appear to be 19 - 34 years old, (51%, 41% composition of UI in Monroe County and Steuben respectively). The Urban Institute has also identified UI in the PPS to be predominantly in low-income brackets (i.e. incomes below 138% of the Federal Poverty Level [FPL]) and between the ages of 25-44. The UI in this region vary widely by racial and ethnic composition even within the same county, and is thus not consistent across the FLPPS region. Therefore our primary target population is defined as belonging to age range 19 – 44, belonging to a household with income below 138% of the FPL and either living within a rural (particularly in zip codes with >20% UI) or urban setting. Thus our project design will adopt a multipronged approach of tailored PA and engagement techniques to capture the variety of racial/ethnic and cultural paradigms in this group. Non-Utilizers (NU): Salient data reveals that there are 5,888 NU in the FLPPS region, with highest numbers being in Monroe (3610), Wayne (336) and Steuben (241) counties. Approximately 33% of NU self-identified as African American or Black while 62%, identified as White. Overall however 52% of NU are female and 48% are male. Similar to the uninsured, NUs also tend to fall within low-income brackets as defined above for the UI. Thus target NU will be White individuals belonging to age range the 18 – 44 in both urban and rural settings. Low-Utilizers (LU): The Finger Lakes Health Services Agency (FLHSA) reveals that there are 42231 LU in the FLPPS region, with highest numbers being in Monroe (19653, 47%), Steuben (3318, 7%), Chemung (3404, 8%) and Wayne (2139, 5%) counties. Since there is very limited data on this population, we will use the same target population parameters as those of the UN.

b. Community Assets and Resources (500 words)

PPS Response (4,000 characters max) Current: 5,126 characters As part of an extensive RFQ process, the FLPPS surveyed its partner organizations and determined there was sufficient capacity to effectively implement an 11th project. Thirty-nine organizations have committed to project participation, including Hospitals, FQHC’s and Community-Based Organizations (CBOs). In addition, the PPS is fortunate to have a foundation of existing assets to support successful project implementation: A) There are a number of organizations across the region already using the PAM tool in various forms such as Monroe Plan for Medical Care, a local Medicaid Managed Care Organization currently serving over 250,000 Medicaid beneficiaries. The PPS will build up on the knowledge and experience of these organizations when implementing PAM across the region. B) Robust network of 5 Federally Qualified Health Centers (FQHCs) who saw approximately 28435 uninsured patients last year alone and are willing to expand, as needed. This expansion will ensure access to care for the UI and LU and/or NU Medicaid patients, regardless of their ability to pay. Local FQHCs provide medical, dental and integrated behavioral health services. In addition, FQHC’s have high Health Professional Shortage Area (HPSA) scores, which facilitates successful provider recruitment through the National Health Service Corps, allowing for timely improvements in access to care, C) Rapidly growing telemedicine programs including telepsychiatry, telepediatric and teledental services in key locations reaching areas that have limited transportation & access. For e.g., Finger Lakes Community Health (FLHC), a 10-


site FQHC which served 21000 patients last year particularly in rural counties, 46% of which were uninsured, houses an array of telemedicine programs including counseling, HIV/AIDS care, medication adherence, and nutrition therapy eligible to all its patients. Telemedicine through FLHC, is responsible for a 55% reduction in PHQ9 (depression) scores in their patients and a 97% success rate of pediatric dental patients adhering to treatment. FLHC also utilizes telemedicine technology to conduct trainings of healthcare providers including cultural competency, with a well-equipped 42% bilingual staff capacity. These key resources can be expanded upon and engaged for PAM administration, PAM training and other PA and health promotion activities. D) Extensive social support services – The FLPPS region houses 1082 programs geared towards basic needs, 195 providing income support and employment, and 1137 for individual and family life to name a few, which can be leveraged for expertise on patient engagement, and expanded to reach rural counties that have more limited coverage of these services, (36% are in Monroe). Additionally, these programs can serve as outlets or hot spots for administering PAM and other PA techniques. E) Numerous CBO's to potentially partner with – The FLPPS region contains over 500 CBO’s to potentially partner with and gain best practice guidance on patient of our target groups. F) Since 2004, the FLHSA has convened the Rochester/Finger Lakes Partnership on the Uninsured, whose membership includes insurance companies, providers, enrollers and CBOs. This coalition has tracked the changing face of the uninsured and monitored barriers to enrollment, over time. Collaboration with this committee will help ensure programmatic success, G) Rochester Regional Health Information Organization Network (used currently by 20 organizations in the PPS region including at least 2 major health care providers in the region Rochester regional and Strong Memorial) and the Integrated Delivery System 2.a.i Project – The IDS project serves to create a more robust EHR system and capitalize on the existing RHIO network which can be expanded to link needed CBO’s to promote management and tracking of patients for measuring interval changes in PAM, a key metric of this study, H) The AD council of Rochester, a local media company that has been providing strategic advice and tactical implementation support to non-profits for the past 60 years. Their expertise and infrastructure can be utilized to develop and implement the project’s media and marketing health awareness campaign drive. I) 211 Lifeline is a 24/7 crisis/suicide intervention program and Information & Referral (I&R) service serving over 7 counties in the FLPSS region. They provide assistance and referrals for emergency food, shelter, clothing, crisis counseling, substance abuse issues, employment, financial and legal issues, physical and mental health needs, and more, and also has Spanish-speaking telecounselors and telephone translation services available. The lifeline is an excellent resource for PA and engagement receiving over 120,000 calls, live chats, emails and TTY contacts for help in 2013 alone. J) Joint Faith based organizations that serve to engage congregation and surrounding community members in health promotion activities, for e.g. the Rochester Faith Collaborative which comprises faith leaders from greater than 10 organizations, representing over 4 faiths, including LGBTQ representation.

c. Key Project Challenges:

PPS Response (2,400 characters max): Current: 2,482 characters The PPS anticipates the following challenges in increasing access an utilization among uninsured and low/non-utilizing Medicaid recipients: 1) Patient activation is a culturally nuanced process r, including demystifying prevailing stigma’s surrounding Medicaid and as uninsured in this region do not have a consistent demographic that will require multifaceted specific approaches per target population; (2) FQHC’s and other provider types serving Medicaid and the uninsured do not have large budgets to support capital expansion; 3) Individuals may need several touches/interventions before they are willing to actively engage in primary care; 4) The health system currently lacks a means for measuring and tracking the defined cohort, over time, 5) Lack of transportation to health care services (for e.g. predominantly in rural areas) alongside insufficient collaboration between health care facilities in FLPPS region


The PPS will address these challenges by: A) Using telehealth infrastructure & programs to reach persons in remote areas who have limited transportation B) Implementing PAM & PA wide training team efforts of existing and added workforce, in addition to widespread distribution of educational materials including the use of media/ marketing campaigns relevant to intended audiences, to address health literacy and cultural competency gaps, C) Developing key CBO/PPS partnerships & joint implementation committees to create extensive opportunities for collaboration & integrating healthcare network with region - supported by relevant, user friendly IT platform (through the creation of an Integrated Delivery System (Project 2.a.i) identify information technology than can track the progress of the defined cohort over time and project website with public facing of project milestones progress for public transparency) D) Developing a continuum of community and clinical prevention and primary care services to which a newly activated patient can be referred, E) Adopting a multifaceted project approach to patient activation techniques will take on various formats to reach multiple target audiences: print, audiovisual materials, in person activation, webinars, community engagement forums (as expanded upon or developed using existing community assets and resources) F)Testing script efficacy for each target population and sharing best practices throughout the PPS G) Utilizing Patient Navigators to support newly activated patients in accessing services.

d. Coordination with Other PPSs:

PPS Response (4,000 characters max): Current: 401 characters When implementing this project, the FLPPS will work with other Performing Provider Systems to develop procedures and tools that facilitate referrals for newly-activated patients based on patterns of mobility and patient choice. In addition, FLPPS will encourage the development of common language and dissemination of best practices to facilitate patient understanding and prevent mixed messaging.

Scale: Speed of Implementation/ Patient Engagement (Total points 40) DSRIP projects will be evaluated based upon the proposed speed of implementation and timeline for patient engagement. The projects with accelerated achievement of project requirements and active engagement of patients will receive more funding than those taking longer to meet goals. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess speed and patient engagement, please complete the following information Please indicate the Demonstration Year (DY) and Quarter by which all project requirements will be met. Project speed is measured by how fast all the project requirements for all chosen locations are met. PPSs will be expected to meet these requirements for all of the participating providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.




c. Please indicate the expected timeline for achieving 100 percent engagement of total expected

number of actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent by the end of DY 3.


For this project, Actively Engaged is defined as the number of participating patients who Number of individuals who completed PAM® or other patient engagement techniques Project Resource Needs and Other Initiatives (750 word limit, not scored) Will this project require Capital Budget funding? (Yes/No)

a. If Yes, describe why capital funding is necessary for the Project to be successful.

PPS Response (3,000 characters max): Current: 1,382 characters This project will require capital funding primarily to support: - The additional IT infrastructure required to track and monitor patients, including but not limited to increased sever capacity at PPS provider sites, database development and management, mobile tablets or devices for community health workers and other outreach staff administering PAM and other patient activation monitored activities. Additionally Wi-Fi hot spots, internet service and cable television is not available in all areas of the PPS which can makes telecommunication and telemedicine difficult for targeted populations, so additional infrastructure to support these would have to be created. - Transportation vehicles (e.g. vans) to increase access for patients to health care facilities and resources, including home visits for follow up by community health workers which maximizes patient activation and can produce better patient outcomes - The creation of additional triage and exam room space, either through renovations of existing facilities or creation of new work spaces to Article 28 standards, to accommodate increased patient volume will require renovations to Article 28 standards in order to. The creation of space for a home base of care and coordination of outreach workers may also need to be established in certain areas where health care resources and/or facilities are more spread out.

Are any of the providers within the PPS and included in the Project Plan currently involved in any Medicaid or other relevant delivery system reform initiative or are expected to be involved in during the life of the DSRIP program related to this project’s objective? (Yes/No)







Chemung County Department of Aging and Long Term Care

Balancing Incentive Payment Program

The Balancing Incentive Program (BIP) is a federal initiative authorizing grants to States to increase access to non-institutional community-based long-term services and supports

Finger Lakes Addictions Counseling and Referral Agency

Health Homes of

Upstate New York

Health Homes and Care Management



The Balancing Incentive Program (BIP) is a federal initiative authorizing grants to States to increase access to non-institutional community-based long-term services and supports. New York was awarded $598.7 million through BIP, a portion of which will be used to strengthen and expand NY Connects, an information and referral service mostly operated by local offices for aging. With the expansion, New Yorkers will come to know NY Connects as the one-stop shop for long-term services and supports. Through outreach activities to identify potential Medicaid eligibles, "No


Wrong Door" single point of entry, "Level 1" screen to identify Medicaid eligibility and need for/linkages to ltc services and supports

Greater Rochester Health Home Network LLC

Health Home Care Management


Supervised and Supported Certified Residential Services

24/7 and less restrictive daily living, medical and clinical supports


CMMI grant The CMMI grant seeks to facilitate practice transformation and patient activation

Planned Parenthood of Central and Western New York

Family Planning Benefits Program

This program covers family planning care in lieu of insurance to preserve confidentiality for the patient.

Rochester Regional Health System

CMMI Care managers Care managers in some practices until 6/15 to help engage and manage chronic ill patients

Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the current Medicaid initiative(s) identified above. A PPS may pursue a DSRIP project that exists as part of another effort if the PPS can demonstrate a significant enhancement to the existing project.

PPS Response (3,000 characters max): Current: 1,993 characters Project 11 speaks to a much broader audience than captured in these initiatives, which focus largely on those with chronic illnesses, the elderly and families with the exception of the CMMI grant at Oak Orchard. It expands significantly on the foundations of these projects to activate and engage not just these populations but the substantive body of the uninsured, and non and low-utilizers of Medicaid in the FLPPS region which in our region primarily belong to a younger demographic (18 – 44), low income and split between the rural and urban centers of the PPS region. The majority of the existing Medicaid initiatives support persons already in care to help manage their conditions, however this project distinguishes itself by creating infrastructure that would activate persons to not only get into care, enroll insurance and become better navigators of the local health system, but create avenues whereby the behavioral paradigm shift of reactive and treatment approach to managing health conditions to a proactive and preventative health care engagement approach is promoted and supported. The scale of project 11 is substantially larger than these programs and requires more complex and dynamic infrastructures including additional workforce, larger IT support and coordination across PPS providers to track activated patient cohort, more sustainable and greater number of partnerships across PPS service providers across the region for efficacy. However these additional layers of complexity for project 11, are merited by the larger impact that it hopes to have on the region as a whole, than these programs which are


more selective and smaller in reach to immediate counties. Project 11 stands is imperative to overall DSRIP goals of reducing avoidable hospital admissions, improper utilization of emergency departments and creating a new wave of patients that more responsible and involved in their care, as measured by interval changes in the Patient Activation Measure (PAM).


3.a.i Integration of Primary Care and Behavioral Health Services

Project Response & Evaluation (Total Possible Points – 100): 1. Project Description and Justification - Project Justification, Assets, Challenges, and Needed Resources (Total Possible Points – 20)

a. Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps this project will fill in order to meet the needs of the community. For example, please identify the approach to develop new or expand current resources, or alternatively, to repurpose existing resources to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community.


- In 2012, of 16 categories of mental diseases and disorders, our region was 142% of the NYS prevalence per 1,000 Medicaid beneficiaries - A Western Region Behavioral Health Organization (WRBHO) study showed that 77% of inpatient mental health or substance abuse admissions had a co-occurring physical need identified during their stay - An all-cause readmission risk study indicated that adults admitted to a medical inpatient bed with a serious mental illness were 22% more likely to be re-admitted - Inpatient psychiatric bed admissions with a co-occurring diabetes or heart disease diagnosis had a 31% and 48% higher likelihood, respectively, of being readmitted - Behavioral health conditions are the third most frequent (and most specific) primary diagnosis cluster seen in the ED - BH disorders represent the most frequently occurring principal diagnosis clusters for inpatient utilization leading to re-admission - Inpatient discharges with a behavioral health primary diagnosis is disproportionately represented in Medicaid vs. other insurance coverage (24.0% vs. 8.5% FLPPS average) - 65% of Medicaid/uninsured adults admitted to an inpatient medical or surgical bed had a co-occurring behavioral health diagnosis documented (compared to 40% of non-Medicaid) Participating primary care settings will implement one of the following 2 models, which will use patient-centered medical home principles to coordinate behavioral and physical care: 1) The IMPACT model , or 2) Integration of behavioral health into their primary care setting Participating behavioral health settings will implement the following model, which will draw from patient-centered medical home principles that have been adapted for specialty care to coordinate behavioral and physical care: 1) Integration of primary care into their behavioral health setting Co-location/integration of both behavioral and physical care will allow for treatment that is


accommodating of the interaction between and existence of the two, ensuring compatible and effective solutions. To illustrate: 1) A patient was quoted as saying, “I always tell them I’m having a manic episode – but they say ‘that’s not important now; your sugar is 625!’ They only deal with my sugar and my blood pressure, but I never end up getting the psychological help I need. It takes them 3 days to get my blood levels under control, and then they discharge me because by then I’ve calmed down and my manic episode is over. But they NEVER deal with my psych problems.” A second patient was quoted as saying, “All my medical problems stem from my psychological problems, but they always blame it on my diabetes. Whenever I get upset, it’s always because I was not able to get to speak with my therapist — then my blood pressure goes up and my blood sugar goes crazy. But every time I’m hospitalized, even though it was always because of psychological issues, the discharge papers always say it was my sugar diabetes and blood pressure. NO ONE LISTENS TO ME when I try to explain!”

b. Please define the patient population you expect to engage through the implementation of this project.

The definition of patient population be specific and could be based on geography, disease type, demographics, social need or other criteria. This patient population that the PPS expects to actively engage over the course of the project will be a subset of the total attributed population (define the target patient population that will be impacted by this project). Target population must be specific and could be based on geography, disease type, demographics, social need or other criteria.

PPS Response (1,600 words max): Current: 1,255 characters

The FLPPS population as a whole is racially/ethnically diverse, but the majority of diversity is tied to Monroe County (62% white, 22% African-American, & 6% Hispanic). The remaining counties identify as 92% white. All counties exhibit per-capita income below the NYS median income. All but two counties have a higher rate than NYS with a high school degree or less. The area has a similar prevalence of chronic disease as rest of NYS Medicaid recipients, but much higher prevalence (approximately twice from a diagnosis perspective) of mental diseases and disorders. Focus groups have led to findings that there’s an inadequacy of or resistance to providing behavioral health treatment in primary care settings. The same focus groups have also found a perceived lack of access to psychiatry – the fifth largest contributor to potential life lost in the Finger Lakes region is suicide which is inextricably linked to mental illness and substance abuse. It’s expected that the total attributed population linked to primary care will be screened for behavioral health conditions, but clearly there’s great need already recognized based on disease prevalence and patient perception of inadequate access to the behavioral health services they require.

c. Please provide a succinct summary of the current assets and resources that can be mobilized and

employed to help achieve this DSRIP Project. In addition, identify any needed community resources to be developed or repurposed.


Current assets and resources that don’t require modification include participating organizations with both behavioral health & primary care (some of which is co-located/integrated), HIT (RHIO, SHIN-NY,


etc.), presence of multiple health homes, and experience cited in this type of integration (74% according to a survey). These strengths support/demonstrate the following: common policies/procedures, coordinated evidence-based protocols, shared EMR documentation, pre-existing linkages for patients with behavioral health/physical health needs to care settings, region-wide buy-in and advocacy for the project. Current assets that require development or repurposing in order to maximize their existence include a higher rate of RN licensure rate than NYS for potential utilization as depression care managers, 45% of participating organizations that plan on collaborating with 3 other organizations, performance improvement leadership with lean six sigma and mental health counseling backgrounds, specialty/niche behavioral expertise, and dedicated staff that collect and evaluate substantial program data for existing addiction treatment services. These translate to -- redeployment possibility of well-suited RNs, a high degree of planned collaboration signifies flexibility to leverage provider and care setting assets, leadership in process improvement and MH that can assist in change management involved in merging primary and BH care, and existing data collection and analysis can be expanded to cover additional growth/evolution in the area of addiction treatment services. In terms of new resources, social workers have been cited through our survey as the #1 new hire need. This role would offer an alternative to the traditional RN care manager, lending flexibility in terms of skill and licensure. An expanded HIT infrastructure is another key new asset requirement, as the growth of EMRs and general interoperability are critical to behavioral health/primary care integration. Lastly, according to a local physician who was recently president of the New York Society of Addiction Medicine, primary care buprenorphine management is an area of great opportunity that could be dramatically improved with as little as one day of training.

d. Describe anticipated project challenges or anticipated issues the PPS will encounter while implementing

this project and describe how these challenges will be addressed. Examples include issues with patient barriers to care, provider availability, coordination challenges, language and cultural challenges, etc. Please include plans to individually address each challenge identified.


