new york medicaid population health symposium · thank you all for your continued commitment to...

NEW YORKMEDICAIDPOPULATION HEALTHSYMPOSIUM NOVEMBER 18-19, 2019

GRAND HYATT NEW YORK | NEW YORK, NY

CONFERENCE GUIDE

WWW.DSRIPLEARNING.COM

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WELCOMETABLE OF CONTENTSSCHEDULE OF EVENTSKEYNOTE SPEAKERS

WELCOME TO THE 2019 NEW YORK MEDICAID POPULATION HEALTH SYMPOSIUM! This event gives us the opportunity to acknowledge the transformational work accomplished under the Delivery System Reform Incentive Payment (DSRIP) demonstration, and recognize the critical roles of community providers, behavioral health providers, traditional medical providers, and payers. Together, we have created a more integrated, innovative, and effective approach to address the needs of Medicaid consumers, shown in measurable improvements across a variety of health outcomes.

This year’s symposium features several multidisciplinary panel presentations that highlight these partnerships, the lessons learned and the best practices in reforming service delivery into financially sustainable value-based arrangements. New York’s DSRIP waiver extension request, which will be formally submitted to the Centers for Medicare and Medicaid Services (CMS) later this month, seeks additional time and funding to support the continuation of these successful initiatives.

Thank you all for your continued commitment to this mission and steadfast dedication to serving Medicaid consumers. Keep up the great work, collaboration, and innovation.

Sincerely,

Donna Frescatore, NYS Medicaid Director

TABLE OF CONTENTSTABLE OF CONTENTSi WELCOME

i TABLE OF CONTENTS

1 SCHEDULE OF EVENTS

2 KEYNOTE SPEAKERS

3 NOVEMBER 17

3 NOVEMBER 18

7 NOVEMBER 19

13 POSTER PROGRAM

19 HOTEL MAP

20 GENERAL INFORMATION

21 NOTES

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NY MEDICAID POPULATION HEALTH SYMPOSIUM | 1

WELCOMETABLE OF CONTENTS

SCHEDULE OF EVENTSKEYNOTE SPEAKERS

SCHEDULE SCHEDULE OF EVENTSOF EVENTSSUNDAY, NOVEMBER 17

4:00-7:00PM Registration

MONDAY, NOVEMBER 188:00-8:45AM Registration Poster Set-up Breakfast

9:00-9:30AM Opening Remarks: Dr. Howard A. Zucker, Donna Frescatore

9:45-10:45AM Breakout Sessions 1-3

11:00-12:00PM Breakout Sessions 4-6

12:00-1:00PM Lunch

1:00-2:00PM Keynote: Sandro Galea, MD, MPH, DrPH


3:30-5:30PM Poster Reception

TUESDAY, NOVEMBER 198:00-8:45AM Registration Breakfast

9:00-9:30AM Opening Remarks: Greg Allen

9:45-10:45AM Breakout Sessions 10-13


12:00-1:00PM Lunch

1:15-2:15PM Breakouts Sessions 18-21

2:30-3:30PM Keynote: Rebecca Onie, JD and Rocco Perla

3:30-4:30PM Closing Remarks: NYS Department of Health


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KEYNOTE KEYNOTE SPEAKERSSPEAKERSSANDRO GALEA

Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published more than 800 scientific journal articles, 50 chapters, and 18 books. He has been invited to present his work in more than 30 countries and 30 US states. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow. Galea was named one of Time magazine’s epidemiology innovators and has been listed as one of the “World’s Most Influential Scientific Minds.” He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. He is a regular contributor to, and his work is regularly featured in, a range of public media.

REBECCA ONIE As co-founder of Health Leads, Onie is a nationally recognized leader in the intersection of social determinants, population health, and health care delivery. A MacArthur “Genius” awardee, Onie is a member of the National Academy of Medicine and an Aspen Institute Health Innovators Fellow. She has received the APHA Avedis Donabedian Quality Award; Network for Excellence in Health Innovation “Innovator in Health” Award; Robert Wood Johnson Young Leader Award; and Forbes’ Impact 30 Award for leading social entrepreneurs. She received her J.D. from Harvard Law School, where she was an editor of the Harvard Law Review.

ROCCO PERLAPerla most recently served as President of Health Leads. Previously, he directed the Learning and Diffusion Group at the CMS Innovation Center, where he established the national learning system to test new delivery and payment models through the Affordable Care Act and oversaw the $1 Billion Partnership for Patients and the Million Hearts Campaign. Perla was a Merck Fellow at the Institute for Healthcare Improvement. He received the 2014 Impact Article of the Year Award from the National Association for Health Care Quality, the 2015 Federal Executive Board Award for Outstanding Creativity and Innovation and, in 2016, the Deming Medal by the American Society for Quality. He is an Assistant Professor at the University of Massachusetts Medical School with a joint appointment in Community Health and Quantitative Health Sciences.

WELCOMETABLE OF CONTENTSSCHEDULE OF EVENTSKEYNOTE SPEAKERS


MONDAY, NOVEMBER 18MONDAY, NOVEMBER 188:00-8:45AM | REGISTRATION | BREAKFAST | POSTER SET-UP Empire State Ballroom Foyer/II-IV

Sign in, pick up your name badge and meeting materials at the registration table. Enjoy breakfast before the program begins. Presenting a poster? Receive your poster mounting location, instructions, and materials at the registration desk and please take this time to set up your poster.

9:00-9:30AM OPENING REMARKSEmpire State Ballroom II-IV

Opening remarks presented by Howard A. Zucker, M.D., J.D., New York State Commissioner of Health and Donna Frescatore, Medicaid Director, New York State Department of Health

9:45-10:45AM BREAKOUT SESSIONS 1-3

Breakout Session 1: The Value of CBO Participation in the SHIN-NY/ Healthix: Interoperability for Addressing SDH

Empire State Ballroom I

If value based care is to achieve the dual objectives of reducing the cost of care while improving health outcomes, risk-bearing provider organizations must work in conjunction with community based organizations (CBOs) to gather and share relevant non-clinical data in standardized, secure and user-friendly ways, in order to effectively address the social determinants of health (SDH) of vulnerable populations.This presentation features a case study of a CBO (AIRnyc), and a Qualified Entity (QE - Healthix) collaborating to build capacity and an effective operational and legal framework for sharing data across silos with the technical assistance of the NYeC/ SHIN-NY in order to better address SDH of people served by AIRnyc’s Community Health Worker-led, home-based interventions. This case study seeks to share lessons learned and identify best practices for CBOs to participate in QEs and the SHIN-NY throughout the state.

