Phase III Reporting Deadlines and Implementation Materials

Download Phase III Deadlines Calendar

Below please find Metric IDs, Process Metric descriptions, Participant Obligations, Due Dates and Implementation Materials for Phase III. Current as of January 1, 2018. Please reference the OneCity Health Partner Reporting Manual for reporting instructions for all Phase III Comprehensive Schedule B Process Metrics. For the most up-to-date information on all metrics and deadlines, please contact the OneCity Health support desk. Please note, OneCity Health partners only need to complete the metrics in their Comprehensive Schedule B.

In addition, click here to download a list of Phase III Comprehensive Schedule B Process Metrics with hyperlinks to all applicable implementation materials.

Metric IDProcess MetricParticipant ObligationsDue DateApplicable Implementation Materials
N_001Sign Comprehensive Schedule B through DocuSign and return NYC Health + Hospitals Vendor Demographics Form to OneCity Health Services within forty-five (45) days of the effective date.Sign Comprehensive Schedule B utilizing DocuSign and return NYC Health + Hospitals Vendor Demographics Form to OneCity Health Services and attest to contract execution on the OneCity Health Partner Portal by the specified due date as outlined in this Comprehensive Schedule B.2/23/2018Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_002Complete the Financial Assessment survey as designed and administered by OneCity Health Services. Complete the Financial Assessment survey and submit to OneCity Health Services by the specified due date as outlined in this Comprehensive Schedule B. 9/15/2018Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_003Complete the Compensation and Benefits survey as administered by the vendor. Complete the Compensation and Benefits survey and submit to the designated vendor and demonstrate completion on the OneCity Health Partner Portal by the specified due date as outlined in this Comprehensive Schedule B. 2/23/2018Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_004.1Report the total number of staff hired, redeployed or retrained to complete DSRIP related activities in the Workforce Impact Survey as designed and administered by OneCity Health Services.Submit documentation that reports total number of staff hired, redeployed or retrained to complete DSRIP-related activities.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/15/2018Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_004.2Report the total number of staff hired, redeployed or retrained to complete DSRIP related activities in the Workforce Impact Survey as designed and administered by OneCity Health Services.Submit documentation that reports total number of staff hired, redeployed or retrained to complete DSRIP-related activities.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/15/2018
N_005Demonstrate successful completion of Value Based Payment training as administered by OneCity Health Services.Provide documentation that demonstrates completion of the trainings as outlined in this Comprehensive Schedule B.

All documentation must be submitted by the specified due date as outlined in this Comprehensive Schedule B.
1/15/2019Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_006Report on the completion of National Committee on Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) Level III 2014, NCQA PCMH 2017, or NYS DOH Advanced Primary Care (APC) recognition.(1) Attest to completion of NCQA PCMH Level III, NCQA PCMH 2017, or NYS DOH APC recognition; (2) Include evidence of recognition for all eligible primary care practices; and (3) Report effective date(s) of recognition

All documentation must be submitted by the specified due date as outlined in this Comprehensive Schedule B, see Section F2 below.
1/15/2019Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_007Demonstrate that Electronic Health Record (EHR) meets connectivity to a Regional Health Information Organization (RHIO)/Health Information Exchange (HIE) and Statewide Health Information Network of New York (SHIN-NY) requirements.Provide documentation that demonstrates EHR connectivity to a RHIO/HIE and active utilization of HL7 Automatic Data Transfer (ADT) message feeds.