In order to improve upon what’s highlighted in the CNA, the following need addressing: a lower rate of physician presence (with the exception of Monroe Co.) than NYS, no county is at/above the NYS average for presence of psychiatrists/psychologists, and 8 counties have both PCP and MH HPSA designations - suggesting the importance of creating synergy between BH/PC. In addition to the lack of providers in both care settings, statistics reflect a burdensome prevalence (and often unrecognized, untreated, or uncoordinated efforts around co-existence) of both behavioral and physical conditions. The current rate of screening for BH issues isn’t well known, as it’s not a billable service that can be tracked. A lack of interoperability between PC and BH EMRs exists, given the historical separation of treatment. Medication non-adherence was cited in 35% of MH and 7.5% of SA re-admissions in a provider survey. Lastly, regulatory relief was cited by 47% of survey respondents as crucial to their success in this project. In order to addresses these challenges the FLPPS plans to: encourage the usage of IMPACT & BH into PC integration vs. PC into BH integration (especially in Monroe Co., where PCP presence is greatest and highest Medicaid concentration exists), maximize the usage of tele-health, ensure that protocols include a minimal annual screening, closely work with project 2.a.i to make sure that project 3.a.i considerations are accommodated, develop effective medication management


protocols, and leverage scarce resources to the extent that regulatory relief permits.

e. Please outline how the PPS plans to coordinate on the DSRIP project with other PPSs that serve

overlapping service areas. If there are no other PPSs within the same service area, then no response is required.


The FLPPS will hold regular conference calls with neighboring PPSs to coordinate care as appropriate.

2. Scale of Implementation (Total Possible Points - 40): DSRIP projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale, please complete the following information:

a. Please indicate the number of programs the PPS intends to include in the project by the end of Demonstration Year (DY) 4, or sooner as applicable. This number should be entered in the table as Total Committed.

PPS Response:

PPS currently drafting finalizing provider and patient scale and speed. Work will continue to be done until application is submitted. PPS committees, board members, and DSRIP project teams are informing and guiding final decisions on scale and speed. You may refer to Appendix A for a high-level overview of the nine FLPPS projects current scale and speed information.

Please identify the number of committed providers who are a part of the local Safety Net. *Based on Department of Health Safety Net Provider designation

PPS Response:



e. Please indicate the total expected volume of patients the PPS intends to engage throughout this project by the end of Demonstration Year (DY) 4. This will become the Expected # of Actively Engaged Patients.


Patient scale is measured by the total number of patients that are expected to be actively engaged by the end of Demonstration Year 4.

PPS Response:



a. Please indicate the Demonstration Year (DY) and Quarter by which all programs will achieve project requirements. Project speed is measured by how fast all the project requirements for all chosen locations are met. PPSs will be expected to meet these requirements for all of the providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.

PPS Response:


While some areas have solid Maternal and Child Health infrastructure, other areas do not and will require infrastructure building in order to reach the Domain 1 milestones and metrics. Particularly since this project intends to coordinate multiple programs that will require different amounts of coordination and implementation planning. For example, Nurse Family Partnership expansion will require applying to the national organization in order to create new programs. Additionally, establishing a workforce strategy and attendant qualifications metrics is a challenge as identified in Part 1d of this application.

b. Please indicate the expected timeline for achieving 100 percent engagement of total expected number of actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent


by the end of DY 3.

PPS Response:


*For this project, Actively Engaged is defined as the total of number of patients engaged per each of the three models in this project, including: A. PCMH Service Site: Number of patients screened (PHQ-9 / SBIRT) B. Behavioral Health Site: Number of patients receiving primary care services at a participating mental health or substance abuse site. C. IMPACT: Number of patients screened (PHQ-9 / SBIRT)

4. Project Resource Needs and Other Initiatives (1000 word limit, Not Scored)


Yes No

X


PPS Response (3,000 character max): Current: 2,809 characters

1) To build out space to allow primary care provider partners to co-locate (and integrate). Will also need EHR infrastructure 2) There is no EMR in our MH clinics. Existing main site for MH services has no room for expansion and is routinely cited in OMH surveys for inadequate space. 3) We would need to add on to our current site to house the BH and PCP initiative. What makes us unique is we sit in the NE quadrant of the city of Rochester where the highest population of individuals needing services live. We are in walking distance and offer an array of other services that will be available to the clients such and day care, food, emergency services, elder care, and youth programming 4) We would need an EHR that would allow communication between providers and hospitals. We would need to add patient portal to our EHR. 5) In order to incorporate BH into our PCP site, we will need to renovate existing space as well as purchase additional equipment and furnishings. 6) Capital is needed to improve infrastructure; communication and buildings to allow this new level of care to be delivered. 7) This project will involve mid to large-scale construction projects that will require capital funding


8) As the co-location of substance abuse treatment aspect of this project is implemented, two additional exam rooms will be needed to support the providers and patient visits. Renovations to meet Article 28 and OASAS requirements are needed. 9) An Article 28 compliant exam room will need to be built and equipped at the Delphi site. There will be IT equipment needed to connect deployed medical staff to the central EMR and for smart phones to be provided the highest risk patients to ensure ongoing monitoring and immediate access to their provider. 10) We have no internal financial resources to implement this project. At present we are working to ensure that our program breaks even each year and continues to serve patients and families. The majority of Medicaid patients, especially Latino and African American individuals, are unserved or underserved with regard to eating disorders. This is why I proposed the idea of mobile specialty trained therapist and care manager to travel to primary care settings. 11) We will need to expand the footprint of current safety net practices that have well established panels of patients at their current locations to create therapy office spaces and on site administrative support capacity. We believe it critical to avoid relocation of practices to expand capacity whenever possible to avoid disturbing the pattern of care already established for our DSRIP eligible patients.–This cost estimate includes cost of construction for expansion, furniture and equipment for behavioral health services and the required expansion of primary care services


or other relevant delivery system reform initiative or are expected to be involved in during the life of the DSRIP program related to this project’s objective?

Yes No X

If yes: Please identify the initiatives in which the provider is participating in the table. Please identify the current or expected initiatives in which the provider is (or may be) participating within the table below, which are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.





Arnot Health VAP/So. Tier MH Project 4/1/14-3/31/17 Operating and systems change, professional psychiatric workforce, BH & SA assessment and management, embed BH in PC

Genesee Co. MH PSYCHES 2008-present Provides data to help improve and adopt psychiatric medications and quality concerns


Genesee Co. MH MU 2014 Better information sharing for coordination of care

Greater Roch HH Network

Health Homes N/A N/A

FLACRA Health Homes 7/1/13-present HHs & care management

FLACRA Ambulatory Patient Group

N/A Medicaid reimbursement

UR Med PC NYS Child Clinic N/A 5 years of funding through the NYS Child Clinic Plus Program and 5 subsequent years of funding through the NYS Early Recognition and Screening Program, to identify children at risk of MH concerns and facilitate their access to evaluation and other services

UR Med PC NYS HMHD Program 2013-2014 The DOH Hospital Medical Home supports initiatives that expand PC capacity to effectively train residents in PCMH principles. The grant supports a depression care manager and one data entry specialist in our family medicine practice and will be completed in December 2014

UR Med PC FLHSA/CMMI Grant July 2015 expiration Funds 1 care manager

UR Med PC Doctors Across NY June 2016 expiration Expand access to PC services to underserved populations through education and curriculum development. It’s targeted adults with special health care needs such as intellectual and developmental


disabilities, movement disorders, cystic fibrosis, sickle cell disease, among others.

c. Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the current Medicaid initiative(s) identified above. A PPS may pursue a DSRIP project that exists as part of another effort if the PPS can demonstrate a significant enhancement to the existing project.


- Directly impacts embedding mental health in primary care - All clinic clients and day treatment clients would be included, instead of Medicaid only - The NYS and grant funded initiatives have enabled us to collect data regarding the prevalence of mental health in our practices, but has not allowed us to implement models that would achieve the overall goals including co-location, coordination, and practice innovation. These practice enhancements will allow us to routinely screen for mental health disorders, impact patient perceptions of mental health treatment as stigmatized and separate from their medical health, and do so in a comprehensive care setting due to the waivers from current regulatory barriers. The proposed projects will enable us to provide timely access to mental health services within primary care setting for children, adolescents, and adults identified through our screening programs and will impact as many approximately 35,000 DSRIP eligible patients. - Assistance w/ moving to MU Stage 2


3.a.ii Behavioral health community crisis stabilization services Project Response & Evaluation (Total Possible Points – 100): 1. Project Justification, Assets, Challenges, and Needed Resources

a. Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps

this project will fill in order to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community.

PPS Response (3,200 characters max): Current: 4,674 characters The need for improving Behavioral Health Community Crisis Stabilization Services in our Finger Lakes PPS (FLPPS) is supported by the health needs data of our population and by qualitative data obtained through focus groups and in conversations with clinicians, community-based organizations and advocates across our 14 county region. Our CNA finds the FLPPS region has a significantly higher prevalence of Mental Illness among Medicaid beneficiaries (411/1000 pop.) when compared to the New York State (NYS) average (289/1000 pop.) and a higher prevalence of substance abuse disorders (99.5/1000 population) than the NYS average (86.8/1000). The need for more outreach, access to outpatient services, and follow-up and care coordination for our PPS members is supported by DSRIP Chart Book data that identifies our FLPPS PPS as below the average for NYS regarding adherence to anti-psychotic use (60.3% [NEED NYS AVERAGE HERE]) and for effective medication treatment for both acute depression (43.9%) and depression management (35.5%) [NEED NYS AVERAGES HERE TOO]. Considering the fact that suicide is the only cause of Years of Potential Life Lost (YPLL) trending upward in the FLPPS region with suicide rates in both our Finger Lakes NOCN and Western NOCN exceeding the NYS average and MDDs ranked among the leading causes of YPLL for these two regions (NEED DATA HERE), the need to implement this project is great. To further support the need for this project, behavioral health disorders are the most commonly seen principal diagnosis clusters among 30 day readmissions in our PPS, i.e., 17 percent of all of our Medicaid 30 day readmissions. An increase in community services would have an impact on decreasing these readmissions by providing support and stabilization services within the community after a hospital discharge. Lastly, among Emergency Department “treat and release” visits for all chronic conditions, MDDs and SUDs account for over 50 percent of all “treat and release” visits across our PPS, visits that might be averted with the collaborative, community crisis stabilization services we plan to implement. Our plan is to decrease the utilization of psychiatric emergency and inpatient services (OVERCROWDING and ever increasing CPEP DATA HERE?) by improving access to 24/7 crisis services across the region in five, geographically strategic hubs, one per NOCN. These services will include all of the project requirements with a focus on expanding our existing Mobile Crisis Teams (MCTs), expanding outreach and strength-based approaches by utilizing and growing our existing Peer services and community-based services, increasing our focus on early identification of those at risk and crisis prevention planning via our Health Home partners, and improving access to crisis, detox and transitional housing in cooperation with our existing housing and substance abuse services. The repurposing of existing space and staff will be utilized. We will also include a Central Triage system that will operate in “real time” connecting


the needs of the individual, no matter where they are in our PPS, to the resources available. This system will be collaboratively built, utilizing electronic health records with local health information exchange as well as policies, procedures and protocols that are agreed upon, across the region. Partners across our PPS widely support this project and bring expertise, resources, experience and enthusiasm to improve upon our current assets. In speaking with partners across our region, there is wide acknowledgement of a low threshold for the utilization of emergency services, primarily for liability reasons, since our residential staff, school staff and outpatient providers cannot provide or access the necessary assessments, interventions, monitoring and follow-up in their setting. There is a commonly expressed need for greater access to MCTs to provide consultation and/or “push-in” support during a crisis not only to individuals, but to their families, Primary Care Providers and to community staff. The need for more crisis housing options, greater access to detox facilities, more readily accessible follow-up for medications and improved communication across the continuum of care, especially regarding what resources are available, are all widely identified as needs in our region. Language and cultural barriers with existing community crisis services have been identified as barriers to intervening in the community since access to culturally competent interpreters are more readily available in the acute setting. Our plan will address these needs by expanding upon our current assets and building new ones.

b. Please define the patient population expected to be engaged through the implementation of this project. The definition of patient population be specific and could be based on geography, disease type, demographics, social need or other criteria. This patient population that the PPS expects to actively engage over the course of the project will be a subset of the total attributed population.

PPS Response (1,600 characters max): Current: 1,162 characters Our target population will initially include current high utilizers of emergency services for MDD and SUD crises who reside across our region (data insert here), as well as communities with high levels of “treat & release” visits for MDDs and SUDs, i.e., our Monroe, Western and Finger Lakes NOCNs (total “lives” here?). Our Southern and Southeastern NOCNs in particular require more services for SUD’s and MDDs so a focus on these regions, including outpatient detox, will occur there. We will target the general population in FLPPs (data insert here) who may have low or no utilization of crisis services but who would engage, as needed, if the services were more accessible, lower cost, strength-based and patient, family, and community-centered. Additionally we will target community-based staff and organizations to assure their awareness and collaboration in utilizing community crisis stabilization services in lieu of emergency services and to provide support and education around the prevalence and the importance of the need to address mental health needs early and to screen for them routinely so that early identification and intervention can occur.

c. Please provide a succinct summary of the current assets and resources that can be mobilized and



Our two lead organizations have expertise and resources in crisis intervention and stabilization and we have two Comprehensive Psychiatric Emergency Programs in our PPS who are willing and able to


provide assistance, leadership and support in the implementation of this project. They plan to expand their teams and hours to improve accessibility, to provide training to new teams and to include more outreach and follow-up. They also plan to repurpose existing space for two of our crisis stabilization hubs. Throughout our region there are also local crisis response and prevention programs along with several Peer run initiatives that include a Self-Help Drop-in Center and Peer run Warm Line lead by our Mental Health Association, and a Peer lead/Peer-Driven Recovery Center for individuals with SUDs. These organizations are willing and able to help with the expansion of these services. We also have the collaboration of well-established crisis and transitional housing programs, e.g., Unity House, DePaul and East House, with new housing options being piloted or established, some with NYS reallocation dollars. The NYS START Program for OPWDD individuals, a community-based crisis and prevention program, has been established in our PPS and utilizes many of the same components that we will be implementing. Local leaders of our START Programs are interested in collaborating with us and in providing guidance on this project. Planned Parenthood of Western and Central NY also has interest in collaboration in light of their expertise with providing crisis intervention and support services through their rape crisis program, RESTORE. They have capital as well to be used to lead project objectives ahead of lagging reimbursement. Additionally, with the closing of St. James Mercy Hospital, some funding is allocated to intensive intervention services for individuals in crisis and Wyoming County Community Health System has space they believe is suitable to support aspects of this project. Finger Lakes Addictions Counseling and Referral Agency (FLACRA) is a willing and able partner with interest in building a 15 bed Safe Haven program that aligns with this project. We also have the Rochester RHIO that has integrated with 23 different EHR’s to help with the coordination and communication across the PPS, and Telemedicine expertise in several NOCNs that has been utilized in clinics, urgent care centers, day care centers, skilled nursing facilities and emergency departments. Providers will be part of a FLPPS EHR, so that information will be available, even in rural areas. Wireless devices may provide network capability in those rural areas. Input and maintenance of provider and services data for rural areas may be the centralized responsibility of FLPPS to ensure a comprehensive data base. There is also a great spirit of collaboration throughout our PPS that has been further inspired by joining together in DSRIP.

d. Describe anticipated project challenges or anticipated issues the PPS will encounter while implementing

this project and describe how these challenges will be addressed. Examples include issues with patient barriers to care, provider availability, coordination challenges, language and cultural challenges, etc. Please include plans to individually address each challenge identified.

PPS Response (1,600 characters max): Current: 2,894 characters In surveying our partners, the greatest challenges they anticipate in moving forward are: Information Technology needs, Workforce Needs, transportation needs and funding. While we have expertise and many resources in our PPS that we will leverage, we have challenges to overcome as well such as insufficient access to psychiatric providers, especially in our more rural areas. Much of the FLPPS has been designated a mental health professional shortage area (see page [x]). There is great variation in the number of mental health clinicians across the PPS and sharing these “resources” across NOCNs may be challenging, especially resources that are bi-cultural and bi-lingual. We are looking to take advantage of


established programs to train non-behavioral health clinicians along with non-clinical staff to become certified in behavioral health care and in cultural competencies that address cultural strengths and barriers to mental health promotion. This training is already underway in several places across our region and can be leveraged. Our capacity for remote access to psychiatric experts for consultation, mentoring, treatment, bilingual/bicultural expertise and Telepsych oversight of our rural MCTs is also limited. Presently Telehealth services are successfully although minimally used due to constraints on paying for these services and the cost of implementing them. We intend to build upon the existing infrastructure and expertise. Transportation for follow-up visits is a challenge across the PPS in both rural and urban environments and we are partnering across the region with our existing transportation services to plan how best to leverage their services in this project. EMS in particular has interest in participating to help direct more care to community-based versus hospital-based services. The creation of a comprehensive Transportation data base (carriers, appointments, etc.) is essential for effective operation of FLPPS to ensure Transportation needs are communicated, met, leveraged and optimized where possible and avoid multiple vehicles traveling to the same place at the same time. Work is underway to reconcile our transportation assets with the needs of this project. IT infrastructure might be absent or inadequate for the ready integration of care across NOCNs and for distance conferencing and learning. FLPPS has an opportunity to explore sharing/leveraging IT infrastructure with the NYS START program. We also have …. Increasing the utilization of Peer/Family Supports will require training and certification for local Peers and Family members interested in this role and will require a shift in culture for mental health professionals who have not experienced collaboration with peer and family advocates. Educating the healthcare workforce on the evidence that supports these services will be one mechanism to facilitate this shift in culture.

e. Please outline how the PPS plans to coordinate on the DSRIP project with other PPSs that serve


PPS Response (1,600 characters max): Current: 122 characters Close collaboration with adjacent PPS’s is planned to assure the best and most accessible services to our

NYS population.

