dsrip meeting agenda - nyp.org · dsrip meeting agenda page 2 . food is medicine presentation to...

DSRIP Meeting Agenda

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Date & Time 11/17/17 @ 9:00 – 10:00AM Meeting Title IT – Clinical Operations Committee

Location NYP Milstein 1HN-144

Facilitator Alvin Lin & Elaine Fleck

WebEx https://nyp.webex.com/nyp/j.php?MTID=m0080f465e5176394053d95ece446f2ae

Conference Line Dial: 415-655-0001 Access Code: 855 960 356

Invitees

Chair: Elaine Fleck (NYP) Chair: Alvin Lin (NYC DOHMH PCIP/REACH)

Gil Kuperman (NYP) Terri Udolf (St. Christopher’s Inn)

Alissa Wassung (God’s Love We Deliver) Sandy Merlino (VNSNY)

Susan Wiviott (The Bridge) Amy Shah (NYC DOHMH)

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

Jean Marie Bradford, MD (NYPSI) Catherine Thurston (SPOP)

Genevieve Castillo (Methodist) Stuart Myer (VillageCare)

Dan Johansson (ACMH, Inc.) Renato Leonel (Isabella)

Julissa Nunez (IT – VNSNY) Mitze Amoroso (ArchCare)

Theo Figurasin (NYSNA) Todd Rogow (Healthix)

Steven Lam (CBWCHC) Priscilla Pena (1199 SEIU)

Andres Pereira, MD Patricia Hernandez (NYP)

Nelson Mesa (NYP) Andrew Missel (NYP)

Linda Reid (Workforce – VNSNY) Rachel Naiukow (NYP)

Dodi Meyer (NYP) Sarah McNabb (NYP)

Meeting Objectives Facilitator Time Start End

Welcome & Roll Call Alvin Lin 10 min 9:00 9:10

Presentation by God’s Love We Deliver

Treating Nutritional Needs of Medically Complex Patients

Challenges with Getting Data for CBOs

Alissa Wassung 15 min

(+10 min Discussion)

9:10 9:35

Screening for Social Determinants of Health

Program Overview

Planned Process for Managing Referrals Using NowPow

Opportunities for CBOs to Serve on AHC Workgroups

Dodi Meyer 10 min

(+10 min Discussion)

9:35 9:55

Next Steps

Governance Committee Transition Process Andrew Missel 5 min 9:55 10:00

Action Items

Description Owner Start Date Due Date Status

https://nyp.webex.com/nyp/j.php?MTID=m0080f465e5176394053d95ece446f2ae



DSRIP Meeting Agenda

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Food Is MedicinePresentation to NYP PPS

Alissa Wassung, Director of Policy & Planning

God’s Love We Deliver

Outline

• Mission in Action

• Medically Tailored Meals (MTM)

• Research

• MTM in Medicaid

• Data Issues

• DSRIP – The Laboratory for VBP

NYP Participation

• Member since the beginning

• Clinical Operations/IT Committee

• MAX Series Member

• Planning Committee

• ED Quality Improvement Retreat

• CMMI/AHC Advisory Group

Mission in Action

• 1.7 million individually-tailored

meals delivered this year

• 7,000 people and 200+

diagnoses

• All 5 boroughs, plus Westchester

County, Nassau County, and

Hudson County, NJ

• 7,000 meals prepared and

delivered each weekday

• Unique focus on severe and

chronic illness

• Meals individually-tailored for

specific medical circumstances

• 7 RDNs with Chefs

• Support trajectory of illness

– Soft, minced, and pureed

• Flexible service plans and

delivery

• No preservatives, starters or fillers

Medically Tailored Meals (MTM)

Meal

Modifications

Low Sodium

Renal (Kidney Disease)

Low Sugar

VegetarianAnd More!

Acid/Bland

Fiber/Gas

Alzheimer's/Neurological

9%

Cancer17%

Cardiovascular16%

Diabetes5%

HIV/AIDS17%

Kidney12%

MS/Musculoskeletal

8%

Other diseases11%

Pulmonary 5%

Secondary Diagnosis

15% behavioral health

35% diabetes

26% obesity

DIAGNOSIS

Target Populations for MTMTOO SICK TO SHOP OR COOK FOR THEMSELVES

• Medically at-risk

• In danger of being institutionalized (in hospitals, nursing homes or long term care

facilities)

• Significantly limited in their activities of daily living that affect shopping and cooking

(standing, carrying, lifting, etc.)