All documentation must be submitted by the specified due date as outlined in this Comprehensive Schedule B, see Section F2 below.
1/15/2019Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_008.1Demonstrate use of an approved social services referral platform to generate and/or receive at least fifteen (15) social service referrals per quarter.Submit verification that demonstrates that social service referrals were generated or received for at least fifteen (15) patients/clients through the approved platform during the quarterly reporting window.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
N_008.2Demonstrate use of an approved social services referral platform to generate and/or receive at least fifteen (15) social service referrals per quarter.Submit verification that demonstrates that social service referrals were generated or received for at least fifteen (15) patients/clients through the approved platform during the quarterly reporting window.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
N_008.3Demonstrate use of an approved social services referral platform to generate and/or receive at least fifteen (15) social service referrals per quarter.Submit verification that demonstrates that social service referrals were generated or received for at least fifteen (15) patients/clients through the approved platform during the quarterly reporting window.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
N_008.4Demonstrate use of an approved social services referral platform to generate and/or receive at least fifteen (15) social service referrals per quarter.Submit verification that demonstrates that social service referrals were generated or received for at least fifteen (15) patients/clients through the approved platform during the quarterly reporting window.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
N_009.1Report on the number of unique patients that received Meds to Beds services that include medication reconciliation and delivery of medication to an inpatient facility pre-discharge.Provide documentation that demonstrates the number of unique patients that received Meds to Beds services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III Pharmacy Project Implementation Summary

Phase III Pharmacy Toolkit
N_009.2
Report on the number of unique patients that received Meds to Beds services that include medication reconciliation and delivery of medication to an inpatient facility pre-discharge.
Provide documentation that demonstrates the number of unique patients that received Meds to Beds services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
N_009.3
Report on the number of unique patients that received Meds to Beds services that include medication reconciliation and delivery of medication to an inpatient facility pre-discharge.Provide documentation that demonstrates the number of unique patients that received Meds to Beds services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
N_009.4Report on the number of unique patients that received Meds to Beds services that include medication reconciliation and delivery of medication to an inpatient facility pre-discharge.Provide documentation that demonstrates the number of unique patients that received Meds to Beds services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
N_010.1Report on the number of unique patients referred by a OneCity Health Transition Management Team that have received medication reconciliation and associated follow-up services.Provide documentation that demonstrates the number of unique patients that were referred by a OneCity Health Transition Management Team and received medication reconciliation and associated follow-up services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018Phase III Pharmacy Project Implementation Summary

Phase III Pharmacy Toolkit
N_010.2Report on the number of unique patients referred by a OneCity Health Transition Management Team that have received medication reconciliation and associated follow-up services.Provide documentation that demonstrates the number of unique patients that were referred by a OneCity Health Transition Management Team and received medication reconciliation and associated follow-up services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
N_010.3Report on the number of unique patients referred by a OneCity Health Transition Management Team that have received medication reconciliation and associated follow-up services.Provide documentation that demonstrates the number of unique patients that were referred by a OneCity Health Transition Management Team and received medication reconciliation and associated follow-up services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019

N_010.4Report on the number of unique patients referred by a OneCity Health Transition Management Team that have received medication reconciliation and associated follow-up services.Provide documentation that demonstrates the number of unique patients that were referred by a OneCity Health Transition Management Team and received medication reconciliation and associated follow-up services.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2019
N_011Demonstrate high rating on the Centers for Medicare and Medicaid Services (CMS) Five-Star Quality Rating System Score for Nursing Homes.Submit evidence of CMS Five-Star Quality Rating System Score for Nursing Homes for Participant’s nursing home facility(ies).

All documentation must be submitted by the specified due date as outlined in this Comprehensive Schedule B, see Section F2 below.
12/31/2018
Phase III IDS Project Implementation Summary

Phase III IDS Toolkit
PS_001.1
Identify and connect appropriate patients to the OneCity Health Care Transitions program.Provide documentation that reports total number of patients connected to the OneCity Health Care Transitions program and meet the quarterly target defined by OneCity Health. This reports the number of patients (per episode) that were enrolled by Transition Management Teams as a result of work with the hospital.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III Care Transitions Project Implementation Summary

