September PAC Meeting: Presentation and Post-Meeting Survey

Thank you to our partners who attended last week’s Project Advisory Committee (PAC) meeting. We appreciate the questions, input and lively discussion, and we will continue to update partners on our progress through our newsletters, monthly OneCity Health Partner Webinars and other venues.

As a reminder to our partners who attended the meeting, please take a minute to complete our post-meeting survey here. Feedback from our partners ensures we continue to make those meetings both engaging and helpful.

For our partners that were unable to attend the meeting, the presentation is available for download here. Following a networking activity, the discussion focused on contracting and our Integrated Delivery System initiatives.

OneCity Health partners gathered in the Bronx for our latest City-Wide PAC Meeting

We looking forward to seeing our partners at our next meeting!

New in NEJM Catalyst: OneCity Health Article on the link Between Coverage Expansion and Delivery System Reform

Under the Patient Protection and Affordable Care Act (ACA), 32 states expanded Medicaid and millions of individuals gained coverage through health insurance exchanges. Provisions in the Affordable Care Act also supported delivery system reform with a strong focus on proactive, community-based care. For safety net providers such as NYC Health + Hospitals —those that by mission or mandate see all patients, regardless of their ability to pay—these two policy objectives are closely linked. As we describe in an article published yesterday in NEJM Catalyst: progress on delivery system reform is maximized when it stands on the shoulders of coverage expansion.

In their article “Coverage Expansion and Delivery System Reform in the Safety Net: Two Sides of the Same Coin,” the authors* describe how maintaining—and optimally, growing—our insured population is crucial in order to take care of those who are still uninsured, but it also is important for our system’s transformation efforts. For example, they discuss how expanding access to high-quality primary care, with integrated behavioral health services, is a linchpin of delivery system improvement. But hiring more primary care clinicians, launching collaborative care programs, and establishing linkages between hospitals and community health centers all require capital investment which stem from coverage expansions.

However, due to recent political developments, this initial progress is still vulnerable. Further progress will depend on keeping the ACA’s health insurance expansion in place.

Click here to read the full article.

* Jeremy P. Ziring, AB, Data Analyst; Kathleen S. Tatem, MPH, Data Analyst; Remle Newton-Dame, MPH, Director of Healthcare Analytics; Jesse Singer, DO, MPH, Assistant Vice President, Care Models and Analytics; and Dave Chokshi, MD, MSc, Chief Population Health Officer, all of OneCity Health

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.

Updates from the PAC: Digital Edge IT Assessments and Next Steps for Partners

At our March 8, 2017 Project Advisory Committee (PAC) meeting, our partners offered feedback and follow-up questions on a number of resources and ongoing initiatives that we have introduced to further develop our integrated delivery system (IDS). Specifically, our partners suggested:

Over the coming weeks, we will discuss each of the topics in depth, and also continue to provide updates on our monthly OneCity Health Partner Webinars. Our webinars are also a forum for additional questions and answers with our partners.

Below please find an update on OneCity Health’s support to partners for achieving electronic connectivity, including an infographic explaining the benefits of connecting to a Regional Health Information Organization (RHIO), IT assessments conducted by our IT technical assistance vendor Digital Edge, and next steps for partners.

RHIO Connectivity, IT Assessments and Next Steps

RHIO and Benefits to Partners
To further develop our IDS, OneCity Health will facilitate connectivity of our partners with a RHIO this year to ensure that all of a patient’s providers can securely access his or her data and share information.

Please note that it is also a Delivery System Reform Incentive Payment (DSRIP) program requirement for partners to connect to a RHIO. However, if a partner does NOT provide clinical services (e.g., social services only) or does NOT have an Electronic Medical Record (EMR), they are not required to connect to a RHIO. For these partners, OneCity Health is currently procuring a web-based “EMR-like” solution as an alternative option for connection to a RHIO.

To learn more about a RHIO and how it will benefit both our partners and patients, please view our infographic below. It is also available for download here.