2. Scale of Implementation (Total Possible Points - 40):

DSRIP projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale, please complete the following information:

a. Please indicate the total number sites the PPS intends to include in the project by the end of

Demonstration Year (DY) 4, or sooner as applicable. This number should be entered in the table as Total Committed.

PPS Response:



Please identify the number of committed providers who are a part of the local Safety Net.



b. Please indicate the total expected volume of patients the PPS intends to engage throughout this project by the end of Demonstration Year (DY) 4. This will become the Expected # of Actively Engaged Patients. Patient scale is measured by the total number of patients that are expected to be actively engaged by the end of Demonstration Year 4.


3. Speed of Implementation/Patient Engagement (Total Possible Points - 40):

DSRIP projects will be evaluated based upon the proposed speed of implementation and timeline for patient engagement. The projects with accelerated achievement of project requirements and active engagement of patients will receive more funding than those taking longer to meet goals. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess speed and patient engagement, please complete the following information:

a. Please indicate the Demonstration Year (DY) and Quarter by which all participating sites will achieve

project requirements. Project speed is measured by how fast all the project requirements for all chosen locations are met.

PPSs will be expected to meet these requirements for all of the providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.



b. Please indicate the expected timeline for achieving 100 percent engagement of total expected number of

actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent by the end of DY 3.


*For this project, Actively Engaged is defined as participating patients receiving crisis stabilization services from participating sites, as determined in the project requirements Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column. 4. Project Resource Needs and Other Initiatives (750 word limit, Not Scored)


Yes No X


PPS Response (3,000 characters max): Current: 0 characters PPS Currently Drafting



Yes No X

If yes: Please identify the current or expected initiatives in which the provider is (or may be) participating


within the table below, which are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.

Name of Entity (200 characters)

Medicaid/Other Initiative (100 characters)



Arnot Health VAP--Southern Tier Mental Health Project

April 1, 2014 - March 31, 2017

Operating and systems change, professional psychiatric workforce, behavioral and substance abuse assessment and management, imbed behavioral health in primary care

FLACRA

Health Homes of Upstate New York Ambulatory Patient Groups

7/1/2013 to present

Health Homes and Care Management Medicaid Reimbursement

GRHHN Health Homes Monroe County Chapter, NYSARC Inc Regional Workforce Development

9/1/2014 to 8/30/2014?

Deployment of Core Competencies for Direct Support Professionals


1/1/2014-3/30/2015

This project will enhance the coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and case management system, and the existing relationships among the medical systems, the health plans, and perinatal support services. The goal is to share both medical and psychosocial information efficiently with all the providers who form the system of


care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women with complex medical and/or psychosocial needs.

URMC Strong Ambulatory Payment Regs

10/2010 -10/2017 Reimburse methodology through DOC

Care Management Health Home 9/13-TBD Contracted with GRHNN and HUNNY



3.a.v Behavioral Interventions Paradigm Project Description and Justification (10000 word limit): Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps this project will fill in order to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community.

PPS Response (3,200 characters max): Current: 4,355 characters The FLPPS region has a significantly higher prevalence of Mental Illness among Medicaid beneficiaries (411/1000 pop.) when compared to the New York State (NYS) average (289/1000 pop.) and a higher prevalence of substance abuse disorders (SUD) than the NYS average, with rates of 99.5/1000 population compared to 86.8/1000 for NYS. Our population is aging and many of these beneficiaries are now requiring a Skilled Nursing Facility (SNF) level of care. This is likely the reason that, from a qualitative perspective, we have consistently heard in meeting with our community partners that there is great interest in Project 3.a.v from SNF care providers across the region. This interest is related to the challenges of caring for residents with behavioral health concerns in the nursing home setting, especially in light of the lack of a behavioral health skill set and the lack of psychiatric consultation or expertise as our region consistently measures below the NY state average availability of behavioral health care workforce. The challenges shared with us include safety concerns for staff


and residents as well as staff turnover in light of these safety issues coupled with low pay for non-clinical staff. The distress behavioral health symptoms cause for the individual experiencing them and the distress these behaviors cause for other residents, families and staff is most often the impetus to transfer the resident to a higher level of care to assure the safety and wellbeing of all concerned. In our PPS, readmissions to acute care beds following a discharge to a skilled nursing facility (SNF) account for about 16 percent of all Medicaid readmissions with behavioral health symptoms among the top 11 “Most Frequent Primary Diagnosis Clusters at Readmission” for SNF Readmissions (SPARCS Database; 2012). Additionally, between July 2013 and March 2014, the percentage of SNF residents with increased depression and/or anxiety symptoms has increased and while, in large part the average for these symptoms across the PPS are below the NYS average (11.6 percent), eight SNFs have averages of worsening depressive and anxiety symptoms greater than the NYS average and 19 of our SNFs have averages that are greater than the National average (6 percent). What we have also learned from SNF care providers is that some SNFs in our region have instituted best practices, including the use of the INTERACT Model, with positive outcomes including a marked reduction in readmissions, e.g., Blossom View SNF in Sodus, NY, St. Anne’s NH in Rochester, et al, have adapted it for their environment and have markedly decreased their BH admissions. These facilities enthusiastically embrace early recognition and intervention models but continue to note challenges in accessing psychiatric expertise or acute care when the behavioral health symptoms exceed the limits of the care that they can safely provide. Telehealth services have been used successfully in several of our SNFs but funding for and access to these services has been a great challenge.

We plan to implement all of the requirements of this project with a focus on education and training for clinical and non-clinical staff by utilizing both local, on-line and web-based training already underway. We will also focus on improved access to psychiatric expertise along with enhanced mental health promoting care at the SNFs leveraging, where we can, infrastructure already in place. The number of SNFs that have expressed interest in collaborating on this project serve more than one half of our SNF population. Improving the care rendered to these residents in the Finger Lakes PPS by implementing Project 3.a.v will improve the lives of all of these individuals whether they have behavioral health concerns or not and will have positive outcomes for their families as well as for the staff who will be more competent and have the support to care for them. The implementation of Behavioral Health Interventions Paradigm in Nursing Homes across our PPS will reduce the transfer of patients from a SNF to an acute care hospital by employing early intervention strategies to stabilize patients with behavioral health issues before crisis levels occur and by assuring access to a more skilled environment when symptoms cannot be managed safely in the current SNF environment.

Target Population

PPS Response (1,600 characters max): Current: 888 characters Our target population will eventually include all SNFs in our PPS with an initial focus upon those SNFs that currently have expressed interest, do not have access to consistent and effective psychiatric expertise (most of them), those that have high rates of acute psychiatric hospitalizations for their residents and those that have low quality indicator scores (need to add more specific data - requested SNF acute ed/admit rates from Salient. Not sure if this is in the queue yet due to other priorities). Allegany, Chemung, Orleans, Schuyler, Seneca, Steuben, Wyoming, and Yates Counties are all identified, in their entirety as lacking mental health services.


Cayuga, Genesee, Livingston, Monroe, Ontario, and Wayne counties are also identified as having subsets of their populations in need of additional mental health services (p. 15) with geriatric psychiatry among these needs.

Assets

PPS Response (3,200 characters max): Current: 2,194 characters Implementing Project 3.a.v across our PPS will be facilitated by the many assets and resources that can be readily mobilized and employed as well as the many community resources that can be developed or repurposed. As mentioned previously, several of our SNFs have successfully implemented best practices that are aligned with the components of this project including some that have implemented the INTERACT Model. Leadership of these SNFs have expressed an interest in helping others to implement the model using their own experiences as a guide. We also have Telementoring access through the Project ECHO® model, an inexpensive readily accessible web-based model that is in place through one of our lead organizations to improve geriatric mental health across our region via biweekly case reviews with an interdisciplinary team and weekly didactic sessions on caring for residents with behavioral health concerns. We plan to expand this service across the PPS to provide case reviews, consultation and mentoring to participating SNFs. Additionally, several SNFs in our PPS have successfully utilized TelePsychiatry and Telehealth when access to these services has been available proving that this technology works in SNFs to overcome our shortage of behavioral health providers and improve the care of this population. We will expand the Telehealth infrastructure utilizing the expertise of the SNFs that already have this in place. Willingness has also been expressed by those SNFs who have already employed best practices to repurpose some of their existing beds to accommodate residents with behavioral health diagnoses in a separate unit at their facility which would expand capacity to manage more challenging BH concerns, transitionally, at the SNF level. There are also many low cost environmental enhancements that some of our SNFs already have in place that can be readily replicated in other facilities, e.g., a calming room, safe access to the outdoors, social networking for residents through outpatient day programming or events with non-residents. The spirit of joining together in this project has already created the sharing of ideas and expertise that exists across our PPS.

Challenges

PPS Response (1,600 characters max): Current: 1,700 characters There is great variation in the number of mental health clinicians across the PPS and sharing these “resources” across SNFs may be challenging. Building upon our current Telephealth services is one way we plan to meet this challenge and providing Behavioral Health certification training for our onsite SNF NPs through our two of local nursing schools where this training already exists is another. Expanding the ECHO telementoring program is also in our plan to better support and equip staff to manage behavioral health crises and concerns. Information Technology (IT) infrastructure might be absent or inadequate in some of our SNFs for the ready integration of care across the care continuum and for distance conferencing and learning. Funding will need to be considered for IT needs, perhaps as coming from the PPS level. Communication, especially around transitions with acute services, when they are needed, is often a


challenge especially in the absence of a “warm handoff” or “facilitated discharge” sometimes related to the distance between facilities. Some of our facilities utilizing evidence-based models like INTERACT have processes in place that have improved communications and are willing and able to help train other SNF/Acute Service staff so that medication reconciliation can occur along with sharing other successful interventions. Another challenge is the stigma that is associated with behavioral health symptoms and diagnoses in the SNF setting that can interfere with care and exacerbate behaviors. Providing training and improving competencies in managing these behaviors as well as increasing awareness of stigma will be a part of the training we implement in this project.

Coordination with other PPS

PPS Response (200 words max): Current: 0 characters PPS Currently Drafting

Scale of Implementation

c. Please indicate the total number of providers by county that the PPS intends to include in the IDS by the end of Demonstration Year 4, or sooner as applicable.


d. Please indicate the total expected volume of patients the PPS intends to target throughout this project by

the end of Demonstration Year 4.



a. Please indicate the Demonstration Year and Quarter by which all participating providers will achieve project requirements.



b. Please indicate the expected timeline for engagement of patients within the project. For example, the PPS

may indicate that 25 percent of targeted patients will be actively engaged by the end of Demonstration year 1, 50 percent by the end of Demonstration year 2, etc.


*For this project, Actively Engaged is defined as patients residing in counties served by the PPS having completed a RHIO Consent Form. Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column.

Project Resource Needs and Other Initiatives

a. Will this project require Capital Budget funding? (Yes/No) a. If Yes, describe why capital funding is necessary for the Project to be successful.


b. Are any of the providers within the PPS and included in the Project Plan PPS currently involved in any Medicaid or

other relevant delivery system reform initiative related to this project’s objective? (Yes/No) a. If yes: Please identify the initiatives in which the provider is participating in the table below, which are

funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.








3.f.i Increase support programs for maternal and child health Partners Participating in this Project Please list the name of the providers for this selected project along with identification numbers. Project Selection For this project, one of the following three project models can be selected. Please indicate which of the three will be chosen: □ Model 1: Implementation of Nurse-Family Partnership program model for pregnant high risk first time mothers. □ Model 2: Establish a care/referral network based upon a regional center of excellence for high risk pregnancies and infants. X Model 3: Implementation of a Community Health Worker (CHW) program on the model of the Maternal and Infant Community Health Collaborative (MICHC) program. Project Response & Evaluation (Total Possible Points – 100): 1. Project Description and Justification - Project Justification, Assets, Challenges, and Needed Resources (Total Possible Points – 20)

f. Utilizing data obtained from the Community Needs Assessment (CNA), please address the identified gaps this project will fill in order to meet the needs of the community. For example, please identify the approach to develop new or expand current resources, or alternatively, to repurpose existing resources to meet the needs of the community. Please link the findings from the Community Needs Assessment with the project design and sites included. For example, identify how the project will develop new resources or programs to fulfill the needs of the community.

PPS Response (3,200 characters max): Current: 5,194 characters In almost two decades, the infant mortality rate in the FLPPS region has decreased by less than one percent – from 7.3 deaths per 1,000 births in 1994 to 6.4 deaths per thousand in 2011. Specifically in Monroe County, the population center of the region with half of the total number of Medicaid births for the region, the infant mortality rate has improved by only .2 deaths per thousand births (7.9 per thousand in 1994 and 7.7 per thousand in 2011). With all of the medical, technological and political advances over that timeframe, the static mortality rate indicates a system-wide problem for the FLPPS. Also, according to the Community Needs Assessment, perinatal conditions are the fourth highest leading cause of years of potential life lost in the FLPPS region at nearly 400 per 100,000 persons and higher than the New York State average of (XXX). Therefore, this project will institute the Community Health Worker (CHW) program based on the Maternal and Infant Child Health Collaborative (MICHC) model as a framework within which CHWs can link patients to existing, evidence-


based programs from pre-conception to the child’s 24th month. CHWs will serve as outreach workers in communities and navigators toward the appropriate service, ranging from pre-conception education to prenatal and perinatal care through child care programs until the child is 24 months. This coordination of services will allow for the holistic care of the target population and will finally improve maternal and child health including infant mortality outcomes. Included in this project are 39 programs that provide services in the full range from pre-conception through the child’s second year. Some of the best performing evidence-based programs will require expansion of capacity to reach the new influx of patients. The Center for Disease Control and Prevention states that infants weighing less than 2500 grams are almost 40 times more likely to die than infants of normal weight and Allegany (8.9%), Monroe (8.7%) and Seneca (8.3%) Counties have higher rates of low birth weight (defined as less than 2500g) than the New York State average (7.9%), with Wyoming County (7.7%) close behind. According to the March of Dimes, pregnant women who smoke are nearly twice as likely to have a low birth weight baby as women who don’t smoke and 21 percent of women in the FLPPS catchment area reported smoking during or within three months prior to pregnancy (an improvement of only 1 percent in 4 years), with occurrence concentrated in FLPPS counties outside of Monroe County (Monroe County = 17% of all hospital births, outlying counties = 28.5% of all hospital births). Through this project, CHWs will utilize home visitation as a means to intervene in detrimental behaviors of the target population, such as smoking, and to gain more insight into patient habits than infrequent physician visits. Early intervention due to regular home visits by the CHW or program staff (i.e. Nurse Family Partnership nurse) and the linkage to the appropriate service allows for the avoidance of negative impacts on the child, thereby improving rates of low birth weight and other health outcomes. The Community Needs Assessments also highlights the staggering disparity in infant mortality rates by race. Infant mortality rates for African Americans were between three and four times higher than for White residents of the FLPPS region and infant mortality rates for Latinos were between two and three times higher than for White residents. In the Fingers Lakes region between 1994 and 2006, large racial disparities in infant mortality have existed without improvement. Infant mortality rates for African American births range from 12.1 to 18 deaths per 1,000 births and for Latino births range from 8 to 12 deaths per 1,000 births compared to a range of 4.1 to 5.8 deaths per 1,000 births for White, non-Latino residents. This project addresses this disparity in the staffing of the Community Health Workers and Nurse Family Partnership nurses for cultural competency, knowledge of the community and relevant expertise that will allow for customized supports. For example, we will staff for Spanish-speaking populations, indigenous to communities and knowledge of the community (leaders, resources, available services). Additionally, 65.1 percent of children in the PPS are receiving the appropriate lead screening and only 53 percent of children (in the nine counties where data is available) complete the 4:3:1:3:3:1:4 vaccination series (FLHSA Regional Profile). FLPPS focus groups and data trends have highlighted that low immunization rates are concentrated in the rural counties and are often a result of access to care. Through this project, Community Health Workers will provide transportation – either their own vehicle or arranged – to ensure that the full immunization series is received. The guidance provided by the CHW eliminates the access barriers such as transportation, education of need, and awareness of where to go. Also, Monroe County implemented a program that successfully and dramatically improved immunization rates; that program will be the model for programming in non-Monroe FLPPS counties.

g. Please define the patient population you expect to engage through the implementation of this project.

The definition of patient population be specific and could be based on geography, disease type, demographics, social need or other criteria. This patient population that the PPS expects to actively engage over the course of the project will be a subset of the total attributed population (define the target


patient population that will be impacted by this project). Target population must be specific and could be based on geography, disease type, demographics, social need or other criteria.

PPS Response (1,600 words max): Current: 475 characters The target patient population for this project includes high risk, Medicaid pregnant females and Medicaid mothers with children aged newborn to 24 months in every county of the FLPPS. Patients will include the migrant worker population, African American population, Latino population, and rural population within the 14-county region. The Community Health Worker will use a screening tool to identify patients who are high risk, particularly in their outreach worker capacity.

h. Please provide a succinct summary of the current assets and resources that can be mobilized and


PPS Response (3,200 characters max): Current: 2,264 characters The FLPPS region does have a multitude of established, evidence-based programs that provide the type of care described by the focus group member in the quote above and have demonstrated success in achieving DSRIP measures. Monroe County and Livingston County both currently employ the MICHC Community Health Worker model, administered by the Perinatal Network of Monroe County. The Perinatal Network employs outreach workers in addition to the Community Health Workers and is process of launching Peer Place as an automated referral system for any partners within their network, a foundation that this project will build on. The momentum from the launching of this program is a significant asset for the creation of the referral system for this project and the initiation of stronger integration and collaboration of existing programs. This project capitalizes on this collaboration, strengthening linkages and emphasizing cultural competency and health literacy. Monroe County also has a highly successful Nurse Family Partnership program that has existed since 2006 and has demonstrated increases in health outcomes as well as Medicaid cost reductions, with 9 percent actually going off of Medicaid according to a RAND Corporation study. Also, Chemung County was the original pilot for Nurse Family partnership and therefore continues to have a solid foundation of maternal and child health infrastructure for this program to build on. This project will include a significant expansion of the Nurse Family Partnership within Monroe County and into outlying counties to expand the evidence-based success throughout the PPS. One FLPPS resident described the benefit of the existing home visitation programs that currently exist and the effect it has had on the health of her child, “I have a lifetime care nurse who comes to the house three times a week to check my baby’s weight, and I have a 24/7 line that I can call. She had thrush on her tongue, and jaundice. But now she’s gotten to four pounds, and the thrush and jaundice have cleared up, so she’s doing good. The nurse is coming out to check her again today.” Existing evidence-based programs include Nurse Family Partnership, Baby Love, Healthy Families Steuben and Finger Lakes Migrant Worker Program.

i. Describe anticipated project challenges or anticipated issues the PPS will encounter while implementing

this project and describe how these challenges will be addressed. Examples include issues with patient barriers to care, provider availability, coordination challenges, language and cultural challenges, etc.