Shoshanah Brown, CEO, AIRnycValerie Grey, Executive Director, New York eHealth CollaborativeTodd Rogow, President and CEO, HealthixDavid Shilane, Director of Analytics, AIRnyc

SUNDAY, SUNDAY, NOVEMBER 17NOVEMBER 174:00-7:00PM | REGISTRATIONMezzanine Foyer

Sign in, pick up your name badge and meeting materials at the registration booth.

SUNDAY, NOVEMBER 17MONDAY, NOVEMBER 18TUESDAY, NOVEMBER 19


Breakout Session 2: A New Model for Integrating Community Health Stakeholders to Address SDH

Empire State Ballroom II-IV

This panel presentation will discuss the creation of one of the first social determinants of health (SDH)-focused Independent Practice Associations (IPAs), from the perspective of the DSRIP PPS leading the IPA (Alliance for Better Health), the non-profit managed care organization paying community based organizations (CBOs) for SDH-focused outcomes (MVP Health Care), and the technology platform that provides the infrastructure for closed loop referrals, data collection, and improved coordination between clinical and social service providers (Unite Us). Discussion will include promising practices for establishing payment models for social care services, a review of managed service organization services offered to CBO members of the IPA, presentation of preliminary outcomes based on Medicaid claims and SDH referral data, and nascent models for using these data to demonstrate return on investment in the transition to Value Based Payment.

Jacob Reider, CEO, Alliance for Better HealthDan Brillman, CEO, Unite UsKimberly A. Kilby, Senior Leader, Regional Medical Directors, MVP Health CareMike Saccocio, CEO, Schenectady City Mission

Breakout Session 3: Payor / Provider Value Based Collaboration for Medication Assisted Treatment Program

Empire State Ballroom V

Recovery Health Solutions IPA (RHS) and Advanced Health Network IPA (AHN), a behavioral health provider network of more than 50 providers across NYC and Long Island, are working in a collaborative partnership with Healthfirst supporting development and implementation of an evidence-based Medication Assisted Treatment program for individuals with opioid and alcohol addictions. The focus is on a patient centered, integrated clinical and service delivery model supported by an aligned payment model with the goals of improving access, care transitions, patient engagement and community tenure of the individual. The approach has been collaborative and iterative, recognizing the organizational, clinical, operational, financial and overall

cultural changes to be implemented by both the provider and payor. Sharing the payor and provider perspectives, the session presenters will detail their approach, the key operational requirements, and their challenges and lessons learned.

Carol Cassell, Executive Director, Recovery Health SolutionsDonna Taylor, Clinical Director, Health and Recovery Plan, HealthfirstRoy Wallach, Executive Vice President Arms Acres/Conifer Park; President Recovery Health SolutionsJeff Steigman, Chief Administrative Officer, Family Service League

11:00-12:00PM BREAKOUT SESSIONS 4-6

Breakout Session 4: Utilizing Smartphone Applications to Improve Integrated Care Outcomes Within VBP Environments


Integrated care is effective in coordinating care for behavioral and medical conditions and improving care quality and outcomes. Despite its promise, practices with varying organizational readiness and resources may encounter challenges in restructuring care delivery to support integrated care models successfully. Using a continuum-based framework to provide a self-assessment and roadmap for implementing key integration domains, augmented by a smartphone application, may help new care models align with Value Based Payment (VBP) requirements. Presenters will include representatives from the NYS Office of Mental Health and community-based primary and behavioral health care organizations implementing integrated care. Speakers will discuss case studies to illustrate lessons learned and the population health impact of continuum-based integrated care with smartphone technology to maximize resources and patient engagement and improve outcomes within a VBP environment. Step-by-step guidance for those interested in implementing a similar model will be provided.

Michelle Blackmore, Project Director, Montefiore Medical Center Care Management OrganizationAmy Jones-Renaud, Director for Primary Care Behavioral Health Integration, NYS Office of Mental HealthWilliam Mullane, Regional Director for Behavioral Health, Westchester Jewish Community ServicesAlissa Mallow, Director of Social Work, Montefiore Medical GroupJ. Robin Moon, Senior Director, System Integration, Bronx Partners for Healthy Communities



Breakout Session 5: Building CBO Capacity – A Journey Toward Value Based Payment


God’s Love We Deliver is a non-profit community based organization (CBO) that provides medically tailored meals and medical nutrition therapy to people who, because of their illness, are unable to provide or prepare meals for themselves. God’s Love has a long history of collaboration with payors and providers, offering a unique perspective on what works and what does not in these innovative partnerships. In this session, God’s Love will lay out key areas of efficacy that CBOs and their healthcare counterparts must develop to achieve impact. Along with their healthcare partners, they will highlight data and outcomes from a variety of their partnerships, showcasing successes and challenges and share new information and insight into the future of these multifaceted arrangements. Finally, they will lead CBOs and healthcare collaborators through a thought exercise that catalogues what is lacking in each area of capacity building and helps partners identify strategies to address them together.

Alissa Wassung, Director of Policy & Planning, God’s Love We Deliver, Inc.Karen Pearl, President & CEO, God’s Love We Deliver, Inc.Dorella Walters, Director of External Program Affairs, God’s Love We Deliver, Inc.Jillian Shotwell, Program Manager, Community Health, Northwell HealthLynn St. Hilaire, Senior Director of Clinical Services, MetroPlus Health Plan

Breakout Session 6: Provider/Payor Partnerships to Support the Move to Value


Over the last five years, Empire/HealthPlus has worked with the SOMOS “legacy” Independent Practice Associations (IPAs) (Corinthian, Excelsior and Eastern Chinese American Physicians ) to establish SOMOS PPS under the DSRIP program by assisting SOMOS in implementing clinical and population health strategies. As the managed care organization (MCO)/ provider partnership matured, Empire helped SOMOS IPA (the Value Based Payment contracting entity) develop the administrative infrastructure needed to participate in advanced risk arrangements. This work reflected Empire’s strategy of closer collaboration with independent physicians but the patient population and

number of physicians were greater than any previous Empire arrangement. For SOMOS, it represented an opportunity to leverage the DSRIP clinical projects to create a new and unique physician organization, clinically and financially integrated, focused on Medicaid beneficiaries. This presentation will describe the collaborative work between payor and provider groups as risk and management functions gradually shift from the MCO to SOMOS.

