PCMH Clinical Quality Improvement and Sustainability Learning Collaborative

Thank you to our partners who joined us earlier in October for our fifth and final Patient-Centered Medical Home (PCMH) Learning Collaborative, focused on Clinical Quality Improvement and Sustainability.

Our engaging facilitators discussed a variety of key concepts related to clinical quality improvement (QI) and how it can help our partners’ practices achieve NCQA PCMH 2014 recognition. Attendees also gained hands on experience developing QI goals to support their practice’s QI activities, which can also help them fulfill Phase II cardiovascular disease management and asthma home-based self-management metrics.

Thank you as well to our partners who joined us as guest speakers: Marion Walters and Sandra Gordon, both of Children’s Aid; Finn Brigham of Callen Lorde; and Renee McConey of The Door, University Settlement.

The following materials from the Learning Collaborative are available for download:

Resources from all our past PCMH Learning Collaboratives are available here.

Partnership in Care Asthma Webinar Now Available to View

In this presentation, we discussed how a partnership between the primary care team and community health worker is essential for effective asthma management for children with asthma. Moreover, we highlighted how asthma self-management education improves patient outcomes, as community health workers utilize a written Asthma Action Plan tailored to the needs and literacy levels of the patient to reinforce patient education provided by the clinical team.

Click here to view the slides or view the full webinar below.

OneCity Health Launches City-wide Program to Better Treat Kids with Asthma and Reduce Avoidable Hospitalizations

NYC Health + Hospitals/OneCity Health today announced the launch of a population health and care management program designed to reduce hospitalizations among New York City children who suffer from frequent or severe asthma attacks. The home-based environmental management program assigns community health workers to visit homes to identify asthma triggers, reinforce strategies to help patients and their families maintain control over asthma, and supply free pillow cases, special cleaning supplies, and professional pest control services as needed.

OneCity Health—a subsidiary of NYC Health + Hospitals focused on population health, care management, and implementation of the State’s Delivery System Reform Incentive Payment (DSRIP) program—is aligning the public health system and its community partners, having already completed its first 500 home assessments, with plans to expand the program to hundreds more children and families this year.

“Asthma is the third-leading cause of hospitalization among children under the age of 15 in the United States, and oftentimes it’s because families may not understand how to reduce triggers or may struggle to address underlying determinants of health, such as substandard housing conditions,” said Dr. Luis Rodriguez, Chief of Pediatrics at NYC Health + Hospitals/Woodhull. “Controlling asthma requires getting to the root of the issue, including triggers in the home, and ensuring patients have access to the proper medications.”

“Through these transformation initiatives, which were enacted through the DSRIP program, we are connecting primary care physicians with community health workers and home remediation services, helping professionals across these organizations work together to care for patients with asthma,” said Andrew Kolbasovsky, Chief Program Officer, OneCity Health. “Our goal is to improve the quality of life for affected children, making sure they don’t miss school or avoid physical activity due to their asthma. That begins with creating a care plan focused on prevention, making sure patients don’t need to come to the emergency department or spend the night at the hospital because of asthma attacks.”

“Community partners and community health workers are essential to engaging patients,” said Janise Germosen, LMSW, Community Health Worker Supervisor and Social Work Care Manager at Asian Community Care Management, a OneCity Heath community partner. “We know our communities well and have done outreach before, so patients are more comfortable allowing us into their homes, which is an important element of support in the program.”

The home-based environmental management program for children with asthma is run by the following OneCity Health partners:

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The program’s initial focus is on pediatric patients with poorly controlled asthma, defined as overuse of “rescue” medications, use of systemic corticosteroids two or more times in the last six months, two or more asthma-related emergency department visits in six months, or hospitalization related to asthma in the past year. Program data will be tracked, including the impact on the proper use of medication and reduction in asthma-related hospitalizations, both DSRIP priorities.