Digital Edge IT Assessments
Throughout 2016, Digital Edge, a OneCity Health IT technical assistance vendor, conducted assessments of our partners’ IT capabilities to help us understand the steps we need to take to electronically connect our partners to a RHIO and securely share patient information across our integrated delivery system. Thank you to our partners who worked with Digital Edge; we now have an overview of the current state of our network’s electronic connectivity and are able to move forward with supporting partners in this regard. Here are some key takeaways:

  • Digital Edge reached out to all partners who have signed a Master Services Agreement (MSA) with OneCity Health, and were able to coordinate an assessment with 153 partners. Of this subset:
    • 133 partners have an Electronic Medical Record (EMR)
    • 36 partners are connected to a RHIO

We have stopped conducting IT assessments, and are now moving forward with supporting all of our partners by initiating or strengthening their electronic connectivity.

Next Steps for Partners
Earlier this year, we conducted a successful pilot with one of our partners to connect their EMR to a RHIO. Next, we will start to connect EMRs to a RHIO for a large wave of partners. To start this process, Digital Edge is again conducting outreach, beginning with an email and following up with a phone call, to OneCity Health partners (including those that did not complete the IT assessment) to schedule an introductory meeting to discuss the connection process. Digital Edge will work directly with partners to enable their connection to a RHIO, and will soon reach out all partners.

If OneCity Health partners would like to request to be in this first wave, they should respond to the initial email from Digital Edge right away or reach out to the OneCity Health support desk. Due to space constraints, these requests will be handled on a first come first served basis.

What will be Required of Partners During the RHIO Connection Process?
Connecting to a RHIO is FREE for OneCity Health partners. This means we will help partners establish a site to site VPN connection with the RHIO, and do a test of data exchange at no cost to partners. However, OneCity Health will not compensate a partner’s current IT vendor that may need to facilitate additional connections to another RHIO(s).

Partners are requested to identify an IT contact who can collaborate with Digital Edge throughout the RHIO connection process, which should take about 3-4 weeks.

PPO: Strategic Advisory Workgroup & Capacity Building Technical Assistance

Our partnerships with community-based organizations (CBOs) are important to meeting Delivery System Reform Incentive Payment (DSRIP) program goals and improving health outcomes. As such, the growth of these CBOs to work in a value-based environment is essential. Therefore, we plan to invest in capacity building skills for partner CBOs to help promote their sustainability. Additionally, through a Strategic Advisory Workgroup, we will seek the advice of partner CBOs as critical providers in the integrated delivery system.

Through this Project Participation Opportunity (PPO), we are seeking to identify OneCity Health partners that are interested in participating in both initiatives:

  • We are seeking to identify 6-10 social service providers who are interested in participating in a Strategic Advisory Workgroup for Phase III contracting (contract period starting January 2018); and
  • We are seeking to identify 1-2 community partners with experience and infrastructure to provide OneCity Health’s social service community partners with technical assistance in capacity building, and creating a value-based-proposition.

Partners are welcome to apply to participate in both the Strategic Advisory Workgroup and provide capacity building technical assistance.

This PPO Interest Form outlines both opportunities, including background, criteria and next steps to express interest.

  • OneCity Health partners interested in applying for the Strategic Advisory Workgroup should complete the simple survey located here by close of business Monday, June 5, 2017
  • OneCity Health partners interested in applying to provide capacity building technical assistance for CBOs need to submit a one page description of their experience to the OneCity Health support desk at by close of business Monday, June 5, 2017

Please review the Interest Form for additional background.

In addition, we will host a webinar to address questions about both opportunities on Thursday, June 1, 2017 from 4-5 p.m. The webinar is not mandatory for participation in either project, but is highly recommended.

Here is how to join:

Thursday, June 1, from 4:00 p.m. – 5:00 p.m. EST
WebEx Meeting Link: click here
Audio Connection: (877) 931-0379
Access Code: 5429582#

Please also email any questions to our support desk at with the subject line “Strategic Advisory Workgroup/CBO Capacity Building.”

