Achieving Transformation Through Training and Education

As we progress with our transformation efforts, it is essential for our partners to have a shared understanding of the Performing Provider System’s (PPS) goals and how to reach them. To that end, OneCity Health has undertaken numerous activities to date – and will soon launch many others – to help train and educate our partners.

From instructing Transition Management Teams to coaching our partners to utilize the Patient Activation Measure® (PAM®) survey, each OneCity Health initiative has been rooted in engaging our PPS partners with educational materials and technical assistance, which helps our partners:

These are just a few examples; education supports improved patient and population health across our integrated delivery system and could extend to areas such as care management and information technology (IT), among other topics. OneCity Health is investing $50 million in workforce training for our network over the Delivery System Reform Incentive Payment (DSRIP) program to support these efforts.

As we make educational content available or schedule opportunities for instruction, we will reach out to our partners and ensure they are well-positioned to improve patient health. Simultaneously, we will coordinate with our PPS partners’ many training-related assets to encourage best practices and leverage our greatest strengths.

Partner Feature: SUNY Downstate Medical Center

In the latest in a series of articles featuring OneCity Health partners, we highlight SUNY Downstate Medical Center and their role within the OneCity Health Performing Provider System (PPS).

Miriam T. Vincent, MD, PhD, JD, Professor, Department of Family Medicine, Executive Director for Healthcare Innovation and DSRIP, and the Medical Director of Ambulatory Care, SUNY Downstate Medical Center and the University Hospital of Brooklyn, currently sits on the OneCity Health Stakeholder & Patient Engagement and Workforce Committees. SUNY Downstate comprises a College of Medicine, College of Health Related Professions, College of Nursing, School of Graduate Studies, School of Public Health, and University Hospital of Brooklyn. SUNY Downstate has just completed the formation of their DSRIP Project Management Office composed of a team of seven individuals dedicated to transforming the care that University Hospital of Brooklyn delivers to their Brooklyn community.

For Dr. Miriam T. Vincent, the Delivery System Reform Incentive Payment (DSRIP) program is a natural next step in the move toward patient-centered care.

“In family medicine, we’ve always understood the need to be a home for patients,” explained Dr. Vincent. “Whether a patient has diabetes, hypertension or a cardiovascular disease, we can best prevent complications and keep our patients healthy when a primary care physician understands the patient’s history and coordinates care.”

To expand on these efforts, Dr. Vincent helped lead a team in the effort for the hospital to become a Patient-Certified Medical Home, which expanded access to primary care appointments, further emphasized continuity of care for patients, encouraged people to work as a team and began their effort to integrate behavioral health into primary care. SUNY Downstate was then well-positioned to join the OneCity Health PPS when New York State announced the DSRIP program.

SUNY Downstate's DSRIP Project Management Team
SUNY Downstate’s DSRIP Project Management Team

“DSRIP takes the Medical Home concept a step further. We are looking at where patients live, their environments, what they are eating and attempting to address these social determinants of health to optimize a patient’s overall wellbeing,” said Dr. Vincent.

Critical to this effort, according to Dr. Vincent, is ensuring the hospital is connected to the community and that patients feel welcome. Otherwise, they won’t feel comfortable seeking care.

Project 11 was the perfect initial OneCity Health opportunity for SUNY Downstate to further engage with patients. The first phase of Project 11 included administering the Patient Activation Measure® (PAM®) survey to uninsured individuals. In order to engage and educate uninsured patients, the survey assesses and utilizes an individual’s knowledge, skills and confidence about health care to provide tailored support in linking these individuals to care. SUNY Downstate also emphasized financial counseling, helping patients gain access to insurance entitlements, and connecting patients to primary care at the hospital regardless of insurance status.

Nakia Alford-Saunders, MPA, Project 11 Assistant Project Manager at SUNY Downstate, has long-time family ties to Brooklyn, so she wanted to ensure she did her part to improve the health of the community.

“I’m here to help my community,” said Alford-Saunders. “I encourage my colleagues and I set an example by helping them to administer the survey effectively. I visit each department and happily meet and greet our patients. I stay positive and upbeat, I encourage my colleagues, and I say, ‘thank you’. It rubs off.”

Alford-Saunders and a colleague trained 58 people at SUNY Downstate to administer the survey – including community workers, emergency department staff, executive staff, and students – trying to identify staff in every area that touches a patient. She has built a strong foundation for the critical next phase of Project 11, as the project is more than administering surveys. Her team of trained PAM administers now begins to conduct additional outreach, linking patients to primary care and financial counseling, and further engaging patients so that they actively participate in managing their health conditions.

