CMMI Staff Event Highlights Program Success, Next Steps for ED Triage

Following treatment in the Emergency Department (ED), we can better meet the health needs of some patients through improved care coordination and a variety of other resources. Ranging from primary care follow-up appointments to care management services for patients with ambulatory care sensitive conditions, these programs can also help prevent unnecessary return visits in the future.

Through a Center for Medicare & Medicaid Innovation (CMMI) grant, teams of registered nurses (RNs), community liaison workers, physician advisors and pharmacists began providing similar support in six NYC Health + Hospitals facilities in September 2014. This program resulted in a steady decrease in ED revisits within 30 days of discharge over the course of the intervention period, and highlighted the need to include a social work component to better address patients’ social determinants of health. In May, CMMI staff gathered for an afternoon of training, team-building activities and a discussion on the success to date, lessons learned and next steps.

CMMI staff engage in a team-building activity, attempting to balance a marshmallow using just dry pasta, tape and string

We plan to apply the findings under this grant regarding patient impact and quality outcomes to OneCity Health’s ED Care Management initiatives, through which we will focus on the highest-needs, highest-utilizing patients instead of all patients with ambulatory care sensitive conditions. Staff will continue to connect patients to primary care, while standardized workflows will help them to better identify providers with capacity, as well as other appropriate outpatient services. Their work will also include developing patient care plans, follow-up phone calls and, when appropriate, home visits, as well as medication reconciliation coordinated through the pharmacist and linking patients to community care management.

Madeline Rivera, RN, MS, CCM, Executive Director, Care Management, OneCity Health, leads a discussion on care management and how it will be incorporated into the Emergency Department

In addition to connecting patients to primary care, ED staff can also refer patients to care management services such as NYC Health + Hospitals/At Home, which includes primary care-care management, and our Health Home At-Risk program. Patients will also be linked to OneCity Health partners who provide community support, such as helping patients adhere to their treatment plan and other follow-up services.

OneCity Health partner 1199 SEIU facilitated an interactive care management training at the event, focused on identifying and addressing patient’s social determinants from the Emergency Department

Thank you to our CMMI teams for their enthusiasm and participation at our recent event. We look forward to building off their success and expanding our support for patients in the comings months.

Care Management Trainings Improve Team Communication and Patient Care

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.

Care coordinators practice motivational interviewing techniques, including open-ended questions, affirmations and reflections. The session was led by Jennifer Nasisi from 1199TEF
Care coordinators practice motivational interviewing techniques, including open-ended questions, affirmations and reflections. The session was led by Jennifer Nasisi from 1199TEF

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.”

Care coordinators from NYC Health + Hospitals/At Home, Village Care, Arch Care, Community Healthcare Network and many of our other partners completed a care management training
Care coordinators from NYC Health + Hospitals/At Home, Village Care, Arch Care, Community Healthcare Network and many of our other partners completed a care management training

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.

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.

OneCity Health Partner Reporting Manual Version 2.1 Now Available

To assist our partners as they continue to complete metrics, we have developed Version 2.1 of the OneCity Health Partner Reporting Manual.

This updated manual replaces Version 2.0 and reflects the following updates:

  • Additional guidance for all Comprehensive Schedule B metrics due December 31, 2016
  • New guidelines on distinct Schedules B, including Health Home At-Risk (HHAR) and Care Transitions Amendment
  • New general reporting guidance; our partners can now answer questions directly through the OneCity Health Partner Portal rather than downloading excel templates for some metrics
  • Updated information on how to resubmit reports

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

Version 3.0 of this manual, with all remaining metrics, including those for distinct Schedules B, will be issued in early 2017.

We will further discuss the updated OneCity Health Partner Reporting Manual and upcoming reporting requirements with our partners on our next OneCity Health Partner Webinar on December 13.

Click here to download version 2.1 of the OneCity Health Partner Reporting Manual.

Coordinating and Integrating Patient Care with GSI

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.

Entering DSRIP Demonstration Year Two

Thank you to everyone who attended our Project Advisory Committee (PAC) meetings last month in one of the four borough-based hubs, as well as those who completed the pre-PAC survey. For those who couldn’t attend, you can view the presentation here. If you did attend one of the recent meetings, please complete this optional post-PAC meeting survey. We value your feedback and use it to shape the agenda at future PAC events.

At both the meetings and in the pre-PAC survey, you emphasized a desire to learn more about Delivery System Reform Incentive Payment (DSRIP) program implementation and funds flow. Since we just concluded DSRIP Demonstration Year One (DY1, April 1, 2015 – March 31, 2016), we feel this is an appropriate time to review our recent milestones and what is on the horizon regarding these two topics.

Project Implementation: We successfully administered over 11,000 Patient Activation Measure (PAM®) surveys as part of Project 11. Over the next 12 months we have committed to administering 55,000 PAM® surveys and in linking at least that many people to high quality care. We are confident that in collaboration with NYC Health + Hospitals and our community partners we can meet this goal.

In addition, we are also proud to announce that we surpassed our initial goal for our palliative care project, as we successfully engaged over 500 patients with simple advance care planning in the primary care setting. This was just the first wave; moving forward, we’ll continue to implement additional interventions with our community partners aimed at ensuring our patients’ symptoms and advanced illnesses are appropriately managed in the primary care setting.

We have also initiated pilots for multiple other DSRIP clinical projects: 1) ED Care Triage, which begins the effort to connect patients with primary care from the Emergency Department; 2) Care Transitions, for which our goal is to provide a supportive transition to the community for patients who were admitted to the hospital and reduce readmissions; and 3) Health Home At-Risk planning, in which the objective is to extend care management services equivalent to the NYS Health Home program.