David Ackman, Lead Medical Director, Empire BCBS/HealthplusRicardo A. Rivera-Cardona, Chief Business Development Officer, SOMOS Community CareJacqueline Delmont, Chief Medical Officer, SOMOS IPA, LLC

12:00-1:00PM | LUNCHEmpire State Ballroom Foyer/II-IV

1:00-2:00PM | KEYNOTEBuilding a Healthier, and More Just WorldEmpire State Ballroom II-IV

Presented by Sandro Galea, MD, MPH, DrPH, Dean and Robert A. Know, Professor, Boston University School of Public Health.

2:15-3:30PMBREAKOUT SESSIONS 7-9

Breakout Session 7: A Future “Use-Case” for Delivery System Reform


Each local health system has its structure or “skeleton” of policy and providers. Since its inception, the Montefiore Hudson Valley Collaborative (MHVC) set out to achieve the PPS goals and to define its role not in duplicating policy or service delivery but in achieving delivery system reform through a series of actions, capacity building, transitional support and coaching which has come to be referred to as “interstitial connection”. MHVC used evidence-based interventions from national and international systems thinking, patient experience, and change management thought leaders to build organizational capacity for change. This presentation will offer a roadmap and specific examples of how these



capacities and successful interventions, along with MHVC’s ability to integrate and not disrupt, can be used to advance health care system improvements beyond DSRIP, including multi-stakeholder efforts to address the opioid epidemic.

Damara Gutnick, Medical Director, Montefiore Hudson Valley CollaborativeKristin Woodlock, Consultant, Woodlock & AssociatesJoan Chaya, Senior Director of Workforce Development and Management, Montefiore Hudson Valley CollaborativeEric D’Entrone, Associate Director of Regional Services, Arms Acres and Conifer Park

Breakout Session 8: Hudson Valley Pathways Community HUB - A Model for Building Health Equity


The Hudson Valley Collective for Community Wellness selected the Pathways HUB model to support their regional collective effort to achieve healthy equity. This pay-for-performance model improves access to services and coordination among providers. It harnesses the capacity of an array of community based organizations addressing the needs as diverse as food insecurity, to independent living and maternal and child health, The HUB is able to identify the comprehensive continuum of interrelated risk factors experienced by high-need individuals and families for a coordinated response within a defined geographic area. The model incentivizes outreach, provides connections to health and human services, and facilitates collective contracting with payors for targeted populations. It standardizes data collection about risks that can, and cannot, be mitigated within a local area, informing collective, cross sector population health planning and targeted investments from multiple funders. Speakers include community leaders, the Pathways HUB co-developer, and experts in legal and operational HUB implementation.

Giovanna Rogow, Executive Director, Maternal Infant Services NetworkHeidi Arthur, Principal, Health Management AssociatesRichard Tuten, CEO, Coordinated Behavioral Health Services Independent Practice AssociationArthur Fried, Health Attorney, Epstein, Becker, GreenMark Redding, Developer of Pathways HUB Model, Pathways Community HUB Institute

Breakout Session 9: Critical Time Intervention: A Model for VBP Arrangements for the High-Risk/High-Need Population


Critical Time Intervention (CTI), an intensive case management program for patients with a diagnosis of serious mental illness and housing insecurity, has become a model for Value Based Payment (VBP) arrangements by integrating care services beyond hospital settings, measuring quality outcomes, and exposing community based organizations to Level 3 risk arrangements. The program built a performance incentive into risk-based contracts, upside and downside, with participating providers, tied to a reduction in hospital utilization. A panel of stakeholders, who have come together in this effort, will discuss outcomes and cost savings and share foreseen challenges with the VBP arrangements. They will address the importance of focusing payments on outcomes rather than substantial documentation for evidence of engagement, and consider how this model can be adapted to serve other high-risk/high-need populations.

Shqipe Gjevukaj, Project Manager, Bronx Partners for Healthy CommunitiesAmanda Falick Ascher, Chief Medical Officer, Bronx Partners for Healthy CommunitiesWilliam Woolis, Associate Program Director, Montefiore University Behavioral Associates Mark Graham, Vice President, Program Services, Coordinated Behavioral CareDonna Demetri Friedman, Mosaic Mental Health, Executive DirectorJ. Robin Moon, Senior Director, System Integration, Bronx Partners for Healthy Communities

3:30-5:30PM | POSTER RECEPTION Empire State Ballroom Foyer

Sixteen posters are on display to be presented by the authors or other organization representatives. Make your way around to view and learn from the posters, engage with the presenters, and network with other symposium attendees. Refreshments served. See full Poster Program on page 13. Have your Poster Passport stamped by each poster presenter to be entered into the drawing for the Avid Learner Prize!



TUESDAY, NOVEMBER 19TUESDAY, NOVEMBER 198:00-9:00AM | REGISTRATION | BREAKFAST Empire State Ballroom Foyer/II-IV

Sign in, pick up your name badge and meeting materials at the registration booth if you did not do so yesterday. Enjoy breakfast before the program begins.

9:00-9:30AM | OPENING REMARKSEmpire State Ballroom II-IV

Opening remarks presented by Greg Allen, Director of the Division of Program Development and Management, New York State Department of Health, Office of Health Insurance Programs.