“It is important that we have so many people involved, and an understanding that there are some patients that don’t feel empowered. They don’t know what options are available to them, and these are the people we must reach out to,” explained Alford-Saunders. “The good news is, we are the ones in a great position to help empower these individuals. Why not get people the care they need to avoid larger problems later?”

PAM Training

Community members participating in Project 11 must be trained to administer the Patient Activation Measure® (PAM®) survey. Once individuals from your organization have been trained, they can use this information to train their colleagues. If you are interested in participating in this training session, please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. You must RSVP by May 9 for this session. We will share the location following an RSVP.

For more information on Project 11 and the trainings, please see an earlier newsletter.

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

PAM Training

Community members participating in Project 11 must be trained to administer the Patient Activation Measure® (PAM®) survey. Once individuals from your organization have been trained, they can use this information to train their colleagues. If you are interested in participating in this training session, please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. You must RSVP by April 13 for this session. We will share the location following an RSVP.

For more information on Project 11 and the trainings, please see an earlier newsletter.

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

PAM Training

Community members participating in Project 11 must be trained to administer the Patient Activation Measure® (PAM®) survey. Once individuals from your organization have been trained, they can use this information to train their colleagues. If you are interested in participating in this training session, please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. You must RSVP by March 26 for this session. We will share the location following an RSVP.

For more information on Project 11 and the trainings, please see an earlier newsletter.

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

OneCity Health has Surpassed its Quarterly Goal for Project 11

We are proud to announce that we have administered over 11,000 Patient Activation Measure (PAM®) surveys, surpassing our quarterly goal as committed to the New York State Department of Health (NYSDOH). Thank you to NYC Health + Hospitals and all of our community partners who helped us meet our initial goal for Project 11.

However, this was just the start! Our transformation goal is not just about 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.

Beginning April 1, we officially enter Delivery System Reform Incentive Payment (DSRIP) program year two, and 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.

We’d like to begin contracting for phase two of Project 11, so please review the following and contact us with questions at DSRIPSupport@nychhc.org.

In our earliest contracts, which end on March 31, 2016, our payment was focused on PAM® survey administration. Starting April 1, we will contract for all activities related to Project 11, which include PAM® survey administration as well as efforts required to link people to insurance and services.

For our partners that had previously signed a Schedule B to administer the PAM® survey, we will ask you to sign a new Schedule B that reflects the full range of activities through March, 2017. We will send you the Schedule B for phase two shortly.

If you have not participated in Project 11 in the past, and are newly interested in participating during DSRIP Year two (April 1, 2016 – March 31, 2017), we will soon share a new Project Participation Opportunity (PPO) with our entire partner network.

Please also remember we are still offering PAM® training sessions for partners that have signed a Schedule B. If you have questions regarding Project 11 or would like to enroll in training, please email PAM-Training-DSRIP@nychhc.org.

PAM Training

Community members participating in Project 11 must be trained to administer the Patient Activation Measure® (PAM®) survey. Once individuals from your organization have been trained, they can use this information to train their colleagues. If you are interested in participating in this training session, please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. You must RSVP by March 10 for this session. We will share the location following an RSVP.

For more information on Project 11 and the trainings, please see an earlier newsletter.

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

Upcoming PAM Trainings

OneCity Health Patient Activation Measure® (PAM®) Trainings
For community members interested in participating in Project 11, please see an earlier newsletter about the opportunity to administer the Patient Activation Measure® (PAM®) survey. Below is a list of upcoming PAM trainings. Please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. Please contact us for the location prior to the training.

Monday, March 14th, 2016, 2 p.m. – 5 p.m.
Friday, April 1, 2016, 10 a.m. – 1 p.m.

For questions or concerns regarding Project 11, please contact Marjorie Momplaisir-Ellis at Marjorie.momplaisir-ellis@nychhc.org.

Commencing Patient Activation for Project 11

OneCity Health has initiated the first phase of Project 11 implementation which includes administering the Patient Activation Measure® (PAM®) survey to uninsured individuals. As part of broader Project 11 efforts to engage and educate uninsured and Medicaid low- and non-utilizers, the PAM® survey assesses and utilizes an individual’s knowledge, skills and confidence about health care to provide tailored support in linking these individuals to care. Project 11 was detailed in a previous newsletter.