You can review the care model webinars on these clinical projects here.

Funds Flow: On April 4, we launched the Master Partner Data Survey to finalize our funds flow. If your organization has signed a Master Services Agreement (MSA) and provides clinical and social services, regardless of whether you bill for Medicaid, then your organization should have received the Data Survey. Please contact us immediately if you believe you should complete the Data Survey. Once it is complete, we will develop a more encompassing Schedule B for your organization, which will detail project deliverables and payments.

Expect more information in the coming weeks on project status and implementation as we advance into DSRIP Demonstration Year Two (DY2, April 1, 2016 – March 31, 2017). As always, if you have feedback or questions, please feel free to email us at DSRIPSupport@nychhc.org.

OneCity Health Care Models Webinar – Health Home At-Risk

The goals of the Health Home At-Risk (HHAR) project are to:

  • Extend care management services equivalent to Health Homes to patients who have one chronic disease and are at risk of worsening health
  • Facilitate communication and coordination between primary care practices and Health Homes
  • Enhance the integration of social services into primary care, drawing on Health Home capabilities and our Performing Provider System (PPS) network
  • Please join this Webinar to learn more.

    Monday, April 4th from 2 p.m. – 3 p.m. EST
    WebEx Meeting Link: click here
    Audio Connection: 855-282-6330 US TOLL FREE
    Access Code: 730 326 790

    Upcoming Care Models Webinars

    We will be presenting our care models during upcoming Webinars. See below for the schedule, and please feel free to email us at DSRIPSupport@nychhc.org with any questions.

    OneCity Health Care Models Webinar – Care Transitions


    The goal of the Care Transitions project is to reduce 30-day readmissions by means of a supported transition period for patients at high risk of readmission. Please join this Webinar to learn more.

    Monday, March 28th from 2 p.m. – 3 p.m. EST
    WebEx Meeting Link: click here
    Audio Connection: 855-282-6330 US TOLL FREE
    Access Code: 737 739 564

    OneCity Health Care Models Webinar – Health Home At-Risk


    The goals of the Health Home At-Risk (HHAR) project are to:

  • Extend care management services equivalent to Health Homes to patients who have one chronic disease and are at risk of worsening health
  • Facilitate communication and coordination between primary care practices and Health Homes
  • Enhance the integration of social services into primary care, drawing on Health Home capabilities and our Performing Provider System (PPS) network
  • Please join this Webinar to learn more.

    Monday, April 4th from 2 p.m. – 3 p.m. EST
    WebEx Meeting Link: click here
    Audio Connection: 855-282-6330 US TOLL FREE
    Access Code: 730 326 790

    OneCity Health Care Models Webinar – ED Care Triage


    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

    OneCity Health Care Models Webinar – Integration of Primary Care and Behavioral Health Services


    This project will disseminate three models of integrated care in the OneCity Health network of primary care and behavioral health services. Please join this Webinar to learn more.

    Monday, April 18th from 2 p.m. -3 p.m. EST
    WebEx Meeting Link: click here
    Audio Connection: 855-282-6330 US TOLL FREE
    Access Code: 730 262 548

    Introducing Health Home At-Risk

    OneCity Health has launched the Health Home At-Risk project to expand access to care management services to patients who do not qualify for services under the New York State Department of Health (NYS DOH) Health Home program.

    To understand the Health Home At-Risk project, it is important to first explain what a Health Home is: a Health Home is a care management service designed by the NYS DOH that focuses on the needs of patients with multiple chronic illnesses. In the Health Home program, all of an individual’s caregivers communicate with one another with the goal of addressing a patient’s medical and social needs in a comprehensive manner. You can read the NYS DOH Health Home requirements here.

    In the Health Home, the work of identifying a patient’s medical and social needs and coordinating care is performed primarily by a Health Home Care Manager, a professional who oversees and organizes access to all of the services an individual needs to assure that they receive everything necessary to stay healthy within the community. If this service is provided effectively, New Yorkers will have less need to visit the Emergency Department and may be admitted less frequently to the hospital.

    We know there are many patients who have significant medical and social care needs, and the Health Home At-Risk project will help us to meet New Yorkers’ needs by expanding access to care management services. In this project, these patients are initially known to have a single chronic disease and appear to have declining health and increasing health care needs.

    We believe that professionals who work within the existing Health Home program have a good level of expertise and can also take care of the population of patients who need care management services, but do not qualify for the NYS DOH Health Home. Within the OneCity Health Performing Provider System (PPS), we have four Health Home lead agencies, and we recently shared a Project Participation Opportunity (PPO) with them in order to learn their interest in extending outreach and care management services to these patients. The full PPO can be read here.

    In order to reach our goal of providing care management services to those who need it, but do not qualify for a Health Home, our initial steps will be to strengthen the link between primary care teams and those Health Home professionals who will now extend care management and coordination services to an expanded population of patients. We believe that this action is one of many that may be effective in helping to improve the identification – and addressing of – the social determinants of health.

    OneCity Health partner organizations that are interested in providing care management and coordination services under this Health Home At-Risk project must be contracted with one of the four lead Health Homes within the PPS. They are:

  • NYC Health + Hospitals
  • Community Healthcare Network (CHN)
  • Community Care Management Partners (CCMP)
  • Coordinated Behavioral Care (CBC)

    OneCity Health partner organizations that provide Health Home care management services, but are not currently working with one of the four Health Home lead agencies, should contact one of the four Health Home lead agencies directly to initiate contracting. Contact information can be found here.

    Questions or concerns regarding this Project Participation Opportunity should be sent to DSRIPSupport@nychhc.org with the subject line “Health Home At-Risk”.