Please include plans to individually address each challenge identified.

PPS Response (1,600 characters max): Current: 1,410 characters The CNA underlines the challenge of the social factors that influence health within the FLPPS and the necessity of incorporating social circumstances, health behaviors and physical environment into the health care solution. Through the CHW or Nurse Family Partnership (NFP) nurse, care is delivered to patients in their own home. Social circumstance, health behaviors and physical environment become easily apparent in regular visits to the home and the training of the CHW/NFP nurse will allow for integration of these external factors into each individual’s care plan. In the focus groups engaged for the Community Needs Assessment, 9 out of 12 mothers identified transportation as a major barrier to accessing care for their children. Home visitation allows us to surmount the transportation challenge that FLPPS mothers highlighted since CHWs and NFP nurses will either transport patients to appointments personally or will arrange for transportation for each patient. Another challenge is establishing workforce strategy and attendant qualifications criteria. However, inherent to this model is a training program that will teach CHWs the skills necessary to be successful, particularly since FLPPS has MICHC programs in existence, we will be able to provide appropriate and effective training. Also, the project will establish qualifications criteria that will guide any hiring practice within the system.

j. Please outline how the PPS plans to coordinate on the DSRIP project with other PPSs that serve


PPS Response (1,600 characters max): Current: 829 characters In the FLPPS, 10 out of 14 counties overlap with other PPSs. However, only Millennium Collaborative Care PPS is participating in this project, which overlaps in Genesee, Orleans and Wyoming Counties. Depending on the model chosen, we plan to coordinate efforts in those three counties to ensure that the target population is served by either PPS. Also of note, no other PPSs in the state are including Nurse Family Partnership in their project plan. The FLPPS includes an expansion of Nurse Family Partnership as an integral part of the success of improving health outcomes for high risk pregnancies. We intend to expand Nurse Family Partnership programming to the rest of the FLPPS counties – NFP already exists in Monroe and Cayuga Counties. Any patients eligible for Nurse Family Partnership will be referred to that program.

2. Scale of Implementation (Total Possible Points - 40): DSRIP projects will be evaluated based upon the overall scale and broadness in scope, in terms of expected impact the project will have on the Medicaid program and patient population. Those projects larger in scale and impact will receive more funding than those smaller in scale/impact. Progress towards and achievement of PPS commitments to these scale measures as provided in the application will be included in achievement milestones for future PPS funding. In order to assess scale, please complete the following information:


b. Please indicate the number of programs the PPS intends to include in the project by the end of Demonstration Year (DY) 4, or sooner as applicable. This number should be entered in the table as Total Committed.


Please identify the number of committed providers who are a part of the local Safety Net. *Based on Department of Health Safety Net Provider designation



f. Please indicate the total expected volume of patients the PPS intends to engage throughout this project by the end of Demonstration Year (DY) 4. This will become the Expected # of Actively Engaged Patients. Patient scale is measured by the total number of patients that are expected to be actively engaged by the end of Demonstration Year 4.



c. Please indicate the Demonstration Year (DY) and Quarter by which all programs will achieve project requirements. Project speed is measured by how fast all the project requirements for all chosen


locations are met. PPSs will be expected to meet these requirements for all of the providers, sites, or other categories of entities included in the PPS "total committed" scale metric, unless otherwise specified in the Domain 1 DSRIP Project Requirements Milestones and Metrics.


While some areas have solid Maternal and Child Health infrastructure, other areas do not and will require infrastructure building in order to reach the Domain 1 milestones and metrics. Particularly since this project intends to coordinate multiple programs that will require different amounts of coordination and implementation planning. For example, Nurse Family Partnership expansion will require applying to the national organization in order to create new programs. Additionally, establishing a workforce strategy and attendant qualifications metrics is a challenge as identified in Part 1d of this application.

d. Please indicate the expected timeline for achieving 100 percent engagement of total expected number of actively engaged patients identified. For example, the PPS may indicate that 25 percent of patients will be actively engaged by the end of Demonstration Year (DY) 1, 50 percent by the end of DY2, and 100 percent by the end of DY 3.


*For this project, Actively Engaged is defined as number of expecting mothers and mothers participating in this program. Please note: It is expected that the baseline number of patients engaged in this project may be 0. If so, please indicate 0 in the Year 0 baseline column. 4. Project Resource Needs and Other Initiatives (1000 word limit, Not Scored)

d. Will this project require Capital Budget funding? (Please mark the appropriate box below)

Yes No X



PPS Response (3,000 character max): Current: 1,106 characters Since this project includes home visitation and therefore does not require physical space, the capital needs are for:

● Laptops

● Information management (server, software, Peer Place system) Each Community Health Worker, and similarly each BSN engaged in Nurse Family Partnership, needs a laptop and access to Peer Place. Peer Place is an automated referral system that communicates with the Rochester RHIO and will allow for coordination across physician practices as well as connect the Community Health Workers with the appropriate programs. As part of the Integrated Delivery System, all outreach workers and participants will share information within the network. In the areas that do not have existing programs that are appropriate for the target population, we intend to build the infrastructure by providing Community Health Workers who will provide home visitation and ensure care for both the mother and the child. Nurse Family Partnership (NFP) will also be expanded in Monroe and Cayuga Counties where programs currently exist as well as into the 12 other counties where NFP does not yet exist.

e. Are any of the providers within the PPS and included in the Project Plan currently involved in any Medicaid


Yes No X

If yes: Please identify the initiatives in which the provider is participating in the table. Please identify the current or expected initiatives in which the provider is (or may be) participating within the table below, which are funded by the U.S. Department of Health and Human Services, as well as other relevant delivery system reform initiative(s) currently in place.





GRHHN Health Homes Planned Parenthood of Central and Western New York

Family Planning Benefits Program

Ongoing Insurance that covers family planning services for underinsured or when using one's insurance can potentially compromise confidentiality of services.

Rochester RHIO

Perinatal Network of Monroe County/HIT for

1/1/2014-3/30/2015

This project will enhance the


Perinatal Health coordination of care for Medicaid-eligible women in Monroe County by leveraging the Greater Rochester GRRHIO, the Peer Place Networks referral and case management system, and the existing relationships among the medical systems, the health plans, and perinatal support services. The goal is to share both medical and psychosocial information efficiently with all the providers who form the system of care for a particular patient. Target Population and Geographic Area(s) to be Served: All Medicaid managed care, Family Health Plus, and Child Health Plus enrollees in Monroe County, with a focus on pregnant women with complex medical and/or psychosocial needs.

RRHS

Healthy Moms 9/2014 - 5/2019 Office based program with four arms: Case managements; Psychiatric support; prenatal/parenting education; GED and job training

Healthy Start Evidence based program of pre natal care with case management

St. James Mercy Health System

MOMS program Serves Medicaid mothers


f. Please describe how this proposed DSRIP project either differs from, or significantly expands upon, the current Medicaid initiative(s) identified above. A PPS may pursue a DSRIP project that exists as part of another effort if the PPS can demonstrate a significant enhancement to the existing project.

PPS Response (3,00 characters max): Current: 738 characters While a few partners participate in the Medicaid initiatives identified above, this project and the Community Health Worker model are meant to prevent programs from working in silos and improve interconnectivity within the FLPPS region. Each program has a slightly different emphasis and scope of work. The FLPPS plans to build on these existing initiatives, and others in the region, to form a coalition of supports, together improving pregnancy outcomes and the health of the mother and child. It is our belief that increasing the linkage between programs and building upon the existing foundation of programming will serve to better support mothers and families thereby reducing poor pregnancy outcomes and subsequent hospitalization.


4.a.iii Strengthen Mental Health and Substance Abuse Infrastructure across systems Project 4.a.iii: Strengthen Mental Health and Substance Abuse Infrastructure across Systems Partnering with Entities outside of the PPS:

PPS Response: Unlimited characters max University of Rochester Rochester Institute of Technology St. John Fisher College Monroe County Medical Society Finger Lakes Health Systems Agency Public Health? DSS? OFA?

Project Response and Evaluation

1. Project Justification, Assets, Challenges and Needed Resources:

PPS Response (4000 character max): Current: 3,575 characters The combination of high disease prevalence and low access to services has led to poor health outcomes for those with Mental Emotional and Behavioral (MEB) health disorders :

● Regional rates of Poor Mental Health for 14 or More Days in the Last Month (10 percent), Adult

Binge Drinking (16.1 percent), and Suicide (9.31/100,000 pop.) are higher than NYS Prevention Agenda goals.

● Suicide is the fifth leading cause of premature mortality across the region, and is the only cause trending upward since 2002.

● Seven percent of all ED admissions have a primary diagnosis of Behavioral Health, the highest of all disease states.

● 17 percent of all hospital readmissions are associated with an individual having a behavioral health diagnosis.

The FLPPS region has a significantly higher prevalence of mental illness (411.2/1000 pop.) when compared to the NYS average (289.4/1000 pop.). This disparity is maintained for nearly all mental health diagnosis. The prevalence of substance abuse disorders is also higher than the NYS average, with rates of 99.5/1000 population compared to 86.8/1000 population.

The high prevalence of behavioral health diagnosis is naturally accompanied by an elevated need for resources, yet systematic chasms persist. The regional behavioral health workforce is less robust than the NYS average across all licensed provider types. As a result, 12 of the 14 counties in the region have received designation as Mental Health- Health Professional Shortage Areas by the Health Resources and Services Administration. Further, few behavioral health providers are multicultural and/or multi-lingual, and there is a shortage of doctors providing Suboxone therapy, a key intervention in managing heroin addiction.


Focus groups with high-utilizing individuals diagnosed with Mental Illness and meetings with Behavioral Health providers further defined system-wide gaps, largely driven by long-standing silos between Physical Health, Mental Health and Substance Abuse providers:

● Medical providers lack cultural and technical competence to manage the behavioral health needs of their patients. As a focus group participant maintained, MY PCP refuses to deal with anything psychological. She says she can’t.

● Medical providers lack the time, skill and information to engage in appropriate pain and anxiety management. As one PCP noted, During a 15 minute appointment, the easiest way to fix pain or anxiety is to prescribe a pill, particularly when there is no information about alternative programs or therapies. The potential consequences of such actions are addiction and/or abuse.

● There is a shortage of partnerships, programs, quality information and trained workforce to effectively

deliver MEB health prevention and promotion activities. Across the full breadth of the PPS region, only 40 prevention programs are available to reach hundreds of thousands of individuals.

In response, this project will address identified gaps, strengthen the MEB health infrastructure and meet project requirements by:

● Convening partnerships that include key stakeholders from across the health system and the wider community;

● Collecting and analyzing population-based data, stratified by race/ethnicity, age and geography; ● Implementing and evaluating targeted evidenced-based programing; ● Disseminating information around best practices and high-value interventions; and ● Training the workforce to address the behavioral health needs of patients in a culturally and technically

competent manner. These interventions are further described below.

a. Project Target Population (300 words):

PPS Response (2,400 characters max): Current: 2,095 characters There are two target populations associated with this project. First, per evidence presented by the Institute of Medicine in the cornerstone study: Preventing Mental, Emotional and Behavioral Disorders Among Young People: Progress and Possibilities (2009) the FLPPS recognizes that the greatest opportunity for MEB disorder prevention is among youth. Evidence suggests that such interventions will reduce the incidence of behavioral health disorders, over time. In response, the PPS will collect local data to determine the Mental Health (i.e. the presence of positive affect, absence of negative affect, and satisfaction with life) of individuals ages 10-24, and the prevalence of environmental and protective risk factors associated with MEB disorders across this age group. This age cohort was selected based the age-specific onset and diagnosis of behavioral health disorders, with a particular focus on those disorders most prevalent across the FLPPS patient population, including depression, anxiety and schizophrenia. The results of this study will be used to define a set of evidence-based interventions to be applied throughout the region, in collaboration with key community stakeholders The second target population for this project is individuals currently living with an MEB disorder, diagnosed or otherwise, and those living on the precipice of illness. This target population requires interventions that assess risk and trauma to diagnose and manage potential or existing MEB disorders to prevent crisis and


reduce further deterioration. Several of the FLPSS Domain 3 projects focus on the improvement of screening, management and treatment of MEB disorders in the clinical setting. This project will complement those interventions, increasing the cultural and technical competence of behavioral health and primary care providers. In addition, this project will work to develop sustainable community-based resources and evidence-based interventions. Again, this will require the PPS to undertake population-based data collection to drive and focus program implementation.

b. Community Assets and Resources (500 words)

PPS Response (4,000 characters max): Current: 3,493 characters The development of an MEB health prevention and promotion infrastructure represents a paradigm shift that: (1) breaches the silos currently maintained by physical health, mental health and substance abuse, and (2) focuses on behavioral health and wellness instead of illness. As such, many assets do not currently exist and will need to be developed. To this end, the PPS will: 1. Convene a MEB health promotion and disorder prevention Partnership: The FLPPS’s greatest asset is it’s

robust and multi-faceted network, which will act as the foundation for Partnership development Organizations committed to this project include Hospital Systems, Departments of Mental Health, Public Health and Social Services, Substance Abuse Providers, Community-Based Organizations, FQHCs, Mental Health Providers and Health Homes. These organizations have each committed to recruiting complimentary stakeholders including law enforcement, school districts, universities, service clubs, etc. The resulting Partnership will: (1) Eliminate silos and work collaboratively; (2) Collect and analyze data, establishing a baseline around sources of trauma and quality of life; (3) Identify, evaluate and determine high-value programs; (4) Train/prepare the clinical and community-based workforce through curriculum development and supported implementation; and (6) Confront social stigma around MEB disorders and treatment.

2. Provide cultural and linguistic training on MEB health promotion, prevention and treatment: The PPS

will train providers to recognize and assess trauma and address the behavioral health needs of patients in a culturally competent manner. In addition the PPS will define and disseminate best practice interventions in pain and anxiety management, including a compendium of local resources to use as an alternative to medication-based treatment, in an effort to minimize local sources of addiction. Training will be targeted at both the existing and future workforce. The 18 colleges and universities in the region will be an important asset in this regard. Institutions of higher learning will be engaged to develop and modify curriculums that embrace changing paradigms and teach best practices in supporting MEB health. In addition, the PPS will engage established workgroups, such as the Addiction Committee of the Monroe County Medical Society, to act as project champions. Project Partnerships described above will lead and facilitate these activities, and all PPS members will be required to participate in MEB health-related trainings.

3. Share data and information on MEB health promotion and MEB disorder prevention and treatment: Successful transition from a hospital-focused health system to one that values prevention of disease and promotion of health will be facilitated by the widespread sharing of high-quality data and information. To this end, the PPS will define, collect and analyze population-based data, identify and implement targeted evidence-based programs, monitor lessons learned, and conduct cost-benefit analysis. As a result, the PPS will develop and share a compendium of high-value evidence-based interventions to facilitate wide-spread adoption. In addition, the PPS will have created a replicable strategy for identification and implementation of such programs, which can be redeployed as the needs of the target population change,


over time. This asset will act as the centerpiece of future MEB Health infrastructure improvement.

c. Key Project Challenges

PPS Response (2,400 characters max): Current: 2,473 characters Paradigm Shift: As previously noted, a sustained focus on MEB health promotion and disorder prevention represents a substantial paradigm shift for the health system. The PPS will address this challenge by building partnerships, proving the value of model programs, engaging the workforce, facilitating cultural competence and confronting stigma. Stigma: Behavioral health disorders are often associated with false stereotypes and prejudice, making it difficult to engage the wider population in MEB health promotion and prevention activities. The PPS will confront stigma by supporting media campaigns around the value of health, including MEB health, employing best practices in social norming, and engaging culturally-competent community champions. Silos: Tremendous silos still exist between Physical Health, Mental Health and Substance Abuse providers. The PPS address this challenge by facilitating collaboration, training and program development Financing: The implementation of programs to support MEB health promotion and disorder prevention requires resources not readily available to project participants. In recognition of these financial constraints, the PPS will create an “incubator fund” to help green-light adoption of evidence-based programs across the region, with the goal of having at least 3 programs implemented in each NOCN by the end of Project Year 3. The PPS will work with local foundations and conduct additional development activities, as needed. Sustainability: The move to value-based reimbursement is an opportunity to increase access to evidence-based prevention programs. Community-based providers must implement infrastructure improvements and demonstrate the value of evidence-based interventions; that they are ultimately able to bill for those programs which highly contribute to the health of population. The PPS will support this evolution by ensuring project implementation includes the deployment of appropriate tools and resources, including technical assistance, information technology and standardized data collection. Workforce: As previously noted, there is a shortage of licensed behavioral health professionals across the PPS region. As such, the PPS cannot rely on clinical interventions to fully drive MEB promotion and prevention activities. The PPS will address this challenge by focusing on the development of community-based prevention services that do not require licensed providers for implementation.

d. Coordination with other PPS’s

PPS Response (2,400 characters max): Current: 80 characters The FLPPS will coordinate with other local PPS’s participating in this project.

e. Project Milestones: (100 words)

PPS Response (800 characters max): Current: 660 characters ● Establish MEB health Partnerships (DY1 Q1/Q2) ● Assess workforce training needs (DY1 Q3/Q4) ● Collect and analyze population-based data (through DY2 1/Q2) ● Establish “incubator fund” (DY2 Q1/Q2)


● Identify IT solutions to support program evaluation (DY2 Q1/Q2) ● Develop curriculums for MEB health competency (DY2 Q3/Q4) ● Begin roll-out of evidence-based programs (DY2 Q3/Q4) ● Begin workforce training intiatives (through DY3 Q3/Q4 and beyond) ● Begin cost-benefit analysis of evidence-based programs (DY4 Q1/Q2 and beyond) ● Develop compendium of best practices (DY5 Q/1/Q2) ● Develop value-based payment methodology for MEB health prevention programs (DY5 Q3/Q4)

2. Project resource needs and other initiatives a. Capital Funding: Yes

PPS Response (3,00 characters max): Current: 617 characters As previously noted, there is a lack of existing infrastructure to deliver MEB health prevention and

promotion programs. As evidence-based practices are identified for implementation, capital funding will be required to ensure that integrated IT solutions are available and used by participating partners. In some cases, space redesign may be necessary to facilitate successful program deployment. Specific capital needs will be identified during implementation planning (January-March 2014). Additionally, some capital investment will be driven by participation in project 2.a.i, and will be included therein.

b. Current Medicaid Initiatives: YES





Arnot Health VAP Southern Tier Mental Health Project

4/2014-3/2017 Operating and systems change; professional psychiatric workforce; behavioral health and substance abuse assessment and management workforce, imbed behavioral health in primary care

Finger Lakes Addictions Counseling and Referral Agency

New York State Health Home

7/2013-present Providing Health Home Care Management

Greater Rochester Health Home Network


2013-present Regional Health home Administrator

c. Expansion of Current Medicaid Initiatives:


PPS Response (3,00 characters max): Current: 447 characters The initiatives described above deal largely with the treatment of MEB disorders, or the provision of Case Management services to those with MEB disorders. In contrast, the proposed project focuses on the prevention of MEB disorders and the promotion of Mental Health and Wellbeing. As such, the proposed project acts as a complement to those initiatives currently funded under Medicaid, and will not duplicate the activities described herein.