9:45-10:45AMBREAKOUT SESSIONS 10-13

Breakout Session 10: PPS Funded Innovation Programs Using a Community Approach to Improve Behavioral Health Outcomes

Uris/Julliard/Broadway

Niagara Falls Memorial Medical Center (NFMMC) plays a vital role serving about 40,000 Medicaid beneficiaries in Niagara County, NY. NFMMC has leveraged Innovation funding through Millennium Collaborative Care PPS to roll out programs that have demonstrated success in closing gaps in care. The programs target gaps in medication adherence, diabetes and cardiovascular disease monitoring, and follow-up after behavioral health inpatient discharges. The NFMMC team has also seen benefits beyond the quality metrics as their home visit strategy has touched lives in powerful ways. The hospital team will outline their program models, provide lessons learned, and share a number of moving home visit experiences.

Christine Blidy, Chief Network Officer, Millennium Collaborative CareSheila Kee, Chief Operating Officer, Niagara Falls Memorial Medical CenterKevin Burgess, Clinical Director, Niagara Falls Memorial Medical CenterDouglas Bisher, Peer Specialist / Certified Recovery Peer Advocate, Addict 2 Addict Program, WNY Independent Living of Niagara County

Breakout Session 11: Nitty Gritty at the Cutting Edge, Networks of CBOs Contracting with Healthcare


Community based organizations (CBOs) are forming networks that may allow them to more successfully partner with traditional healthcare service providers as a solution to coordination and funding challenges. Using data gathered from the Nonprofit Finance Fund (NFF)’s Advancing Resilience for Community Health initiative, which focuses on human services networks partnering with healthcare payors, this session will share the opportunities and challenges of a network approach. Attendees will learn from a cutting-edge NYC network, EngageWell Independent Practice Association, Amida Care (its healthcare partner), and CBO members of EngageWell about the nitty gritty considerations of each party as they attempt to coordinate and leverage the work of a diverse range of community organizations within a value-based payment model. As panel moderator, NFF will also provide context on nonprofit economics and how they play into CBO/healthcare collaborations and the importance of understanding and anticipating full costs in order to achieve sustainability.

Deirdre Flynn, Associate Director, Nonprofit Finance FundDoug Wirth, President and CEO, Amida CareKevin Muir, Executive Director, EngageWell Matt Bernardo, President, Housing Works Inc. Sharen Duke, CEO, The Alliance for Positive Change

SUNDAY, NOVEMBER 17MONDAY, NOVEMBER 18

TUESDAY, NOVEMBER 19


Breakout Session 12: Case Study: Finger Lakes IPA - Primary Care/Behavioral Health Join for Clinical Integration & VBP


Finger Lakes Independent Practice Association (FLIPA) was formed in 2017 by five Federally Qualified Health Centers, six behavioral health provider organizations, and S2AY Rural Health Network (comprising eight county public health departments). The IPA operates in a thirteen-county region in Upstate NY. During its participation in its first Value Based Payment (VBP)-like arrangement with the Finger Lakes PPS, FLIPA dramatically exceeded all of its quality measures. It currently participates in VBP arrangements with the two of the largest managed care organizations (MCOs) in its area, and is working with a large statewide MCO on integrating behavioral health into its VBP program for 2020. The presentation will go into what factors have brought FLIPA to where it is today, focusing on organizational and operating success factors and potential pitfalls.

Pauline Clark, Executive Director, Finger Lakes Independent Practice AssociationAnn Domingos, CEO, CASA-TrinityJohn Gillespie, Medical Director, Finger Lakes Independent Practice AssociationNathan Franus, Director, Behavioral Health Programs, Finger Lakes Performing Provider System

Breakout Session 13: BronxFUSE: Using Data to House the Most Vulnerable Through Value Based Partnerships


Sustainable value-based partnerships between traditionally siloed sectors are necessary to achieve the “Triple Aim” for some of Medicaid’s most vulnerable and high-cost members: homeless frequent users of hospital systems. Corporation for Supportive Housing, in partnership with the Bronx Health & Housing Consortium and the Bronx RHIO, are leading an initiative that includes five health plans and four supportive housing providers in a data-match identifying high-cost Medicaid members experiencing homelessness and connecting them to appropriate housing and services. During this session, participants will learn about

the multi-faceted Bronx FUSE (Frequent Users of Systems Engagement) pilot and how Medicaid claims and homeless data are being matched to target and prioritize individuals for housing interventions. Session participants will acquire the tools and action steps to scale and/or replicate FUSE initiatives in their own communities.

Courtney Christenson, Program Manager, Corporation for Supportive HousingKristin Miller, Director, Corporation for Supportive HousingShali Sharma, Department Director, BronxworksSusan Beane, Executive Medical Director, HealthfirstJohn Coffey, Chairman of Emergency Medicine, BronxCare Health System Kristen Mitchell, Associate Commissioner, Homeless Program Innovation & Intergovernmental Reporting, Office of Planning and Performance Management, Human Resource Administration, NYC Department of Social Services


Breakout Session 14: Integration is Not One Size Fits All


This presentation will describe two different models for behavioral health and primary care integration supported by Community Partners of Western New York PPS – one a fully integrated practice, and the other a primary care practice with on-site behavioral health services using a satellite license. The presenters will focus on lessons learned, challenges and successes for each of the unique models; what works for one practice/clinic may not work for another. Presenters will share results, address the details of the application process to become a satellite behavioral health clinic, relevant billing information, integrating electronic medical record data, and provide guidance on achieving sustainability.

Roxanne Cuebas, Project Administrator, Community Partners of Western New YorkElizabeth Mauro, CEO, Endeavor Health ServicesScott Morton, Director of Clinical Services, Endeavor Health ServicesPat Curatolo, Office Manager, Dr. Frank R. Laurri MD & AssociatesKristi Dierolf, Licensed Clinician, Niagara County Department of Mental Health



Breakout Session 15: Providing Critical Housing Services to Homeless and At-risk Medicaid Enrollees:The journey from Partnership to Collaboration


In December of 2018, Capital District Physicians’ Health Plan (CDPHP) teamed up with St. Catherine’s Center for Children to provide an innovative model of housing and care management support for 25 homeless and at-risk Medicaid enrollees in the Capital Region. Hear case vignettes and learn about the inspiration and motivation for this partnership and their journey from collaboration to formal contracting. Presenters will provide an overview of the program, evidence-based approaches to housing and case management and their plans for measuring the project’s performance.

