Transcript DSRIP Project Review

Clinical Project Meeting
Asthma
(3dii)
NYHQ PPS
Delivery System Reform Incentive Payment (DSRIP)
June 10, 2015
Agenda
Welcome & Introductions
Clinical Leadership
Meeting Purpose
Scope of Clinical Sub-Committee
PPS Updates & Timeline
DSRIP Project Review
Clinical Case Vision & Example
Clinical Planning
SWOT
Next Steps / Next Meeting
Questions / Adjourn
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Clinical Leadership
Chair:
Hadi Jabbar, M.D. – [email protected]
3
Meeting Purpose
Initiate the clinical planning process of the NYHQ PPS DSRIP
projects in order to complete the Project Implementation Plans
due July 31, 2015, develop strategies for actualization of projects,
identify operational process, IT, budget, or workforce needs, and
ensure all engaged partners are actively engaged in planning &
implementation.
4
Scope of Clinical Sub-Committee
• Engage PPS network partners to operationally plan, develop,
and design the clinical program outlined in the DSRIP
application submitted in December 2014
• Focus on collaborative planning processes that meet project
requirements, metrics, and scale & speed expectations
associated with the clinical program
• Complete the Project Implementation Plans due July 31
• Inform budgets and operational needs such as workforce & IT
• Guide partners by becoming a resource and communication
channel to ensure effective engagement
5
Scope of Clinical Sub-Committee
• Clinical planning will include, but is not limited to:
• Implement project design to include all committed PPS partners
• Establish and meet performance reporting expectations
• Establish expectations for evidence based medicine protocols & best
practice standards
• Communicate internally and externally on program development
and progress
• Explain variances of project requirement or metric progress
• Ensure success of the project by improving clinical quality and
meeting expectations of project requirements, scale & speed, and
metrics
• Work with other committees and sub-committees to ensure cross
communication & feedback
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PPS Updates & Timeline
 Organization Implementation Plans – Submitted
 PPS Valuation Notification – Received
 Project Implementation Plans – Due 7/31/2015
 Executive Committee Meeting – 6/11/2015
 PAC Meeting – 6/19/2015
 Workforce Data Due – 10/31/2015
 Budgets, Funds Flow, Business Agreements – In Development
 Clinical Planning Meetings – Begin week of 6/8/2015
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PPS Updates & Timeline
Organization Development, Budget & Funds Flow Development, Committee & Governance Structure Development,
Clinical Planning & Implementation, IT Development, Workforce Planning, Partner Engagement, etc.
DY1 Quarterly
Report Due
(7/31/15)
Clinical Planning
& Development
Project
Implementation
Plans Due
(7/31/15)
Workforce Data
Due
(10/31/2015)
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PPS Updates & Timeline
DSRIP
Year/Quarter
Dates Covered
Quarterly Report Due
DY1, Q1
April 1, 2015 – June 30, 2015
July 31, 2015
DY1, Q2
July 1, 2015 – September 30, 2015
October 31, 2015
DY1, Q3
October 1, 2015 – December 31, 2015
January 31, 2016
DY1, Q4
January 1, 2016 – March 31, 2016
April 30, 2016
DY2, Q1
April 1, 2016 – June 30, 2016
July 31, 2016
DY2, Q2
July 1, 2016 – September 30, 2016
October 31, 2016
DY2, Q3
October 1, 2016 – December 31, 2016
January 31, 2017
DY2, Q4
January 1, 2017 – March 31, 2017
April 30, 2017
Bi-annual payments driven by quarterly reports of
milestone, metric, & scale & speed achieved deliverables
Payment Date
January 2016
July 2016
January 2017
July 2017
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DSRIP Project Review:
Project Requirements
Expand asthma home-based self-management program to include home environmental trigger reduction, self-monitoring, medication
use, and medical follow-up.
Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions.
Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests, mold, and second hand
smoke.
Develop and implement evidence based asthma management guidelines.
Implement training and asthma self- management education services, including basic facts about asthma, proper medication use,
identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control,
and using written asthma action plans.
Ensure coordinated care for asthma patients includes social services and support.
Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root cause analysis of what
happened and how to avoid future events.
Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary
care providers, and specialty providers.
Use EHRs or other technical platforms to track all patients engaged in this project.
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DSRIP Project Review:
Scale & Speed: Committed Providers
Total # committed providers
Primary Care Physicians
13
Non-PCP Practitioners
Clinics
14
0
Health Home / Care Management
Pharmacy
CBO
All Other
0
2
1
6
All Committed Providers
36
NYS Designated Categories
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DSRIP Project Review:
Scale & Speed: Patient Engagement
Engaged Patient Definition: The number of participating patients based on home
assessment log, patient registry, or other IT platform.