After identifying a patient with frequent or severe asthma attacks, the primary care team develops an Asthma Action Plan and refers the patient to a community health worker. The community health worker meets with the patient and reinforces recommendations from the clinical team, including self-monitoring strategies and instructions on the correct use of medications. In addition, the community health worker conducts a home visit to evaluate the environment for asthma triggers, such as rodents, pests, mold, and dust. Based on the assessment, the community health worker can provide pillow cases and cleaning supplies, instruct families in home-cleaning strategies, and engage with the New York City Department of Health & Mental Hygiene—OneCity Health’s partner providing professional cleaning and pest management—at no cost to the patient.

Community health workers ensure that patients and their families are adhering to the Asthma Action Plan on an ongoing basis, through both home visits and phone calls. The community health workers also communicate with each patient’s clinical care team, using care management software to document interventions and receive alerts when patients are in the hospital.

Partner Webinar: Completing the Phase III Contracting Survey & Highlighting our Asthma Initiatives

Thank you to our partners who attended today’s OneCity Health Partner Webinar: Completing the Phase III Contracting Survey & Highlighting our Asthma Initiatives.

For our partners who were unable to view the webinar, the slides are available to view here.

As discussed on the webinar:

Our partners should keep in mind next steps:

We look forward to continuing to engage with our partners on future webinars.

Agenda for August 8 Partner Webinar

On Tuesday, August 8, we are hosting our next monthly OneCity Health Partner Webinar.

As a reminder, on these webinars we intend to further assist partners in understanding Comprehensive Schedule B requirements, discuss practical steps for project execution and reporting, and highlight best practices. Moreover, throughout Phase II, we expect to focus more on educational topics and begin to showcase how we are collectively meeting various outcomes.

The agenda for Tuesday’s webinar is:

  • Final Phase I reminders
  • Upcoming Phase II deadlines
  • Completing the Phase III Contracting Survey
  • Highlighting OneCity Health’s Expansion of Asthma Home-Based Self-Management Program
  • Final reminders

Here is how to join:

Tuesday, August 8th, from 2:00 p.m. – 3:30 p.m. EST
WebEx Meeting Link: click here
Audio Connection: 1-877-428-9139
Access Code: 2535398#

Partner Webinar: HIV, RHIO Connectivity and Training to Support Implementation

Thank you to our partners who attended today’s OneCity Health Partner Webinar: HIV, RHIO Connectivity and Training to Support Implementation.

We apologize for the technical difficulties, and appreciate your patience as we attempted to work through them. For our partners who were unable to view the webinar, or were unable to connect to the revised dial-in, the slides are available to view here.

If we are able to use a recording of the webinar, it will be embedded here as soon as it is available.

Our partners should keep in mind next steps:

  • Due July 14, 2017: PM002.1 (skilled nursing services), and PM022.1 (Integrated Palliative Care Outcome Scale assessments)
  • July 17: Listening session on changing healthcare landscape in Queens. Registration details are on our website
  • July 21: Listening session on changing healthcare landscape in the Bronx. Registration details are on our website
  • July 26: Listening session on changing healthcare landscape in Manhattan. Registration details are on our website
  • July 27: Listening session on changing healthcare landscape in Brooklyn. Registration details are on our website
  • Due July 27, 2017: PM003.1 and PM012.1 (asthma) and PM010.1 and PM011.1 (Care Transitions)
  • Due July 27, 2017: Seven Patient Engagement Metrics
  • Due July 31, 2017: PM005.1 (HIV)
  • August 7, 2017: Last day for our partners to remediate Phase I metrics and earn the money associated with those metrics in their Phase I Comprehensive Schedules B
  • August 8, 2017: Attend our next monthly OneCity Health Partner Webinar. The webinar will be held from 2 – 3:30 p.m. Details are on our website Events Calendar
  • Due August 15, 2017: PM016 (NPI Survey) and PM029 (Phase III Contracting Survey) – all partners are required to complete these

In addition, if our partners are interested in learning more about our HIV resources, such as the HIV Coalition, we recommend they reach out to our support desk.