Louisa Marra, Associate Executive Director of Homeless Services, St. Catherine’s Center for Children Kathy Leyden, Director, Community Engagement, Capital District Physicians Health PlanCharlene Schule, Director, Care Management, Capital District Physicians Health Plan

Breakout Session 16: Mount Sinai’s Institute for Advanced Medicine: Building Value-Based Payment and Delivery Models for Medically Complex Patients


Early on in the HIV/AIDS era, Mount Sinai Health System was one of the first to deliver specialized care to persons living with HIV (PLWH). As the HIV population ages, managing the quality and cost of care requires coordination between multiple care providers, better integration with community based organizations, and stronger partnerships with managed care organizations (MCOs). The Institute for Advanced Medicine at Mount Sinai (IAM) and their partners will share their experience developing innovative care delivery models to address prevention, treatment, and long-term HIV management, including establishing one of the first Value Based Payment (VBP) arrangements at a New York Designated AIDS Center. These same delivery models may be applied to care for all medically complex patients. Panelists will discuss the current structure of HIV value-based payments and innovative full-risk models like

HIV-specific ACOs. They will also share best principles in designing VBP arrangements that others can adapt for their population with medically complex needs, such as the IT infrastructure and clinical workflow redesign necessary for quality improvement.

Vivek Vishwanath, Strategy & Operations Associate, Mount Sinai Health Partners, Institute for Advanced Medicine at Mount SinaiMatt Baney, Senior Director, Institute for Advanced Medicine at Mount SinaiShruti Ramachandran, Director of Quality Management and Evaluation, Institute for Advanced Medicine at Mount Sinai Health SystemDoug Wirth, President and CEO, AmidaCare

Breakout Session 17: New Value Based IPA Approach to Serving Families with Complex Health and Social Needs


As NYS makes progress towards its health care goals, the remaining areas ripe for improvement are complex and will require innovative solutions focused on the continuum of health care and related needs. This session will convey key information about AsOne, an emerging Independent Practice Association (IPA), that seeks to be part of that solution. AsOne focuses on the mental, physical, and social needs of children, adults, and families and is developing transformative new treatment approaches aimed at addressing the complex needs of families, beyond just the single patient, in order to break the cycle of co-occurring illnesses and ailments that often afflict high-risk / high-need families. This session, presented by two of the IPA’s co-founders and the current executive director, will explore the benefits and challenges of this type of model within the context of the existing Medicaid program and VBP Roadmap.

Caroline Heindrichs, Executive Director, AsOne Health Care Independent Practice Association, LLCDavid Woodlock, President and CEO, Institute for Community LivingSylvia Rowlands, Senior Vice President of Evidence-Based Community Programs, The New York Foundling

12:00-1:00PM | LUNCHEmpire State Ballroom Foyer/II-IV





Breakout Session 18: Homelessness and the Managed Care Population: A Multi-sector Collaboration to Improve Health Outcomes of Health Plan Members At-risk of or Currently Homeless


This presentation will cover all aspects of multi-partner collaborations to address social determinants of health (SDH) through value based agreements- including contracting, data use, intervention design, and evaluation. As part of a Level 2 Value Based Payment contract, VillageCareMAX (VCM) partnered with AIRnyc to address homelessness and risk of homelessness among their members. VCM is a non-profit leader in providing long-term services to special needs populations that launched its own managed care products in 2012. AIRnyc is a community based organization that addresses SDH through home-based self-management services and community engagement. In addition to their established interventions to address chronic diseases in the home setting, AIRnyc has also built internal capacity for clinical-community linkages by training staff to conduct health assessments during home visits. By leveraging AIRnyc’s experience with clinical-community linkages and home health resources, the team designed an intervention to alleviate the impacts of homelessness and its effects on member health.

Gilbert Burgos, Chief Medical Officer, VillageCareMAX Monica Wilder, VillageCareMAXM. Rose Gasner, Executive Vice President, AIRnycTywan Mata, Director of Care Coordination, AIRnycLatanya Bather, Senior Clinical Manager, Premier Home Health Care ServicesMerita Rouge-Fingall, Manager of Social Work and Behavioral Health, VillageCareMAX (in absentia)

Breakout Session 19: Lessons Learned: Implementing Medicare and Medicaid Value Based Payment Models


Community Care of Brooklyn Independent Practice Association’s (CCB IPA) mission is to improve the health of all Brooklyn residents, regardless of insurance coverage. Since July 1, 2018, CCB IPA has negotiated five value-based arrangements with Medicaid managed care organizations, begun participating in Medicare’s risk-bearing Bundled Payment for Care Improvement Advanced model, and been approved as an Accountable Care Organization in the Medicare Shared Savings Program. These programs are well-aligned in many ways, however, there are key differences, including attribution methodology, factors driving patient morbidity, the specifics of data analysis and quality measurement, and regulatory requirements driving governance and other structural considerations. The presenters will share CCB IPA’s experience to date, including preliminary results, lessons learned, and opportunities to enhance future performance.

Tina Hansen Pickett, Senior Director, Sustainability and Strategic Initiatives, Maimonides Medical Center, Population Health Monica Gould, Senior Manager, Value-Based Contracting, Maimonides CSO/Department of Population Health, Maimonides Medical CenterCaroline D. Greene, Senior Vice President, Chief Administrative and Financial Officer, Maimonides Medical Center, Population HealthJames Burnosky, Vice President, Strategic Initiatives, Fidelis Laurie Ward, Director, Population Health, Wycoff Heights Medical Center

Breakout Session 20: System Transformation- Small Steps Towards Big Behavioral Health Outcomes in Western New York


In this presentation, Value Network Behavioral Health Care Collaborative Independent Practice Association will lead the discussion with a diverse panel who will provide an overview of how four lead partner behavioral health entities worked collaboratively with





their local PPS towards the achievement of identified outcome measures. An interactive discussion will focus on what has worked and what hasn’t worked in their efforts to change a complicated system, and how to help operationalize changes across a large human services entity from intake, admissions and beyond. Participants will hear how Value Network’s strategies are leading to contracting opportunities with managed care organizations (MCOs) and learn the simple (and not so simple) steps that can help them on the road to developing Value Based Payment contracts with their local MCOs.

