AGENDA I.Our DSRIP: ACP / AW Medical What it means for community providers like us? II.The Physician and DSRIP: Pay for performance III.Patient engagement:

AGENDA

I. Our DSRIP: ACP / AW Medical

What it means for community providers like us?

II. The Physician and DSRIP:

Pay for performance

III. Patient engagement:

Simple steps to higher payment

OUR DSRIP: ACP / AW MEDICAL

NYCPP North Shore - LIJ

MEDISYS SYSTEM

LEAD: AW MEDICAL

NEW YORK COMMUNITY PREFERRED PROVIDER

COMMUNITY PREFFERED NETWORK

RENAISSANCE COLLABORATIVE

• Asian American ACO• Chinese American IPA• Chinese Community ACO• Eastern Chinese American Physicians IPA• Korean American Physicians IPA• CBW Community Health Center

Community Provider Network (CPN)

• Balance Medical ACO• Balance Medical IPA• Breukelen Community Network IPA• Corinthian Medical IPA• Excelsior Medical IPA• Queens County IPA

Renaissance Collaborative (RC)

• Dr. George Liu, Co-Chairman• Dr. Ramon Tallaj, Co-Chairman• Dr. Henry Chen, Treasurer • Dr. Emilio Villegas - Secretary• Dr. Bing Lu, Board of Manager• Dr. Hanbin Zheng, Board of Manager• Dr. Jonathan Chang, Board of Manager• Dr. Michael Li, Board of Manager• Dr. Sunhoo Foo, Board of Manager• Dr. Vincent Wang, Board of Manager• Dr. Hal Sadowy, Co-Chief Operating Officer• Ms. Peggy Sheng, Co-Chief Operating Officer

NYCPP Leadership Team

WHAT IT MEANS FOR COMMUNITY PROVIDERS LIKE US?

我們是一家人

Somos

uno

We have brought over 2,000 physicians together as ONE

Non-physician partners

AW Medical PPS is not just made up of Physicians

Behavior Health and

other important providers

Physicians

Hospitals

• ACMH, Inc.• Affinity Health Plan• Alpine Home Health Care• Amazing Home Care• Amber Court At Home• Amber Court Of Pelham Gardens• Arms Acres, Inc• Best Choice Home Health Care, Inc.• Beth Abraham Health Services• Boris Dubrovsky, Phd• Bronx Center For Rehabilitation &

Health Care• Bronx Lebanon Hospital Center• Bronx Park Rehab & Nursing Center• Bronx Supported Housing • Bronx-Lebanon Hospital Center• Center for Urban Community Services• Centerlight Healthcare Inc.• Centerlight Healthcare Diagnostic & Tr

eatment Center• CL Healthcare Inc• Community Access Inc• Daughters Of Jacob Nursing Home

Company Inc.• Doshi Diagnostic Imaging Services,

P.C.• Eli Leiter, Phd• Friends And Family• Hebrew Home At Riverdale• Jewish Association For Services For

The Aged (Jasa) • Jewish Board Of Family And Children'S

Services• Kings Harbor Multicare Ctr.• Kingsbridge Hieghts Rehab And Care

Center• Mvp Housing Development Fund

Company Inc.• Narco Freedom, Inc• New York Dialysis Services, Inc.

• New York Psychotherapy And Counseling Center

• Palisade Nursing Home Company, Inc.• Park Housing Development Fund

Company Inc.• Phoenix Houses Of New York, Inc.• Postgraduate Center For Mental Health • Project Renewal• Rain (Regional Aid For Interim Needs)• Riverdale Mental Health Association• Rosselle Estrella, Pt• Scheuer Gardens Limited Partnership• Scheuer Plaza Limited Partnership• Schnurmacher Center For

Rehabilitation And Nursing• Seniorcare Emergency Medical

Services• Seniorride• Sheryll Garcia, Pt• St Barnabas Hospital Health System• St Joseph's Hospital• Steinway Child And Family Services,

Inc• Success Counseling Services, Inc• Sus-Mental Health Programs, Inc.• Terrace Health Care Center, Inc• The Bridge• The Pac Program Of The Bronx, Inc• University Consultation & Treatment

Center For Mental Hygiene, Inc.• University Nursing Home• VIP Community Services• Westchester Family Health Center• Weston United Community Renewal,

Inc.• Williamsbridge Manor Nursing Home

Bronx

• MJHS License Home Care Service Agency

• AlphaCare• Amber Court at Home• Amber Court of Brooklyn• Americare Certified

Specialty Services, Inc.• Anna Sidorkina, LAC• Best Choice Home Health

Care, Inc.• BETH ISRAEL MEDICAL CTR• BGR Services, Inc.• Boro Park Center for

Rehabilitation & Health Care• Breukelen Community

Network IPA• Bridge Back to Life Center,

Inc.• Bridger• BRIDGING ACCESS TO

CARE• Brooklyn Center for

Rehabilitation and Residential Health Care

• Brooklyn Community Services

• Bushwick Brooklyn ACT• Bushwick Center for

Rehabilitation and Health Care

• CAIPA Social Day Care Center

• Catholic Charities• Center for Nursing and

Rehabilitation• Center for Urban Community

Services• CenterLight Certified Home

Health Agency• Central Brooklyn ACT• CL Healthcare Inc• Cobble Hill Health Center,