We look forward to continuing to engage with our partners on future webinars.

Serving the Patients We Do Not See

“When [marginalized patients] do seek care, it is sporadic,” describes Dr. Dave Chokshi, Chief Population Health Officer, OneCity Health. “They may show up in the Emergency Room (ER), but not to a primary care follow-up appointment. If an ensuing phone call goes unanswered, or their phone is out of service, we label them as ‘lost to follow-up’ and move on to the next patient on the list.”

In his article “The Patients We Do Not See,” recently published by The Conversation, Dr. Chokshi questions the role of the health care system in treating patients who may be sick but don’t seek care.

From social isolation, to the current political climate, to the barriers the health care system itself erects, Dr. Chokshi walks through potential reasons that people don’t actively seek care. One of the most unfortunate aspects, notes Dr. Chokshi, is that the most marginalized patients are those with the greatest unmet needs.

Emphasizing a public health mindset, and moving the locus of accountability for health further into communities, is one solution favored by Dr. Chokshi. Through our transformation initiatives, OneCity Health is actively linking patients to primary care and social services, conducting home visits to kids with asthma and transitioning patients to the community following a stay in the hospital. However, we also need to take the next step, as it is also necessary “to equip patients to be better stewards of their own health,” says Dr. Chokshi.

“Sometimes this involves health care providers, sometimes not. While physicians can’t do it alone, we can lend our voices to those calling for greater outreach, less stigma and protection of the most vulnerable.”

Read the full article here.

PACE at NYC Health + Hospitals/Elmhurst Highlights Ongoing Asthma Trainings

Since launching Physician Asthma Care Education (PACE) trainings last December, we’ve helped align clinical staff and community health workers around key elements of basic asthma care, including asthma severity classification, asthma control, and appropriate treatments. These efforts are critical to reducing the health effects of asthma on children and their families.

To date, we’ve coordinated nearly 20 PACE trainings for well over 300 clinical staff. Participants have found the sessions educating and engaging, and we appreciate the energy they bring to each training. Following one recent session, one participant noted that she will begin to, “apply an Asthma Control Test (ACT) score [to patients] to evaluate their asthma severity, inhaler teaching and proper counseling.” Other participants noted their plans to begin enforcing Asthma Action Plans and planning more regular meetings with fellow physicians to track the overall effectiveness of their asthma programs.

Dr. Randall Brown, Director and Co-author of Physician Asthma Care Education (PACE), recently led a training for physicians, nurses and other clinical staff at NYC Health + Hospitals/Elmhurst

PACE is an interactive, multi-media educational seminar that improves physician awareness, ability, and the use of communication and therapeutic techniques for patients with asthma. The training also provides supplemental asthma clinical practice instruction for our clinical partners and their office staff on how to efficiently and consistently enhance asthma quality improvement measures.

PACE trainings provide clinical staff with educational strategies and tools that can easily be introduced into their practices, replacing less effective behaviors

We will continue to schedule PACE trainings in the coming months. For our partners that are implementing our home-based self-management asthma initiative, completing PACE training is a Phase II process metric.

Asthma Webinar Recap: Identifying and Addressing the Root Causes of Exacerbations

Thank you to everyone who attended our March 20, 2017 webinar “Asthma Exacerbations: Identifying and Addressing the Root Causes”.

In this presentation we discussed the important role of community health workers (CHWs) and other health care workers in helping patients who have had an asthma exacerbation. During the webinar, we detailed:

  • Why asthma exacerbations occur
  • The role of a CHW in identifying and addressing root causes of asthma
  • How CHWs can use alerts in the GSI software program to find out when a patient with asthma was in the hospital or emergency department

Miss the webinar? The slides are available to view here.

You can also view a recording of the webinar here. We will embed it below soon.