• Dealing with serious behavioral health issues that impede their ability to take care

of their nutritional needs

• In the progressive stages of dementia that require dietary modifications (pureed or

minced)

• On the cusp of developing to severe diabetes, or those who need temporary

support to recover from a relapse of diabetes-related complications

• Being discharged from the hospital after an acute episode with no supports in home

High Risk, High Need, High Cost

Healthcare Spending

Food is Medicine

While adequate food and nutrition is

important for all people, proper

nutrition is critical for the

management of chronic illness.

The Problem The Solution

Food Insecurity Leads to:

• Poor medication adherence

• Reduced control of chronic conditions

• Poor engagement in medical care

• ER/inpatient/institutional use

Malnutrition Results in:

• 50% more likely to be readmitted

• More than 2 million hospital stays annually (nationally)

For People with Serious Illness

Medically Tailored Meals =

• 28% drop in healthcare costs

• 50% fewer hospital admissions

• 23% more likely to be discharged to home and not an institution

For People with HIV = More Likely to:• Adhere to medication• Achieve viral suppression• Have better health functioning

Research Summary

Citations and studies available

NO DEDICATED FEDERAL BENEFIT

for medically tailored food for critically ill people

State by state by state etc.

INNOVATION

RESULT

NYS Reimbursement: Medicaid

Fully Reimbursable:

• Medicaid Managed Long Term Care (MLTC)

• Fully Integrated Duals Advantage Plans (FIDA) –Medicaid/Medicare

Reimbursable through DSRIP Direct Contract:

• Mainstream Medicaid Managed Care (MMC)

3,0819,397

24,76751,780

57,871

66,80194,131

121,767

150,901

201,506

231,359

263,121

312,543

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017

Me

als

pe

r FY

MLTC Community Partner Program Growth FY2005-FY2017

Our Process

Identify

• NYSDOH Balancing Incentives Program (MLTC) – We used

the UAS to develop an MTM Referral Tool

• NYP MAX Series (Mainstream Medicaid) – As a member of

the MAX Series team, I co-developed an HU SDOH screen

• NYP CMMI/AHC Project – CMS has developed a 10 question

screen

• National Malnutrition Blueprint – God’s Love was co-author

with AARP, NANASP and others. Recommends the:

– Malnutrition Screening Tool

– The Mini Nutritional Assessment

Authorize

We work to provide:• Flexibility with delivery days and requested service adjustments

• Customized menu based on diagnosis, medication interaction and dietary

needs

• Streamlined authorization process

• Responsive customer service care for all clients

We:• Are fully HIPAA compliant

• Utilize HCFA 1500 billing forms (to bill per meal per service day) that are

sent electronically to each provider

Nourish

We provide meals by addressing a combination of restrictions,

resulting in almost infinite meal variety for members.

• All meals are low in sodium and balanced for other nutrients.

Meal restrictions include:

• Pork, Beef, Fish, Vegetarian

• Sugar, Fat, Dairy

• Renal, Minced, Pureed

• Acid/Bland and Fiber/Gas

• More…

Outcomes Data?

Data and Closed Loop Referrals

Data NeedsBarriers to Providing Quality CBO Interventions in DSRIP

• Medical field lacks a comprehensive assessment of SDOH

• If there is an assessment, and it is positive, staff are unsure where to refer

• If staff understand where to refer, referrals contain incomplete data, or may be inappropriate

• Staff turnover

• Lack of payment for additional services

Barriers to CBOs Being Effective Partners in DSRIP

• Outcomes data medical field hopes to track is not available to CBOs

So: CBOs are being asked to prove the efficacy of services in particular populations without access to outcomes data.

Positive Screen for Malnutrition

In-Depth Intake and Diet Prescription***Client is MLTC

Contact Case Manager

MLTC

If Yes = Reimbursed ServicesAuthorization

Identify

Authorize

Nourish

1. MLTC2. MMC

2 Referral

Pathways

In-Depth Intake and Diet Prescription***Client MMC

MCO

Medical Outcomes and Utilization

• Clinical nutrition data• Medication reconciliation• Contextual data on life of

the client that ensures success of treatment

• Client surveysHealthcare Cost and Utilization Data

Data

Pathways

Rx

Healthcare Cost

Billing/Encounters

Outcomes Data

Outcomes Data

?

