Town Hall WELCOME March 11 2016 Agenda Topic

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Town Hall WELCOME! March 11, 2016

Town Hall WELCOME! March 11, 2016

Agenda Topic Discussion Speaker Welcome & Breakfast • Introduction • Dennis Maquiling General Updates

Agenda Topic Discussion Speaker Welcome & Breakfast • Introduction • Dennis Maquiling General Updates • • CBO Panel DY 1 Cash Position CRM PCMH • • Dennis Maquiling Victor De. Marco Steve Maggio Duane Granston Workforce Update • • Staff Impact Reporting Workforce Survey Results • • Selena Griffin-Mahon Sig Shirodkar, KPMG Bronx RHIO • Bronx RHIO Enrollment Process • Kathy Miller, Bronx RHIO Partner Highlight • • VIP Community Services Sol’s Pharmacy • • Debbie Witham, VIP Andrew Silverman, Sol’s Pharmacy Project Highlight • 2. biv Care Transitions • • Natalie Cruz Dr. Isaac Dapkins Partner Engagement Commitment • What does it mean to be a partner? • • Roy Wallach Joann Casado Q&A Networking Session © Bronx Health Access 1

Value-based Payment Workgroup on Social Determinants and CBOs Definitions in VBP Workgroup context: •

Value-based Payment Workgroup on Social Determinants and CBOs Definitions in VBP Workgroup context: • Tier 1 -Non-profit, Non-Medicaid billing, community-based social and human service organizations e. g. housing, social services, religious organizations, food banks • Tier 2 -Non-profit, Medicaid billing, non-clinical service providers e. g. transportation, care coordination • Tier 3 -Non-profit, Medicaid billing, clinical and clinical support service providers licensed by the NYS Department of Health, NYS Office of Mental Health, NYS Office with Persons with Developmental Disabilities, or NYS Office of Alcoholism and Substance Abuse Services. • February 2016 © Bronx Health Access 2

DY 1 CASH POSITION

DY 1 CASH POSITION

DSRIP Award Letter

DSRIP Award Letter

Budgeted Funding by Year Net Project Valuation Equity Infrastructur e Program Equity Performance Program

Budgeted Funding by Year Net Project Valuation Equity Infrastructur e Program Equity Performance Program Total DY 1 $11, 515, 003 $7, 927, 277 $5, 284, 852 $24, 727, 132 DY 2 $12, 271, 038 $7, 927, 277 $5, 284, 852 $25, 483, 167 DY 3 $19, 838, 663 $7, 927, 277 $5, 284, 852 $33, 050, 792 DY 4 $17, 556, 017 $7, 927, 277 $5, 284, 852 $30, 768, 146 DY 5 $11, 515, 003 $7, 927, 277 $5, 284, 852 $24, 727, 132 Total $72, 695, 724 $39, 636, 387 $26, 424, 258 $138, 756, 369

DY 1 Funding Received Payment Date Net Project Valuation Equity Infrastructure Payment Equity Performance

DY 1 Funding Received Payment Date Net Project Valuation Equity Infrastructure Payment Equity Performance Payment 5/28/15 $6, 906, 677 $0 $0 1/26/16 $2, 099, 309 $0 $0 $9, 005, 986 $0 $0 $2, 304, 163 $7, 927, 277 $5, 284, 852 Total Expected Future Payments @ 100%

DY 1 Amounts Spent or Committed Project # - Project Name Administration DY 1

DY 1 Amounts Spent or Committed Project # - Project Name Administration DY 1 Cost $5, 516, 515 2. a. iii Health Home at Risk $190, 392 2. b. i Ambulatory Intensive Care Units $192, 407 2. b. iv Care Transitions Intervention $74, 124 3. a. i Integration of Primary Care/Behavioral Health $132, 508 3. d. ii Asthma Home Based Self-Management $359, 080 3. f. i Maternal and Child Health $145, 604 4. a. iii Mental Health & Substance Abuse Infrastructure $34, 957 4. c. ii Early Access/Retention in HIV Care $70, 097 - IT Committee $481, 528 - PCMH Committee $276, 250 - Stakeholder Committee $134, 235 - Workforce Committee $1, 882, 500 Total $9, 490, 197

