4 NYCPPNorth Shore - LIJMEDISYS SYSTEMLEAD: AW MEDICAL
5 NEW YORK COMMUNITY PREFERRED PROVIDER COMMUNITY PREFFERED NETWORKRENAISSANCE COLLABORATIVE
6 Community Provider Network (CPN) Asian American ACOChinese American IPAChinese Community ACOEastern Chinese American Physicians IPAKorean American Physicians IPACBW Community Health Center
7 Renaissance Collaborative (RC) Balance Medical ACOBalance Medical IPABreukelen Community Network IPACorinthian Medical IPAExcelsior Medical IPAQueens County IPA
8 NYCPP Leadership Team Dr. George Liu, Co-Chairman Dr. Ramon Tallaj, Co-ChairmanDr. Henry Chen, TreasurerDr. Emilio Villegas - SecretaryDr. Bing Lu, Board of ManagerDr. Hanbin Zheng, Board of ManagerDr. Jonathan Chang, Board of ManagerDr. Michael Li, Board of ManagerDr. Sunhoo Foo, Board of ManagerDr. Vincent Wang, Board of ManagerDr. Hal Sadowy, Co-Chief Operating OfficerMs. Peggy Sheng, Co-Chief Operating Officer
10 We have brought over 2,000 physicians together as ONE 我們是一家人Somos uno
11 Non-physician partners AW Medical PPS is not just made up of PhysiciansBehavior Health and other important providersPhysiciansHospitalsNon-physician partners
12 Bronx ACMH, Inc. Center for Urban Community Services Rain (Regional Aid For Interim Needs)Kings Harbor Multicare Ctr.Success Counseling Services, IncAffinity Health PlanRiverdale Mental Health AssociationSus-Mental Health Programs, Inc.Alpine Home Health CareKingsbridge Hieghts Rehab And Care CenterCenterlight Healthcare Inc.Rosselle Estrella, PtTerrace Health Care Center, IncAmazing Home CareCenterlight Healthcare Diagnostic & Treatment CenterMvp Housing Development Fund Company Inc.Scheuer Gardens Limited PartnershipThe BridgeAmber Court At HomeThe Pac Program Of The Bronx, IncScheuer Plaza Limited PartnershipCL Healthcare IncNarco Freedom, IncAmber Court Of Pelham GardensUniversity Consultation & Treatment Center For Mental Hygiene, Inc.Community Access IncSchnurmacher Center For Rehabilitation And NursingNew York Dialysis Services, Inc.Arms Acres, IncDaughters Of Jacob Nursing Home Company Inc.Best Choice Home Health Care, Inc.New York Psychotherapy And Counseling CenterSeniorcare Emergency Medical ServicesUniversity Nursing HomeBeth Abraham Health ServicesDoshi Diagnostic Imaging Services, P.C.Palisade Nursing Home Company, Inc.VIP Community ServicesBoris Dubrovsky, PhdSeniorrideSheryll Garcia, PtWestchester Family Health CenterBronx Center For Rehabilitation & Health CareEli Leiter, PhdPark Housing Development Fund Company Inc.St Barnabas Hospital Health SystemFriends And FamilyWeston United Community Renewal, Inc.Hebrew Home At RiverdaleBronx Lebanon Hospital CenterPhoenix Houses Of New York, Inc.St Joseph's HospitalJewish Association For Services For The Aged (Jasa)Williamsbridge Manor Nursing HomeBronx Park Rehab & Nursing CenterPostgraduate Center For Mental HealthSteinway Child And Family Services, IncBronx Supported HousingJewish Board Of Family And Children'S ServicesProject RenewalBronx-Lebanon Hospital Center
13 Brooklyn MJHS License Home Care Service Agency Bushwick Center for Rehabilitation and Health CareGuidance Center of BrooklynOhel Childrens Home and Family ServicesHealth HomesPhoenix House Foundation, Inc.AlphaCareCAIPA Social Day Care CenterHomecrest Community Services, IncAmber Court at HomePhoenix Houses of New York, Inc.Amber Court of BrooklynCatholic CharitiesICLAmericare Certified Specialty Services, Inc.Center for Nursing and RehabilitationICM BrooklynPostgraduate Center for Mental HealthJewish Board of Family and Children's ServicesAnna Sidorkina, LACCenter for Urban Community ServicesPreventive DiagnosticsBest Choice Home Health Care, Inc.John J. Pershing Intermediate School 220Rockaway Park CenterCenterLight Certified Home Health AgencyShiel Medical LaboratoryBETH ISRAEL MEDICAL CTRLawton Street Community ResidenceSt. Joseph's HospitalCentral Brooklyn ACTSt. Mark's MICA Supported HousingBGR Services, Inc.CL Healthcare IncLinden House Community ResidenceBoro Park Center for Rehabilitation & Health CareCobble Hill Health Center, Inc.St. Mark's Scattersite Supported HousingLivonia AvenueBreukelen Community Network IPACommunity Access Inc./ Warren StreetLUTHERAN MEDICAL CENTERSteinway Child and Family Services, Inc.Bridge Back to Life Center, Inc.Community Radiology of NYMarizza Dulfo, PTSteppingstone Congregate TreatmentDoshi Diagnostic Imaging Services, P.C.Menorah Center for Rehabilitation and Nursing CareBridgerSummit Home Health CareBRIDGING ACCESS TO CAREEast Brooklyn ACT TeamSupported Housing for Women with HIV/AIDSElderplanMJHS Long Term CareBrooklyn Center for Rehabilitation and Residential Health CareEmerson TAPNew York Congregational Nursing CenterSUSEmpire City LaboratoriesTillary Street Women's ShelterFederation of Organizations for NYS Mentally DisabledNew York Psychotherapy and Counseling CenterBrooklyn Community ServicesWilliamsburg Physical TherapyFreseniusNEW YORK THERAPEUTIC COMMUNITIES, INCBushwick Brooklyn ACTGod's Love We Deliver, Inc