Inc.• Community Access Inc./

Warren Street• Community Radiology of NY• Doshi Diagnostic Imaging

Services, P.C.• East Brooklyn ACT Team• Elderplan• Emerson TAP• Empire City Laboratories• Federation of Organizations

for NYS Mentally Disabled• Fresenius• God's Love We Deliver, Inc• Guidance Center of

Brooklyn• Health Homes

• Homecrest Community Services, Inc

• ICL• ICM Brooklyn• Jewish Board of Family and

Children's Services• John J. Pershing

Intermediate School 220• Lawton Street Community

Residence• Linden House Community

Residence• Livonia Avenue • LUTHERAN MEDICAL

CENTER• Marizza Dulfo, PT• Menorah Center for

Rehabilitation and Nursing Care

• MJHS Long Term Care• New York Congregational

Nursing Center• New York Psychotherapy

and Counseling Center• NEW YORK THERAPEUTIC

COMMUNITIES, INC• Ohel Childrens Home and

Family Services • Phoenix House Foundation,

Inc.

• Phoenix Houses of New York, Inc.

• Postgraduate Center for Mental Health

• Preventive Diagnostics• Rockaway Park Center• Shiel Medical Laboratory• St. Joseph's Hospital• St. Mark's MICA Supported

Housing• St. Mark's Scattersite

Supported Housing• Steinway Child and Family

Services, Inc.• Steppingstone Congregate

Treatment• Summit Home Health Care• Supported Housing for

Women with HIV/AIDS• SUS• Tillary Street Women's

Shelter• Williamsburg Physical

Therapy

Brooklyn

• 181 Street Medical PC• 3rd Street Men's Shelter• ACMH, Inc• Alberto De Castro, PT• Aleksey Kleyman, LAC• Americhoice• Amerigroup MLTC• Amerigroup/Healthplus• Asian American Accountable Care

Organization, LLC• Balance Medical ACO• Balance Medical IPA, Inc• Beacon of Hope House• BETH ISRAEL MEDICAL CTR• Bridge Back to Life Center, Inc.• CareNext• Center for Alternative Sentencing

and Employment Services• Center for Urban Community

Servcies• Charles B. Wang Community

Health Center• Chinese American IPA, Inc.

• Chinese Community Accountable Care Organization

• CL Healthcare Inc• Community Access Inc.• Community Association of

Progressive Dominicans (ACDP)• Comunilife Inc• Coordinated Behavioral Care, Inc

Pathways to Wellness HH• Corinthian Medical IPA, Inc• Diana Badillo• Doshi Diagnostic Imaging

Services, P.C.• Elizabeth Uzor• Elmont Open MRI• Empire State Dental• Geffner House• Good Sheperd Services• Gouverneur Healthcare Services -

Skilled Nursing Facility• Gramercy Park Digestive Disease

Center, LLC• Greenwich House, Inc.

• Harlem East life Plan• Healthfirst• Heritage Health Home Network• Heritage Healthcare Network• ICL Broadway Community

Residence• Isabella Nursing Home• Jason Waterman• Jewish Board of Family and

Children's Services• Kenneth Ged• Kenton Hall Men's Shelter• L&L Orthotics, LLC• Manhattan Supportive Housing• Mary Claire Arbilo, PT• MARY MANNING WALSH• Melida Knibbs• Metroplus Health Plan• Metropolitan Center for Mental

Health• Metropolitan Jewish Home Care

Inc. d/b/a MJHS Home Care

Manhattan

• MIH Experience LTD• Mitzy Baldovino, PT• MJHS Hospice and Palliative Care• National Association on Drug

Abuse Problems, Inc.• New York Dialysis Services, Inc.• New York eHealth Collaborative

(NYeC)• NEW YORK EYE & EAR

INFIRMARY• Ninel Platsman, PT• Palladia, Inc.• Phoenix House Foundation, Inc.• Postgraduate Center for Mental

Health• Project Renewal• Rapid Care Solutions• Rowell Arguelles, PT• Salcare Home Health Services,

Inc• SCAN New York• Senior Health Partners

• Senior Whole Health• Seong Chul Ha, LAC• Service Program for Older People,

Inc.• Shiel Holdings, LLC • Shiel Medical Laboratory• ST LUKES ROOSEVELT HOSP-

ROOSEVELT HOSP• ST LUKES ROOSEVELT HOSP-

ST LUKES HOSP• St. Nicholas House• SUS- Mental Health Programs,

Inc. • TERENCE CARDINAL COOKE• The Bridge• The Fifth Avenue Counseling

Center, Inc.• The First Chinese Presbyterian

Community Affairs Home Attendant Corp.