Upcoming Asthma Webinar: Identifying and Addressing the Root Causes of Exacerbations

Asthma is the third leading cause of hospitalization among children under the age of 15 in the United States, often times because families may not understand how to reduce triggers. So how can we help reduce the number of asthma attacks?

Please join OneCity Health for a webinar on March 20, 2017 entitled “Asthma Exacerbations: Identifying and Addressing the Root Causes” where we will discuss how community health workers (CHWs) and other health care workers can best help patients who have had an asthma exacerbation.

Dr. Luis Rodriguez, Chief, Department of Pediatrics, NYC Health + Hospitals/Woodhull and Elvira Fardella-Roveto, MSN, FNP, Home Care Director, St. Mary’s Healthcare System for Children will join us on the webinar to discuss:

  • Why asthma exacerbations occur
  • How CHWs are identifying and addressing the root causes of asthma
  • How CHWs can use alerts in the GSI software program to find out when a patient with asthma was in the hospital or emergency department

Participants will be able to ask questions via the chat function during the webinar. For our partners who cannot attend live, this webinar will be recorded and posted to our website.

Here is how to join the webinar:

Monday, March 20, from 3 p.m. – 4 p.m. EST
WebEx Meeting Link: click here
Audio Connection: 1-855-282-6330 US TOLL FREE
Access Code: 737 673 960

About the Presenters
Luis Rodriguez, MD, FAAP, Chief, Department of Pediatrics, NYC Health + Hospitals/Woodhull
As Chief of NYC Health + Hospitals/Woodhull’s Department of Pediatrics, Dr. Rodriguez is responsible for overseeing the complete range of services the hospital provides to younger patients. He is particularly concerned with efforts to increase wellness and manage chronic conditions – such as asthma – that are having a devastating impact on our communities. Dr. Rodriguez has served in several leadership roles in the American Lung Association at the city, state, and regional levels. He has volunteered with the Open Airways in School Program which teaches New York City elementary school children with asthma about their disease, and in the “Rostros de la Gripe” campaign encouraging the Hispanic community to get their annual influenza vaccine.

Elvira Fardella-Roveto, MSN, FNP, Home Care Director, St. Mary’s Healthcare System for Children
Ms. Fardella-Roveto, has been with St. Mary’s Healthcare System for Children for over seven years, serving as Director of Professional Services & Home Care Administrator. In her role, Ms. Fardella-Roveto oversees all aspects of the Special Needs Certified Home Health Care Agency, which helps families care for their special needs child at home. Her additional responsibilities include ensuring the provision of quality care to clients and families, managing a staff of skilled professionals and maintaining compliance with Department of Health regulations. Ms. Fardella-Roveto has an extensive background in healthcare, having held positions in various healthcare settings. She has experience with private duty and high tech nursing, case management, community health, and education.

OneCity Health Partner Reporting Manual Version 3.0 Now Available

To assist our partners with completing all remaining metrics that are included in their Schedules B for DSRIP Year Two (DY2, which runs through March 31, 2017), we have developed Version 3.0 of the OneCity Health Partner Reporting Manual.

The updated manual replaces Version 2.1 and reflects the following updates:

  • How to report on the remaining Comprehensive Schedule B metrics due in the fourth quarter of DY2 (through March 31, 2017)
  • Reporting requirements for three additional distinct Schedules B (Asthma Community Health Worker, Cultural Competence & Health Literacy [CCHL] Organizational Self-Assessment, CCHL Focus Group Facilitation)
  • Additional reporting instructions for both the Health Home At-Risk and Care Transitions Amendment Schedules B, which were included in the previous version of the manual

Page one (1) of the manual includes a summary of the updates in this version, including specific page numbers of updated content.

We will further discuss the updated OneCity Health Partner Reporting Manual and upcoming reporting requirements with our partners on tomorrow’s OneCity Health Partner Webinar.

Click here to download version 3.0 of the OneCity Health Partner Reporting Manual.