1. Clinical Project Meeting NYHQ PPS Delivery System Reform Incentive Payment (DSRIP) June 11, 2015 Cardiovascular (3bi)

2. Agenda 2 Welcome & IntroductionsClinical LeadershipMeeting PurposeScope of Clinical Sub-CommitteePPS Updates & TimelineDSRIP Project ReviewClinical Case Vision & ExampleClinical PlanningSWOTNext Steps / Next MeetingQuestions / Adjourn

3. Chair: Maria D’Urso-mda9005@nyp.orgmda9005@nyp.org 3 Clinical Leadership

4. 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 Meeting Purpose

5. 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

6. 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 6 Scope of Clinical Sub-Committee

7.  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 7 PPS Updates & Timeline

8. Clinical Planning & Development Project Implementation Plans Due (7/31/15) DY1 Quarterly Report Due (7/31/15) Workforce Data Due (10/31/2015) 8 PPS Updates & Timeline Organization Development, Budget & Funds Flow Development, Committee & Governance Structure Development, Clinical Planning & Implementation, IT Development, Workforce Planning, Partner Engagement, etc.

9. 99 Bi-annual payments driven by quarterly reports of milestone, metric, & scale & speed achieved deliverables DSRIP Year/Quarter Dates CoveredQuarterly Report DuePayment Date DY1, Q1April 1, 2015 – June 30, 2015July 31, 2015 January 2016 DY1, Q2July 1, 2015 – September 30, 2015October 31, 2015 DY1, Q3October 1, 2015 – December 31, 2015January 31, 2016 July 2016 DY1, Q4January 1, 2016 – March 31, 2016April 30, 2016 DY2, Q1April 1, 2016 – June 30, 2016July 31, 2016 January 2017 DY2, Q2July 1, 2016 – September 30, 2016October 31, 2016 DY2, Q3October 1, 2016 – December 31, 2016January 31, 2017 July 2017 DY2, Q4January 1, 2017 – March 31, 2017April 30, 2017 PPS Updates & Timeline

10. 10 DSRIP Project Review: Project Requirements Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. Ensure that all PPS safety net providers are actively connected to EHR systems with local health information exchange/RHIO/SHIN-NY and share 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 by the end of Demonstration Year (DY) 3. Use EHRs or other technical platforms to track all patients engaged in this project. Use the EHR or other technical platform to prompt providers to complete the 5 A's of tobacco control (Ask, Assess, Advise, Assist, and Arrange). Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol.

11. 11 DSRIP Project Review: Project Requirements Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management. Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment. Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment. Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit.

12. 12 DSRIP Project Review: Project Requirements Prescribe once-daily regimens or fixed-dose combination pills when appropriate. Actions to Optimize Patient Reminders and Supports: Document patient driven self-management goals in the medical record and review with patients at each visit. Follow up with referrals to community based programs to document participation and behavioral and health status changes Develop and implement protocols for home blood pressure monitoring with follow up support.

13. 13 DSRIP Project Review: Project Requirements Generate lists of patients with hypertension who have not had a recent visit and schedule a follow up visit. Facilitate referrals to NYS Smoker's Quitline. Perform additional actions including “hot spotting” strategies in high risk neighborhoods, linkages to Health Homes for the highest risk population, group visits, and implementation of the Stanford Model for chronic diseases. Adopt strategies from the Million Lives Campaign.

14. 14 DSRIP Project Review: Scale & Speed: Committed Providers NYS Designated Categories Total # providers committed (as per project plan application) Primary Care Physicians131 Non-PCP Practitioners50 Clinics1 Health Home / Care Management0 Behavioral Health1 Substance Abuse0 Pharmacy2 Community Based Organizations0 All Other100 All Committed Providers285

15. 15 Engaged Patient Definition: The number of participating patients receiving service from participating providers with documented self-management goals in the medical record (diet, exercise, medication management, nutrition etc.) DSRIP Project Review: Scale & Speed: Patient Engagement Expected # of actively engaged patients 3630 DY1, Q2DY1, Q3DY1, Q4DY2, Q1DY2, Q2DY2, Q3DY2, Q4 Patients Engaged72610531815490163420152904 DY3, Q1DY3, Q2DY3, Q3DY3, Q4DY4, Q1DY4, Q2DY4, Q3DY4, Q4 545181523603630545181523603630