The Solution

• DSRIP is a laboratory to test new models that drive down the cost of care

• Opportunity for reimbursed pilot projects to evaluate community based interventions on medical outcomes and utilization

• Pilots should be predicated on existing SDOH impact data; but also acknowledge the field is being built as we go

• Opportunity to work in collaboration on new data structures –as data pathways do not yet robustly exist

• Remember: VBP requires:– One Tier One CBO

– One SDOH project

Q and A

God’s Love We Deliver Contacts

Alethea Hannemann

Chief Operating Officer

[email protected]

212-294-8136

Dorella Walters

Senior Director of External Program Affairs

[email protected]; 212-294-8123

Lisa Zullig

Director of Nutrition Services

[email protected]; 212.294.8157

Danielle Christensen

Policy & Grants Coordinator

[email protected]; 212-294-8185

Alissa Wassung

Director of Policy & Planning

[email protected];

212-294-8171

Karen Pearl

President & CEO

[email protected];

212.294.8194

God’s Love We Deliver

166 Avenue of the Americas

New York, NY 10013

glwd.org

Accountable Health Communities GrantCenter for Medicare and Medicaid Innovation

Housing

– Quality

– Stability

Food insecurity

Utility Needs

Transportation Needs

Interpersonal Violence

Health Related Social Needs

• Housing

o Quality

o Stability

• Food insecurity

• Utility Needs

• Transportation Needs

• Interpersonal Violence

Housing

– Quality

– Stability

Food insecurity

Utility Needs



Target Population

• 51% community-dwelling Medicaid and/or

Medicare beneficiaries

• Must live in zip codes 10031, 10032, 10032,

10034, 10040

• Goal is to screen 75,000 community-dwelling

beneficiaries per year

Housing

– Quality

– Stability

Food insecurity

Utility Needs



Screening Algorithm

Risk Stratification

Low-Risk: Stable• Low-Risk AHC (+ need, no ED visits)• Negative screens

High Risk (5%)• High

Utilizers• Unstable

Medium Risk: Stable• High-Risk AHC (+ need plus 2

ED visits)• Positive screens w/

Depression, DV, already engaged

Housing

– Quality

– Stability

Food insecurity

Utility Needs



Utilization of Screeners Impact the Rate of Identified Resource Needs: Work to Date

• Selected IT platform for screening and referral: NowPow

• Building IT infrastructure for interface with EMR, screening and referral

• Identifying downstream screening referral sites

• Identified social needs of patients served by NYP at pilot sites

• Goal

Align model partners to optimize community

capacity to address health related social needs

• Objectives

• Identify resource gaps and develop strategies

to address them

• Align with existent community wide initiatives

• Explore Collective Impact Model

24%

40%

15%

7%

2% 9%

0%1% 1% 1%

Months 14 & 15 (Aug & Sept) -Families' Most Common Resource

Needs (n=215 needs)

Physical Activity

Early Literacy

Early Education

Food Insecurity

Other

Nutrition

Adult Literacy

Early Intervention

Housing

Legal Aid

17%

10%

18%31%

5%

14%

1%1% 2% 1%

Month 16 (October) - Families Most Common Resource Needs (n=211

needs)

Physical Activity

Early Literacy

Early Education

Food Insecurity

Other

Nutrition

Adult Literacy

Early Intervention

Housing

Legal Aid

• Completed pilot which involved universal screening for social needs, waiting room

education and referral to one CBO

Housing

– Quality

– Stability

Food insecurity

Utility Needs



Work to Date


• Building NYP IT infrastructure for interface with EMR, screening and referral


Housing

– Quality

– Stability

Food insecurity

Utility Needs



Community Collaborator Alignment


• Building IT infrastructure for interface with EMR, screening and referral


• Identified social needs of patients served by NYP at pilot sites

• Goal

Align model partners to optimize community

capacity to address health related social needs

• Objectives

• Identify resource gaps and develop strategies

to address them

• Align with existent community wide initiatives

• Explore Collective Impact Model

Housing

– Quality

– Stability

Food insecurity

Utility Needs



Example: Food Insecurity

Outcome Measures:Increase screening for food insecurity NYP Primary Care and Emergency Room sites

Ensure that those who screen positive are referred to appropriate entitlement programs (SNAP/WIC) and emergency food resources

Primary Driver/System Change:

Work with Citywide Food Coalition to enhance # of emergency resources in Northern Manhattan and the South Bronx

Work with CBO’s to address capacity issues secondary to increase number of referrals

Implement training for faculty and trainees in sites where screening will take place: ED,OBGYN, internal medicine and pediatrics by 3rd quarter 2018

GLOBAL AIM: Ensure that every community member has adequate, healthy sources of food

Questions?

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