DY 1 Cash Position Funding Received $9, 005, 986 Amounts Spent or Committed $9,

DY 1 Cash Position Funding Received $9, 005, 986 Amounts Spent or Committed $9, 490, 197 Cash Position ($484, 211)

Steve Maggio, Senior Project Manager © Bronx Health Access 9

Steve Maggio, Senior Project Manager © Bronx Health Access 9

CRM Salesforce is the CRM platform which will be used by BHA Salesforce will

CRM Salesforce is the CRM platform which will be used by BHA Salesforce will allow you to: • View/Update Organization Information • Update participating sites in the PPS • Submit back-up documentation for PPS deliverables • Complete necessary PPS Surveys • Update providers in organizations • View Project related information • Status of projects- Actively engaged counts and completion of milestones • View organization specific information within a project • # of patients submitted • Funds distributions to date • Performance criteria © Bronx Health Access 10

Patient Centered Medical Home Duane Granston, Project Manager © Bronx Health Access 11

Patient Centered Medical Home Duane Granston, Project Manager © Bronx Health Access 11

PCMH • Bronx Health Access is committed to helping primary care providers achieve NCQA

PCMH • Bronx Health Access is committed to helping primary care providers achieve NCQA PCMH Level 3 (2014) certification by March 2018 • In an effort to meet this goal, Bronx Health Access retained Insight Management to provide technical assistance for our primary care practices. • Insight Management • Over 25 years of experience in comprehensive Healthcare management. • Specializes in Patient-Centered Medical Home Practice Transformation and Certification, Meaningful Use, and EMR Solutions • Has led PCMH transformation in over 150 NYC clinics and practices. © Bronx Health Access 12

Workforce Update Selena Griffin-Mahon, Co-Lead © Bronx Health Access 13

Workforce Update Selena Griffin-Mahon, Co-Lead © Bronx Health Access 13

Workforce- Staff Impact Reporting © Bronx Health Access 14

Workforce- Staff Impact Reporting © Bronx Health Access 14

Workforce- Staff Impact Reporting Bronx Health Access PPS (BHA) - DSRIP Workforce Planning &

Workforce- Staff Impact Reporting Bronx Health Access PPS (BHA) - DSRIP Workforce Planning & Development DSRIP Staff Impact Form #3 B (New Hire related costs) Reporting Timeframe: 4/1/15 - 3/31/16 Item Cost # employees Recruitment Fee 0 Advertising 0 Fingerprinting 0 Background Investigation 0 Pre-Employment Physical 0 Central Registry 0 Other: 0 0 0 © Bronx Health Access Total Cost 15

Bronx Health Access PPS Town Hall Meeting DSRIP Workforce Survey Results & Insights March

Bronx Health Access PPS Town Hall Meeting DSRIP Workforce Survey Results & Insights March 11, 2016

Overview of BHA Workforce Survey ■ The BHA workforce survey was distributed on Dec

Overview of BHA Workforce Survey ■ The BHA workforce survey was distributed on Dec 8, 2015 to 241 partners in the PPS network ■ The goal of the workforce survey was to obtain quantitative information about the incumbent staff of the BHA partner organizations ■ Data from the survey will be used to assess the PPS workforce supply. The partner workforce counts will enable the PPS to calculate gaps in specific job categories when compared to the target state projections by project © 2015 KPMG LLP, a Delaware limited liability partnership and the U. S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. 17

BHA Workforce Survey Results – Response Rate Survey Response Rate All Partners Survey Response

BHA Workforce Survey Results – Response Rate Survey Response Rate All Partners Survey Response Rate Key Partners (89. 5%) (46. 9%) 38 241 113 34 # Surveys Distributed # Surveys Received © 2015 KPMG LLP, a Delaware limited liability partnership and the U. S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. # Surveys Distributed # Surveys Received 18

BHA Workforce Survey Results – Job Categories Top 10 Workforce Job Categories Nursing: ■