• THE MOUNT SINAI HOSPITAL• The National Alliance for the

Mentally Ill of New York City, Inc.• The PAC Program of The Bronx,

Inc• United Rx Buying Group LLC• University Settlement Early

Intervention Program• Vidyasagar Pamulapati, PT• Vijayalakshmi P. Davuluri, PT• Visiting Nurse Service of New

York Home Care• VNS Choice• VNSNY• VNSNY Behavioral Health• VNSNY Hospice and Palliative

Care• Washington Heights Imaging• WellCare Health Plan• WellCare MLTC• Weston United Community

Renewal, Inc.• Women In Need

Manhattan (continued)

• ACMH, Inc.• Alvin Orodio, Pt• Amber Court Of Westbury• Arms Acres, Inc• Bleuler Psychotherapy Center,

Inc.• Bridge Back To Life Center, Inc.• Catholic Charities• Center For Urban Community

Services/Rikers Island Single Stop• CL Healthcare Inc• Conifer Park, Inc• Cornerstone Medical Arts Center

Hospital• Cuatro Llc Dba Access Medicare

Ny• Doshi Diagnostic Imaging

Services, P.C.• Dr. William O. Benenson Rehab

Pavilion• Eastern Chinese American

Physicians Ipa• Excelsior Medical IPA• Fed Of Org For Nys Mentally

Disabled• Fidelis Care

• Fishman Center Total Eye Care• Flushing Manor Care Center• Flushing Manor Dialysis Center• Flushing Manor Nursing Home• Goodwill Industries• Holliswood Center For

Rehabilitation And Healthcare• Jewish Board Of Family And

Children'S Services• Liberty Physical Medicine &

Rehab• Long Island Care Center• Long Island Consultation Center• Margaret Tietz Nursing And

Rehabilitation Center• Michael K.T. Mangubat, Pt• Milestone Supportive Housing• New Horizon Counseling Center• New York Psychotherapy And

Counseling Center• Ohel Childrens Home And Family

Services • Parker Jewish Institute For

Healthcare & Rehabilitation• Phoenix House Foundation, Inc.• Phoenix Houses Of New York, Inc.

• Postgraduate Center For Mental Health

• Qsa Services, Inc.• Queens Center For Rehabilitation

& Residential Health Care• Queens County Ipa• Queens Treatment Apartment

Program• Samaritan Village • Samuel Field YM/YWCA• Shiel Medical Laboratory• South Shore Physician Group• St Joseph's Hospital• Steinway Child And Family

Services, Inc.• Supportive Services For Veteran

Families• Sus- Mental Health Programs, Inc. • The Mount Sinai Hospital Of

Queens• Union Plaza Nursing Home Dba

Union Plaza Care Center• Venture House• Xeron Labs

Queens

THE PHYSICIAN AND DSRIP:

ABOUT DSRIP

• Delivery System Reform Incentive Payment

• Incentive payments are performance based

• Patient engagement is KEY for incentive payment

calculation which starts 01/01/2015

• Goals 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.

ACHIEVING THE GOAL

• Implementing collaborative models of patient care

• Enhanced care coordination and care management

models

• Monitoring specific performance measures

• Adherence to evidence-based protocols

• Adherence to standardized processes across the PPS

• EDI and PCMH level 3 certification

2.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           

Projects Selection

PATIENT ENGAGEMENT:

• 2.a.i Create Integrated Delivery Systems that are focused on Evidence Based Medicine / Population Health Management

• Target: All patients and Providers

• Engagement: Every patient has a sign RHIO consent form.

PCMH (2014 Version) Level 3 by 2017

2014 2015 3/31/2015 2016 3/31/2016 2017 3/31/2017

Action Attest Data Action Attest Data Action Attest Data

EHR

Adopt, Implement, Upgrade (AIU) to 2014 Certified EHR

AIU to Certified EHR

AIU any 90-day period from 2014

Use Certified EHR

MU Stage 1-Y1any 90-day period from 2015

Use Certified EHR

MU Stage1-Y2 & meet MU Stage 2 criteria

full yr. 2016

MU Stage 1-Y1 any 90-day period from 2014 MU Stage 1-Y2 full yr. 2015 MU Stage 2-Y1 full yr. 2016

MU Stage 1-Y2 any 90-day period from 2014 MU Stage 2-Y1 full yr. 2015 MU Stage 2-Y2 full yr. 2016

MU Stage 2-Y1 any 90-day period from 2014 MU Stage 2-Y2 full yr. 2015 MU Stage 3-Y1 full yr. 2016

PCMHUpgrade to PCMH 2014 version

Prepare PCMH Level 3 Submit PCMH Level 3 Achieve PCMH Level 3 by 6/2017

2.a.iii Health Home At-Risk Intervention Program

Target: Patients with one progressive chronic disease, serious mental Illness or traumatic brain Injury Engagement: Every patient that has a documented comprehensive care plan in place

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

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

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

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 Hyperlipidemia Engagement: Every patient must have life style change counseling documented

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

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

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

4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings

Target: All patients Engagement: Document and Prescribe Colonoscopy, Mammogram, Pap Smear, Prostate exam, HPV Vaccination, Safe Sex Education

Support Team

• Lidia Virgil [email protected]

• John Dionisio [email protected]

• Susan Lau [email protected]

• Liz Webb [email protected]

Q & A