“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.”
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.
“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.”
Enhancing care management, which includes improving staff communication and leveraging available resources to better coordinate an individual’s and family’s comprehensive health needs throughout the continuum of care, is essential to improving patient care. OneCity Health recently launched a series of trainings for our partners’ care management staff to reach this goal.
To kick off the series, earlier this month we held a two-day training session focused on motivational interviewing. Led by our partner 1199 Training & Employment Fund (TEF), participants learned techniques to assist patients with the prevention and self-management of chronic diseases. Future trainings will focus more specifically on care coordination and working within a medical team, and care plan documentation.
Our initial participants quickly embraced the training, as one noted that the session taught her to, “listen more and have a person-centered approach,” while another learned that to maximize patient outcomes, he needs to, “be more conscious of what I say and the way I talk to my patients.”
For our partners implementing Health Home At-Risk, Care Transitions, and ED Care Triage transformational efforts, we will hold sessions from January through March to ensure their care coordinators are trained. Please make sure to register and attend trainings as we make them 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.
The following article appeared in the December 27, 2016 edition of the NYC Health + Hospitals Insider, and highlights our initial care transitions work at our largest partner.
Anthony*, a young man struggling with mental illness and a family history of mental health problems, found himself hospitalized again and again with no one to lean on.
Mercedes*, a woman in danger of going blind, skipped medical appointments and wouldn’t pick up the phone to get care although her potential blindness could be prevented.
These stories represent real-life cases of patients at a number of hospitals in the NYC Health + Hospitals system whose complex medical, emotional, and socio-economic conditions put them at risk of repeated hospitalizations that can be avoided.
But thanks to a new Transition Management Team – part of the Delivery System Reform Incentive Payment (DSRIP) program – many high-risk patients under our care will receive the extra care coordination and attention they need to help improve their health and stay out of the hospital.
“We’re introduced as part of the team at the bedside so that the patient understands from day one that we are on their side,” explains Nyasha Cupid, RN, BSN, Care Manager at NYC Health + Hospitals/Kings County.
Cupid developed a deeper and more meaningful rapport with Anthony and soon became a trusted advisor. She quickly learned the real reason Anthony was not taking his medications: he was experiencing negative side effects and had trouble paying for prescriptions.
Cupid joined Anthony at doctors’ appointments and navigated the system to find a way to help him pay for his medication. With his mental health condition in check, Anthony is now stable, staying out of the hospital, taking his meds, keeping his doctors’ appointments, and looking for a job.
“The Transition Management Teams are filling a unique role and really taking the baton in terms of caring for these patients,” says Dr. Douglas Bails, Chief of Medicine, NYC Health + Hospitals/Bellevue, “We’re seeing patients who had previously been admitted multiple times now staying home and out of the hospital.”
The new teams, now in place at NYC Health + Hospitals/Kings County and NYC Health + Hospitals/Bellevue, create comprehensive plans for patients who are at a high risk of readmission. Consisting of a nurse, a social worker, and a community liaison, each team educates the patient about their health care needs and care plans, explains medications and helps secure them, ensures that the patient attends their follow-up appointments, and addresses social barriers or needs that arise.
So far, the program has served nearly 600 individuals at the two patient care sites. Similar teams will soon be in place at additional NYC Health + Hospitals facilities.
For Mercedes, the team created an intervention plan that included a home visit.
“When we went to her home and explained that our job is to keep her healthy and nothing else — she started to trust us,” says Nancy Aponte, RN, BSN, Care Manager, NYC Health + Hospitals/Bellevue.
It turned out that Mercedes had a low level of health literacy and didn’t fully understand what to do to prevent blindness. She also received an expensive medical bill and was afraid to seek treatment, worried that someone would try to collect the money that she simply did not have.
Aponte worked with the finance department and helped Mercedes to re-enroll in health insurance to cover all her basic needs. Mercedes is on the right track now and tending to her medical care.
“She even called to thank us and sounded excited. I’m sure that was a new lease on life,” says Aponte. “Each of these cases serve as a constant reminder that what one person may see as a few simple steps to take charge of their health can feel like an insurmountable barrier to someone else.”