Phase III Care Transitions Hospitals Toolkit
PS_001.2Identify and connect appropriate patients to the OneCity Health Care Transitions program.Provide documentation that reports total number of patients connected to the OneCity Health Care Transitions program and meet the quarterly target defined by OneCity Health. This reports the number of patients (per episode) that were enrolled by Transition Management Teams as a result of work with the hospital.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_001.3Identify and connect appropriate patients to the OneCity Health Care Transitions program.Provide documentation that reports total number of patients connected to the OneCity Health Care Transitions program and meet the quarterly target defined by OneCity Health. This reports the number of patients (per episode) that were enrolled by Transition Management Teams as a result of work with the hospital.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_001.4Identify and connect appropriate patients to the OneCity Health Care Transitions program.Provide documentation that reports total number of patients connected to the OneCity Health Care Transitions program and meet the quarterly target defined by OneCity Health. This reports the number of patients (per episode) that were enrolled by Transition Management Teams as a result of work with the hospital.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_002.1Demonstrate that a minimum of sixty (60%) percent of patients assigned in the OneCity Health Care Transitions program have at least one (1) care plan update completed for each week of enrollment. Accurately document within GSI all patients that have been enrolled in the Care Transitions Program in the defined reporting period and each weekly update made to the care plan.

Provide patient level documentation that demonstrates at least sixty (60%) percent of assigned care transitions patients have at least one (1) care plan update completed for each week of enrollment.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III Care Transitions Project Implementation Summary

Phase III Care Transitions TMT Medical Floors Toolkit

Phase III TMT Psychiatry Toolkit
PS_002.2Demonstrate that a minimum of sixty (60%) percent of patients assigned in the OneCity Health Care Transitions program have at least one (1) care plan update completed for each week of enrollment. Accurately document within GSI all patients that have been enrolled in the Care Transitions Program in the defined reporting period and each weekly update made to the care plan.

Provide patient level documentation that demonstrates at least sixty (60%) percent of assigned care transitions patients have at least one (1) care plan update completed for each week of enrollment.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_002.3Demonstrate that a minimum of sixty (60%) percent of patients assigned in the OneCity Health Care Transitions program have at least one (1) care plan update completed for each week of enrollment. Accurately document within GSI all patients that have been enrolled in the Care Transitions Program in the defined reporting period and each weekly update made to the care plan.

Provide patient level documentation that demonstrates at least sixty (60%) percent of assigned care transitions patients have at least one (1) care plan update completed for each week of enrollment.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_002.4Demonstrate that a minimum of sixty (60%) percent of patients assigned in the OneCity Health Care Transitions program have at least one (1) care plan update completed for each week of enrollment. Accurately document within GSI all patients that have been enrolled in the Care Transitions Program in the defined reporting period and each weekly update made to the care plan.

Provide patient level documentation that demonstrates at least sixty (60%) percent of assigned care transitions patients have at least one (1) care plan update completed for each week of enrollment.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_003.1
Identify and connect appropriate patients to the OneCity Health Asthma Community Health Worker (CHW) program.Provide documentation that reports total number of patients connected to the OneCity Health Asthma CHW program and meet the quarterly target defined by OneCity Health. Connected is defined as a patient having been referred to the home visit program in GSI.

A complete connection must include a completed asthma action plan in GSI

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018TBD
PS_003.2Identify and connect appropriate patients to the OneCity Health Asthma Community Health Worker (CHW) program.Provide documentation that reports total number of patients connected to the OneCity Health Asthma CHW program and meet the quarterly target defined by OneCity Health. Connected is defined as a patient having been referred to the home visit program in GSI.

A complete connection must include a completed asthma action plan in GSI

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_003.3Identify and connect appropriate patients to the OneCity Health Asthma Community Health Worker (CHW) program.Provide documentation that reports total number of patients connected to the OneCity Health Asthma CHW program and meet the quarterly target defined by OneCity Health. Connected is defined as a patient having been referred to the home visit program in GSI.

A complete connection must include a completed asthma action plan in GSI

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_003.4
Identify and connect appropriate patients to the OneCity Health Asthma Community Health Worker (CHW) program.Provide documentation that reports total number of patients connected to the OneCity Health Asthma CHW program and meet the quarterly target defined by OneCity Health. Connected is defined as a patient having been referred to the home visit program in GSI.

A complete connection must include a completed asthma action plan in GSI

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_004.1Demonstrate that a minimum of thirty (30%) percent of patients enrolled in the OneCity Health Asthma Community Health Worker (CHW) program have a completed home visit.Accurately document within GSI all patients that have been enrolled in the Asthma CHW Program in the defined reporting period and the status of a completed home visit.