4.b.ii Increase access to high quality chronic disease preventive care and management in both clinical and community settings Project 4.b.ii Increase Access to High Quality Chronic Disease Preventative Care and Management in Both Clinical and Community Settings

1. Partners outside the PPS

Entity Name (Unlimited characters)

Finger Lakes Health Systems Agency et al.

Project Response and Evaluation

3. Project Justification, Assets, Challenges and Needed Resources: a. Identified Gaps

PPS Response (4,000 characters max): Current: 3,922 characters The widespread prevalence of chronic disease is forcing a significant paradigm shift across the health system. In the past, acute disease was the primary cause of illness and patients were generally passive recipients of care. Today, chronic disease management is ultimately the responsibility of the individual, requiring life and behavior change skills. Some high-risk segments of the population lack the knowledge and health literacy to take on this level of accountability. (Plumb et.al) In addition, existing reimbursement models fail to incentivize chronic disease prevention and management. Per the Community Needs Assessment (CNA), volume based incentives inherent to a fee-for-service payment model are a significant barrier to promoting a model of care focused on value and health. In the management and prevention of chronic disease, the region falls short of New York State (NYS) Prevention Agenda objectives for: Adult Obesity (29.9 percent vs. 23.2 percent); Adult Smoking (21.1 percent vs. 15 percent); Age-Adjusted Heart Attack Hospitalizations/ 10,000 pop. (17.3 vs. 14); and Rate of Hospitalizations for Short-Term Complications of Diabetes/10,000 pop. ((7.21 vs. 4.86). Even greater disparities exit when accounting for a person’s race/ethnicity. African Americans and Hispanics are more likely to experience potentially avoidable hospitalization across all disease types. The ratio of African Americans experiencing preventable hospitalizations, when compared with Whites is 2.22, well above the Prevention Agenda goal of 1.85. Similar disparities exist for the Hispanic population, with a comparative ratio of 1.88, whereas the Prevention Agenda goal is 1.35. Prevention Quality Indicators (PQIs) which are attributable to chronic disease (diabetes, respiratory, and heart) accounted for 85 percent of all potentially preventable inpatient hospitalizations in the FLPPS region in 2012. Furthermore, the most common causes of premature death across all population types are Cancer, Heart Disease, COPD and Stroke. These illnesses share a number of conditional risk factors including smoking, physical inactivity and unhealthy diet. The burden of having one or more chronic conditions increases a person’s risk of deterioration and hospitalization. A patient with three comorbid conditions has a 24 percent greater risk of being readmitted


within 30 days of discharge compared to a patient with no comorbid diagnosis. Furthermore, per an analysis of regional SPARCS data, 65 percent of Medicaid or uninsured adults, admitted to an inpatient medical or surgical bed, had a co-occurring behavioral health diagnosis. Having low Socioeconomic Status (SES) also increases your risk for poor health outcomes. Across the FLPPS region, 10% of the population has delayed or failed to seek care due to cost. This is contrary to the long-term commitment required for effective chronic disease management. Finally, there are environmental factors that inhibit effective prevention and management services. For example, per the CNA, transportation was the most frequently cited barrier to receiving necessary services and support. In response to these gaps, the PPS will meet all the requirements outlined in Project 4.b.ii, including but not limited to:

● Delivering evidence-based clinical preventive services in medical homes, including the use of clinical decision supports, reminders and registries.

● Connecting patients to community-based preventive resources, including self-care management and support

● Monitoring and providing feedback around clinical outcomes ● Incentivizing the delivery of high quality services ● Reducing or eliminating out-of-pocket costs

All interventions will be targeted toward high-risk patients who will be identified using a standardized tool, and tracked using an integrated IT solution that will be implemented in both clinical and community settings.

b. Project Target Population

PPS Response (2,400 characters max): Current: 2,322 characters The target population for this project includes those individuals identified as being “high-risk” for developing chronic illness and those who currently have a diagnosis of chronic illness and are at “high-risk” for further deterioration. High-risk populations in need of prevention services include those who are obese (27.7% of the region’s population), those who smoke (21.1% of the region’s population), those who are uninsured (11.3% of the region’s population) and those who have low health literacy and are in need of patient activation (to be determined through implementation of project 2.d.i) High-risk populations in need of targeted chronic disease management support include those with two or more chronic conditions, and those with a diagnosis of Mental Illness (411.2/1,000 population) or Substance Use Disorder (99.5/1,000 population). Social and environmental factors also impact an individual's level of risk, and must be taken into account. For example, having an inadequate income affects many aspects of health, including access to care, ability to buy and eat a healthy diet, adequacy of housing etc. Thirty-one percent of the regional population has Low SES, earning less than 200% of the Federal Poverty Guideline (FPG); thirteen percent live in poverty. Poverty rates are highest in the city of Rochester but poor and near-poor live in all areas of the region. Racial and ethnic populations living in Rochester are especially affected by poverty. Almost two-thirds (65%) of African Americans


and 69 percent of Hispanics have household incomes below 200% of the FPG. Also in the city of Rochester, over three-quarters (76%) of children, ages six and under, live in or near poverty. Other social factors impacting risk include: Limited English Proficiency (2% of the regional population), Less than High School Education (11% of the regional population), presence of a disability (11.4% of the regional population), geographic isolation, and having inadequate transportation to services. To support the identification of those individuals falling with the project’s target population, the PPS will select and implement a standardized risk assessment to be delivered in clinical and community settings using an integrated IT solution. Those found to be of high risk will be referred to Medical Homes and community-based programs developed to support individuals in their pursuit of better health.

c. Community Assets and Resources

PPS Response (4,000 characters max): Current: 3,843 characters There are a number of critical community assets and resources that the PPS will utilize when implementing this project:

● Fifty-one percent of FLPPS providers are recognized as Patient Centered Medical Homes (PCMHs). This number will only grow through 2017 with the implementation of Project 2.a.i. Under this project (4.b.ii), medical homes will function as the hub for tracking and improving clinical outcomes for high-risk patients. PCMH will also spur the adoption and use of certified electronic health records, especially those with clinical decision supports and registry functionality. Providers will send reminders to patients for preventive and follow-up care, and identify community resources available to patients to support disease self-management. Success will be determined by establishing innovative ways to connect with a highly mobile patient population. This can be facilitated by an integrated IT solution.

● There are already common priorities in Community Health Improvement Plans (CHIPs) and hospital

Community Services Plans (CSPs), both of which focus on Prevention Agenda Goals; however, CHIPs are largely an unfunded mandate and some plans will need to be updated to include the targeting of high-risk populations. The PPS will support this asset, facilitating collaboration across counties and providing resource support, as needed.

● The region has some readily established community-based prevention programs already in place.

Across the region, over 15 organizations employ Master Trainers specializing in the delivery of Stanford-Model Chronic Disease Prevention Programs. In addition, over twenty CBO’s in the city of Rochester offer Weight Management and Nutrition programs targeting a range of age groups, neighborhoods and communities. Going forward, the PPS will document available community-based resources. Using this information, the PPS will work across its partnership to define and fill gaps, as needed. In addition, the PPS will create linkages between providers and CBOs to facilitate referrals to community-based preventive resources offering self-management support.

In addition, some assets will be need to be developed to ensure project success:

● Given that individuals access services across a variety of care settings, including Behavioral Health and Family Planning, there is a need to expand chronic disease management and prevention services to these provider types. To support this growth, the PPS will facilitate the adoption of best practice paradigms, including clinical interventions, motivational interviewing, health coaching and self-care


management, providing technical assistance, as needed.

● CBOs are also an important asset in assuring population health. To this end, the PPS must establish and integrated IT solution for CBOs to share and exchange information with the health system. The development of this asset will facilitate standardized performance measurement in terms of risk assessment, referrals, quality and outcomes

● Given the target population associated with this project, the PPS will need to adopt a standardized risk-

assessment to be utilized across systems to identify and target “high-risk” individuals. Risk factors might include the presence of two or more chronic conditions, presence of a behavioral health diagnosis, low SES, language barriers, educational attainment, geographic proximity to care, transportation barriers etc.

● The PPS must review gaps and best practices to ensure that providers are properly incentivized to

deliver chronic disease prevention and management activities, with a particular focus on the care provided to high-risk patients. The PPS will also use this opportunity to review the charge schedule for prevention services and will modify, as needed, to ensure full access for the target population.

d. Key Project Challenges: (300 words)

PPS Response (2,400 characters max): Current: 2,391 characters Paradigm Shift. The high prevalence of chronic illness is forcing the health system to redefine the way it delivers and reimburses care. Going forward, value will be placed on keeping people well instead of treating them when they are ill. In recognition and in support of this transition, the PPS will engage providers and the community at large, developing and disseminating a new and shared lexicon around the value of health and wellness. Coordination across counties. Each county is currently working towards implementation of their CHIP and CSP. To be successful, the PPS must ensure regional integration and the development of targeted interventions for high-risk populations. For example, nearly all counties have a Worksite Wellness component in their CHIP/CSP. Some Worksite Wellness interventions are well-developed and scalable, while others focus on employers of low-earning workers. In these instances, the PPS will need to facilitate collaboration among key stakeholders. Sustainability. CBOs often track programmatic success using process measures. What is lacking, however, is an integrated data system that monitors the effectiveness of a given prevention program in improving and maintaining a participant’s health status. An integrated IT solution that includes community-based prevention programs would have the ability to monitor a patient’s health status before, during and after participation. Over time, this type of evaluation will allow the PPS to identify best practices and determine programmatic value in preparation for the inclusion of high quality prevention and disease management programming in a value-based payment. Infrastructure gaps. Many CBOs do not have the infrastructure in place to bill for services- they lack the administrative depth, technology, compliance programming, etc. Over the next five years, those CBOs delivering high-value programs may need to position themselves for the receipt of payment. Technical assistance must be provided, as needed, to ensure successful transitions in this area. Facilitation of Partnerships. Likewise, not every CBO delivering prevention activities will be interested in direct


billing. In this case, prevention service providers will require a mechanism for partnering with PPS providers. The PPS must facilitate these partnerships to ensure that high-value programs remain intact.

e. Coordination with other PPS’s


f. Project Milestones

PPS Response (800 character max): Current: 706 characters In order to meet the goals set forth in this project, the PPS must:

● Achieve PCMH as outlined in project 2.a.i ● Establish contracts with CBOs (DY1 Q1/Q2) ● Identify and test standardized risk assessment (through DY1 Q3/Q4) ● Expand clinical interventions across diverse provider-types (DY2 Q1/Q2) ● Assess gaps and support the implementation community-based programming (DY2 Q3/Q4) ● Implement Integrated IT solution including standardized risk assessment (DY3 Q1/Q2) ● Review and expand incentive programs (DY3 Q1/Q2) ● Reduce out of pocket cost (DY3 Q1/Q2) ● Begin cost-benefit analysis (DY4 Q1/Q2 and beyond) ● Develop value-based payment methodology (DY5 Q3/Q4) ● Facilitate long-term partnerships (DY5 Q3/Q4)

2. Project Resource Needs and Other Initiatives: a. Capital Funding: YES

PPS Response (3,00 characters max): Current: 336 characters Capital funding, not covered under project 2.a.i, will be needed to develop bricks and mortar infrastructure at community-based organizations to support the development or expansion of chronic disease self-management programs. Similar infrastructure will be necessary for clinical providers looking to expand these services on-site.

b. Current Medicaid Initiatives: YES





Center for Community Health Departments of Public Health

New York State Medicaid Cancer Treatment Program

Ongoing The MCTP is a Medicaid program for eligible persons who are found to be in need of treatment for breast, cervical, colorectal or prostate


cancer.

Finger Lakes Addictions Counseling and Referral Agency Trillium Health Finger Lakes Migrant Health Care Project


7/2013-present Providing Health Home Care Management

Finger Lakes Migrant Health Care Project, Inc. Rochester Primary Care Network Rochester Regional Health System

CMS: CMMI through Finger Lakes Health System Agency

6/13-5/15 Funding for Nurse Care Manager and Practice Transformation

c. Expansion of Current Medicaid Initiatives:

PPS Response (3,000 characters max): Current: 541 characters The proposed project will not duplicate, but instead expand upon existing Medicaid initiatives by sharing lessons learned across a large geographic area and a diverse set of provider types (e.g. Behavioral Health and community-based providers). Some funded projects, such as Health Home, have begun to stratify the population based on level of risk. The PPS will learn from this experience. In addition, the Cancer Treatment program can be used as a model intervention on how to engage high-risk populations in screening and treatment.


Section 5 – PPS Workforce Strategy Description The overarching DSRIP goal of a 25 percent reduction in avoidable hospital use (emergency department and admissions) will result in the transformation of the existing health care system - potentially impacting thousands of employees. This system transformation will create significant new and exciting employment opportunities for appropriately prepared workers. PPS plans must identify all impacts on their workforce that are anticipated as a result of the implementation of their chosen projects. Detailed workforce strategy identifying all workplace implications to the PPS In this section, please describe the anticipated impacts on the workforce the DSRIP program will have and the overall strategy to minimizing the negative impact to the workforce. In the response, please include:

● Summarize how the existing workers will be impacted in terms of possible staff requiring redeployment, retraining, as well as potential reductions to workforce.

● Demonstrate the PPS’ understanding on the impact to the workforce by identifying and outlining the specific workforce categories of existing staff (by category: RN, Specialty, case managers, administrative, union, non-union) that will be impacted greatest specifically citing the reasons for the anticipated impact.

PPS Response (3,00 characters max): Current: 6,802 characters The healthcare workforce supply in the Finger Lakes region as recently illustrated in the Community Needs Assessment has some significant shortages, with the majority of the counties presenting with lower than NYS average per capita patient care providers. The total physician workforce is lower than New York State average in all counties but Monroe where the lead organizations and major medical centers are located. 11 out of 14 counties are designated Health Professional Shortage Areas for Primary Care Providers. Only 80 - 100 of all physicians in the region will accept Managed Medicaid; by assisting to redesign their internal operations through process improvement methodologies, we may have the ability to expand the patient panel for those providers especially in rural areas. There are approximately [#] employees across all partners working with FLPPS across xxx number of partners participating in 11 projects. FLPPS has identified that in some counties RNs and Nurse Practitioners distribution is well above New York State average. According to initial estimates, there may be over [#] new employment opportunities across [#] partners. In a preliminary assessment of our 300 + partners, we identified that xx percent of the workforce would be impacted by redeployment, retraining and hiring of new staff. The FLPPS recognizes the complexity of the multilayered and in some ways unpredictable impact of the upcoming changes on the most important asset, human capital, and is in the process of designing a comprehensive Finger Lakes Workforce Strategy (FLWS). Key areas of focus in minimizing the impact on workforce while LPPS include:

● Engagement of front line staff during project planning and implementation to inform solutions and foster buy-in to program and role changes. Data-driven and directed approach to project prioritization and implementation with an early focus on projects with the greatest gaps in workforce and potential resources to meet those gaps. As the DSRP projects get implemented and start driving the performance metrics, the model will adjust appropriately to address the gap in supply and demand in real time through effective recruitment or rapid redeployment of skilled workforce to fill those gaps. This approach will allow FLPPS to identify positions quickly with the hopes of evolving to a strategy where the model leads anticipated change. (this one needs to be redone - not clear what’s meant)Flexibility and reward for innovative solutions (don’t know what this means - what’s the flexibility gained? What


are the rewards and from whom?) will ensure workforce solutions are tailored toward cost effective and high quality training programs, redeployment methodologies and recruitment strategies informed by the key stakeholders which include Workforce Committee, FLPPS Performing Providers, front line staff, partner academic institutions, vendors and the Medicaid members. All this is done with the individual mission of each partner organization in mind as FLPPS works to develop a shared vision.

The FLPPS area is subdivided into 5 naturally occurring care networks (NOCN). Within each NOCN, a lead organization/entity has been identified to support DSRIP goals locally with their community partners. Utilizing standardized toolkits, developed by an identified workforce strategy vendor, with the goal of implementing standards of practice to operationalize the workforce strategy, the NOCN workgroups will identify and implement comprehensive dashboard with measurable criteria to evaluate workforce impact, needs and demands on an ongoing basis, using data reported by participating providers; as needed, the NOCN will develop proposed solutions for issues identified. A number of policies and guidelines will be developed centrally by the FLPPS to support the dashboard implementation and usability by NOCN workgroups such as:

• Employee redeployment policies and procedures across providers and settings • Process to evaluate and address staff turnover within NOCNs and providers • Process measures for best practice reporting, evaluation and dissemination • Newly identified position needs and proposed initiatives to address them • Employee engagement measures

FLPPS expects the following positions will be impacted by DSRIP Projects with XX% being new hires and X% being redeployments; no reductions are planned at this time.

