Working to End the HIV Epidemic through Collaborative Routine Screening and Rapid Linkage to Care

When looking at the US cities with the largest population of people living with HIV, it is striking to see that New York City has more people with HIV than the next four cities combined. Despite this serious situation, NYC has made tremendous progress to date, and continues to move closer to ending epidemic levels of HIV in our communities.

HIV screening and linkage to care are critical to success, and OneCity Health’s work is focused on strengthening the existing systems within our network to ensure that we identify the people who are HIV positive and link them efficiently and effectively into life-saving HIV care.

For our OneCity Health partners implementing HIV initiatives during Phase II, our work focuses on a review of our HIV screening and testing efforts, and success with tracking linkage to care. The resources we’ve developed, and continue to develop, can assist our partners with meeting these objectives.

The HIV Assessment Survey, due from OneCity Health HIV partners in late September, will provide a brief assessment for clinical sites to ensure their compliance with New York State law requiring the routine offer of HIV screening to all patients 13 and over. For non-clinical sites, this assessment seeks to capture information on current testing efforts and desire to expand the services offered. The data we receive will help improve our clinical and non-clinical screening network and help individual partners optimize their existing HIV screening resources.

We designed the Phase II Comprehensive Schedule B HIV Linkage Metric (PM005) to help partners that test patients for HIV track their progress with linking patients to care. This will help ensure a direct focus on improving patient outcomes, while also providing partners with a longitudinal view of their patient’s efforts to connect to HIV care. We are asking partners to report progress three times, beginning July 31, 2017 and again at the end of October, 2017 and in January, 2018.

OneCity Health is not alone in these Delivery System Reform Incentive Payment (DSRIP) HIV efforts – there is a city-wide coalition of Performing Provider System (PPS) networks that meets regularly to support this work’s success on a population-wide scale. The DSRIP HIV Coalition is a forum to foster shared understanding, promote best practices, and facilitate collaboration between care settings to maximize the effectiveness of DSRIP HIV activities. If our OneCity Health partners are interested in learning more about these meetings, please reach out to our support desk.

HIV screening and linkage to care are core strategies used to combat HIV. By improving the way we identify and manage patients with HIV, we can improve their outcomes and reduce avoidable hospital use.

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.

Agenda for July 11 Partner Webinar

On Tuesday, July 11, 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:

  • Comprehensive Schedules B updates
    • Closing Phase I
    • Approaching Phase II deadlines
  • OneCity Health’s HIV initiatives
  • OneCity Health’s training strategy
  • Q&A on connecting to the RHIO
  • Upcoming listening sessions and final reminders

Here is how to join:

Tuesday, July 11th, from 2:00 p.m. – 3:30 p.m. EST
WebEx Meeting Link: click here
Audio Connection: 1-855-282-6330 US TOLL FREE
Access Code: 737 967 457

Agenda for Wednesday’s PAC Meeting

We look forward to seeing our partners at Wednesday’s City-Wide Project Advisory Committee (PAC) meeting at the CUNY School of Law.

Here is the agenda for the 3 p.m. meeting:

  • Welcome & Networking Activity
  • Follow-up from March 8th PAC Meeting
  • Other Updates
    • Phases I, II and III Contracting
  • Project Spotlight
    • 2.a.i Integrated Delivery System
    • 4.c.ii Increase Early Access to and Retention in HIV care
  • Upcoming Dates and Events

In addition, partners can download the full presentation here. We will go through it in detail during the PAC meeting.

For complete details on the location and travel instructions, please visit our Events Calendar.

As a reminder, PAC meetings are important opportunities for partners to share their experiences with project implementation, provide input into our planning, design and evaluation activities, and get to know fellow OneCity Health partners.

Partner Webinar: Concluding Phase I, Initiating Phase II

Thank you to our partners who attended today’s OneCity Health Partner Webinar: Concluding Phase I, Initiating Phase II.

For our partners who were unable to view the webinar, the slides are available to view here. In addition to discussing the final Phase I deadlines, we recognized our progress across a number of initiatives. Thank you to all our partners for their efforts to date!

Please also view the webinar here:

As we discussed on the webinar, our partners can view an updated sample Phase II Comprehensive Schedule B here. Our partners should keep in mind next steps:

  • This week: We have begun to distribute Phase II Comprehensive Schedules B. Our partners should inform us if they haven’t received one by March 31. Instructions to sign via DocuSign are here
  • March 20, 2017 was the DSRIP compliance deadline: If our partners haven’t done so yet, they need to satisfy their DSRIP training and compliance requirements. Complete and submit the Attestation form to Kevin Rogan, and contact him with any questions. His contact information is on our website along with instructions to complete compliance training
  • Beginning March 21: NYC Health + Hospitals is hosting panel discussions across the city to address health care rights for immigrants. Visit our Events Calendar for details
  • March 28 and March 29, 2017: New York State behavioral health value-based payment feedback sessions. Details are on our website Events Calendar
  • March 29, 2017: Our partner, SUNY Downstate Medical Center, is hosting a forum on HIV and pre-exposure prophylaxis (PrEP). Click here for details
  • Due March 31, 2017: We’ve been recommending to our primary care partners that they submit an application for the Mental Health Service Corps to support behavioral health integration. The deadline was extended to March 31. Click here for details
  • Due March 31, 2017: Three Phase I Data & Tracking (DT) metrics, and Participation (P) metrics 1 and 3
  • March 31, 2017: Phase I ends. Our partners need to remember to invoice!
  • April 1, 2017: Phase II begins
  • Beginning April 1, 2017: Our partners can now submit their Workforce Impact Survey to the OneCity Health support desk. Deadline is April 20. We posted a Q&A from our Office Hours session to our website; please view it here
  • On April 11, 2017: Attend our next monthly OneCity Health Partner Webinar. The webinar will be held from 2 – 3:30 p.m. Click here for details
  • April 26, 2017: Five Phase I Patient Engagement (PE) metrics are due to OneCity Health
  • April 30, 2017: Four Phase I recurring Operations & Outcomes (OO) metrics are due to OneCity Health
  • If our partners have questions about completing metrics or submitting reports, please contact our support desk

Finally, as we discussed on the webinar, we will continue to update partners on the development of the closed loop referral platform and our program to connect partners to the Regional Health Information Organization (RHIO).

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

Partner Feature: Community Healthcare Network

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.

As OneCity Health continues to implement efforts to connect patients with primary care from the Emergency Department, and to provide a supportive transition for patients of high need who were admitted to the hospital, CHN will be an important referral source, providing quick access to a primary care physician.

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.”