16. DSRIP Project Review: Clinical Project Requirements: Metrics 16 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 2 – System Transformation Potentially Avoidable Emergency Room Visits ± Number of preventable emergency visits as defined by revenue and CPT codes Number of people (excludes those born during the measurement year) as of June 30 of measurement year 24.27 per 100 Medicaid enrollees *High Perf Elig # SW measure NYS DOH P4RP4P Potentially Avoidable Readmissions ± Number of readmission chains (at risk admissions followed by one or more clinically related readmission within 30 days of discharge) Number of people as of June 30 of the measurement year 0.00 per 100,000 Medicaid Enrollees *High Perf Elig # SW measure NYS DOH P4RP4P PQI 90 – Composite of all measures ± Number of admissions which were in the numerator of one of the adult prevention quality indicators Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P PDI 90– Composite of all measures ± Number of admissions which were in the numerator of one of the pediatric prevention quality indicators Number of people 6 to 17 years as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees # SW measure NYS DOH P4RP4P

17. DSRIP Project Review: Clinical Project Requirements: Metrics 17 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Primary Care – Length of Relationship – Q3 Percent of Responses at least 1 year or longer All Responses100%^ # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 20 to 44 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 20 to 44 as of June 30 of the measurement year 91.1% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 45 to 64 years Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 45 to 64 as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P Adult Access to Preventive or Ambulatory Care – 65 and older Number of adults who had an ambulatory or preventive care visit during the measurement year Number of adults ages 65 and older as of June 30 of the measurement year 94.4% # SW measure NYS DOH P4RP4P

18. DSRIP Project Review: Clinical Project Requirements: Metrics 18 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Children’s Access to Primary Care – 12 to 24 months Number of children who had a visit with a primary care provider during the measurement period Number of children ages 12 to 24 months as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 25 months to 6 years Number of children who had a visit with a primary care provider during the measurement period Number of children ages 25 months to 6 years as of June 30 of the measurement year 98.4% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 7 to 11 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 7 to 11 years as of June 30 of the measurement year 100.0% # SW measure NYS DOH P4RP4P Children’s Access to Primary Care – 12 to 19 years Number of children who had a visit with a primary care provider during the measurement period or year prior Number of children ages 12 to 19 years as of June 30 of the measurement year 98.8% # SW measure NYS DOH P4RP4P

19. DSRIP Project Review: Clinical Project Requirements: Metrics 19 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Getting Timely Appointments, Care and information (Q6, 8, 10, and 12) Number responses Usuall LJ o ƌ Al ǁ a LJ s got appt for urgent care or routine care as soon as needed, got answers the same day if called during the day or response as soon as needed if called after hours Number who answered they called for appointments or called for information 100%^ # SW measure NYS DOH P4RP4P Helpful, Courteous, and Respectful Office Staff (Q24 and 25) Number responses Usuall LJ o ƌ Al ǁ a LJ s that clerks and receptionists were helpful and courteous and respectful All responses100%^ # SW measure NYS DOH P4RP4P Medicaid Spending on ER and Inpatient Services ± Total spending on ER and IP services Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R

20. DSRIP Project Review: Clinical Project Requirements: Metrics 20 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Medicaid spending on Primary Care and community based behavioral health care Total spending on Primary Care and Community Behavioral Health care as defined by MMCOR categories Per member per month of members attributed to the PPS as of June of the measurement year NA – Pay for Reporting measure only NYS DOH P4R H-CAHPS – Care Transition Metrics (Q23, 24, and 25) Sum of Hospital specific results for the Care Transition composite Hospitals with H-CAHPS participating in the PPS network 100%^NYS DOH P4RP4P CAHPS Measures – Care Coordination with provider up-to- date about care received from other providers Number responses Usuall LJ o ƌ Al ǁ a LJ s that doctor informed and up- to-date about care received from other providers All responses with member seeing more than one provider 100%^ # SW measure NYS DOH P4RP4P

