PCMH Clinical Quality Improvement and Sustainability Learning Collaborative

Thank you to our partners who joined us earlier in October for our fifth and final Patient-Centered Medical Home (PCMH) Learning Collaborative, focused on Clinical Quality Improvement and Sustainability.

Our engaging facilitators discussed a variety of key concepts related to clinical quality improvement (QI) and how it can help our partners’ practices achieve NCQA PCMH 2014 recognition. Attendees also gained hands on experience developing QI goals to support their practice’s QI activities, which can also help them fulfill Phase II cardiovascular disease management and asthma home-based self-management metrics.

Thank you as well to our partners who joined us as guest speakers: Marion Walters and Sandra Gordon, both of Children’s Aid; Finn Brigham of Callen Lorde; and Renee McConey of The Door, University Settlement.

The following materials from the Learning Collaborative are available for download:

Resources from all our past PCMH Learning Collaboratives are available here.

PCMH Learning Collaborative Webinar on Care Coordination Available to View

We recently hosted our latest Patient-Centered Medical Home (PCMH) Learning Collaborative, a webinar focused on care coordination, for our primary care partners. Our primary care partners learned strategies to improve communication and coordination between providers, and implement systems to better share information, which leads to improved access and higher quality of care for patients. The Learning Collaborative included sample documentation and workflows to help partners better understand best practices.

Miss the webinar? Click here to review the slides, or watch the recording below:

This session was the fourth installment in our series of Learning Collaboratives for primary care partners, which is a part of our efforts to assist 54 sites in the OneCity Health network toward achieving PCMH recognition. Past events have focused on population health management, care management and team-based care and access. Our fifth and final PCMH Learning Collaborative will be an in-person session this October. Stay tuned for registration details.

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.

OneCity Health PCMH Learning Collaborative Webinar Available to View

Thank you to our partners who attended our recent Patient-Centered Medical Home (PCMH) Learning Collaborative focused on population health management.

Population health management refers to a data-driven approach used to systematically monitor a whole patient panel in real time, and intervene accordingly. We host these Learning Collaboratives to help our partners implement these strategies, support their transformation efforts to earn or maintain PCMH recognition, and improve upon a fragmented delivery system through better coordination and management of care.

Please click here to view the slides from the presentation, or watch the full webinar below. In addition to describing the importance of population health management, the learning collaborative focused on data collection strategies, maximizing patient outreach and in-reach, and integration with other programs.

Thank you to our partner Boriken Neighborhood Health Center for being a guest presenter during the webinar.

Watch the full webinar:

Upcoming Webinars for Primary Care Partners

We are pleased to announce that registration is now open for the following three webinars:

Patient Centered Medical Home (PCMH) Learning Collaborative on Population Health Management
We are co-hosting this event with New York City Regional Electronic Adoption Center for Health (NYC Reach), one of our PCMH technical assistance vendors, on Wednesday, January 25, 2017 (there are two sessions, both with the same content). Please join us online for this informative webinar which will introduce key concepts in population health management.

We will feature a presentation and question and answer component with a provider who has implemented various population health management workflows in her practice, as well as highlight case studies from other practices of various sizes and patient populations. Click the dates for additional details and registration instructions.

Mental Health Service Corps
OneCity Health is co-hosting a webinar with the New York City Department of Health on January 19, 2017 from 9 – 10 a.m. to discuss the Mental Health Service Corps, a key initiative of ThriveNYC, a city program committed to promoting and protecting the wellbeing of all New Yorkers.

We encourage our primary care partner sites to attend, as this presentation will be geared towards those interested in implementing the IMPACT model through the Integration of Primary Care and Behavioral Health Services project.

The webinar will include additional background, discuss the application process and deadlines. Click here for additional details and instructions on how to attend.

PSYCKES Application
New York State and Public Consulting Group are hosting a webinar in February to discuss the PSYCKES application.

We encourage our partners to attend, as this presentation will be geared towards those interested in integrating primary care and behavioral health through the Integration of Primary Care and Behavioral Health Services project.

This webinar will be available live at two different times (it will be the same presentation both times). Click the dates for registration instructions:

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.

PCMH Transformation: Update on Achieving Recognition

Helping our community partners achieve Patient-Centered Medical Home (PCMH) recognition is critical to ensuring that New Yorkers have access to high-quality primary care. OneCity Health is initially investing $1.8 million in PCMH transformation for our network through March, 2017, which will improve upon a fragmented delivery system through better coordination and management of care.

After kicking off the initiative last July, OneCity Health technical assistance (TA) vendors completed comprehensive baseline assessments for an initial wave of 44 community-based primary care partner practices, which was a critical step in helping these practices achieve National Committee for Quality Assurance (NCQA) 2014 PCMH Level 3 accreditation.

Baseline assessments help our partners to understand their gaps in achieving PCMH recognition, which can include information technology (IT) gaps, access gaps such as limited operating hours or the need to institute quality improvement processes. They will now work with our TA vendors to implement a work plan to become accredited. An important component of this process is now on the horizon, as they will soon attend their first PCMH transformation learning collaborative. This in-person event will focus on team-based care and enhancing access for our patients. We have reached out directly to our primary care partners who completed a baseline assessment to register for this event.

We will soon begin reaching out to our second wave of community-based primary care partner practices to begin conducting their baseline assessments.