Five Comprehensive Schedule B metrics are due on December 31, 2016 and five additional Patient Engagement metrics are due on January 15, 2017. For partners required to complete these metrics, they are now available to complete and submit on the OneCity Health Partner Portal
Partners who have attended GSI training for the Care Transitions or Asthma clinical projects can now report this information and invoice for payment through the OneCity Health Partner Portal
Pediatric clinical providers participating in the Asthma clinical project should contact our support desk to let us know whether they want information about OneCity Health’s PACE training offerings or plan to hold their own PACE training
Continue to attend monthly OneCity Health Partner Webinars. Our next one will be January 10, 2017
On our July 13th OneCity Health Partner Webinar, participants asked for additional background on GSI, a care coordination and management solution platform, which is mentioned in our partners’ Comprehensive Schedules B. The OneCity Health Reporting Manual, which will be sent to our partners on August 1, contains a detailed description of GSI and how it will be utilized across our Performing Provider System (PPS). Prior to reading the manual though, the following overview can help our partners become more familiar with GSI and how it will help standardize care within our network.
GSI is shorthand for GSIHealthCoordinator, and is software that we are utilizing to better coordinate and integrate patient care. It is free for our partners, and we will soon host trainings to ensure they are comfortable utilizing it. As a reminder to our partners, we provided guidance this week on how to provide a list of people to OneCity Health that will require training in GSI. Our partners should complete this metric on the OneCity Health Partner Portal by July 31.
The software allows us to establish interdisciplinary care teams and build an individualized care plan for each patient based on his or her medical, behavioral and social needs across DSRIP projects. In addition to tracking the number of patients engaged by one of our partner organizations, this care plan will be accessible to the entire team for quick access to relevant information in real time. A GSI patient dashboard also allows for direct, secure communication between providers. For Care Transitions, Health Home At-Risk and other DSRIP projects to be successful, it is essential that we share and collaborate on patient care plans. GSI will help facilitate this communication.
In the first of a series of articles featuring OneCity Health partners, we highlight Community Healthcare Network and their role within the OneCity Health Performing Provider System (PPS). Elizabeth Howell, Vice President of Development and Public Relations at Community Healthcare Network, currently sits on the OneCity Health Executive Committee, and Elizabeth DuBois, Associate Vice President of Medical Affairs, is a member of the Care Models Committee.
Community Healthcare Network (CHN) began in the 1970’s with a focus on family planning and later HIV care. Over the last decade, the network of 11 Federally Qualified Health Centers (FQHCs) has prioritized bringing primary care to underserved communities throughout Brooklyn, the Bronx, Queens and Manhattan. An important component of their strategy has been to collaborate with other organizations, so when New York State launched Delivery System Reform Incentive Payment (DSRIP), CHN saw it as a natural fit.
“DSRIP really forces us all to communicate with one another,” notes DuBois, “it enables us to be a team and provide better care to our patients.”
Because of a shared commitment to underserved patients and improving access to care, CHN joined the OneCity Health Performing Provider System (PPS) and has contributed clinical and strategic advice to DSRIP program planning. Forming a PPS and laying the groundwork for transformation in healthcare takes careful thought and consideration, and both DuBois and Howell helped in a variety of key areas, including project design, data collection and governance structures.
Moving forward, the role of CHN will only become more prominent.
CHN is also poised to help ensure patients remain cared for in their communities.
DuBois said, “By removing silos and aligning with OneCity Health and other partners in the PPS, we can continue to tap into one another’s resources and share best practices, all of which ultimately helps improve the way we deliver care to patients and reduces unnecessary visits to the hospital.”
For patients who require extra support when leaving the hospital, OneCity Health recently conducted an initial training for our first group of interdisciplinary Transition Management Teams. These teams work closely with hospital staff to create a comprehensive plan for our patients who are at a high risk of returning to the hospital within weeks of leaving. Pilots for our Care Transitions project, which we previously detailed, occur within the inpatient setting of four OneCity Health partner hospitals.
The Transition Management Team visits a patient identified by the inpatient care team while he or she is still in the hospital and determines if the patient could benefit from additional support over the critical 30 days following discharge. Support may include calling patients within 48 hours of leaving the hospital, assisting them with obtaining medications or ensuring follow-up occurs with a physician. The Transition Management Team also identifies and refers patients for any longer-term care management needs.
For our Transition Management Teams to be successful, it is essential for hospital staff to identify and refer patients who require extra support to stay healthy after leaving the hospital. Additionally, we need to strengthen the provider network that supports our patients’ transitions from the hospital to the community. As our pilot efforts mature, we will begin to incorporate our community partners into this work.
We will discuss the referral criteria in more detail soon. If you have questions in the meantime, please email DSRIPSupport@nychhc.org with the subject line “Care Transitions”.
The goals of the ED Care Triage project are to strengthen primary care linkage for patients presenting to the Emergency Department (ED), and to support transitions to outpatient services for high-risk patients by means of ED transitions management. Please join this Webinar to learn more.
Monday, April 11th from 2 p.m. – 3 p.m. EST WebEx Meeting Link: click here Audio Connection: 855-282-6330 US TOLL FREE Access Code: 735 676 794