Andrea J. Wanat, Vice President of Operations, Value Network, Behavioral Health Care Collaborative Independent Practice AssociationMichelle Curto, Vice President of Operations, Horizon HealthSaralin Tiedman, Director of Population Health Clinical Performance, Millennium Collaborative Care

Breakout Session 21: EmblemHealth/Cityblock- An Innovative Payor/Provider Partnership


In this session, panelists will describe an innovative partnership between EmblemHealth and Cityblock Health, a technology-enabled risk-bearing provider in Emblem’s network, to provide a personalized model of care that unites primary care, behavioral health, and social services to address the root influencers of health, including housing instability, unemployment, food insecurity, insufficient childcare, loneliness, and fragmented social supports. Discussion will include the role of each organization in the comprehensive model of care described via a member journey; secrets of success for this value-based partnership for plans and providers seeking to do something similar; the pathway to a total cost of care arrangement for a fully integrated model; and early learnings of what is working and modifications made along the way.

Carol Huffman, Vice President Strategic Partnerships, EmblemHealthMelanie Bella, Head of Partnerships and Policy, Cityblock Jaqueline Prince, Director, Medicaid Initiatives, EmblemHealth Ari Rosner, Head of Social Care, Cityblock

2:30-3:30PM | KEYNOTEChanging the Questions: From Healthcare to HealthEmpire State Ballroom II-IV

Presented by Rebecca Onie, JD and Rocco Perla, Founding Partners, The Health Initiative.

3:30-4:30PM | CLOSING REMARKSEmpire State Ballroom II-IV

Presented by Greg Allen, Director of the Division of Program Development and Management, New York State Department of Health, Office of Health Insurance Programs.


POSTER POSTER PROGRAM PROGRAM MONDAY, NOVEMBER 183:30-5:30PM | POSTER RECEPTION

01 NYS DSRIP Breathes New Life Into One Rockland County CBO and

Creates a Rising Star

The poster describes the transformation of Konbit Nèg Lakay, the lifeline for much of Rockland County’s Haitian community, from a financially struggling volunteer organization to a mature, focused non-profit with the infrastructure and skills to persist in today’s value and data-driven environment. Konbit Nèg Lakay’s development is a direct result of the NYS DSRIP program and targeted support from Refuah Community Health Collaborative and WMCHealth PPS/Center for Regional Healthcare Innovation. In conjunction with 1199SEIU Training and Employment Funds Konbit Nèg Lakay has begun to address two key social determinants of health - education and economic stability - among the Home Health workforce to reduce disparities in the community it serves which includes one of the largest minority pockets outside New York City per the Office of Minority Health census map.

Corinna Manini, Chief Administrative & Chief Medical Officer, Refuah Community Health CollaborativeRenold Julien, Executive Director, Konbit Nèg LakayBonnie Reyna, Director, Community Workforce Transformation, WMCHealth Performing Provider System (PPS)/Center for Regional Healthcare InnovationBassie Friedman, Chief Marketing Officer, Marquis Home CareKaren Mejia, Workforce Consultant, 1199SEIU Training and Employment Funds

02 Information Outposts: Disseminating Healthful Knowledge and Facilitating

Linkage to Care

This poster describes an innovative partnership that uses food as an incentive to engage community residents in health screenings and linkages to care. Supported by a Montefiore Hudson Valley Collaborative Innovation Grant, a collaboration with providers, the food bank and community-based organizations was established to help improve the health and well-being of those who are struggling with food insecurity. “Hunger Mapping” using the “meal gap” metric, was used to identify the Yonkers census tracks with the highest levels of food insecurity for targeted food-based interventions. Four community-based organizations within the catchment area that met community member usage and space criteria were established as “healthy food” distribution sites. A survey assessing physical, mental and social determinants of health needs was administered to community members who visited the food pantries. The data will inform strategic deployment of targeted health programming and linkages to care via health navigators that meets each local community’s needs.

Andrew Telzak, Research Fellow, Montefiore Hudson Valley CollaborativeVirgil Dantes, Director of Community Impact, Feeding WestchesterDamara Gutnick, Medical Director, Montefiore Hudson Valley CollaborativeBruce Rapkin, Professor, Albert Einstein College of Medicine/Montefiore

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03 Connections to Care: Transitions from the

Correctional Health System

The transition of incarcerated individuals back into the community is an especially vulnerable time for individuals with health needs. Connections to Care was implemented by The Fortune Society and NYC Health + Hospitals/Correctional Health Services in conjunction with community partners through a OneCity Health Innovation Fund award. This poster presentation details the project serving individuals incarcerated at Rikers Island Correctional Facility, targeting chronically ill adults who are Medicaid-eligible, at high risk of substance abuse relapse or avoidable emergency room use, and are returning to NYC neighborhoods. By providing them with the support they need, patients can more easily and seamlessly engage in care in the community, avoid relapse and be connected to other services that provide housing or enable them to re-enter the workforce. By enabling patients to manage their care in the community, the programs demonstrate value for future Value Based Payment arrangements.

Molly Chidester, Assistant Vice President, Chief Strategy Officer, OneCity Health

04 Clinically Integrated Pharmacy Services

to Address Behavioral Health Needs

Community Pharmacy Enhanced Service Network (CPESN) is a network of over 140 community-based pharmacies with the goals of improving patient outcomes and lowering overall health care costs. Designed by CPESN and supported through partnership with the Alliance for Better Health PPS, the Pharmacy Enhanced Services Program addresses gaps in care for people with a behavioral health diagnosis that are on prescription medication and frequent emergency services and/or are disconnected from Primary Care. This poster presentation describes how the program tailors medication regimens to individual needs, increases adherence rates, and shares documentation of clinical interactions between pharmacists and patients with other care team members through shared electronic medical records.