BHA Workforce Survey Results – Job Categories Top 10 Workforce Job Categories Nursing: ■ The Non-Licensed Care Coordinators, Navigators & Community Outreach Workers were captured in the Clinical Support Category: 3025 Administrative Support: 2535 Clinical Support: § § 745 Social Worker Case/Care Manager: 499 Physicians: 491 Other Allied Health: 461 Behavioral Health: 279 Health Information Technology: 112 Physicians Assistants: 93 Nurse Practitioners: 57 0 136 – Community Health Workers 128 – Care Coordinators 88 – Patient Navigators 81 – Outreach Coordinators ■ The positions noted above had the 3 rd largest volume of incumbent staff, yet there is still a need for additional staff to meet the demand required for the DSRIP projects ■ Nursing had the largest volume of incumbent staff, yet the demand across the DSRIP projects is not as high as other categories 500 1000 1500 2000 © 2015 KPMG LLP, a Delaware limited liability partnership and the U. S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. 2500 3000 3500 19

BHA Workforce Survey Results - Training Partner Training by Topic ■ Out of 113

BHA Workforce Survey Results - Training Partner Training by Topic ■ Out of 113 responses, up to 69% of partner organizations provide training internally in the areas related to the DSRIP projects 49 Substance Abuse: 12 78 Quality Improvement: 10 60 Patient Centered Care / Engagement: ■ More than 60% of BHA partner organizations have internal training programs in 5 critical staff development areas 7 45 Health Literacy: 4 72 Cultural Competency: 7 ■ Only 15% of the BHA partners have the capacity to develop and provide training outside of their organizations 30 Community Health Worker: 7 51 Care Transitions: 5 ■ 31% of BHA partners indicated a need for Community Health Worker Training 60 Care Coordination: 11 63 Behavioral Health/Chronic Conditions: 17 0 Provided Internally 10 20 30 40 50 60 70 80 90 Capacity to Provide Externally © 2015 KPMG LLP, a Delaware limited liability partnership and the U. S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. 20

BHA Workforce Survey Results – Cultural Competency Strengths and Challenges Time Constraints 37 Effective

BHA Workforce Survey Results – Cultural Competency Strengths and Challenges Time Constraints 37 Effective Communication (Language Barriers) 25 Cultural Awareness 90 9 87 Culturally Diverse Staff Patient Satisfaction 84 13 Staff Training/Education 68 25 Ensuring Follow-up Care 63 15 48 Linguistic Competency 24 47 Interpreter Services 44 Use of Staff Interpreters 44 Culturally Defined Dietary Needs 13 0 Strengths 24 7 10 Other ■ Care for People with Physical Disabilities § 69% involve family members § 66% provide staff training § 31% utilize interpreters (e. g. sign language 64 17 Maintaining Organizational Commitment to CC Screening and Assessment Methods/Tools ■ Care for Non-English Speaking Patients § 93% indicated multilingual staff § 62% utilize Family members to assist with translation § 3% utilize certified medical interpreters 10 20 30 40 50 60 70 80 90 100 ■ Care for People with Emotional or Intellectual Disabilities: § 76% involve family members § 66% have staff training § 41% provide training, education and support to Peers ■ Care for the LGBT Community: § 21. 6% are trained as ‘Safe Space’ provider § 64. 7% provide staff training § 39. 2% provide Peer training, education and support Challenges © 2015 KPMG LLP, a Delaware limited liability partnership and the U. S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. 21

Kathy Miller, Bronx RHIO © Bronx Health Access 22

Kathy Miller, Bronx RHIO © Bronx Health Access 22

Clinics Nursing Homes Community Based Organizations Health Plans Hospitals Bx. RHIO Data Quality &

Clinics Nursing Homes Community Based Organizations Health Plans Hospitals Bx. RHIO Data Quality & Normalization Databases for Analytics and Portal Viewing Provider Portal REPORTING

Bronx RHIO – What We Do Integrate data Allow authorized healthcare providers to access

Bronx RHIO – What We Do Integrate data Allow authorized healthcare providers to access critical patient info Manage and report on populations Send alerts to providers Deliver key reports on behalf of members Ensure member compliance with privacy, security, training, auditing, and use. Assist members in data quality management Serve as on-ramp to SHIN-NY 24