Updates from the PAC: Partner Services Directory

At our March 8, 2017 Project Advisory Committee (PAC) meeting, our partners offered feedback and follow-up questions on a number of resources and ongoing initiatives that we have introduced to further develop our integrated delivery system. Specifically, our partners suggested:

Over the coming weeks, we will continue to discuss each of the topics in depth, and also continue to provide updates on our monthly OneCity Health Partner Webinars. Our webinars are also a forum for additional Q&A with our partners.

Below please find an update on a partner services directory.

Closed Loop Referral System
Through a Closed Loop Referral System, we will provide all partners a robust and searchable directory of social services, which will include the capability to make electronic referrals. It will be inclusive of all of our Performing Provider System (PPS) partner organizations.

Earlier this year we distributed a Request for Proposals (RFP) for this system, and we expect to select the software vendor by the end of June. Our chosen vendor will customize the platform this summer, and our goal is to begin piloting the Closed Loop Referral System with a small group of partners this fall. Following the pilot, we plan to expand the system to all partners in early 2018. We will further discuss this program as more details are available. Please note some partners have Phase II metrics regarding the use of this system.

Ongoing CCHL Self-Assessments, Upcoming Focus Groups, Lay the Foundation for Tailored Care

We serve a variety of diverse populations throughout our network, and to optimally support all patients and clients and strengthen our integrated delivery system, it is critical that we tailor care to meet their social, cultural and linguistic needs.

As part of our efforts to improve cultural competence and health literacy (CCHL), 25 percent of our partner sites (amongst those with a Schedule B to complete the CCHL survey) have completed self-assessments, using the Communication Climate Assessment Toolkit (C-CAT) survey and other tools, to understand the current state, strengths and opportunities for improvement.

However, we still have a long way to go! Additional sites are continuing with the assessment through the month of May. This initiative will provide the OneCity Health network with additional insights on disparities and gaps in service delivery, and an opportunity to promote best clinical and administrative processes to improve them. We would like to thank our partners for their hard work to date surveying staff and patients and laying the foundation for the significant work ahead.

Additionally, 14 OneCity Health community partners will soon begin to conduct focus groups with patients or consumers from our identified priority populations, including uninsured individuals, individuals born outside the United States and individuals with developmental disorders. Feedback from our patients and consumers will add to the data on sites and their staff that we are collecting through the CCHL self-assessments. Our partners will conduct up to 28 focus groups.

We look forward to sharing the results and steps for improvement with our network later this year.

Updates from the PAC: Enhancements to the Partner Portal

At our March 8, 2017 Project Advisory Committee (PAC) meeting, our partners offered feedback and follow-up questions on a number of resources and ongoing initiatives that we have introduced to further develop our integrated delivery system. Specifically, our partners suggested:

  • A comprehensive update regarding the OneCity Health Partner Portal, including enhancements, partner valuation, notifications and the invoicing process
  • More information regarding IT assessments conducted by Digital Edge and next steps for partners
  • Additional details regarding a partner services directory
  • A recap of our network’s metric submission performance in Phase I

Over the coming weeks, we will discuss each of the topics in depth, and also continue to provide updates on our monthly OneCity Health Partner Webinars. Our webinars are also a forum for additional Q&A with our partners.

First, below please find an update on the OneCity Health Partner Portal, including specific questions our partners raised at the PAC meeting.

OneCity Health Partner Portal

Provide an update on the enhanced Portal for Phase II and when resources will be available
Our team has made several improvements that are now available, or will be soon. Improvements include the following:

  • New interface with ability to access information on one screen
  • Improvement of notifications of pending actions, and visual indication of submission deadlines and progress
  • Ability to submit invoice concurrent to metric submission
  • Ability to download submissions and invoices for records
  • Improved features to give greater guidance for metric submissions and remediation

For more information about the updates to the Portal, please view the slides from our April OneCity Health Partner Webinar here, where we detailed the enhancements that were available as of April 11, 2017. We will discuss the new features that are since live on our May 9, 2017 Partner Webinar.