14 Manhattan 181 Street Medical PC Chinese Community Accountable Care OrganizationHarlem East life Plan3rd Street Men's ShelterHealthfirstACMH, IncCL Healthcare IncHeritage Health Home NetworkAlberto De Castro, PTCommunity Access Inc.Heritage Healthcare NetworkAleksey Kleyman, LACCommunity Association of Progressive Dominicans (ACDP)ICL Broadway Community ResidenceAmerichoiceComunilife IncAmerigroup MLTCIsabella Nursing HomeCoordinated Behavioral Care, Inc Pathways to Wellness HHAmerigroup/HealthplusJason WatermanAsian American Accountable Care Organization, LLCJewish Board of Family and Children's ServicesCorinthian Medical IPA, IncDiana BadilloBalance Medical ACOKenneth GedDoshi Diagnostic Imaging Services, P.C.Balance Medical IPA, IncKenton Hall Men's ShelterBeacon of Hope HouseL&L Orthotics, LLCElizabeth UzorBETH ISRAEL MEDICAL CTRManhattan Supportive HousingElmont Open MRIBridge Back to Life Center, Inc.Mary Claire Arbilo, PTEmpire State DentalCareNextMARY MANNING WALSHGeffner HouseCenter for Alternative Sentencing and Employment ServicesMelida KnibbsGood Sheperd ServicesMetroplus Health PlanGouverneur Healthcare Services - Skilled Nursing FacilityCenter for Urban Community ServciesMetropolitan Center for Mental HealthGramercy Park Digestive Disease Center, LLCCharles B. Wang Community Health CenterMetropolitan Jewish Home Care Inc. d/b/a MJHS Home CareGreenwich House, Inc.Chinese American IPA, Inc.
15 Manhattan (continued) MIH Experience LTDSenior Whole HealthThe PAC Program of The Bronx, IncMitzy Baldovino, PTSeong Chul Ha, LACMJHS Hospice and Palliative CareService Program for Older People, Inc.United Rx Buying Group LLCNational Association on Drug Abuse Problems, Inc.University Settlement Early Intervention ProgramShiel Holdings, LLCNew York Dialysis Services, Inc.Shiel Medical LaboratoryVidyasagar Pamulapati, PTNew York eHealth Collaborative (NYeC)ST LUKES ROOSEVELT HOSP-ROOSEVELT HOSPVijayalakshmi P. Davuluri, PTVisiting Nurse Service of New York Home CareNEW YORK EYE & EAR INFIRMARYST LUKES ROOSEVELT HOSP-ST LUKES HOSPVNS ChoiceNinel Platsman, PTSt. Nicholas HouseVNSNYPalladia, Inc.SUS- Mental Health Programs, Inc.VNSNY Behavioral HealthPhoenix House Foundation, Inc.VNSNY Hospice and Palliative CarePostgraduate Center for Mental HealthTERENCE CARDINAL COOKEThe BridgeWashington Heights ImagingProject RenewalThe Fifth Avenue Counseling Center, Inc.WellCare Health PlanRapid Care SolutionsWellCare MLTCRowell Arguelles, PTThe First Chinese Presbyterian Community Affairs Home Attendant Corp.Weston United Community Renewal, Inc.Salcare Home Health Services, IncWomen In NeedTHE MOUNT SINAI HOSPITALSCAN New YorkThe National Alliance for the Mentally Ill of New York City, Inc.Senior Health Partners
16 Queens ACMH, Inc. Fishman Center Total Eye Care Postgraduate Center For Mental HealthAlvin Orodio, PtFlushing Manor Care CenterAmber Court Of WestburyFlushing Manor Dialysis CenterQsa Services, Inc.Arms Acres, IncFlushing Manor Nursing HomeQueens Center For Rehabilitation & Residential Health CareBleuler Psychotherapy Center, Inc.Goodwill IndustriesQueens County IpaHolliswood Center For Rehabilitation And HealthcareBridge Back To Life Center, Inc.Queens Treatment Apartment ProgramCatholic CharitiesJewish Board Of Family And Children'S ServicesSamaritan VillageCenter For Urban Community Services/Rikers Island Single StopLiberty Physical Medicine & RehabSamuel Field YM/YWCACL Healthcare IncShiel Medical LaboratoryConifer Park, IncLong Island Care CenterSouth Shore Physician GroupCornerstone Medical Arts Center HospitalLong Island Consultation CenterSt Joseph's HospitalMargaret Tietz Nursing And Rehabilitation CenterSteinway Child And Family Services, Inc.Cuatro Llc Dba Access Medicare NyMichael K.T. Mangubat, PtSupportive Services For Veteran FamiliesDoshi Diagnostic Imaging Services, P.C.Milestone Supportive HousingNew Horizon Counseling CenterSus- Mental Health Programs, Inc.Dr. William O. Benenson Rehab PavilionNew York Psychotherapy And Counseling CenterThe Mount Sinai Hospital Of QueensEastern Chinese American Physicians IpaOhel Childrens Home And Family ServicesUnion Plaza Nursing Home Dba Union Plaza Care CenterExcelsior Medical IPAParker Jewish Institute For Healthcare & RehabilitationVenture HouseFed Of Org For Nys Mentally DisabledXeron LabsPhoenix House Foundation, Inc.Fidelis CarePhoenix Houses Of New York, Inc.