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?”

Achieving Patient-Centered Medical Home Recognition

Because health improvement depends so much on New Yorkers’ access to high-quality primary care teams, we are pleased to announce our support of our OneCity Health community partners in achieving Patient-Centered Medical Home (PCMH) recognition.

Best described by the National Committee for Quality Assurance (NCQA), the Patient-Centered Medical Home is a “model of care that emphasizes care coordination and communication to transform primary care into ‘what patients want it to be.’” Not only is PCMH recognition a core component of certain DSRIP projects, but the overall values associated with the Patient-Centered Medical Home closely align with our larger transformation efforts, including empowering patients to manage their own health conditions, and improving upon a fragmented delivery system through better coordination and management of care.

While not all OneCity Health primary care partners are required to achieve PCMH Level 3 recognition, all partners should understand that we consider PCMH certification a critical step in improving the processes through which we improve care for our patients. We are currently confirming which OneCity Health partner organizations are eligible to earn PCMH certification, and we will soon contact those specific partners to discuss plans.

We are working with Health Management Associates (HMA), NYC Reach / Fund for Public Health in New York, and the Primary Care Development Corporation (PCDC) to provide technical support to primary care partners throughout PCMH certification process. HMA is the lead coordinator in the effort and will contact eligible organizations.

For any questions regarding PCMH recognition, please email DSRIPSupport@nychhc.org with the subject line “PCMH”.

Important Updates for Asthma, Primary Care Transformation, and Palliative Care

Community Health Workers for Asthma Patients: Project Participation Opportunity

We are pleased to announce a Project Participation Opportunity for Asthma for our community-based partners that wish to implement or expand community health worker programs, in support of the project “Expansion of Asthma Home-Based Self-Management.” OneCity Health anticipates funding new or expanded community health worker programs in order to meet the needs of patients treated within our clinical network. OneCity Health recognizes community health workers as trained personnel with understanding of local communities who will provide home visits in support of existing clinical, care management, and social services. Please note that this is not a procurement process, but rather a way for OneCity Health partners to self-identify interest in participating in project implementation.

We strongly encourage community-based organizations who may be interested in this program to fill out and return the brief Partner Interest Form by Wednesday, December 23, 2015. An optional informational webinar will be held on Tuesday, December 15, 2015, 9am -10am (details to follow via email). An expression of interest in this opportunity will allow OneCity Health to include a partner organization in its understanding of the resources within our PPS partner network for both early and future roll-out of community health worker services.

Questions regarding this opportunity will be addressed during the scheduled webinar. In addition, partners may address questions to OneCity Health at DSRIPSupport@nychhc.org with the subject line “Asthma”.

Update on Primary Care Transformation and the Patient Centered Medical Home

Coordinated, accessible, and culturally competent primary care is a foundational component of OneCity Health’s DSRIP program. Our primary care partners play a critical role in enabling seamless care transitions, managing chronic illnesses, and integrating across the medical and behavioral health services spectrum. One approach to achieving this vision for primary care delivery is the Patient Centered Medical Home (PCMH) model. PCMH is a nationally recognized model for transforming the organization and delivery of primary care. The model focuses on five key functions and attributes:

  • Comprehensive Care
  • Patient-Centered Care
  • Coordinated Care
  • Accessible Services
  • Quality and Safety
A core requirement of the New York State DSRIP program is that all participating primary care providers in the PPS achieve accreditation from the National Committee for Quality Assurance (NCQA) for 2014 PCMH Level 3 Standards by the end of DSRIP Year 3 (March, 2018).

Many of the primary care partners in the OneCity Health PPS are already well on their path to PCMH transformation. One of the ways OneCity Health will support our participating primary care partners on this journey is to offer technical assistance through partnerships with organizations that have deep experience in primary care transformation.

On Monday, November 16, 2015, OneCity Health released a Request for Proposals (RFP) for vendors to support primary care transformation at participating partner sites within the PPS. For more information on this RFP, please refer here.

Please stay tuned for more information about how OneCity Health will be working with its primary care partners to ensure robust, accessible, and coordinated primary care for all patients across our integrated delivery system.

Palliative Care: Project Participation Opportunity

OneCity Health’s palliative care project aims to help primary care teams integrate palliative care skills into their practices, including advance planning, symptom management, goal-setting, and complex care planning for patients with serious advanced illness.

OneCity Health’s Project Participation Opportunity for Palliative Care seeks partners with specialized expertise both in palliative care and in clinical education to provide training and coaching services to primary care teams. While we anticipate that our journey towards an integrated delivery system will include many roles for palliative care services, the focus of this opportunity is specifically on training and coaching in the primary care setting. Please note that this is not a procurement process but rather a way for qualified OneCity Health partners to self-identify interest in supporting training and coaching.

The deadline for an expression of interest is Friday,December 4, 2015; a proposal of no more than 5 pages is due on Friday,December 11, 2015. Please direct all communications regarding this project, including questions as well as expressions of interest and proposals, to DSRIPSupport@nychhc.org, with the phrase “Palliative Care” in the subject line.

NYC Health + Hospitals’ Medical-Legal Partnership

NYC Health + Hospitals is working in collaboration with LegalHealth to provide legal support to patients to improve health outcomes by addressing social and economic factors such as income, education, and employment. Click here to learn more.