● Case Manager/Care managers ● IT staff ● Social Worker ● Administrative staff ● Community Navigator (or equivalent) ● Data Analysts ● Nurse Practitioner (FNP, ANP/GNP) ● Primary Care Provider (MD, DO) ● Physician Assistants ● Psych NP ● Project Director ● Physician (other) ● Psychiatrist (with expertise in intellectual/developmental disabilities) ● Psychiatric Nurse Practitioners ● Psychologist ● Drug/Alcohol counselors or addiction specialist ● Translator ● Mental health professionals ● Para professional (direct care personnel, i.e. Nurse Assistant, patient Care Tech)

The FLPPS provider network anticipates hiring approximately [#] employees, retraining [#] and redeploying xxx employees according to the recently collected data from the Request for Qualifications from interested partners and refined by a recent supplemental assessment. The primary driver of Workforce change and new hiring is the addition or expansion of programs and services. Secondarily, and quite minimally, a few positions will be redeployed within current department/organization,


to support a DSRIP initiative. Throughout the implementation planning work, it is possible other Workforce impacts will be recognized. However, the FLPPS is committed to minimizing the disruption to its current workforce while transforming the existing health care delivery system. The planned NOCN-based approach to workforce solutions will help in minimizing adverse impact on individual employees. Despite the FLPPS commitment to minimize adverse impact to Workforce as a result of the DSRIP initiative, redeployment, retraining, and potential Reductions in Force (RIF) may become necessary based on the requirements and outcomes of the initiatives. In the event that redeployments, retraining, or RIF(s) occur, the FLPPS is committed to ensuring that affected employees are treated in a respectful, fair, and consistent manner and that the affected organizations/providers maintain the ability to meet the needs of the initiative. The FLPPS will be engaging an external HR vendor to develop fair and appropriate policies and procedures for performing providers/organizations to follow. Staff retraining to meet the demands of a rural region with access challenges (i.e. telemedicine), The implementation of 11 DSRIP projects, and anticipated process improvement projects to allow providers to expand capacity are expected to influence the current workforce.

Strategy 2:

Describe the PPS’ high level approach and strategy to minimize the negative impact to the workforce, including: identifying training, re-deployment, recruiting plans and strategies.

Describe any workforce shortages that exist and may the impact on the PPS’ ability to achieve the goals of DSRIP and the selected DSRIP any projects.

PPS Response (3,99 characters max): Current: 2,006 characters The interim FLPPS Workforce Operational Committee (WOC) developed a “request-for-qualifications” process to evaluate local workforce strategy vendors with demonstrated expertise in addressing workforce impact. The criteria for evaluation included (1) workforce development through experience to allow for career ladder growth, (2) demonstrated strategies in front line worker engagement when designing data-driven objectives, (3) demonstrated experience with compensation and benefits strategy, (4) demonstrated expertise in outplacement strategies and services, including individual career planning and resume development (5) direct access to high quality local resources of higher education that are equipped to lead educational needs of the workforce. The FLPPS is currently experiencing workforce shortages in several key professions, namely primary care physicians, psychiatrists, psychiatric nurse practitioners, pharmacists and dentists. These shortages are even more pronounced in the rural areas. Strategies to address the PCP shortage include hiring FNPs to provide primary care (effective 1/1/15 they will be able to practice independently), exploring innovative recruiting/retention approaches for PCPs and, for the longer term, developing the pipeline of primary care physicians and APPs starting with engaging students at the regional high schools, the local medical school and NP/PA training programs. We plan to do a thorough assessment of PCP availability, panel size and capacity over the next few months to gain a better understanding of the gaps, and work to design innovative means for addressing them. One example of a strategy we will employ to extend the reach of our PCPs is to add telehealth capabilities in the rural areas. Expansion of primary care in our FQHCs [reference], primary care in behavioral health and behavioral health in primary care are the initiatives most likely to be impacted if we are unable to expand our cadre of primary care and behavioral health providers.

Strategy 3: In the table below, please identify the percentage of existing employees will require re-training,


percentage of employees that will be redeployed, and the percentage of new employees expected to be hired. I It is expected that a specific project may have various levels of impact to the workforce, as a result, the PPS will be expected to complete a more comprehensive assessment on the impact to the workforce on a project by project basis in the immediate future as a Domain 1 process milestone for payment. Workforce Implication Percent of Employees Impacted Redeploy 20 percent Retrain 20 percent New Hire 25 percent Analysis of Workforce Impact Retraining 1 Please outline the expected retraining to the workforce, please respond to the following:

Describe the process by which the identified employees and job functions will be retrained. Please indicate whether the retraining will be voluntary.

PPS Response (3,900 characters max): Current: 7,437 characters FLPPS is committed to ensuring that all employees have the training and education necessary to be successful as position workflows and requirements change. We recognize that there will be a broad continuum of retraining needs that will be identified, from those who stay in role but need some additional knowledge, to those who are redeployed to entirely new roles and need to develop new skills and/or certifications. Effective training and development will require an accurate assessment of new KSA needed; an appropriate match of training modality with learning need; motivation and time on the part of the employee; and support and involvement of local level leadership. In addition, the principles of adult learning will be incorporated into all training design especially creating/incorporating learner-directed, applied (experiential) approaches. A survey of the FLPPS performing providers indicated that many have in-house training protocols and/or resources, with the majority expressing receptivity to a centrally coordinated training approach managed by FLPPS. FLPPS will support both centralized and decentralized training by offering a variety of training options to its partners, ranging from maintenance of a catalogue of relevant training resources available to FLPPS partners, to offering targeted, Instructor-led training for each NOCN. FLPPS will also serve as a consultant to its providers as needed, to help them determine which types of training best meet the specific learning needs of their employees. Given the range of needs and diversity of opportunities available in the rural and urban areas, it is imperative that multiple opportunities and mediums are made available to the FLPPS providers. In addition, the FLPPS region is rich with educational institutions, with the largest local academic centers being partners in the FLPPS. Discussions are underway with the University of Rochester and Rochester Institute of Technology about certification and/or continuing education offerings that will be needed, e.g. specialized behavioral health training for clinical providers such as nurses; Kathy Rideout, Dean and Professor of Clinical Nursing at the University of Rochester and Daniel Ornt, Vice President, Dean & Professor, College of Health Sciences & Technology at Rochester Institute of Technology are the co-chairs of the FLPPS Workforce Committee. Both institutions are able to offer on-line and in-classroom options, supporting the diverse needs of participating providers and their employees.


To develop consistency of position definition and expectations across FLPPS providers, as well as to support ease of movement (including redeployment) between organizations, for the most common positions, e.g. Community Health Worker, standard position descriptions including required knowledge, skills and abilities (KSA) will be developed along with a recommended set of offerings to support development of these KSAs, including offering ILT/ Train the Trainer sessions as indicated by level of learning required. In addition, the Workforce Committee, will identify and develop core key competencies that cut across many positions supporting the DSRIP initiatives and develop recommended resources for developing each of the key competencies. This will allow for a “modular” approach to KSA development and facilitate career growth and redeployments. The FLPPS performing providers were given the opportunity to express their organization-specific retraining strategies as part of the Request for Qualifications. Overall many of our partners have in-house training protocols, but open to regional FLPPS-managed training program to ensure consistency across the region. The proposed training processes will be evaluated by each regional workforce group and each project will have an assigned lead organization who will develop the centralized curriculum to be adopted by other agencies. We plan to take the “train the trainer” approach due to the large region FLPPS encompasses which will also allow us to leverage strengths each organization holds in the region. Processes will be developed within a NOCN for staff to take positions in other partner organizations. FLPPS is looking to resource an instructional design specialist to design and implement the strategy for curriculum and education implementation. Retraining of employees will be achieved via: 1. In-person group and individual retraining: The lead trainer organization for each of the projects will work with a training vendor to design and deliver regional training courses for staff working on a particular project. This team will review competencies and align them with competencies required to achieve the projects. The goal of each program will be to identify gaps and resources to close those gaps.. Teamlets will be established in the first group training composed of staff in various care settings working on a each project. Each teamlet will work to design their team’s charter and success measures that will be revisited annually at the FLPPS Summit. 2. Online module-based training: FLPPS workforce oversight committee will work with a training vendor to identify core competencies required for each project. Partners from the region will then be recruited to advise the process of designing “Core FLPPS Curriculum” that will be structured in electronic modules categorized into project buckets. In partnership with NOCN lead workgroups each agency will determine the training requirements for their staff.

3. Voluntary PPS training: Under the leadership of WOC which is being co-lead by Kathy Rideout, Dean and Professor of Clinical Nursing at the University of Rochester and Daniel Ornt, Vice President, Dean & Professor, College of Health Sciences & Technology at Rochester Institute of Technology, FLPPS will coordinate with academic organizations and other performing provider partners to administer career training programs for those workforce members who may potentially be negatively impacted by the changes brought forth during the implementation phase.

As mentioned, the FLPPS plans to hold educational summits where DSRIP providers and participating staff will assemble to and share the results of their work and carry discussions around innovative solutions. The first planning summit is scheduled to take place in January where workgroups will be assembled to map out the next 5 years of FLPPS. In the preliminary assessment, nearly 17 percent of the performing providers indicated that any required (current positions required additional training) it will be mandatory for most employees participating in DSRIP project implementation, while 13 percent stated most employee training will be voluntary. FLPPS will offer Change Management workshops to leaders within participating organizations/practices to equip them in


communicating the need for training (change) in a way that engages and motivates employees. One specific strategy for increasing motivation to participate in training will be to support organizations in offering CEU/CNE/CME for required training where possible. FLPPS will engage its external vendor in developing policies and procedures that address the manner in which retraining will be implemented/enforced for positions in which training/retraining is required. The WOC is also working to engage partners in identifying incentives for staff who engage in voluntary training.

Retraining 2 Describe the process and potential impact of this retraining approach, particularly in regards to any identified impact to current wages and benefits to existing employees.

PPS Response (3,900 characters max): Current: 1,229 characters Based on the preliminary assessment, one third of the providers believe there will not be significant changes in employee wages and benefits while almost three percent of performing providers anticipate an increase in salary as a result of retraining. Cross-functional training in the realm of DSRIP will be an important focal point for regional and oversight committees to evaluate, ensuring an allocation of resources at the right time and in the right setting. While we anticipate minimal impact to compensation at least in the early years of DSRIP, it is not yet clear how the shifts in location and level of care delivered will be balanced by increases in the population served due to the efforts of project 2.d.i. , We anticipate using our external vendor to help develop strategies, policies and procedures for managing these types of global shifts in types and quantities of positions. We do anticipate more staff to be employed by our region in positions other than the current position matrix, as the region progresses away from densely staffing acute and long-term care (which historically requires more specialized training and experience) to staffing required to support population health and preventive care models.

Retraining 3 Articulate the ramifications to existing employees who refuse their redeployment assignment.

PPS Response (800 characters max): Current: 908 characters FLPPS is committed to minimizing any adverse impact to current employees within the FLPPS network as a result of DSRIP initiatives, and will encourage all partners/providers to find a role for those employees that want to remain with the organization/practice. FLPPS will engage with its external HR vendor to develop strategies, policies and procedures for providers to use in these situations. In general, performing providers either (1) did not anticipate any refusals, (2) would offer alternative solutions to employees or (3) would turn to their organization’s disciplinary action process to address the issue of redeployment refusal. Due to the regional leadership and staff empowerment approach the FLPPS plans to take in workforce planning, we anticipate employees to be the drivers of redeployment assignments, by identifying the areas of need in order to meet project requirements within their NOCN.

Retraining 4 Describe the role of labor representatives, where applicable – intra or inter-entity – in this retraining plan.


Whereas the number of FLPSS partner organizations with organized labor is relatively small, the Labor union


representatives of these partners have been invited and engaged in NOCN workgroups and planning sessions to ensure close integration with the appropriate stakeholders during the planning period. In addition, labor representatives have engaged in the PAC and have open access to the PPS leadership and their respective Human Resource staff. They have continuously participated in PAC meetings and webinars that FLPPS has led over the planning period

Retraining 5 In the table below, please identify those staff that will be retrained that are expected to achieve partial or full placement. Please identify the percentage of all workers impacted by retraining. Partial placement is defined as those workers that are placed in a new position with at least 75 percent and less than 95 percent of previous total compensation. Full placement is defined as those staff with at least 95 percent of previous total compensation.

Placement impact Percent of retrained employees impacted Partial placement 5 percent Full Placement 22 percent

Redeployment 1 Please outline the expected redeployment to the workforce, please respond to the following: Describe the process by which the identified employees and job functions will be redeployed.

PPS Response (3,900 characters max): Current: 1,994 characters FLPPS is committed to transforming our existing healthcare delivery system while minimizing the disruption to our current workforce. However, redeployments, retraining, and potential reductions in force (RIF) may become necessary to achieve such commitment based on the requirements of the initiatives and due to the success of these initiatives. .In the event that redeployments, retraining, or RIF(s) occur, FLPPS is also committed to ensuring that affected employees are treated in a respectful, fair, and consistent manner while also ensuring that organizations/providers maintain the ability to meet the needs of the initiative. FLPPS anticipates redeployment to be an evolving process over the course of DSRIP program and beyond, depending on success of the initiatives and achieving desired delivery system transformation and outcome metrics. . While FLPPS will use its external HR vendor to develop strategies, policies and procedures for performing providers and partners to use in these situations, FLPPS will also implement a “Job Board” which will serve as a central site for performing partners to list positions they have open along with associated competencies required for the positions, and for employees to post positions they are qualified to fill. The process, briefly outlines, is as follows: (below needs work - needs revision)

1. Within each regional workgroup (NOCN), each team will be required to monitor and update the staffing dashboard.

2. A comprehensive menu of available competencies and positions matching those competencies will be developed at a NOCN level using standardized templates in order to evaluate available resources in all settings of all organizations.

3. Teamlets will work to crosswalk and determine gaps in committed versus required resources and make recommendations on filling the gaps. If required, The FLPPS team will follow a structured approach in designing the process around employee redeployment into an organization other than their own.

Redeployment 2 Describe the process and potential impact of this redeployment approach, particularly in regards to any identified impact to current wages and benefits to existing employees.


PPS Response (1,200 characters max): Current: 665 characters Between 40 and 50 percent of participating providers do not expect salary changes as a result of redeployment, at least in the near term and within their own organization. As shifts occur in where care is being provided and who is providing it, it is unclear how this will settle out and impact current employees whose roles may change and/or who may be redeployed. FLPPS intent is to minimize negative impact to individuals through encouraging and providing access to continuing education and competency development to support career growth, and centralized Job Board postings to provide access to information about open positions individuals may be qualified for.

Redeployment 3 Articulate the ramifications to existing employees who refuse their redeployment “assignment”.

PPS Response (800 characters max): Current: 642 characters

The Workforce Committee recognizes redeployment as proposed by a number of performing providers. FLPPS and aims to minimize the need to terminate personnel if they refuse their redeployment assignment. We strongly believe that bottom up management approach in allowing the front line staff to make their own recommendations on how to fill the workforce gaps across the region, will shift the need to discipline or terminate personnel to the minimum. For employees to make informed recommendations, they will be engaged in the planning process early by identifying early adapters of change and mentoring them through career coaching programs.

Redeployment 4 Describe the role of labor representatives, where applicable – intra or inter-entity – in this redeployment plan.

PPS Response (1,200 words max): Current: 558 characters

Whereas the number of FLPSS partner organizations with organized labor is relatively small, the Labor union representatives of these partners have been invited and engaged in NOCN workgroups and planning sessions to ensure close integration with the appropriate stakeholders during the planning period. In addition, labor representatives have engaged in the PAC and have open access to the PPS leadership and their respective Human Resource staff. They have continuously participated in PAC meetings and webinars that FLPPS has led over the planning period.

New Hires Please outline the expected additions to the workforce, please respond to the following:

Briefly describe the new jobs that will be created as a result of the implementation of the DSRIP program and projects.


PPS is currently drafting.

In the table below, please itemize the anticipated new jobs that will be created and approximate numbers of new hires per category.

Selections: administrative, physician, mental health providers case managers, social workers, IT staff, nurse practitioners, other Approximate Number of New


Hires PPS Response (3,99 characters max): Current: 0 characters

PPS is currently drafting.

Workforce Strategy Budget In the table below, identify the planned spending the PPS is committing to in its workforce strategy over the term of the waiver.

PPS Response (3,99 characters max): Current: X characters

Draft created and will be finalized once the final draft of scale and speed have been submitted.

State Program Collaboration Efforts Describe the PPS workforce strategy and how it may intersect with existing State program efforts, please include the following in the response below: As applicable, describe any plans to utilize existing state programs (i.e., Doctors across New York, Physician Loan Repayment, Physician Practice Support, Ambulatory Care Training, Diversity in Medicine, Support of Area Health Education Centers, Primary Care Service Corp, Health Workforce Retraining Initiative, etc.) in the implementation of the Workforce Strategy – specifically in the recruiting, retention or retraining plans.


Health Workforce Retraining Initiative and Ambulatory Care Training programs reflected within most projects. [evaluate previous use of these programs by lead organizations] Support of Area Health Education Centers have been identified as the main training programs by our partners to utilize. A representative from Rural AHEC has been invited to join the FLPPS workforce committee. As the agency focuses on meeting health workforce shortage needs in the most needed counties, FLPPS will ensure the strategic vision is aligned to deliver comprehensive training programs to meet DSRIP project needs. Similar to the centrally led Capital restructuring finance program application triage system through the FLPPS Project Management Office, the Workforce Committee will identify and implement a subcommittee of key professionals from partner organizations who will be design a process by which all State programs are compiled, reviewed to identify integration and combine efforts as appropriate. This process also promotes collaboration among providers if two or more organizations share the benefits of State programs. [List currently funded initiatives through other State Programs] In a preliminary assessment of the FLPPs partners there is a shared understanding and availability of State funding programs. The State program subcommittee will consist of members with expertise in multiple programs and best practice training initiatives. This team will also be responsible for regular monitoring of funding period for current programs, present and engage workgroups during FLPPS summit to confirm and refine future opportunities.