Membership & Data Providers § § § § § § Acacia (Promesa) Albert Einstein

Membership & Data Providers § § § § § § Acacia (Promesa) Albert Einstein College of Medicine of § § Yeshiva University § All Medical & Rehabilitation § Amida. Care (Health Plan) § Anil Gupta, MD APICHA § Argus Community, Inc. § ASCNYC § Bailey House Bronx Accountable Healthcare Network § Bronx AIDS Services, Inc. (BOOM!Health) § § Bronx Community Health Network § Bronx Health Home § Bronx Gastroenterology OBS § Bronx Lebanon Hospital Center § Bronx Works § Cardinal Mc. Closkey Services Care for the Homeless § Center. Light (Beth Abraham) § Children of Zion Pediatrics Community Healthcare Network (CHN) § § Compassionate Care Hospice § Cure Urgent Care § § Essen Medical Associates, P. C. GMHC Golden. Hearts Elderly Care Service Harlem Medical Group Harlem United Hebrew Home for the Aged at Riverdale Help/PSI Services Corp. Hemant Patel, M. D. /Physicians PLLC Housing Works Institute for Family Health James J. Peters VA Medical Center Jewish Home Lifecare Kings Harbor Multicare Center Liberty Management - Arms Acres Martin Luther King, Jr. Health Center Medalliance Medical Health Services Metropolitan Jewish Health System (MJHS) Montefiore Medical Center Morris Heights Health Center Muhammad Adam, MD Narco Freedom New York Associates in Gastro New York City Department of Health New York GI Center § § § § § § Olive Osborne, MD Optimum Family Medicine Perry Avenue Family Medical PET/CT Diagnostic Medical Imaging Quick. Rx R. A. I. N. Home Health Richmond Home Need Services Riverdale Family Practice Riverdale Mental Health Association Robert Morrow, M. D. Salud Medical, PC Salvation Army Sindhu Gupta, MD St. Barnabas Hospital Union Community Health Center University Diagnostic Medical Imaging Uptown Healthcare Management Urban Health Plan Veena Chadda, M. D. Village Care VIP Community Services Visiting Nurse Service of New York Wakefield Pediatrics 1199 SEIU List Current as of 3/8/2016 25

Bronx Health Access § § § § All Medical & Rehabilitation Amida. Care (Health

Bronx Health Access § § § § All Medical & Rehabilitation Amida. Care (Health Plan) APICHA Argus Community, Inc. Bailey House Bronx AIDS Services, Inc. (BOOM!Health) Bronx Health Home Bronx Lebanon Hospital Center Bronx Works Cardinal Mc. Closkey Services Care for the Homeless Center. Light (Beth Abraham) Community Healthcare Network (CHN) Cure Urgent Care GMHC Harlem Medical Group § § § § Harlem United Hebrew Home for the Aged at Riverdale Help/PSI Services Corp. Hemant Patel, M. D. /Physicians PLLC Kings Harbor Multicare Center Liberty Management - Arms Acres Martin Luther King, Jr. Health Center Medalliance Medical Health Services R. A. I. N. Home Health Riverdale Mental Health Association Salvation Army University Diagnostic Medical Imaging Uptown Healthcare Management Urban Health Plan VIP Community Services Visiting Nurse Service of New York 26

JOINING THE RHIO 1. Download Application and Participation Agreement (PA) from our website at

JOINING THE RHIO 1. Download Application and Participation Agreement (PA) from our website at http: //bronxrhio. org/forproviders/how-to-participate 2. Complete the Application and PA and contact us for pricing (current fee schedule attached to this presentation). If you have questions about the fee or application, please call Kathy Miller at 718 -708 -6632. 3. All applications are presented to the RHIO Board of Directors for approval, after which the site is notified and invoiced for the fee. 27

INCENTIVE PROGRAMS FOR RHIO CONNECTION Incentive programs are currently available to support costs of