John Croce, Network Lead, Community Pharmacy Enhanced Service NetworkBrianna Brennan, Sr. Director of Performance & Data Strategy, Alliance For Better Health PPSChristopher Daly, Community Pharmacy Enhanced Service Network Facilitator, Community Pharmacy Enhanced Service Network

05 Redesigning the Sub-acute Discharge

Model for Patients with Chronic Diagnoses

A redesign of the sub-acute discharge model to include longitudinal supports and increased engagement with the community health system can reduce the risk of rehospitalizations and improve outcomes in the population of patients with chronic disease. This poster presentation addresses the unique challenges in transfers of care for patients with chronic diagnoses. The poster will include data outcomes and cost savings from a DSRIP-funded pilot developed by Centers Health Care and Bronx Partners for Healthy Communities to reduce emergency department utilization and rehospitalizations in patients with cardiovascular disease, diabetes, fall risk, HIV/AIDS, renal failure, and wound care. Moreover, the presentation demonstrates how redesign supports Value Based Payment objectives, improved communication between providers, and a patient-centered approach to patient education and engagement during discharge.

Cipora Moskowitz, Director of Value-Based Program Development, Centers Health CareJ. Robin Moon, Senior Director of System Integration, Bronx Partners for Healthy CommunitiesShqipe Gjevukaj, Project Manager at Bronx Partners for Healthy CommunitiesVictoria Caligiuri, Director of Market Development, CentersLink and Centers Plan for Healthy Living

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06 Enhancing Behavioral

Health Crisis Stabilization Services Across a Large Geographically-Diverse Region

This poster illustrates the successful process by which Better Health for Northeast New York PPS supported the expansion and coordination of a behavioral health crisis stabilization system across a large geographical region with numerous population centers, each with varying needs and preexisting resources. It demonstrates the PPS collaboration with local governmental units, health systems, managed care organizations, law enforcement, behavioral health providers, and community based organizations; and results indicative of service expansion, crisis stabilization and improvements in care. Results indicative of service expansion and improvements in care, as well as findings from a recent reevaluation of crisis stabilization needs and next steps will be included.

Brendon M Smith, Behavioral Health Clinical Director, Better Health for Northeast New YorkKallanna Manjunath, Chief Medical Officer, Better Health for Northeast New YorkLucas Popolizio, Clinical Project Manager, Better Health for Northeast New York

07 Enhanced Patient Services - Making a

Difference Out and About in the Community

The Enhanced Patient Service Program is designed to augment primary care with care coordination and communication by traveling to the patient’s home and addressing the patient’s health and social needs through RN health coaching, pharmacy care coordination, and closing gaps in social determinants of health. This poster will demonstrate how the program and the multidisciplinary team of registered nurses, social workers, clinical pharmacists, and community health workers, through bi-directional communication with primary care, improves healthcare outcomes, decreases hospital utilization and improves patient engagement and satisfaction.

Michele Mercer, Chief Clinical Integration Officer, Millennium Collaborative Care

08 Applying a Transitional Care

Management Model with Proven Outcomes in Medicare Populations to the Medicaid Populations at Staten Island University Hospital

Northwell Health Solutions created a Transitional Care Management model in 2014 to address the needs of the Bundled Payments for Care and Comprehensive Care for Joint Replacement Care programs for Medicare fee-for-service patients. The Registered Nurses and Resource Coordinators formed care management teams, who engage the patient population during their index admission and provide coordinated follow up after each visit. This model consistently demonstrated reductions in readmission rates and cost. The team has replicated this model for Staten Island University Hospital Medicaid patients and has been charged with enrolling at least 700 patients per demonstration year. The poster presentation will highlight key program elements and their overall impact.

Melinda Stone, Director Patient Services, Northwell Health Solutions


09 Community-Based, Patient-Centered

Buprenorphine Program: Are Primary Care Physicians Ready?

Integration and coordination of addiction treatment and continued care/service delivery is foundational to improving access, care/service delivery, person and provider engagement, and improved performance outcomes. This poster highlights the SOMOS and Advanced Health Network and Recovery Health Solutions Independent Practice Association collaboration to integrate and coordinate addiction treatment through redesign of clinical and operational workflows, assessing and managing provider readiness to switch from a provider-centered culture to patient-centered focus, implementation of multidisciplinary teams supported by communication and data reporting systems, and the development and use of data systems to support management and measurement of goals.

Diego Ponieman Chief Medical Officer, Somos Community CareRoy Wallach, President, Recovery Health Solutions Independent Practice Association, LLCCarol Cassell, Executive Director, Recovery Health Solutions independent Practice Association, LLC

10 Enhancing & Adapting Community

Hot-Spotting to Serve High-Utilizers of NYC Hospital Systems

This poster presentation will highlight the collaboration between a PPS, an Independent Practice Association and a community based organization to adapt and implement a unique community hot-spotting program in NYC. The poster will present a “Stratified Care Needs Model”, which allows fluidity between levels of care within the hot-spotting model. With the addition of a peer-led, six-month post-intervention follow up, this adapted version of the traditional model is designed to address varying levels of acuity within the most complex population. Data collection and evaluation will be highlighted as a means for measuring impact, assessing cost-savings and attracting sustainable pay sources.

Juliana Steen, Director of Innovative Programs, Coordinated Behavioral Care Amy Whelan, Program Director, Community Outreach for Recovery and Engagement, The Bridge, Inc.Brittany Sachs, Project Coordinator, Mount Sinai PPS

11 Outcomes and Lessons Learned From an

Asthma Community Health Worker Program

The OneCity Health PPS implemented an Asthma Community Health Worker (CHW) program with eight community based organizations providing services across 24 medical facilities in New York City. Patients, mostly children with asthma, receive home visits from a CHW to review the asthma action plan, assist with asthma management, and conduct a home assessment. As needed, integrated pest management (IPM) services are provided in the home at no cost to patients. Almost 3,500 referrals were made to the program, and more than 3,200 home assessments and 1,200 IPM services have been provided. Poster presenters will share their program outcomes including improvements in avoidable asthma admissions and other asthma metrics and cost savings using claims-based analysis. They will also describe efforts underway to enhance the cost-efficiency and sustainability of the program.