Stakeholder & Worker Engagement Describe stakeholder and worker engagement process, please include the following in the response below: Engagement 1 Outline the steps stakeholder engagement process undertaken in developing the workforce strategy.


● The Workforce Committee is representative of the FLPPS region and service categories ● Continuously looking for new membership and appropriate expertise around the table to inform


decision making ● Academic, vendor, performing provider and union contacts are represented on the committee

Strategy has also been informed by DSRIP project teams representative of the attested providers who have indicated interest in participating in corresponding projects

Engagement 2 Identify which labor groups or worker representatives, where applicable, have been consulted in the planning and development of the PPS approach.


● Identified Human Resources representative to coordinate with the various unions as to representation on the Finger Lakes PPS’ PAC

● Letter to Unions on August 11 requesting to identify Union representatives for partner organizations. ● 4 unions have identified 11 contacts for PAC representing nearly 1500 employees

Engagement 3 Outline how the PPS has and will continue to engage the frontline workers in the planning and implementation of system change.


● Team-based approach to project implementation within NOCNs composed of front line staff. ● Non-managerial PAC members ● Front line staff engagement in NOCN workgroups

Engagement 4 Describe the steps the PPS plans to implement to continue stakeholder and worker engagement and any strategies the PPS will implement to overcome the structural barriers that the PPS anticipates to encounter.


● Website ● Newsletters ● Webinars ● NOCN planning days ● FLPPS-wide Summit


Section 6 – Data-Sharing, Confidentiality & Rapid Cycle Evaluation Section 6 – Data Sharing, Confidentiality & Rapid Cycle Evaluation (5 percent of the Overall PPS Structure Score)

Description The PPS plan must include provisions for appropriate data sharing arrangements that drive towards a high performing PPS while appropriately adhering to all Federal and State privacy regulations. The PPS plan must include a process for rapid cycle evaluation (RCE) and indicate how it will tie into the state’s requirement to report to DOH and CMS on a rapid cycle basis. Data Sharing & Confidentiality (worth 50 percent of total points available for Section 6) PPS plan must have a data sharing & confidentiality plan that ensures compliance with all Federal and State privacy laws while also identifying opportunities within the law to develop clinical collaborations and data sharing to improve the quality of care and care coordination. In the response below, please include: ● Provide a description of the PPS’ plan for appropriate data sharing arrangement amongst its partner

organizations.

PPS Response (1,000 character max): Current: 805 characters

FLPPS goal is to make possible the exchange of pertinent patient information among our participants for authorized purposes to improve the quality, coordination and efficiency of patient care. At the same time we will ensure the protection of patients’ privacy and data security in compliance with all NYS and Federal laws and policies. We will ensure that all PPS participants agree to comply with developed policies and procedures regarding the access and use of patient PHI. An active IT Governance structure will be implemented that monitors the data sharing and confidentiality practices throughout the PPS. In all situations, electronic forms of PHI will be the strongly preferred media. Any paper-based partners will be requested to explore electronic methods of capturing patient information.

● Explain the strategy describing how all PPS partners will act in unison to ensure privacy and security of data,

including upholding all HIPAA privacy provisions.

PPS Response (1,000 character max): Current: 874 characters

PPS Partners will all be required to sign BAA’s and Participation Agreements. The IT Governance team will develop applicable policies and procedures related to the restriction of individual access to PHI to the minimum necessary to accomplish the objectives of the PPS; electronic data security measures; and mitigation measures in the event of breach. Participants will be required to formally confirm their acknowledgement of these policies and procedures and their ability to comply. Each participant will be required to complete a survey on an annual basis demonstrating their compliance with industry standards related to the protection of PHI in all forms. Participants will need to identify an individual who is knowledgeable regarding HIPAA privacy provisions and demonstrate competency through annual training opportunities developed by the IT Governance team.

● Describe how the PPS will have/develop an ability to share relevant patient information in real-time so as to

ensure that patient needs are met and care is provided efficiently and effectively while maintaining patient privacy.



Through engagement with FLPPS providers, we have identified two primary paradigms of data sharing – “care/referral management” and “care delivery”. Care/referral management is episodic in nature, focusing on navigating patients between care settings. It requires a limited set of recent, relevant, and real time clinical data in order to make a decision related to patient referral/placement. Not all members of the PPS are clinical providers with EMR’s, nevertheless FLPPS will need to achieve an interconnected state with all providers. We expect to close any gaps by evaluating existing processes for care/referral management with the goal of implementing a unified, real-time platform for PPS-wide care/referral management. The tool(s) would provide web-based connectivity for all providers to make real-time placement decisions, and would aggregate all FLPPS referral data for simplified integration with the local RHIO/SHIN-NY. The care delivery paradigm is longitudinal in nature and focuses on a comprehensive understanding of patient medical history and condition. Providers who have existing EMR’s will be engaged to integrate with the applicable RHIOs, making data for patients available to PPS providers for patient care and analytics in alignment with the established DSRIP data sharing model proposed by NYS DOH, which utilizes an opt-out model. Providers without EMR’s will be engaged to evaluate and overcome implementation barriers by providing guidance in selecting/deploying an EMR that meets the DSRIP-related requirements. These changes will impact clinical workflows and workforce/training. The IT committee strategy to address these changes involves regular, frequent, structured sessions with established clinical and workforce teams to define and validate requirements. Specific use-cases/protocols with clearly outlined and approved data sharing requirements will be developed for each type of transition, and privacy agreements/system development will align with the approved use-case scenarios.

Rapid Cycle Evaluation (worth 50 percent of total points available for Section 6) As part of the DSRIP Project Plan submission requirements, the PPS must include in its plan an approach to rapid cycle evaluation (RCE). RCE informs the system in a timely fashion of its progress, how that information will be consumed by the system to drive transformation and who will be accountable for results, including the organizational structure and process to be overseen and managed. A description of the PPS’ plan for the required rapid cycle evaluation, interpretation and recommendations. In the response, please describe: ● Identify the organizational unit within the PPS organizational structure that will be accountable for reporting

results and making recommendations on actions requiring further investigation into PPS performance. Describe the organizational relationship of this unit to the PPS’ governing team.

PPS Response (1,200 characters max): Current: 1, 227 characters

The Project Management Office (PMO) and Advanced Performance Improvement (API) team will be focused on defining, rolling out, and supporting centralized processes and procedures related to project management and performance improvement. The PMO and API team will work closely with the operational committees, which will provide subject matter expertise and strategic guidance in clinical, financial, IT, and workforce related matters.


The IT committee and the PMO and API teams will establish a Data and Measures workgroup to support the PMO in developing the data reporting requirements as they relate to DSRIP metrics and to ensure timely delivery of frequent data summaries to the appropriate operational committee. Under the direction of the executive committee, the various committees will be responsible and accountable to support the PMO and API office in evaluating the data, inferring courses of action from those data, and inculcating changes back into the organization. For each metric, the PMO and API office, in coordination with the Data and Measures workgroup, will work with the executive committee to determine the primary owner (committee and individual) who has the ultimate accountability for the metric.

● Outline how the PPS intends to use collected patient data to:

- evaluate performance of PPS partners and providers; - conduct quality assessment and improvement activities; and - conduct population-based activities to improve the health of the targeted population.


A consolidated view of the patient population is an essential building block for healthcare quality and performance improvement initiatives. To that end, FLPPS will implement a data management system to compile key data elements from claims and clinical sources, which relate to DSRIP quality and utilization metrics. This system will include analytic processes necessary for building patient registries to support condition management (e.g. diabetes), high risk/high cost patient identification, as well as the corresponding process and outcome measures logic. A data model that links patient interactions and outcomes to FLPPS partners and providers will allow performance evaluation and reporting to governance participants. Additionally, decision support tools will be provided to enable rapid identification of improvement opportunities and confirmation of best practices.

● Describe the oversight of the interpretation and application of results (how will this information be shared

with the governance team, the providers and other members, as appropriate?).


As indicated above, activities of the FLPPS operational committees (IT, Workforce, Finance, Clinical) will be governed by the Operational Oversight Committee. As jointly determined by the Operational Oversight Committee, the PMO and API office and the Data and Measures workgroup, each operational committee/designated member will be responsible for interpreting the results based on the data provided and developing response strategies. Beyond basic dashboards/balanced scorecard, FLPPS will implement a web-based tool (Salesforce.com or equivalent) to support interaction with the provider community. Key components of the tool will include the ability to foster collaboration with, and among, providers, as well as capture and share data related to performance against key metrics.

● Explain how the RCE will assist to facilitate in the successful development of a highly functioning PPS.



As the transition from fee-for-service to pay-for-performance accelerates, the rapid accumulation and evaluation of data, and the necessary corrective action that comes from that evaluation, becomes critical. Organizations will not have the luxury of long data collection and evaluation cycles, as a small variance in a key metric may potentially have significant impacts on revenue – which ultimately impacts the ability of an organization to deliver quality care. As such, our approach to performance management will be defined as agile. Opportunity improvements will be reviewed and evaluated by the API Office. Incremental change will be implemented and outcomes evaluated against defined clinical and financial metrics. Results will drive further cycles of iterative change. This approach will allow us to better gauge progress and quality quicker, and provide feedback and adaptation for continuous improvement. Weaving performance management into the fabric of all participating providers, through leadership by FLPPS, is critical to achieving the Triple Aim of “simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.”


Section 7 – PPS Cultural Competency/Health Literacy Competency 1: Describe the identified and/or known cultural company challenges which the PPS must address to ensure access:

PPS Response (2,000 characters max): Current: X characters [need to break up]

As indicated in our Community Needs Assessment, greater use of primary care for patients and building a relationship with that caregiver are important factors in reducing PQI rates. FLPPS is comprised of a large racially and ethnically diverse region which presents cultural competency challenges in achieving that goal. FLPPS is a 14 county region with approximately ½ of the population residing in an urban center, Monroe County, and the other dispersed in mostly rural settings. The majority of the diversity is in Monroe County with 62 percent white, 22 percent African American and 6 percent Hispanic. There are significant disparities in mortality and premature death rates in our region among African Americans and Latinos as well as higher preventable admission rates. Additionally, our cultural challenges include special populations in FLPPS: large deaf population, high rate of developmental disabilities, American Indian tribes, migrant workers, refugee resettlement program and Mennonite/Amish and the institutionalized population as well as an aging population--- all with different cultural needs. The largest population increase in the region is among non-white ethnic groups. FLPPS Strategic Plan for cultural competency includes a Cultural Competency and Health Literacy Committee, comprised of a panel of experts that will:

● Establish baseline knowledge of system performance outcomes related to cultural competence ● Provide a cultural competence lens to reviewing the projects through all phases ● Develop standardized assessment tools and training programs for the workforce ● Monitor evidence-based practices that have not been used for all cultural groups and measure

their effectiveness, while also promoting best practices. ● Oversee the development of a workforce that is representative of our community ● Oversee performance based contracting which has clear expectations for cultural proficiency

at every level ● Partner with local colleges to train the incoming health workers on cultural competency. ● Develop a set of policies and procedures that enable caregivers to work more effectively across

multi-cultural situations.

FLPPS will contract with community based organizations to help achieve these goals, recognizing that they are key partners due to trust level and local knowledge of our patient base.

Competency 2: Describe the strategic plan and ongoing processes the PPS will implement to develop a culturally competent organization and a culturally responsive system of care. Particularly address how the PPS will engage and train frontline healthcare workers in order to improve patient outcomes by overcoming cultural competency challenges.


See above.

Competency 3: Describe how the PPS will contract with community based organizations to achieve and maintain cultural competence throughout the DSRIP Program.



See above.

Approach to Improving Health Literacy:

● Describe the PPS plan to improve and reinforce health literacy of patients served. ● Indicate the initiatives that will be pursued by the PPS to promote health literacy. For example, will the PPS

implement health literacy integral to its mission, structure and operations, has the PPS integrated health literacy into planning, evaluation measures, patient safety and quality improvement.

● Describe how the PPS will contract with community based organizations to achieve and maintain health literacy throughout the DSRIP program.


According to the National assessment of adult literacy, only 12 percent of adults have proficient health literacy. Populations most likely to experience low health literacy rates are older adults and racial and ethnic minorities, people with less than a high school degree and people with compromised health status. In FLPPS, 12 out of our 14 counties have a larger percentage of their population with a high school degree or less than the state-wide average; FLPPS is comprised of a large racially and ethnically diverse region which, with the majority of the diversity in Monroe County with 62 percent white, 22 percent African American and 6 percent Hispanic, which also has the largest percentage of our Medicaid population. Additionally there are special populations in FLPPS: large deaf population, high rate of developmental disabilities, American Indian tribes, migrant workers, refugee resettlement program and Mennonite/Amish and the institutionalized population as well as an aging population. The largest population increase in the region is among non-white ethnic groups. FLPPS recognizes that improved health literacy is essential for the patient population to comprehend their health information and take action in improving their health outcomes.

● FLPPS will include Health literacy initiatives in our vision, goals, principles and key strategies. ● Our plan is to utilize our Cultural Competency and Health Literacy committee, comprised of a panel of

experts and community based organizations to oversee all health literacy initiatives. ● Project plans will utilize appropriate health literate tools, such as post discharge care instructions ● We will Collect data on race, ethnicity, reading skills and English language proficiency ● FLPPS will develop standards, implementation of services and evaluation measures.

FLPPS will contract with community based organizations, such as the Monroe County of aging, to help achieve our Health Literacy goals, recognizing that they are key partners due to patient trust level and local knowledge of our patient base


Section 8 – DSRIP Budget & Flow of Funds DSRIP Budget & Flow of Funds - (Pass/Fail with No Scoring) Description: The PPS will be responsible for accepting a single payment from DOH tied to the organization’s ability to achieve the measurable goals of the DSRIP projects. In accepting the performance payments, the PPS must establish a plan to allocate the DSRIP funding amongst the participating providers in the PPS. In the response below, please address the following on DSRIP budget and flow of funds:

● Describe the plan in which the PPS plans on distributing DSRIP funds. ● Describe, on a high level, how the PPS plans to distribute funds among the clinical specialties, such as

primary care vs. specialties; among all applicable organizations along the care continuum, such as SNFs, LTACs, Home Care, community based organizations, and other safety-net providers, including adult care facilities (ACFs), assisted living programs (ALPs), licensed home care services agencies (LHCSAs), and adult day health care (ADHC) programs

● Outline how the distribution of funds is consistent and/or ties to the governance structure. ● Describe how the proposed approach will best allow the PPS to achieve its DSRIP goals.

PPS Response (3,900 characters max) Current: 3,528 characters The FLPPS funds flow plan establishes four primary budget categories. First, an administrative fund is established to cover the costs of staffing and running FLPPS. Second, consistent with the desire to move towards being able to accept value-based payment, a sustainability fund is established that would allow FLPPS to take on the risk associated with such payment methodologies. Third, in recognition of the potential for unforeseen financial events, a contingency fund is established. Fourth, and representing the majority of the funds, is the Partner Share of Funds, which would flow to the providers and partners who are engaged in the work that produces the desired transformation results. In the event of a performance bonus, that would be passed to the providers creating the favorable results. Within the Partner Share of Funds, 85 percent would be distributed in a way that mimics how FLPPS itself is funded. Providers will be distributed funds based on the number of lives they touch, the complexity of the projects they participate in, and the success under those projects. The formula is multiplicative so the larger the number of lives impacted, the more transformative the projects, and the better their relative performance, the higher their share of funds. It also ensures that providers who do not meet project metrics are not rewarded. Separately, 5-10 percent of funds would be distributed to partners based on their engagement in the FLPPS planning and governance functions and 5-10 percent would be distributed to providers without attributed lives who provide valuable services. The funds flow plan supports the goals of the FLPPS as developed by the sum total of its governance structure, including its Board of Directors, and many committees that provide representation across the care continuum, across the large 14 county region that it services, and across the many functions required to support FLPPS as an entity. Those goals, consistent with the DSRIP program goals, are to transform the delivery system by selecting and participating in DSRIP projects deemed most appropriate for its communities. For FLPPS to achieve the goals and metrics of each project, it must reward its providers based on their support and performance in achieving the goals and metrics for each project, relative to the size of the overall population that they impact. The goals of the funds flow plan are threefold: 1) to allow for the creation of the FLPPS as an entity able


to provide the oversight and project management necessary to meet the goals of the DSRIP projects, 2) to prepare the FLPPS to be able to take on value-based payment methodologies in the future, and 3) to incentivize and reward providers in a way consistent with them helping FLPPS achieve the goals of the selected projects. FLPPS has chosen to not include the costs of project implementation and revenue loss in its funds flow plan. Including projects costs as factor in determining provider reimbursement does not encourage the very type of economic efficiency that both FLPPS and the State are hoping will lead to delivery system transformation as a result of the DSRIP program. Similarly, funding of revenue losses at providers only delays the necessary transformation that each must undergo as required by the goals of the program. However, should a specific, significant risk to a fragile but essential provider exist, the FLPPS, at the discretion of its Board of Directors, could address it by tapping its contingency funds.

To summarize e the methodology, please identify the percentage of payments PPS intends to distribute amongst defined funding distribution categories. Funding distribution categories must include (but are not limited to):

1. Cost of Project Implementation: the PPS should consider all costs to be incurred by the PPS, such as salary and benefits, contractor costs, materials and supplies, and its participating providers in implementing the DSRIP Project Plan.

2. Revenue Loss: the PPS should consider the revenue lost by participating providers in implementing the DSRIP Project Plan through changes such as a reduction in bed capacity, closure of a clinic site, or other significant changes in existing business models. In addition, funding can be distributed based upon providing the necessary funding to sustain the safety net.

3. Internal PPS Provider Bonus Payments: the PPS should consider the impact of individual providers in the PPS meeting and exceeding the goal of the PPS’ DSRIP Project Plan.

Please complete the following chart to illustrate the PPS’ proposed approach for allocating performance payments. Please note the percentages requested represent aggregated estimated percentages over the five-year DSRIP period; are subject to change under PPS governance procedures; and are based on the maximum funding amount.