INCENTIVE PROGRAMS FOR RHIO CONNECTION Incentive programs are currently available to support costs of joining and connecting to Bronx RHIO for eligible providers. Bronx RHIO will assist with this. • Incentive can be up to $30, 000 for a practice/facility • Requires completion of connection with feed of at least 5 of 7 data elements: • Encounters, demographics, medications, labs, allergies, procedures, diagnoses Incentive payment process requires filing two attestations: Attestation A - On approval of RHIO membership $2, 000 Attestation B – On “Go Live” $8, 000 PLUS $500 per eligible provider up to 40 providers in a practice (up to $20, 000) 28

EMRs Already Working with Bronx RHIO COMMERCIAL VENDORS* All. Scripts HBOC Awards (Foothold) Centricity

EMRs Already Working with Bronx RHIO COMMERCIAL VENDORS* All. Scripts HBOC Awards (Foothold) Centricity e. CW Care. Cast EPIC Provation Sigma. Care Mind. Linc Next. Gen Mc. Kesson EICare Med. Gen Criterions e. CW Population Health Adapter NON-STANDARD SYSTEMS Home-Grown Systems IF No EMR System: Ø Bronx RHIO accepts Flat Files of data and converts into messages to load into the HIE 29

What will YOU Get From Joining? Staff access to Provider Portal to look up

What will YOU Get From Joining? Staff access to Provider Portal to look up patient activity at other locations Ø View all available data on consented patients through the portal Ø Request data from other RHIOs in NY State on specific patients (HHC Data Available now) Ø Wherever possible, we will set up RHIO access from within your EMR via “single sign-on” Staff access to Spectrum Dashboard and Reporting tool to track PPS project measures for YOUR assigned/identified patient groups Ø Identify your patient group & tell us what you want to know and/or track Ø We set up the group and related data for you to see at the aggregate level, and to drill down to patient specific information within a few clicks (if you have PHI permission) Ø You can export reports for use at your facility Ø Staff without a need for PHI access can view dashboards and aggregated data Subscribe to get Alerts about your patients’ ED and IP activity Get free DIRECT email addresses for staff 30

CONTACT INFORMATION KATHY MILLER, DIRECTOR OF POPULATION HEALTH KMILLER@BRONXRHIO. ORG 718 -708 -6632 BRONX

CONTACT INFORMATION KATHY MILLER, DIRECTOR OF POPULATION HEALTH KMILLER@BRONXRHIO. ORG 718 -708 -6632 BRONX RHIO 2275 OLINVILLE AVENUE BRONX, NY 10467 WWW. BRONXRHIO. ORG 31

HISTORY • • Founded in 1974 by a local priest to address the perils

HISTORY • • Founded in 1974 by a local priest to address the perils of poverty, addiction, and housing in the Bronx In the basement of his rectory, he began training individuals in recovery to return to work Today VIP employs 250 people, serves 10, 000 individuals per year Full continuum of addiction, mental health, housing, homeless and recovery services

VIP’s Continuum • Opioid Treatment Program - Maintenance using addiction medications (Methadone, Suboxone) to

VIP’s Continuum • Opioid Treatment Program - Maintenance using addiction medications (Methadone, Suboxone) to prevent opioid withdrawal and cravings to allow clients to focus on recovery - Individual and Group Counseling - Psychiatric Services - Medical and health services - Medication Assisted Recovery Services (MARS)- adapted from the nationally recognized peer model • Outpatient Substance Use Disorder Treatment - Individual and Group Counseling - Psychiatric Services - Medical and health services • Residential Substance Use Disorder Treatment - Individual and group counseling - Mental Health Services - Oversight of medical needs - Rehabilitation of Activities of Daily Living

VIP’s Continuum (Cont) • Outpatient Mental Health Services - Individual and Group Therapy -

VIP’s Continuum (Cont) • Outpatient Mental Health Services - Individual and Group Therapy - Psychiatric Evaluation - Medication Management - Health Monitoring • Primary Care Clinic - Federally Qualified Health Center - Primary Care Services - Gynecology - HIV Specialty - Pr. EP/PEP - Medical Case Management - Psychiatric Services

VIP’s Continuum (Cont) Supportive Housing - 198 units in 5 buildings - Populations include:

VIP’s Continuum (Cont) Supportive Housing - 198 units in 5 buildings - Populations include: HIV/AIDS, Serious Mental Illness, Chronic Substance Use Disorders, Families Exiting Shelter, Families with a physical disability - Case Management, Counseling, Psychiatric Services - Access to VIP’s full continuum - Housing First Model and Harm Reduction Models • Shelter - 48 women - History of Substance Use Disorder - Offer housing placement, psychiatric evaluations, medical services, case management, substance use disorder counseling • Care Coordination - Offers care coordination through two Health Homes (Bronx Lebanon and Mount Sinai) - Outreach, navigation and peer services •

Our Philosophies • • • Same Day/Coordinated Access to Care - All who come

Our Philosophies • • • Same Day/Coordinated Access to Care - All who come to VIP will begin the screening process the same day - Intake is centralized so clients receive an assessment for all of VIP’s programs - Maintain a strong network of partners and all clients who seek services will receive support in finding the place that meets their needs- there is no wrong door Effective Transitions/Warm Hand-Offs - VIP provides transportation from courts, detox and other referral sources - This is conducted by an Outreach Worker who coordinates with the referring organization and facilitates a warm hand-off between the referent and VIP - Peer Navigators provide services through all levels of care within VIP and beyond Peer Support is Essential - Every Friday morning is a peer run celebration of Recovery for VIP clients, alum, and the community - Peer Academy provides work readiness, group facilitation and other skills - MARS (Medication Assisted Recovery Services) is a peer run recovery group supporting those using Medication Supported Recovery

Outcomes Behavioral Health - 83% of clients are retained in care for 30 Days

Outcomes Behavioral Health - 83% of clients are retained in care for 30 Days -34% have maintained or improved employment status - 43% of clients are engaged in work-related activities - 68% of clients complete one level of care and successfully transition into the next level - 7% reduction in ER visits • Primary Health - 49% have controlled asthma - 63% are engaged in smoking cessation - 62% have controlled hypertension • Housing - 95% of tenants maintain permanent housing - 85% of tenants maintain or improve income - Average length of stay in permanent housing is 10 years - 50% of people exit our shelter and do not return •

Bronx Lebanon and VIP DSRIP Partnerships • • • VIP has taken this opportunity

Bronx Lebanon and VIP DSRIP Partnerships • • • VIP has taken this opportunity to have a voice and impact in how healthcare is delivered in New York Strengthened partnerships with other providers in the PPS Opportunities to improve infrastructure and delivery system Co-Lead of 3 ai Behavioral Health Integration Co-Lead of 4 cii HIV Population Health Represent Bronx Lebanon at City Wide Collaborative for 4 cii Health Clinical and Quality Committee Workforce Committee PCMH Committee

Learn More About VIP www. vipservices. org Intake Line: 1 -800 -850 -9900 info@vipservices.

Learn More About VIP www. vipservices. org Intake Line: 1 -800 -850 -9900 info@vipservices. org

Partner Highlight Sol’s Pharmacy Andrew Silverman, Owner, Sol’s Pharmacy © Bronx Health Access 41

Partner Highlight Sol’s Pharmacy Andrew Silverman, Owner, Sol’s Pharmacy © Bronx Health Access 41

Sol’s Pharmacy • Over 15 years of service to the Queens and South Bronx

Sol’s Pharmacy • Over 15 years of service to the Queens and South Bronx communities • Dedicated to provide quality care, education, and delivery services to improve medication adherence • Medication Compliance Program and Medication Therapy Management (MTM) services • Website: www. solspharmacy. com © Bronx Health Access 42

Project 2. biv Care Transitions Dr. Isaac Dapkins, Co-Lead Natalie Cruz, Co-Lead © Bronx

Project 2. biv Care Transitions Dr. Isaac Dapkins, Co-Lead Natalie Cruz, Co-Lead © Bronx Health Access 43

Care Transitions Review of the Task Reduce unnecessary hospitalizations Create a transitions record Risk

Care Transitions Review of the Task Reduce unnecessary hospitalizations Create a transitions record Risk Stratify Ensure continuity with provider and care coordination • Improve the patient experience • • © Bronx Health Access 44

Care Transitions Clearinghouse Functionality - Risk Stratification - Continuity by Provider/Care Management Agency -