Make partner valuation something that gets updated or removed
Partner valuation will not be updated in the Phase I version of the OneCity Health Partner Portal, and is not included in the Phase II version of the OneCity Health Partner Portal. We are still deciding how to best display performance data, including partner valuation via the Partner Portal.

Fix the portal notifications window to ensure it is in chronological order
The chronological order of the portal notifications was fixed in the Phase I version of the OneCity Health Partner Portal. In Phase II, there is no longer a notifications window, and partners can see the status of their submissions in their Home Page after they log into the Portal.

Ensure the OneCity Health support desk has a list of invoices awaiting submission to provide to partners when they call
The OneCity Health support desk has the ability to confirm what invoices are currently available for submission, as well as what metrics are pending submission. The support desk has been and will continue to update partners regarding their invoice and submission status upon request by phone and/or email.

PCMH Recognition at NYC Health + Hospitals Demonstrates Improved Care, Significant Return on Investment

Since last summer, we have been assisting 52 of our OneCity Health primary care partner sites to achieve Patient-Centered Medical Home (PCMH) recognition to ensure that New Yorkers have access to high-quality primary care.

Similarly, over the past year, NYC Health + Hospitals, our largest partner, has been on a journey with 32 of its primary care facilities to renew their Level 3 PCMH status, which is the highest level of recognition conferred by the National Committee for Quality Assurance (NCQA). As our primary care partner sites continue their certification process, the work completed at NYC Health + Hospitals demonstrates the ultimate value of these efforts, both in improved care for patients and a significant return on investment.

Achieving PCMH recognition does not mean construction of a physical space; instead, it is a care model that emphasizes patient-centered access, improved care coordination and enhanced communication. Rather than a patient feeling that his or her care is fragmented, the PCMH model supports patients and families/caregivers in self-management and shared decision making. First, to improve access for patients, NYC Health + Hospitals launched centralized, borough-based call centers to help patients more easily schedule appointments across the system.

Next, it enhanced convenience for patients to access primary care.

“For continuity of care, patients can now access their primary care provider (PCP) by phone for appropriate follow-up care without needing to take time off from work or spend money on transportation to visit one of our practices,” said Rebecca Miller, Director, Primary Care Transformation, NYC Health + Hospitals.

NYC Health + Hospitals’ work toward achieving PCMH certification has not only improved patient care, but has also increased revenue. Following PCMH certification, the New York State Department of Health (NYSDOH) provides incentive payments for certain patient populations, including Medicaid Managed Care (MMC) and Medicaid Fee-for-Service (FFS). After accounting for expenditures such as those made to the NCQA and staff time devoted to the recognition process, NYC Health + Hospitals determined that achieving PCMH certification led to net revenue of $18.3M for fiscal year 2015 and $16.8M for fiscal year 2016.

Moreover, due to increased payment rates from the NYSDOH under the Level 3 2014 PCMH certification standards, NYC Health + Hospitals projects a total net revenue of $84.3M over the next three years (FY’17-FY’19).

OneCity Health is continuing its investment of $1.8M in primary care transformation for our network, not including NYC Health + Hospitals. As NYC Health + Hospitals demonstrates though, our investment in the patient-centered medical home model can yield significantly more revenue for our partners, as well as drive transformation in patient care and improve coordination throughout our developing integrated delivery system.

Listening Session Focuses on Unique Health Needs of Patients with Intellectual/Development Disabilities

According to the state’s Department of Health, an estimated one in 21 hospitalizations involve persons with Intellectual/Development Disabilities (I/DD) across New York State. As a special population with a particularly high utilization rate, it is critical that our transformation initiatives integrate specific programs to ensure we meet their unique health care needs, both in the hospital and across community settings, to prevent avoidable hospitalizations.