18 ABOUT DSRIP Delivery System Reform Incentive Payment Incentive payments are performance basedPatient engagement is KEY for incentive payment calculation which starts 01/01/2015Goals are to achieve transformation of the health care safety net provider system, improving healthcare quality, improving population health, reducing avoidable hospital and ED use, and lowering healthcare cost.
19 ACHIEVING THE GOAL Implementing collaborative models of patient care Enhanced care coordination and care management modelsMonitoring specific performance measuresAdherence to evidence-based protocolsAdherence to standardized processes across the PPSEDI and PCMH level 3 certification
20 Projects Selection2.a.i Integrated Delivery System 2.a.iii Health Home At-Risk Intervention Program 2.b.iii ED care triage for at-risk populations 2.b.iv Care Transition 3.a.1 Integration of Primary Care & Behavioral Health 3.b.1 Cardiovascular Disease Management 3.c.1 Diabetes Disease Management 3.d.iii Asthma Management 4.b.i Tobacco Use Cessation 4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings
22 2.a.i Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health ManagementTarget: All patients and ProvidersEngagement: Every patient has a sign RHIO consent form.
23 PCMH (2014 Version) Level 3 by 2017 20153/31/201520163/31/201620173/31/2017ActionAttestDataEHRAdopt, Implement, Upgrade (AIU) to 2014 Certified EHRAIU to Certified EHRAIUany 90-day period from 2014Use Certified EHRMU Stage 1-Y1any 90-day period from 2015MU Stage1-Y2 & meet MU Stage 2 criteriafull yr. 2016MU Stage 1-Y2full yr. 2015MU Stage 2-Y1MU Stage 2-Y2MU Stage 3-Y1PCMHUpgrade to PCMH 2014 versionPrepare PCMH Level 3Submit PCMH Level 3Achieve PCMH Level 3 by 6/2017
24 2.a.iii Health Home At-Risk Intervention Program Target: Patients with one progressive chronic disease, serious mental Illness or traumatic brain InjuryEngagement: Every patient that has a documented comprehensive care plan in place
25 2.b.iii ED care triage for at-risk populations Target: Every patient seen in the EDEngagement: Every patient is given an appointment with their PCP or Health Home
26 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions Target: Every patient with a Hospital admission or ER visitEngagement: Every patient in with pre-discharge planning and transitional care visit
27 3.a.i Integration of primary care and behavioral health services Target: Every patient seen in the Primary Care or Behavioral Health settingEngagement: Every patient must have PHQ9 screening performed and documented
28 3.b.i Evidence based strategies for disease management in high risk/affected populations (adult only) (Cardiovascular Health)Target: Every adult patient with Cardiovascular disease or HyperlipidemiaEngagement: Every patient must have life style change counseling documented
29 3.c.i Evidence based strategies for disease management in high risk/affected populations (adults only) (Diabetes Care)Target: Every adult patient with DiabetesEngagement: Every patient must have a documented HgbA1C
30 3.d.iii Evidence based medicine strategies for asthma management (Asthma) Target: Every patient with AsthmaEngagement: Every patient must have a documented Asthma action plan in place
31 4.b.i Tobacco Use Cessation Target: All smokersEngagement: Every patient must be screened for tobacco use and smokers counseled on cessation and referral to NY QUITS documented
32 4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community SettingsTarget: All patients Engagement: Document and Prescribe Colonoscopy, Mammogram, Pap Smear, Prostate exam, HPV Vaccination, Safe Sex Education
33 Support Team Lidia Virgil 212-567-4918 email@example.com John DionisioSusan LauLiz Webb