Care Transitions Clearinghouse Functionality - Risk Stratification - Continuity by Provider/Care Management Agency - Clinical Integration of Psychosocial Drivers of Health Admitted Patient Clearinghouse Enabling Services © Bronx Health Access Care Coordination Primary Care Specialty Care 45

Care Transitions Clearinghouse Functionality - Enabling Services Primary Care Coordination RHIO Data Outcomes Driven

Care Transitions Clearinghouse Functionality - Enabling Services Primary Care Coordination RHIO Data Outcomes Driven 7 -Day appointments HEDIS Measures Engagement Metrics Specialty Care Clearinghouse Ambulatory Patient © Bronx Health Access 46

Care Transitions Where are the resources? • Transitions Care RN’s, Care Coordinators and physicians

Care Transitions Where are the resources? • Transitions Care RN’s, Care Coordinators and physicians • Participating organizations include: • • • Brightpoint Health Calvary Hospital CASES Comunilife Dominican Sisters Urban Health Plan First Care of New York God’s Love We Deliver Arms Acre/Conifer Park R. A. I. N Pioneer Homecare Self. Help Community Services © Bronx Health Access • • • • Uptown Healthcare Management VIP Community Services Hospice of New York Edison Home Health Care Archcare Bronx Jewish Community Council Concern for Independent Living Grand Manor Nursing Home Regeis Care Center Rebekah Rehab JASA Methodist Home for Nursing and Rehab EAC/TASC Mental Health Court Program Community Healthcare Network 47

Care Transitions What is needed? • Collaboration needed with pharmacies, medically tailored home food

Care Transitions What is needed? • Collaboration needed with pharmacies, medically tailored home food services, Home Health Agencies, Rehab facilities, and Ambulette services • Requires active response for engaged Heath Home members, Health Home at risk and providers • Requires risk stratification/ assignment © Bronx Health Access 48

Partner Engagement Commitment Roy Wallach & Joann Casado Co-Leads of Stakeholder Engagement Committee ©

Partner Engagement Commitment Roy Wallach & Joann Casado Co-Leads of Stakeholder Engagement Committee © Bronx Health Access 49

- There are many issues in patient’s lives, as well as how our health

- There are many issues in patient’s lives, as well as how our health care system is organized. - This can lead to patient’s recurrent use of the ER as the primary place for care. - No PCP appointments No effective patient call-in system for guidance and direction Social issues Economic issues Behavioral issues Substance abuse issues Housing issues Transportation issues Child care issue Educational issues Pharmacy issues © Bronx Health Access 50

 • Desired State – A system where patients can be effectively cared for

• Desired State – A system where patients can be effectively cared for in an outpatient setting by a care giving team that know them best, providing for better access and for addressing the issues and barriers that currently exist to patient health. © Bronx Health Access 51

Desired State • Better communication with patients • Better communication and sharing of info

Desired State • Better communication with patients • Better communication and sharing of info between providers • Better access to PCPs and BH/SA • Addressing social determinants and barriers • Designated coordinators of care for patients who need them • Better monitoring of outcomes to insure we are moving in the right direction © Bronx Health Access 52

What is a PPS? Team Approach • There are 25 Performing Provider Systems (PPSs)

What is a PPS? Team Approach • There are 25 Performing Provider Systems (PPSs) across New York State that are participating in DSRIP. Bronx Health Access (BHA) is a PPS and Bronx Lebanon is the PPS lead • BHA partners include: Hospitals; Medicaid and uninsured beneficiaries; Physicians; CBOs; Social Service entities; Behavioral Providers; and Community Coalitions © Bronx Health Access 53

What Does it Mean to be a Partner? © Bronx Health Access 54

What Does it Mean to be a Partner? © Bronx Health Access 54

o Be a voice in healthcare transformation o Provide greater quality of care to

o Be a voice in healthcare transformation o Provide greater quality of care to the patient o Encourages you to think out of the box o New collaboration opportunities o Learn new reimbursement modalities o View your business differently o Continuity in a changing healthcare world © Bronx Health Access 55

Q&A © Bronx Health Access 56

Q&A © Bronx Health Access 56