Provide documentation that demonstrates thirty (30%) percent of patients enrolled in the Asthma CHW Program have a completed home visit.

A completed home visit includes a completed home assessment and follow up care coordination services with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018TBD
PS_004.2Demonstrate that a minimum of thirty (30%) percent of patients enrolled in the OneCity Health Asthma Community Health Worker (CHW) program have a completed home visit.Accurately document within GSI all patients that have been enrolled in the Asthma CHW Program in the defined reporting period and the status of a completed home visit.

Provide documentation that demonstrates thirty (30%) percent of patients enrolled in the Asthma CHW Program have a completed home visit.

A completed home visit includes a completed home assessment and follow up care coordination services with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_004.3Demonstrate that a minimum of thirty (30%) percent of patients enrolled in the OneCity Health Asthma Community Health Worker (CHW) program have a completed home visit.Accurately document within GSI all patients that have been enrolled in the Asthma CHW Program in the defined reporting period and the status of a completed home visit.

Provide documentation that demonstrates thirty (30%) percent of patients enrolled in the Asthma CHW Program have a completed home visit.

A completed home visit includes a completed home assessment and follow up care coordination services with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_004.4Demonstrate that a minimum of thirty (30%) percent of patients enrolled in the OneCity Health Asthma Community Health Worker (CHW) program have a completed home visit.Accurately document within GSI all patients that have been enrolled in the Asthma CHW Program in the defined reporting period and the status of a completed home visit.

Provide documentation that demonstrates thirty (30%) percent of patients enrolled in the Asthma CHW Program have a completed home visit.

A completed home visit includes a completed home assessment and follow up care coordination services with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_005.1Identify and connect appropriate patients to the OneCity Health Health Home At-Risk program.Provide documentation that reports total number of patients (per episode) connected to the OneCity Health Health Home At-Risk program and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III HHAR Project Implementation Summary

Phase III HHAR Primary Care Sites Toolkit
PS_005.2Identify and connect appropriate patients to the OneCity Health Health Home At-Risk program.Provide documentation that reports total number of patients (per episode) connected to the OneCity Health Health Home At-Risk program and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_005.3Identify and connect appropriate patients to the OneCity Health Health Home At-Risk program.Provide documentation that reports total number of patients (per episode) connected to the OneCity Health Health Home At-Risk program and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_005.4Identify and connect appropriate patients to the OneCity Health Health Home At-Risk program.Provide documentation that reports total number of patients (per episode) connected to the OneCity Health Health Home At-Risk program and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_006.1Demonstrate that care coordination activities have been completed for a minimum of sixty (60%) percent of patients assigned to the OneCity Health Health Home At-Risk programAccurately document all patients that have been assigned in the Health Home At-Risk Program in the defined reporting period.

Provide documentation that demonstrates sixty (60%) percent of patients assigned to the Health Home at Risk Program have completed care coordination activities.

Care coordination activities include completed care plan and coordination with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III HHAR Project Implementation Summary

Phase III HHAR Health Homes Toolkit
PS_006.2Demonstrate that care coordination activities have been completed for a minimum of sixty (60%) percent of patients assigned to the OneCity Health Health Home At-Risk programAccurately document all patients that have been assigned in the Health Home At-Risk Program in the defined reporting period.

Provide documentation that demonstrates sixty (60%) percent of patients assigned to the Health Home at Risk Program have completed care coordination activities.

Care coordination activities include completed care plan and coordination with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_006.3Demonstrate that care coordination activities have been completed for a minimum of sixty (60%) percent of patients assigned to the OneCity Health Health Home At-Risk programAccurately document all patients that have been assigned in the Health Home At-Risk Program in the defined reporting period.

Provide documentation that demonstrates sixty (60%) percent of patients assigned to the Health Home at Risk Program have completed care coordination activities.

Care coordination activities include completed care plan and coordination with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_006.4Demonstrate that care coordination activities have been completed for a minimum of sixty (60%) percent of patients assigned to the OneCity Health Health Home At-Risk programAccurately document all patients that have been assigned in the Health Home At-Risk Program in the defined reporting period.