The goal for Project 11 is to administer 11,000 PAM® surveys by March 31, 2016, and OneCity Health needs your help! Please remember that a key component of all DSRIP projects is payment to providers based on their performance in meeting outcome milestones and metrics.

For community partners to begin administering the PAM®, the organization must sign the Project 11 schedule and attend a PAM® training. Project 11 schedules have been sent to the designated signatories at organizations who responded to the Project 11 Project Participation Opportunity.

OneCity Health will also be hosting a number of PAM® trainings. Please note that once individuals from your organization have been trained, they can use this information to train their colleagues.

Here are the upcoming dates for PAM® trainings. Please RSVP at PAM-Training-DSRIP@nychhc.org as soon as possible. There is a limited number of seats available per session.

OneCity Health Patient Activation Measure® (PAM®) Trainings
199 Water Street 31st Floor, New York, NY 10038

January 29th, 2016, 9AM – 12PM
February 8th , 2016, 2PM – 5PM
February 26th , 2016, 2PM – 5PM
March 14th, 2016, 2PM – 5PM
March 31st , 2016, 9AM – 12PM

For questions or concerns regarding Project 11, please contact Marjorie.momplaisir-ellis@nychhc.org.

DSRIP Care Model Webinars

Upcoming Sessions
Cardiovascular Health Care Model: January 20, 2016, 2PM – 3PM
Cardiovascular Health WebEx Address

Past Sessions
Here are links to the materials presented during past webinar sessions. Webinar recordings will be made available shortly.
Asthma Care Model
Palliative Care Model

For more information about care models, please click here.

Upcoming Citywide Project Advisory Committee (PAC) Meeting

OneCity Health’s Project Advisory Committees (PACs) serve as indispensable advisory forums as we develop policies, programmatic processes and guidelines for the design, implementation, monitoring and evaluation of DSRIP projects. We are actively seeking agenda items from our partners for the next citywide PAC meeting scheduled for January 26, 2016 at Brooklyn Borough Hall. Please email DSRIPSupport@nychhc.org with the subject line ‘PAC Agenda Suggestions.’ We look forward to seeing you on January 26, 2016. All are welcome!

Citywide PAC Meeting

  • Date & Time: Tuesday, January 26th, 2016, 6:00PM- 7:30PM
  • Location: Brooklyn Borough Hall, 209 Joralemon St, Brooklyn, NY 11201

Project 11 Project Participation Opportunity

We are excited to announce that the inaugural “Project Participation Opportunity” for Project 11 was released last Friday. As described in a recent partner newsletter, a “Project Participation Opportunity” is OneCity Health’s transparent mechanism and process intended to:

  • Describe the design of a particular project
  • Identify the opportunities for a partner to participate in the implementation of a project
  • Allow potential partners (project participants) to indicate their interest in supporting one or more facets of project implementation
  • Facilitate contracting with qualified partners

The focus of Project 11 is to engage, educate, and activate people who are uninsured and those who could benefit from additional primary care and preventive services (Medicaid “low- or non-utilizers”). We are currently identifying partners who can deliver training on the Insignia Patient Activation Measure 10-question survey (PAM-10) and/or conduct outreach and engagement to administer the Insignia PAM-10 survey to uninsured individuals and low-utilizing or non-utilizing Medicaid members.

OneCity Health recognizes that our community partners are experts in outreach and engagement. We are asking you to review the Project 11 Project Participation Opportunity and “raise your hand” or self-identify your interest and capabilities by completing the Project 11 Project Participation Opportunity Form. Please email it to DSRIPSUPPORT@nychhc.org with the subject line “Project 11” by Friday, October 23. 

As questions arise, please email them to us at DSRIPSUPPORT@nychhc.org and we will answer them on the webinar on October 19. More information about the contracting process, the PAM instrument, and coaching for activation will also be provided during the webinar.

We are thrilled that our first Project Participation Opportunity to be announced is one that will allow us to work more closely with our community-based partners to activate New Yorkers towards better health.

Please note the following key dates:

October 16: Partners identify one staff person to attend the Patient Activation Measure (PAM) training via DSRIPSupport@nychhc.org

October 19, 10:00am- 11:00am: Project 11 Informational Webinar hosted by OneCity Health

October 23: Deadline for the completion and submission of the Project Participation Opportunity Form

October 26: OneCity Health identifies partners for the first phase of Project 11 implementation

October 28, 1:30pm-5:00pm or October 29, 9:00am-12:30pm: 1/2-day PAM training

Additional PAM trainings will be available on later dates.