To that end, OneCity Health hosted an initial listening session with three of our partners – Young Adult Institute (YAI), AHRC NYC and Cerebral Palsy Association of NYS (CP of NYC) – to learn how we can provide more culturally competent care to individuals with I/DD and their families, and share their collective expertise across our integrated delivery system (IDS).

An important first step is to help our partners and providers be aware of and understand the unique health concerns of I/DD patients so they can be proactive with treatment.

“Often times, providers haven’t received training in how to work with I/DD patients,” explained one of our participants. “Not only are there unique ways to communicate with an I/DD patient, but there are different ways to communicate with their support system as well.”

A training curriculum composed of e-Learning modules, in-person sessions or roundtable conversations, along with complementary resources, are potential approaches to begin instruction of clinical staff, noted our participants. These would focus not just on communication to patients and their support systems, but distinguishing intellectual and development disabilities from other behavioral health conditions, to ensure they receive appropriate services.

In addition to helping our partners learn more about the needs of I/DD patients, a secondary component is ensuring that we refer patients to appropriate settings that can manage their unique, long-term health needs and reduce the amount of care delivered in the hospital. One approach we’ll soon engage in with session participants and other agencies is to develop a screening tool for I/DD patients. Concurrently, we have initiated plans to further integrate social service providers and their expertise in transformation work by introducing a closed loop referral system to our network. Within this system, we plan to include partners and providers that are well-equipped to take care of our I/DD patients, which will allow health care delivery sites to access and make referrals to appropriate social and community services.

Thank you to YAI, AHRC NYC and CP of NYC for joining our initial listening session. We continue to look for opportunities to leverage the expertise of our partners and share collective learning across our IDS to improve the care of patients and clients.

Linking Patients to Primary Care and Social Services Through Project 11

The initial phase of Project 11 focused on administering the Patient Activation Measure® (PAM®) survey to uninsured individuals. However, our transformation goals extend far beyond surveys; it is about effective outreach, linkage to primary care and social services, and training our partner staff to engage clients and patients in a culturally humble way so that they actively participate in managing their health conditions.

Marjorie Momplaisir-Ellis, Senior Director of Engagement and Collaboration and Annika Ginsberg, Brooklyn Hub Director and Project 11 Project Manager, both of OneCity Health, discussed our work at the November 16, 2016 “Community Connections” briefing series hosted by the Greater New York Hospital Association. They presented on how the partnerships between community-based organizations (CBOs) and NYC Health + Hospitals as part of the Delivery System Reform Incentive Payment (DSRIP) program are essential to meeting this goal and the creation of an integrated delivery system that includes the uninsured.

The PAM® survey is a valuable tool to begin conversations with patients about the importance of health insurance and the use of preventative services. However, how do we help patients to better engage with their health when, for many community members, their main use of the system is reactionary, such as a visit to the Emergency Department?

OneCity Health contracted with 17 NYC Health + Hospitals facilities implementing Project 11 and 35 community partners across four boroughs to administer the PAM® and connect individuals to insurance and primary care. From April, 2016 through September, 2016, across the Bronx, Brooklyn, Queens and Manhattan, our community-based partners administered 4,055 PAM® surveys, connected 1,246 people to primary care and 1,828 individuals to insurance.

As the OneCity Health team members discussed, partnerships with CBOs enable these connections by bringing trust and local knowledge to the community, proactively engaging with people about their health. Moreover, we’ve integrated social service providers, who may have less experience in this area, but can impact health outcomes through their work to tackle social determinants of health, like housing and food security.

Appointments for preventative care and insurance are just the beginning of the development of a truly integrated delivery system. In future years, OneCity Health will continue to work with community partners to move beyond counting the number of appointments to capturing patient engagement in a more meaningful way, such as tracking the proportion of appointments kept and insurance applications completed. Additionally, a care management screening tool will be developed so that both health care and social service providers can screen individuals for social service needs.