DY1, Q2 DY1, Q3 DY1, Q4 DY2, Q1 DY2, Q2 DY2, Q3 DY2, Q4
Patients Engaged per
Quarter
259
336
517
104
345
500
863
DY3, Q1 DY3, Q2 DY3, Q3 DY3, Q4 DY4, Q1 DY4, Q2 DY4, Q3 DY4, Q4
104
345
500
863
104
345
500
863
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DSRIP Project Review:
Denominator Description
Performance Goal
Payment:
DY 4 & 5
Numerator Description
Payment:
DY 2 & 3
Measure Name
Reporting
Responsibility
Clinical Project Requirements: Metrics
Prevention Quality Indicator
# 15 Younger Adult Asthma ±
Number of admissions with a
principal diagnosis of asthma
Number of people ages 18 to 39 0.00 per 100,000 Medicaid
as of June 30 of the measurement Enrollees
year
NYS
DOH
P4P
P4P
Pediatric Quality Indicator
# 14 Pediatric Asthma ±
Number of admissions with a
principal diagnosis of asthma
Number of people ages 2 to 17 as 0.00 per 100,000 Medicaid
of June 30 of the measurement
Enrollees
year
NYS
DOH
P4P
P4P
Asthma Medication Ratio (5 – 64
Years)
Number of people with a ratio Number of people, ages 5 to 64
of controller medications to total years, who were identified as
asthma medications of
having persistent asthma
0.50 or greater during the
measurement year
NYS
DOH
P4P
P4P
P4P
P4P
*High Performance eligible
#Statewide measure
Medication Management for People who filled prescriptions for
with Asthma (5 – 64 Years) – 50% asthma controller medications
of Treatment Days Covered
during at least 50% of their
treatment period
Number of people, ages 5 to 64
years, who were identified as
having persistent asthma, and
who received at least one
controller medication
76.0%
NYS
DOH
68.6%
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DSRIP Project Review:
Clinical Project Requirements: Metrics
Performance Goal
*High Performance eligible
#Statewide measure
Medication Management for People who filled prescriptions for
with Asthma (5 – 64 Years) – 75% asthma controller medications
of Treatment Days Covered
during at least 75% of their
treatment period
Number of people, ages 5 to 64
years, who were identified as
having persistent asthma, and
44.9%
who received at least one
controller medication
Payment:
DY 4 & 5
Denominator Description
Payment:
DY 2 & 3
Numerator Description
Reporting
Responsibility
Measure Name
P4P
P4P
NYS
DOH
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DSRIP Project Review:
Project Implementation Plan
3.d.ii Expansion of Asthma Home-Based Self-Management Program
1. Measurable milestones and implementation risks
Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them.
The primary challenge for this project is the adherence to home based treatment regimens once determined by the PCP, non PCP, pulmonologists and other health care providers. A population health
management strategy will be developed using IT software that will be determined to best connect with the attributed patient population, to serve as a trigger for compliance, with medication reminders,
appointment reminders, and general asthma health reinforcement. The tool will assist with patient tracking and planning, and serve as a component of a proposed Asthma Resource Center for care
coordination. Alternative ways for monitoring for adherence, such as one way communication such as text reminders will help move the efforts already in place with the Pediatric Asthma Center to more
all-inclusive care coordination with improved patient outcomes and better management of a home based program.
Interconnectivity with PPS school systems will be a concern and prove a risk to the successful achievement of milestones and metrics. Electronic school based health records are in different stages of
technology development and the connection to an Asthma Resource Center will have to be recognized by the PPS leads to ensure that pathways to share the Medication Administration Form (MAF) with
providers to coordinate care for the children associated with the project. The plan is to develop coalitions, protocols, and best practice technology based platforms to enhance bidirectional transfer of
information to best support this patient population.
Another risk to the expansion project of asthma home-based self-management program is the ability for providers to gain access to conduct the initial environmental assessment for trigger identification
and subsequent visits to monitor and adjust recommendations once triggers are identified. Financial reimbursement and lack of funding for these visits is a component and risk for this project also. The
Pre-existing Pediatric Asthma Center will serve as a model the PPS best practice, led by Dr. Jabbar, who will leverage existing collaborations among community organizations to ensure all CBO, including
schools, shelters, housing representatives, and other organization are in alignment with risk modification once identified. The initiative will take pre-existing best practice and expand to repeat visit needs
to determine compliance with recommendations for home environment adjustments. The team is leveraging established asthma community based programs to support PCPs, non-PCPs and health care
providers on evidence based practice guidelines to support home management, including repeat home visits when necessary with financial components/incentives.
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DSRIP Project Review:
Project Implementation Plan
Project 3.d.ii
Project Requirements/sub-steps
1. Expand asthma home-based self-management program to include home environmental trigger reduction, selfmonitoring, medication use, and medical follow-up.
Target Completion Date
Unit Level Reporting
DY3, Q4
Project Level
DY2, Q4
Project Level
DY2, Q4
Project Level
DY2, Q4
Project Level
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
2. Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction
interventions. Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as
pests, mold, and second hand smoke.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
3. Develop and implement evidence based asthma management guidelines.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
4. Implement training and asthma self- management education services, including basic facts about asthma, proper
medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of
asthma symptoms and asthma control, and using written asthma action plans.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
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DSRIP Project Review:
Project Implementation Plan
5. Ensure coordinated care for asthma patients includes social services and support.
DY3, Q4
Project Level
DY2, Q4
Project Level
DY3, Q4
Project Level
DY2, Q4
Project Level
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
6. Implement periodic follow-up services, particularly after ED or hospital visit occurs, to provide patients with root
cause analysis of what happened and how to avoid future events.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
7. Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home
care managers, primary care providers, and specialty providers.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
8. Use EHRs or other technical platforms to track all patients engaged in this project.
Step 1…
Step 2…
[Please add additional steps based on your plan and timeline]
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Clinical Case Vision & Example
18
Clinical Planning
Space / Location
IT Needs
Patient Tracking
Billing
Clinical Implementation
Workforce Impact / Need
Non-Covered Services Anticipated
19
SWOT Analysis
Strengths
Weaknesses
Opportunities
Threats
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Next Steps / Next Meeting
• Additional webinar based clinical planning meetings – TBD
• Project Implementation Plan drafting & distribution
• Executive Team Development of budgets, funds flow,
agreements
• Executive Committee review & approval
• Partner agreement completion
• PAC meeting 6/19/15
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Questions /
Open Discussion
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Resources
Website: www.nyhq.org/dsrippps
Maureen Buglino, VP, Community & Emergency Medicine
[email protected]
Maria D’Urso, Administrative Director, Community Medicine
[email protected]
Crystal Cheng, Data Analyst, DSRIP
[email protected]
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