Provide documentation that demonstrates sixty (60%) percent of patients assigned to the Health Home at Risk Program have completed care coordination activities.

Care coordination activities include completed care plan and coordination with the medical provider.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_007.1Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (2.b.iii Emergency Department Triage for At-Risk Populations).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III ED Care Triage Project Implementation Summary

Phase III ED Care Triage ED Care Management Toolkit

Phase III ED Care Triage Primary Care Linkage Toolkit
PS_007.2Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (2.b.iii Emergency Department Triage for At-Risk Populations).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.7/31/2018
PS_007.3Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (2.b.iii Emergency Department Triage for At-Risk Populations).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.10/31/2018
PS_007.4Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (2.b.iii Emergency Department Triage for At-Risk Populations).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.1/31/2019
PS_008.1Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.a.i Integration of Primary Care and Behavioral Health Services).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.4/30/2018Phase III PCBH Project Implementation Summary

Phase III PCBH Collaborative Care Community Partners Toolkit

Phase III PCBH Co-Location Toolkit
PS_008.2Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.a.i Integration of Primary Care and Behavioral Health Services).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.7/31/2018
PS_008.3Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.a.i Integration of Primary Care and Behavioral Health Services).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.10/31/2018
PS_008.4Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.a.i Integration of Primary Care and Behavioral Health Services).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.1/31/2019
PS_009.1Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.b.i Evidence-Based Strategies for Disease Management in High-Risk /Affected Populations, Adults Only).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.4/30/2018Phase I and II CVD Community Partners Toolkit

Phase III CVD Community Partners Toolkit
PS_009.2Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.b.i Evidence-Based Strategies for Disease Management in High-Risk /Affected Populations, Adults Only).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.7/31/2018
PS_009.3Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.b.i Evidence-Based Strategies for Disease Management in High-Risk /Affected Populations, Adults Only).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.10/31/2018
PS_009.4Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.b.i Evidence-Based Strategies for Disease Management in High-Risk /Affected Populations, Adults Only).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.1/31/2019
PS_010.1Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.g.i Integration of Palliative Care into the PCMH Model).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.4/30/2018Phase III Pall Care Project Implementation Summary

Phase II Palliative Care Enhancing Care Team Skills Toolkit

Phase II Palliative Care Enhancing Care Team Skills Toolkit Appendices
PS_010.2Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.g.i Integration of Palliative Care into the PCMH Model).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.7/31/2018
PS_010.3Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.g.i Integration of Palliative Care into the PCMH Model).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.10/31/2018
PS_010.4Report the number of actively engaged patients based upon NYS DOH and PPS defined criteria. (3.g.i Integration of Palliative Care into the PCMH Model).Submit timely and accurate reports based on the defined criteria outlined in this Comprehensive Schedule B, see Section F2 below.1/31/2019
PS_011.1Submit documentation of at least thirty (30) completed Integrated Palliative Care Outcome Scale (IPOS) assessments for eligible primary care patients as detailed by OneCity Health Services. Provide documentation that demonstrates completion of at least thirty (30) IPOS assessments for eligible primary care patients.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018Phase III Pall Care IPOS Project Implementation Summary