21. DSRIP Project Review: Clinical Project Requirements: Metrics 21 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Prevention Quality Indicator # 7 (HTN) ± Number of admissions with a principal diagnosis of hypertension Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Prevention Quality Indicator # 13 (Angina without procedure) ± Number of admissions with a principal diagnosis of angina without a cardiac procedure Number of people 18 years and older as of June 30 of measurement year 0.00 per 100,000 Medicaid Enrollees NYS DOH P4P Cholesterol Management for Patients with CV Conditions – LDL-C Testing Number of people who had at least one LDL-C screening performed during the measurement year Number of people, ages 18 to 75 years, with a cardiovascular condition 96.8%PPS and NYS DOH P4RP4P Cholesterol Management for Patients with CV Conditions – LDL-C > 100 mg/dL Number of people whose most recent LDL- C result during the measurement year was below 100mg/dL Number of people, ages 18 to 75 years, with a cardiovascular condition 55.0%PPS and NYS DOH P4RP4P

22. DSRIP Project Review: Clinical Project Requirements: Metrics 22 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Controlling High Blood PressureNumber of people whose blood pressure was adequately controlled (below 140/90) or if diabetes below 140/80. Number of people, ages 18 to 85 years, who have hypertension 73.3% (2012 Data) *High Perf Elig PPS and NYS DOH P4RP4P Aspirin UseNumber of respondents who are currently taking aspirin daily or every other day Number of respondents who are men, ages 46 to 65 years, with at least one cardiovascular risk factor; men, ages 66 to 79 years, regardless of risk factors; and women, ages 56 to 79 years, with at least two cardiovascular risk factors 100%^NYS DOH P4RP4P Discussion of Risks and Benefits of Aspirin Use Number of respondents who discussed the risks and benefits of using aspirin with a doctor or health provider Number of respondents who are men, ages 46 to 79 years, and women, ages 56 to 79 years 100%^NYS DOH P4RP4P

23. DSRIP Project Review: Clinical Project Requirements: Metrics 23 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Medical Assistance with Smoking and Tobacco Use Cessation – Advised to Quit Number of respondents who were advised to quit Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^NYS DOH P4RP4P Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Medication Number of respondents who discussed or were recommended cessation medications Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^NYS DOH P4RP4P Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Strategies Number of respondents who discussed or were provided cessation methods or strategies Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day 100%^ *High Perf Elig NYS DOH P4RP4P Flu Shots for Adults Ages 18 – 64 Number of respondents who have had a flu shot Number of respondents, ages 18 to 64 years 100%^NYS DOH P4RP4P

24. DSRIP Project Review: Clinical Project Requirements: Metrics 24 Measure NameNumerator DescriptionDenominator DescriptionPerformance Goal *High Performance eligible #Statewide measure Reporting Responsibility Payment: DY 2 & 3 Payment: DY 4 & 5 Domain 3 - Clinical Improvement Projects Health Literacy (QHL13, 14, and 16) Number responses Usuall LJ o ƌ Al ǁ a LJ s that instructions for caring for condition were easy to understand, described how the instruction would be followed and were told what to do if illness/condition got worse or came back Number who answered they saw provider for a illness or condition and were given instructions 100%^NYS DOH P4RP4P

25. 25 DSRIP Project Review: Project Implementation Plan 3.b.i Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (Adults Only) 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. A high level risk that is associated with the implementation of a cardiovascular evidence-based standardized care pathway is coordinating with the implementation speed of the Patient Centered Medical Home recognition (Project 2.a.ii) and meeting PCMH level 3 targets. This risk may directly associate with the level of speed and scale attributed to this project. Inherent to a successful mitigation strategy for adaptation of evidence-based care pathways and standardization for cardiovascular disease risk reduction is to coordinate timing of standardized strategies with implementation of the PCMH initiatives. The PPS will need to coordinate activities within the different project work plans to ensure collaboration with the PCMH initiatives, without slighting either of these two projects or undermining the other projects, such as behavioral health integration. Current state assessment of cardiovascular disease prevention initiatives that are already a component of the existing PCMH framework will be used as a springboard to enhance collaboration with health care providers to heighten cardiovascular prevention awareness as a means to improve patient outcomes. Another risk to the project is the inability to meet patient engagement and improvement in health outcomes due to a shortage of community health workers in the targeted community that could serve as a liaison between health and social service to establish trusting relationships with the patient population. The PPS will align with the resources of workforce plan to collaborate with community leaders to develop, strengthen and empower community health team workers to integrate culturally sensitive patients into the engaged population. Specific focus will begin with those patients that require complex core coordination for hypertension and one or more comorbidities. If needed, a project plan to actively recruit community health workers to fill gaps in workforce will be coordinated at the PPS level. Another risk for this project is the potential for low compliance of both patients and practitioners. This risk will be mitigated by utilizing the practitioner engagement committee to ensure that providers are knowledgeable about DSRIP and utilizing best practices accross the PPS. Patients will be engaged through education, possible IT solutions including portal messaging etc. to ensure that they are compliant with their self-management goals.