Budget Category Percent Administrative Costs for FLPPS

● PPS is responsible for oversight, overall success, project management, reporting, and technical assistance

15 percent

Sustainability Fund ● As the PPS moves to take risk-based payments, there may be a need for a fund

of dollars to make up financial losses from unforeseen levels of utilization

5 – 10 percent

Contingency Fund ● There may be unforeseen financial needs for which contingency funding

should be available – this may include offsetting of losses in very specific situations

5 – 10 percent

Partner Share of Funds ● Majority of funds would flow to providers and partners who are engaged in

the work that produces the desired transformation results ● Further split:

o 85 percent based on attributed lives x complexity of chosen projects

65-75 percent


x performance on project metrics (consistent with distribution methodology to FLPPS but modified to reflect intra-FLPPS relative performance and projects chosen)

o 10 percent based on response to surveys, information requests, and engagement in planning and governance

o 5 percent for CBOs and other providers who are not attributed lives but provide value-add services to the FLPPS population

Bonus Funds ● If FLPPS receives bonus funds based on performance, those will be distributed

to the underlying providers contributing to that performance

Total 100 percent

Project Budget and DSRIP Flow of Funds Milestones Description: Progress towards achieving the project goals and core requirements specified above will be assessed by specific milestones for the DSRIP program, which are measured by particular metrics. Investments in technology, tools, and human resources will strengthen the ability of the Performing Provider Systems to serve target populations and pursue DSRIP project goals. Domain 1 process milestones and measures will allow DOH to effectively monitor DSRIP program progress and sustainability. The following outlines the milestones that will be required and expected of the PPS to earn DSRIP payments. The milestone is presented for informational purposes only, however, the PPS will be expected to develop a work plan to outline the steps and timeframes in which these milestones will be achieved. -Quarterly or more frequent reports on the distribution of DSRIP payments by provider and project and the basis for the funding distribution to be determined by the Independent Assessor.


Section 9 – Financial Sustainability Plan Description: The continuing success of the PPS’ DSRIP Project Plan will require not only successful service delivery integration, but the establishment of an organizational structure that supports the PPS’ DSRIP goals. One of the key components of that organizational structure is the ability to implement financial and operational strategies that will ensure the financial sustainability of the PPS as a whole. Each PPS will have the ability to establish the financial practices that best meet the needs, structure, and composition of their respective PPS. In this section of the DSRIP Project Plan the PPS must illustrate its plan for implementing an operating model that will support the financial sustainability of the PPS throughout the five year DSRIP demonstration period and beyond. Assessment of PPS Financial Landscape

● It is critical for the PPS to understand the overall financial health of the PPS. The PPS will need to understand the providers within the network that are financially fragile and whose financial future could be further impacted by the goals and objectives of DSRIP projects. In the narrative, please address the following:

● Describe the assessment the PPS has performed to identify the PPS partners that are currently financially challenged and are at risk for financial failure.

PPS Response (limited to 2,000 characters) Current: 1,232 characters As part of its work to identify and include providers in its network, the FLPPS created a survey tool, the Request for Qualifications (RFQ), which asked interested provider respondents to provide organizational, IT, and financial data for their organizations. Included in the Financial Viability section required of all providers except those small practices with 4 or fewer providers, was a request for income statement, balance sheet, financial ratio, grant, and utilization data for 2013 and 2014 YTD and questions asking the providers to indicate how they anticipated DSRIP and other reforms impacting their organizations. The providers were also asked to provide 2013 audited financial statements where applicable. The FLPPS Finance Committee then adopted a scoring process for evaluating provider financial viability that broke providers into scoring buckets based upon the type of provider (i.e. SNFs, Hospitals, PCPs, community based organizations, etc.) and then assessed them, relative to each other, on categories including days cash on hand, operating margin, current ratio, and percent of revenue from grants. The bottom 25 percent were then identified for further and more detailed organization specific assessment.

● Identify at a high level the expected financial impact DSRIP projects will have on financially

fragile providers and/or other providers that could potentially be negatively impacted by the goals of DSRIP.

PPS Response (Limited to 3,900 characters) Current: 2,802characters At a high-level, there are two main DSRIP impacts: the impact of reducing existing volumes, in particular inpatient admissions and emergency room visits, and the cost of implementing the DSRIP projects themselves.


With the stated objective of reducing 25 percent of preventable inpatient and emergency room visits, there will be decreases in traditional hospital volumes. The extent of the impact on a particular provider will vary. First, it will vary based upon how many of those preventable visits they currently have at their facilities and how the changes focused on the Medicaid program will also impact the non-Medicaid volumes at their facilities; any reduction in volumes will not be limited to just the Medicaid population. Second, it will vary based upon how flexible their current business model is. Larger hospitals may have greater ability to reduce staffing levels as volumes change but smaller providers may run into obstacles such as minimum required staffing that make it difficult to reduce direct costs as volumes fall. Most of the cost savings, aside from the direct cost of supplies that is easier to reduce, will come from labor and will result in either job retraining costs so affected employees may transition to other ambulatory focused positions or severance costs. The cost of implementing the DSRIP projects will also have a financial impact on providers. The projects all require some investment by providers, whether it is in capital investments, in the form of new buildings or IT systems, or an increase in operating expenses in the form of adding new providers, staffing, and/or contracted vendors. The time delay inherent in the DSRIP program, with award dollars not coming for months after a performance period, will put pressure on available cash at providers, and potentially on operating margins if performance metrics the projects are designed to hit are not met and there is no revenue to cover the incremental expense. The availability of capital funding under the Capital Restructuring Financing Program could provide some relief to providers but it is likely those funds will require at least a 1-to-1 match from the provider. Both of these impacts can be especially acute for those providers deemed financially fragile. While the FLPPS does not want to directly budget for revenue loss at providers as that may discourage quicker transformation and it does not want to directly reimburse providers for project implementation costs as that does not reward economic efficiency in achieving project goals, the FLPPS is including in its Funds Flow plan a contingency fund that is available, at the discretion of the Board of Directors, to support providers in the event of unforeseen financial events, especially those that may be financially fragile.

Path to PPS Financial Sustainability The PPS must develop a strategic plan to achieve financial sustainability, so as to ensure all Medicaid members attributed to the PPS have access to the full ranges of necessary services. In the narrative, please address the following:

● Describe the plan the PPS has or will develop, outlining the PPS' path to financial sustainability, citing any known financial restructuring efforts that will require completion.

PPS Response (Limited to 2,400 characters) Current: 1,627 characters The FLPPS will develop a Financial Sustainability Plan (FSP) that will address the financial sustainability of the PPS and that will ensure that all Medicaid members in its 14 county region have access to the full range of necessary services. The FSP will be developed under the oversight of the FLPPS Finance Committee and will be presented to the Board of Directors for approval by April 1st, 2015. In order for the PPS to fulfill its role of ensuring access for all Medicaid members, it must first ensure that it can sustain itself, which includes being able to obtain the funds necessary for operations. To this point, the FSP will define specific financial and operational metrics that will allow it to track its success against the DSRIP project goals and that will allow for identification of potential performance issues within its provider network. Actual performance will be compared to budgeted performance at regular intervals


and a process to address issues will be outlined. Also within the FSP will be a process for regularly monitoring the financial health of PPS providers and an outline of a process for how FLPPS will address issues at providers, including, but not limited to, access to FLPPS contingency funds. At this time, it is known that the FLPPS will need to address two facilities within its network who have accepted funding via the Interim Access Assurance Fund (IAAF): St James Mercy Hospital and Wyoming County Community Health System. The Finance Committee will work with each to create a plan that will be accepted by the Finance Committee and the Board of Directors prior to April 1st, 2015.

● Describe how the PPS will monitor the financial sustainability of each PPS partner and ensure those fragile

safety net providers, essential to achieving the PPS’ DSRIP goals, will achieve a path of financial sustainability.

PPS Response (Limited to 1,200 Characters) Current: 509 characters As indicated above, the FLPPS will adopt a Financial Sustainability Plan (FSP) that will include a process for monitoring the financial sustainability of each PPS partner on a regular basis, utilizing a process similar to that used in initially establishing the PPS network, and will include requiring financial statement and financial ratio data. If providers are found to be trending towards financial distress, a Distressed Provider Plan will be developed and managed by the PPS Project Management Office.

● Describe how the PPS will sustain the DSRIP outcomes after the conclusion of the program.

PPS Response (Limited to 1,200 characters) Current: 857 characters The DSRIP program provides a mechanism to fund many of the changes necessary for the shift from a fee-for-service based approach to Medicaid to an approach based on value. The implementation of specific project deliverables will develop and mature the population health and disease management capabilities of FLPPS and its PPS partners. It will create an organization that is both willing and able to move to quality and outcomes models under value-based reimbursement methodologies. FLPPS intends to engage with Medicaid managed care organizations early in the process to ensure that the programs, projects, and processes put in place over the 5 years result in an organization that can be financially sustainable while delivering the value that payors seek and that the patient population needs. The goal is to sustain and improve upon the gains of the 5 years as an organization able to accept value-based reimbursement methodologies into the future.

Strategy to Pursue and Implement Payment Transformation to Support Financial Sustainability Please describe the PPS’ plan for engaging in payment reform over the course of the five year demonstration period. This narrative should include:

● Articulate the PPS’ vision for transforming to value based reimbursement methodologies and how the PPS plans to engage Medicaid managed care organizations in this process.

PPS Response (Limited to 1,600 characters) Current: 1,295 characters The DSRIP program represents a unique opportunity to invest in the population health capabilities of the PPS and its partners that can result in the reduction in the cost of care for the Medicaid population while


increasing quality outcomes and patient experience. However, DSRIP funding is limited, both in terms of amount per year, and in the duration for which it is available, and the ability for FLPPS to work with Medicaid managed care organizations (MCOs) to develop value-based reimbursement methodologies both during the 5 years and after, will result in additional dollars available to fund incremental improvements in population health capabilities and further the move away from fee-for-service. To this end, FLPPS plans to engage with the Medicaid MCOs in the region, to discuss current FLPPS project plans given their experience with the population, and to discuss how partnering on value-based reimbursement methodologies might further the alignment of the organizations. What those methodologies look like may be different by MCO and by year. It is anticipated that they may start simpler with arrangements like shared savings and move towards more complex and shared risk arrangements like capitation as FLPPS develops its capabilities and financial ability to take on risk.

● Outline how payment transformation will assist the PPS to achieve a path of financial stability, particularly

for financially fragile safety net providers.

PPS Response (Limited to 2,400 characters) Current: 1,275 characters As mentioned above, DSRIP funding is limited, both in terms of the amount, and the number of years for which it is available. Payment transformation creates a second source of potential income that will allow FLPPS to further invest in the integrated delivery system DSRIP is creating and by ensuring sufficient funds, provide additional resources for FLPPS to be able to ensure that financially fragile safety net providers exist and that the Medicaid population has access to the necessary services. The move to value-based reimbursement methodologies across this big of a population, with its unique needs and requirements, is a big lift, both operationally and financially for the PPS providers. The FLPPS has selected projects that have the ability to reduce preventable utilization by 25 percent and meet the DSRIP projects goals, but there are other projects and opportunities still to be mined, for which the DSRIP funding alone cannot cover the cost to implement. Through alignment with the DOH and MCOs, and the development of value-based reimbursement methodologies that allow all 3 organizations to share in the savings, there are further improvements in cost and quality of care to be had with the future state being a transformed and enhanced safety net.


Section 10 – Bonus Points Proven Population Health Management Capabilities (applicable to Project 2.a.i. only) Population health management skill sets and capabilities will be a critical function of the PPS lead to successfully develop an integrated delivery system. If applicable, please outline the experience and proven population health management capabilities of the PPS Lead, particularly with the Medicaid population. Alternatively, please explain how the PPS has engaged key partners that possess proven population health management skill sets.

PPS Response (Limited to 2,000 characters) Current: 1,155 characters Both lead organizations have significant experience with population management, including such things as:

● Monitoring screening data to identify high-risk patients ● Pre-visit planning ● Implementation of PCMH Level 3 certification throughout primary care practices ● Increased access through telemedicine, extended hours, ● Assignment of patients to primary care teams ● Integration of primary care and specialty care services, including but not limited to

- Dental services - Behavioral health and substance abuse - Optometry - Recuperative care programs - Environmental health - Nutrition - Occupational therapy - Physical therapy - Speech

● Limited integration of behavioral health into primary care ● Use of data of improve quality of care ● Use of evidence-based programs to improve care ● Implementation of hand-off protocols ● Group visits for education and management ● Managing preventable visits to emergency room and admission to hospital through:

- Enhanced discharge processes - Post-discharge contacts and care (education and protocols for standardized care) - Facilitators and navigators for continued management - Call Center ***for post-discharge follow-up?***

Proven Workforce Strategy Vendor Minimizing the negative impact to the workforce to the greatest extent possible is an important DSRIP goal. If applicable, please outline whether the PPS has or intends to contract with a proven and experienced entity to help carry out the PPS’ workforce strategy of retraining, redeploying, and recruiting employees. Particular importance is place on those entities that can demonstrate experience successfully retraining and redeploying healthcare workers due to restructuring changes.

PPS Response (Limited to 2,000 characters) Current: 939 characters


The Finger Lakes PPS anticipates that significant changes in our region’s health care workforce will need to be addressed in order to successfully carry out our plans to achieve DSRIP goals. In fact, our ability to effectively transform our workforce is one of the most critical factors in our overall success of changing the way we provide care. Especially given the size of the FLPPS, we believe it is essential that we contract with a workforce strategy vendor who can assist us in planning and implementing an extremely comprehensive, large-scale workforce strategy that is also responsive to the existing resources and identified needs of sub-areas throughout the PPS region. Based on the needs identified in Section 5 (PPS Workforce Strategy), the FLPPS Workforce Committee has developed, and is in the process of finalizing, a Request for Applications to assist in choosing the best vendor to meet the specific needs of the FLPPS.

Selection of 11th Project (2.d.i.) As previously articulated by DOH, the bonus points will be attributed to those PPSs that have elected to pursue the 11th project. Please indicate whether the PPS has elected to pursue the 11th project by marking the appropriate box below.)

Yes No X


Section 11 – Attestation


Appendix A – Currently Known Scale & Speed Methodology to arrive at scale & speed

Patient Partner Provider

Scale Speed (ramp to 100%)

Scale Speed

a) # Patient Benefiting c) ramp per # activated definition a) # Providers Partnering c) when are all at 100%

b) total attribution a) # Patient Benefiting b) total all provider types a) # Providers Partnering


Definitions of “Actively Engaged” by project option as defined by NY DOH

Project ID Definition

2.a.i: Create integrated delivery systems Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).

2.b.iii – ED care triage for at risk populations

Number of participating patients presented at the ED and appropriately referred for medical screening examination and successfully redirected to PCP as demonstrated by a connection with their Health Home care manager or a scheduled appointment.

2.b.iv – Care transitions intervention model to reduce 30 day readmissions for chronic health conditions

Number of participating patients with a care transition plan developed prior to discharge who are not readmitted within that 30-day period.

2.b.vi – Transitional supportive housing services

Number of participating patients who utilized transitional supportive housing and were appropriately monitored via telephonic or face-to-face contact throughout a 90-day transition period to address a specific housing-related need.

2.d.i. Project 11” Number of individuals who completed PAM® or other patient engagement techniques

3.a.i – Integration of behavioral health and primary care

Total of number of patients engaged per each of the three models in this project, including:

1. PCMH Service Site: Number of patients screened (PHQ-9 / SBIRT) 2. Behavioral Health Site: Number of patients receiving primary care services at a

participating mental health or substance abuse site. 3. IMPACT: Number of patients screened (PHQ-9 / SBIRT)

3.a.ii – Behavioral health community crisis stabilization services

Participating patients receiving crisis stabilization services from participating sites, as determined in the project requirements.

3.a.v – Behavioral Interventions Paradigm in Nursing Homes (BIPNH)

Number of participating patients impacted by program initiatives (bed census).

3.f.i – Increase support for maternal and child health (including high risk pregnancies)

Number of expecting mothers and mothers participating in this program.


Project Title

a) Total Patient Benefitting over 4 yrs. *

c) Activated Patient

a) # Partnering Providers

Major Assumptions

Capital Range

Critical Path

All Project Requirements Achieved

2.b.iv Care Transition

25,000 # with CT plan prior discharge

<150 Focused on certain chronic conditions

$3M-$9M PCMH (tbd) and MU (tbd) for all eligible provider entities

1H 2018

2.b.vi Transitional

Housing

3,000-5,000 # pts. Placed post discharge

<50 Reuse and repurpose

$4M - $12M

MU Stage 1 for eligible providers

1H 2018

2.a.i. Integrated Delivery System

200,000-225,000

# RHIO Consents

600 (all) 77% overall Rochester RHIO current consents

$40M-$120M

PCMH (115) and MU (200) for all eligible provider entities

2H 2017

2.b.iii. ED Care Triage

50,000 # Referrals from ED to PCP

<100 Kick start at hot spots, using excess capacity

$20M-$60M

PCMH (tbd) and MU (tbd). Capital not a driver

2H 2017


Project Title

a) Total Patient Benefitting over 4 yrs. *

c) Activated Patient

a) # Partnering Providers

Major Assumptions

Capital Range

Critical Path

All Project Requirements Achieved

3.a.i. Integrated

BH and PCP

65,000-73,000 # PHQ9 or # pts primary care @ BH site

<50 Options 1, 3 faster ramp (PHQ9 only)

$11M-$33M

PCMH (tbd) and MU (tbd) for all eligible provider entities

2H 2017

3.a.ii. Crisis Stabilization

7,000 pts. Or 14,000

services

# Receiving Services

<40 5 crisis stabilization hubs

$4M - $12M

Renovations 2H 2017

3.a.v. BIP Nursing Home

4,000-5,000 Bed census <40 Repurpose existing

$4M - $12M

Central Services, Training, certification

2H 2016

3.f.i. Child & Maternal

1988-2108 # Receiving Services

<40 Based on Medicaid births; laptops needed

$70K-$200K

Resource and training plan

1H 2016

2.d.i. Patient Activation

75,000-85,000 # PAM completed

<40 Estimates incl. uninsured

$4M - $12M

Resource and training plan

2H 2017

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