Phase III Palliative Care into Primary Care IPOS Toolkit
PS_011.2Submit documentation of at least thirty (30) completed Integrated Palliative Care Outcome Scale (IPOS) assessments for eligible primary care patients as detailed by OneCity Health Services. Provide documentation that demonstrates completion of at least thirty (30) IPOS assessments for eligible primary care patients.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
PS_011.3Submit documentation of at least thirty (30) completed Integrated Palliative Care Outcome Scale (IPOS) assessments for eligible primary care patients as detailed by OneCity Health Services. Provide documentation that demonstrates completion of at least thirty (30) IPOS assessments for eligible primary care patients.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
PS_011.4Submit documentation of at least thirty (30) completed Integrated Palliative Care Outcome Scale (IPOS) assessments for eligible primary care patients as detailed by OneCity Health Services. Provide documentation that demonstrates completion of at least thirty (30) IPOS assessments for eligible primary care patients.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
PS_012.1Demonstrate that applicable uninsured patients were connected to primary care providers and/or insurance specialistsProvide documentation that reports total number of applicable uninsured patients connected to primary care providers and/or insurance specialists and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
4/30/2018Phase III Project 11 Toolkit
PS_012.2Demonstrate that applicable uninsured patients were connected to primary care providers and/or insurance specialistsProvide documentation that reports total number of applicable uninsured patients connected to primary care providers and/or insurance specialists and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
7/31/2018
PS_012.3Demonstrate that applicable uninsured patients were connected to primary care providers and/or insurance specialistsProvide documentation that reports total number of applicable uninsured patients connected to primary care providers and/or insurance specialists and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
10/31/2018
PS_012.4Demonstrate that applicable uninsured patients were connected to primary care providers and/or insurance specialistsProvide documentation that reports total number of applicable uninsured patients connected to primary care providers and/or insurance specialists and meet the quarterly target defined by OneCity Health.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B, see Section F2 below.
1/31/2019
PS_013Demonstrate implementation of formal referral workflows to screen and enroll uninsured patients who have been treated in the Emergency Department.Provide documentation that demonstrates implementation of workflow to screen and enroll uninsured patients who have been treated in the emergency department. This must be demonstrated for at least five (5) facilities

All documentation must be submitted by the specified due date as outlined in this Comprehensive Schedule B.
10/15/2018Phase III Project 11 Toolkit
QI_001.1Demonstrate implementation of and report progress on a quality improvement (QI) activity to address one (1) of the eligible measures indicated by OneCity Health related to primary care and behavioral health integration.
Identify one (1) QI activity and report the QI plan and baseline data for one (1) of the following indicators based on provider type:

For primary care providers:
-Antidepressant Medication Management; OR
-Screening for Clinical Depression and Follow-Up Plan; OR
-Initiation and/or Engagement of Alcohol and Other Drug Dependence Treatment.

For mental health providers:
-Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication; OR
-Diabetes Monitoring for People with Diabetes and Schizophrenia: OR
-Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.

For substance abuse treatment providers:
-Preventive care screening for physical health conditions (e.g. diabetes, cardiovascular disease, etc.); OR
-Linkage to primary care services; OR
-Management of physical health conditions (e.g. diabetes, cardiovascular disease, etc.).

Report performance against the baseline data and provide a progress update for the selected indicator.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018
Phase III PCBH Project Implementation Summary

Phase III PCBH Collaborative Care Community Partners Toolkit

Phase III PCBH Co-Location Toolkit
QI_001.2Demonstrate implementation of and report progress on a quality improvement (QI) activity to address one (1) of the eligible measures indicated by OneCity Health related to primary care and behavioral health integration.Identify one (1) QI activity and report the QI plan and baseline data for one (1) of the following indicators based on provider type:

For primary care providers:
-Antidepressant Medication Management; OR
-Screening for Clinical Depression and Follow-Up Plan; OR
-Initiation and/or Engagement of Alcohol and Other Drug Dependence Treatment.

For mental health providers:
-Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication; OR
-Diabetes Monitoring for People with Diabetes and Schizophrenia: OR
-Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.

For substance abuse treatment providers:
-Preventive care screening for physical health conditions (e.g. diabetes, cardiovascular disease, etc.); OR
-Linkage to primary care services; OR
-Management of physical health conditions (e.g. diabetes, cardiovascular disease, etc.).

Report performance against the baseline data and provide a progress update for the selected indicator.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
QI_001.3Demonstrate implementation of and report progress on a quality improvement (QI) activity to address one (1) of the eligible measures indicated by OneCity Health related to primary care and behavioral health integration.
Identify one (1) QI activity and report the QI plan and baseline data for one (1) of the following indicators based on provider type:

For primary care providers:
-Antidepressant Medication Management; OR
-Screening for Clinical Depression and Follow-Up Plan; OR
-Initiation and/or Engagement of Alcohol and Other Drug Dependence Treatment.

For mental health providers:
-Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication; OR
-Diabetes Monitoring for People with Diabetes and Schizophrenia: OR
-Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.