26. 26 DSRIP Project Review: Project Implementation Plan Project 3.b.i Project Requirements/sub-stepsTarget Completion DateUnit Level Reporting 1. Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 2. Ensure that all PPS safety net providers are actively connected to EHR systems with local health information exchange/RHIO/SHIN-NY and share health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of Demonstration Year (DY) 3. DY3, Q4Provider Level: PCP Step 1… Step 2… [Please add additional steps based on your plan and timeline] 3. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards by the end of Demonstration Year (DY) 3. DY3, Q4Provider Level: PCP Step 1… Step 2… [Please add additional steps based on your plan and timeline] 4. Use EHRs or other technical platforms to track all patients engaged in this project. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

27. 27 DSRIP Project Review: Project Implementation Plan 5. Use the EHR or other technical platform to prompt providers to complete the 5 A's of tobacco control (Ask, Assess, Advise, Assist, and Arrange). DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 6. Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 7. Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 8. Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment. DY3, Q4Provider Level: PCP Practice Step 1… Step 2… [Please add additional steps based on your plan and timeline]

28. 28 DSRIP Project Review: Project Implementation Plan 9. Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 10. Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 11. Prescribe once-daily regimens or fixed-dose combination pills when appropriate. Actions to Optimize Patient Reminders and Supports: DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 12. Document patient driven self-management goals in the medical record and review with patients at each visit. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

29. 29 DSRIP Project Review: Project Implementation Plan 13. Follow up with referrals to community based programs to document participation and behavioral and health status changes DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 14. Develop and implement protocols for home blood pressure monitoring with follow up support. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 15. Generate lists of patients with hypertension who have not had a recent visit and schedule a follow up visit. DY2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 16. Facilitate referrals to NYS Smoker's Quitline. Dy2, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline]

30. 30 DSRIP Project Review: Project Implementation Plan 17. Perform additional actions including “hot spotting” strategies in high risk neighborhoods, linkages to Health Homes for the highest risk population, group visits, and implementation of the Stanford Model for chronic diseases. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 18. Adopt strategies from the Million Lives Campaign. DY2, Q4 Provider Level: PCP, Non-PCP, BH Step 1… Step 2… [Please add additional steps based on your plan and timeline] 19. Form agreements with the Medicaid Managed Care organizations serving the affected population to coordinate services under this project. DY3, Q4Project Level Step 1… Step 2… [Please add additional steps based on your plan and timeline] 20. Engage a majority (at least 80%) of primary care providers in this project. DY3, Q4Provider: PCP Step 1… Step 2… [Please add additional steps based on your plan and timeline]

31. Clinical Case Vision & Example 31

32. 32 Space / LocationIT NeedsPatient TrackingBillingClinical ImplementationWorkforce Impact / NeedNon-Covered Services Anticipated Clinical Planning

33. 33 StrengthsWeaknessesOpportunitiesThreats SWOT Analysis

34. 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 34 Next Steps / Next Meeting

35. 35 Questions / Open Discussion

36. Website: www.nyhq.org/dsripppswww.nyhq.org/dsrippps Maureen Buglino, VP, Community & Emergency Medicine mabuglin@nyp.org Maria D’Urso, Administrative Director, Community Medicine mda9005@nyp.org Crystal Cheng, Data Analyst, DSRIP crc9038@nyp.org 36 Resources