Andrew Kolbasovsky, Chief Performance Improvement Officer, OneCity Health



12 Postpartum Navigation to Improve

Connection to Care in the Fourth Trimester

In New York City, rates of postpartum care vary greatly based on race, socioeconomic background and underlying high-risk conditions. In an effort to address these disparities, Mount Sinai, Healthfirst and New York Academy of Medicine developed and implemented a novel payment and delivery system model. This poster presentation highlights their care navigation intervention that began post-delivery in the hospital prior to member discharge and continued for two months. Women were provided education, connections to community resources and follow up care. Mount Sinai and Healthfirst created a cost-sharing agreement to cover the staffing, and Healthfirst instituted a postpartum care incentive. Presenters will share their results including positive patient perceptions of the program and improvements in timeliness of care in the 90 days after delivery.

Rashi Kumar, Director, Health Policy and Innovation, HealthfirstTom Wang, Research Specialist, HealthfirstSusan Beane, Executive Medical Director, HealthfirstElizabeth Howell, System Vice-Chair of Research, Department of Obstetrics, Gynecology, and Reproductive Science; Mount Sinai Health System; Associate Dean for Academic Development, Icahn School of Medicine at Mount Sinai

13 Transitioning from DSRIP to the VBP/IPA

World: Focus on Improving Communities Behavioral Health Needs in a Post-DSRIP Environment

Through the support of the NYS DSRIP initiative, NYS achieved many critical successes in improving chronic illnesses of its population, as well as reducing the cost of care and avoiding unnecessary hospitalizations. This poster will focus on two areas: 1) the PPS’ efforts to improve the health of psychiatric patients, including program designs that were created and implemented, and successful outcomes, and 2) transitioning the sustainability of these programs away from DSRIP dependent funding toward Value Based Payment and Independent Practice Association structures through the development of partnerships with managed care organizations and others.

Jon Marrelli, Program Manager, NYU Langone HealthOlga Lanina, Manager, Data Analytics, NYU Langone Health

14 Improving Care Alignment for

Medically Complex People Living with HIV/AIDS

Based on experience and building on evidence, Alliance for Positive Change and Healthfirst determined that improving long-term outcomes for their medically complex members living with HIV/AIDS requires building trust between patients and providers. In addition, members living with HIV/AIDS are likely to experience barriers to optimal outcomes because of housing instability, food insecurity, recent incarceration, immigration status, gender status, stigma and marginalization. This poster presents Healthfirst and Alliance’s model of care that outreaches unengaged members, assesses for multiple needs and current alignment with care, and navigates members to the resources they need including social services, care management, and health care providers. Working together, Alliance and Healthfirst have spent one year developing a financially sustainable and clinically relevant Value Based Payment model that launched in April of 2019.

Rashi Kumar, Director, Health Policy and Innovation, HealthfirstRonald Sanchez, Manager of Innovation, HealthfirstSusan Beane, Executive Medical Director, HealthfirstSharen I. Duke, Executive Director/CEO of Alliance for Positive Change


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15 Be Healthy. Get Paid. Leveraging Behavioral Economics and Value Based

Payment to Improve Outcomes

Gestational Diabetes (GD) is a complicated condition that has significantly increased over the past twenty years. Aside from the adverse consequences for newborns and infants, GD is linked to an increased risk of diabetes and obesity for those women who do not adhere to treatment plans. This poster presentation will provide an overview of how Staten Island PPS has leveraged Value Based Payment in collaboration with Wellth, a digital health company that utilizes behavioral economics, to improve health outcomes for patients with Type 2 diabetes, and will explore how such a program can be applied to GD. Attendees will learn how innovative mobile technologies are uniquely positioned to engage hard-to-reach populations.

Sadia Choudhury, Director, Ambulatory Care Initiatives, Staten Island PPSMatthew Loper, CEO, Wellth Inc.Matt Ma, Head of Operations, Wellth Inc.

16 DSRIP Success Stories: Alternative Methods to Demonstrate PPS

Improvement Beyond the Already Established Performance Measure and Earned Funds Definitions

When looking at the overall success of the DSRIP program, many will gravitate towards the number of Annual Improvement Targets that were met, and the amount of funds earned. However, there are other components of DSRIP data that can be used to demonstrate that the PPS are improving the lives of the Medicaid population. This poster describes a series of analyses conducted by the NYS Department of Health to identify areas of DSRIP success beyond just the standard definitions of performance measurement and earned funds. The poster will focus on two specific areas: 1) “The Number of Lives Matter” – This analysis focuses on the positive raw numerator movement and distance traveled from MY0-MY4 for certain performance measures, even if AITs weren’t met. 2) “Consistent Cohort” – The responsibility of DSRIP attributed membership often changes hands from one PPS to another based on a number of different factors, thus impacting performance measurement. Members may also move in to or out of the Medicaid program overall. However, what would measure outcomes look like if membership remained constant throughout the life of the DSRIP program? This analysis identified a consistent cohort of members who remained with the same PPS from MY0-MY4. The purpose is to determine if measure outcomes improved for the population that stayed in the same care relationship with a PPS throughout the life of the program.

Jason Ganns, Bureau Director, NYS Department of Health, Office of Health Insurance ProgramsBob Pollock, NYS Department of Health, Office of Health Insurance Programs




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GENERAL GENERAL INFORMATIONINFORMATIONWI-FI ACCESSWi-Fi is available in all of the meeting space throughout the Symposium.

Network: nymedicaid Password: symposium

NAME BADGESPlease wear your name badge at all times. Your name badge is your ticket to the symposium sessions, meals and reception. If you need a replacement, please visit the registration booth.

PRESENTATION SLIDES View and download breakout session slides and materials at www.dsriplearning.com/agenda. Click on the individual session links to access materials for that session.

HOTEL CHECKOUT AND LUGGAGE STORAGECheckout time at the Grand Hyatt New York is 11:00 a.m. Please plan accordingly. The coat check for the Empire Ballrooms does not have the capacity to store luggage for this event. Please work with the Grand Hyatt concierge desk to have your luggage stored.

COAT CHECK For your comfort and convenience, coat check is offered throughout each day. Please use the coat check to store all coats, umbrellas and the like to keep the meeting and seating spaces clear and dry.



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