For substance abuse treatment providers:
-Preventive care screening for physical health conditions (e.g. diabetes, cardiovascular disease, etc.); OR
-Linkage to primary care services; OR
-Management of physical health conditions (e.g. diabetes, cardiovascular disease, etc.).

Report performance against the baseline data and provide a progress update for the selected indicator.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
QI_001.4Demonstrate implementation of and report progress on a quality improvement (QI) activity to address one (1) of the eligible measures indicated by OneCity Health related to primary care and behavioral health integration.Identify one (1) QI activity and report the QI plan and baseline data for one (1) of the following indicators based on provider type:

For primary care providers:
-Antidepressant Medication Management; OR
-Screening for Clinical Depression and Follow-Up Plan; OR
-Initiation and/or Engagement of Alcohol and Other Drug Dependence Treatment.

For mental health providers:
-Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication; OR
-Diabetes Monitoring for People with Diabetes and Schizophrenia: OR
-Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.

For substance abuse treatment providers:
-Preventive care screening for physical health conditions (e.g. diabetes, cardiovascular disease, etc.); OR
-Linkage to primary care services; OR
-Management of physical health conditions (e.g. diabetes, cardiovascular disease, etc.).

Report performance against the baseline data and provide a progress update for the selected indicator.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
QI_002.1Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to address Human Immuno Deficiency (HIV) screening and linkage to care.Review HIV screening assessment report and establish a QI plan based upon assessment results.

Report on HIV screening and linkage performance following provided performance indicators.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018Phase III HIV Project Implementation Summary

Phase III HIV Toolkit
QI_002.2Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to address Human Immuno Deficiency (HIV) screening and linkage to care.Review HIV screening assessment report and establish a QI plan based upon assessment results.

Report on HIV screening and linkage performance following provided performance indicators.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
QI_002.3Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to address Human Immuno Deficiency (HIV) screening and linkage to care.Review HIV screening assessment report and establish a QI plan based upon assessment results.

Report on HIV screening and linkage performance following provided performance indicators.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
QI_002.4
Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to address Human Immuno Deficiency (HIV) screening and linkage to care.Review HIV screening assessment report and establish a QI plan based upon assessment results.

Report on HIV screening and linkage performance following provided performance indicators.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
QI_003.1Demonstrate implementation of and report progress on one (1) quality improvement(QI) activity to address standardization of discharge planning for Congestive Heart Failure.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018Phase I and II CVD Community Partners Toolkit

Phase III CVD Community Partners Toolkit
QI_003.2Demonstrate implementation of and report progress on one (1) quality improvement(QI) activity to address standardization of discharge planning for Congestive Heart Failure.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
QI_003.3Demonstrate implementation of and report progress on one (1) quality improvement(QI) activity to address standardization of discharge planning for Congestive Heart Failure.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
QI_003.4Demonstrate implementation of and report progress on one (1) quality improvement(QI) activity to address standardization of discharge planning for Congestive Heart Failure.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
QI_004.1Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to increase statin use amongst applicable patient population.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018Phase I and II CVD Community Partners Toolkit

Phase III Community Partners Toolkit
QI_004.2Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to increase statin use amongst applicable patient population.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
QI_004.3Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to increase statin use amongst applicable patient population.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
QI_004.4Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to increase statin use amongst applicable patient population.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019
QI_005.1Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to improve follow up after hospitalization for mental illness.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
4/30/2018
Phase III Care Transitions Project Implementation Summary

Phase III Care Transitions TMT Medical Floors Toolkit

Phase III Care Transitions TMT Psychiatry Floor Toolkit
QI_005.2Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to improve follow up after hospitalization for mental illness.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
7/31/2018
QI_005.3
Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to improve follow up after hospitalization for mental illness.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
10/31/2018
QI_005.4Demonstrate implementation of and report progress on one (1) quality improvement (QI) activity to improve follow up after hospitalization for mental illness.Identify one (1) QI activity and report the QI plan and baseline data for the intended cohort.

Report performance against the baseline cohort data and provide a progress update.

All documentation must be submitted by the specified due dates as outlined in this Comprehensive Schedule B.
1/31/2019