Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) Project Implementation Plan Development Primary Care Medical Home (PCMH) (2aii)

Agenda 2 Welcome & IntroductionsPurpose of MeetingPPS UpdatesReview TimelineReview Action ItemsProject Requirement Step DevelopmentNext Steps / Next MeetingQuestions / Open Discussion

3 PPS Updates NYS DSRIP Updates PPS DSRIP Updates

4 Timeline June 15 – June 19 Clinical Development Meeting Develop PIP Requirements June 22 – June 26 Clinical Development Meeting Develop PIP Requirements June 19 – July 3 No Meetings July 6 – July 10 Clinical Development Meeting Develop PIP Requirements July Meeting: Finalize Draft PIP July 20 – 24 Present PIP(s) to Clinical Integration Committee July 27 – July 31 PMO input PIP into MAPP July 31st PIP’s Due

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6 Ensure that all participating PCPs meet NCQA 2014 Level 3 PCMH accreditation and/or meet state- determined criteria for Advanced Primary Care Models by the end of Demonstration Year (DY) 3. Identify a physician champion with knowledge of PCMH implementation for each primary care practice included in the project. Identify care coordinators at each primary care site who are responsible for care connectivity, internally, as well as connectivity to care managers at other primary care practices. DSRIP Project Review: Meeting #1 PIP Requirement Development

7 Ensure that all staff are trained on PCMH or Advanced Primary Care models, including evidence based preventive and chronic disease management. Implement preventive care screening protocols including behavioral health screenings (PHQ-9, SBIRT) for all patients to identify unmet needs. A process is developed for assuring referral to appropriate care in a timely manner. Implement open access scheduling in all participating primary care practices. DSRIP Project Review: Meeting #2 PIP Requirement Development

8 Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers. Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up by the end of Demonstration Year (DY) 3. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards. DSRIP Project Review: Meeting #3 PIP Requirement Development

9 DSRIP Project Review: Meeting #4 PIP Risks & Mitigations – 2bv, 2bvii A risk to this project is the interdependencies between PCMH certification and the other projects. Many of the other projects chosen by the PPS require a successful implementation of PCMH Level 3. The PPS will mitigate this risk by creating a realistic timeline and phased approach to implementation of projects to ensure that the deliverables that are interdependent are appropriately coordinated. An additional risk identified for this project is the level of diversity in the PPS catchment basin and the cultural challenges associated with patient engagement, health literacy and communication with providers. Mitigation strategies would include processes for engaging patient through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations to garner a care transition partnership with this culturally diverse population. This project will need to align closely with the Cultural Competency / Health Literacy work stream for the roles of community health workers, community councils, and health literacy improvements.

10 DSRIP Project Review: Meeting #4 PIP Review & Revisions Review Draft Project Implementation Plan Revise Draft PIP

Team “Homework” Distribution of Draft PIP Action Item Tracking & Clarification Next Meeting Scheduled Any additional attendees Presentations needed 11 Next Steps / Next Meeting

12 Questions / Open Discussion

Website: Maureen Buglino, VP, Community & Emergency Medicine Maria D’Urso, Administrative Director, Community Medicine Crystal Cheng, Data Analyst, DSRIP 13 PMO Resources