Webinar Available to View: Collaborative Care for Depression

America’s Essential Hospitals recently hosted this webinar on collaborative care for depression in the primary care setting.

Led by Jessica Black, MPH, MSW, Program Manager, Collaborative Care and Kathleen Tatem, MPH, Data Analyst, both of OneCity Health, attendees learned how NYC Health + Hospitals developed collaborative care tools to drive operational workflows and quality improvement across multiple sites. As a result, the depression improvement rate at NYC Health + Hospitals increased from 17.7 percent to 58.2 percent.

The full webinar is available to view here:

This past June, NYC Health + Hospitals was awarded the 2017 Gage Award for Innovation and Excellence from America’s Essential Hospitals for implementing collaborative care for depression in the primary care setting. Read more about the award and program here.

Commonwealth Fund Report Highlights NYC Health + Hospital Transformation Activities

In a recent report, “An Emerging Approach to Payment Reform: All-Payer Global Budgets for Large Safety-Net Hospital Systems,” the Commonwealth Fund defines all-payer global budgets and details three primary steps to implementing them in large safety-net hospitals: a vision for transformation, an operational strategy, and an environment conducive to success.

Their approach, however, is not one-size fits all, as larger urban hospitals and small rural hospitals face different situations. To help illustrate how global budgeting – an annual expectation for revenue for all inpatient and hospital outpatient care in advance – might be applied in an urban area, the authors focus on some of our transformation activities underway at NYC Health + Hospitals through OneCity Health and the Delivery System Reform Incentive Payment (DSRIP) program.

Our major initiatives, which include primary care improvement, collaborating with community partners, identifying high-need patients and integrating behavioral health and primary care, are examples of how to establish a vision to improve health outcomes and lower costs. Moreover, they demonstrate how to operate when revenue is independent of inpatient volume, which would occur under an all-payer hospital budget.

Click here to read the full report.

100 Schools Project, Back-to-School Checkups, Promote Classroom Wellness

Whether kids are adjusting to a new grade or a whole a new school, the first few weeks back in school have the potential to be both physically and mentally challenging. However, initiatives from both OneCity Health and NYC Health + Hospitals can help alleviate the stress, keep kids healthy and in school, and ensure they are able to excel.

100 Schools Project Promotes Mental Health
Through the 100 Schools Project – which, we’re proud to share, was recently featured in the New York Times! – Mental Health Coaches are now in place at 43 schools across Manhattan, Brooklyn, Queens and the Bronx. While they don’t work directly with students, these Coaches are training staff to identify the early signs of mental illness and substance abuse, and to promote wellness and prevention in the classroom.

For example, to help students feel more comfortable utilizing community resources, Coaches are training school staff in methods to reduce the stigma around mental health. Teachers are also learning motivational interviewing, which is a counseling technique to better engage students with positive behavior change.

Students aren’t the only focus though. School staff and teachers are also learning self-care practices to reduce classroom turnover and promote professional development.

Launched in September 2016 with a ten-school pilot, OneCity Health and three other New York City-based Performing Provider Systems (PPS) —Community Care of Brooklyn, Bronx Health Access, and Bronx Partners for Healthy Communities—oversee the 100 Schools Project while the Jewish Board of Family and Children’s Services (The Jewish Board) coordinates the initiative and leads the trainings. Participating schools are also learning how to connect students who have emotional, behavioral, or substance-use challenges with top-tier local mental health providers while enabling the students to remain in school.

The project will continue to expand throughout the remainder of 2017, as the Jewish Board has identified the next 58 schools for project implementation.

Visit the Exam Room Prior to the Classroom
From vision and hearings tests to advice on proper eating, a clean bill of health can help kids stay and strive in the classroom. To help, NYC Health + Hospitals offers pediatric and adolescent health services at little or no cost. Click the borough name below for a flyer detailing the locations where families can receive immunizations, physicals and other back-to-school check-ups.

OneCity Health partners can feel free to download and share the flyers as needed.

Partnership in Care Asthma Webinar Now Available to View

In this presentation, we discussed how a partnership between the primary care team and community health worker is essential for effective asthma management for children with asthma. Moreover, we highlighted how asthma self-management education improves patient outcomes, as community health workers utilize a written Asthma Action Plan tailored to the needs and literacy levels of the patient to reinforce patient education provided by the clinical team.

Click here to view the slides or view the full webinar below.

Webinar Series: Co-Location of Primary Care and Behavioral Health Services

Throughout August, OneCity Health hosted a series of webinars on the Co-Location of Primary Care and Behavioral Health Services for our ten pilot sites currently planning for co-location. Led by consultants from Grassi & Co., our vendor currently working with our pilot sites, the webinar recordings were posted on this page following each session.

In addition to the webinars posted below, in June we hosted a webinar titled, “Navigating the Regulatory Options for Co-location of Primary Care and Behavioral Health,” which is available to view here.

Webinar Recordings
Implementation of Co-Location of Primary Care and Behavioral Health Services
This webinar covered the key components of implementing co-location of primary care and behavioral health, including needs assessment, regulatory requirements, identification of resources needed (e.g. space, staffing, health information technology systems, etc.), care coordination, as well as monitoring implementation.

Click here to view the slides, or watch the recording below:

Measures and Quality Improvement for the Co-Location of Primary Care and Behavioral Health Services
This webinar covered clinical and operational measures recommended for co-location of primary care and behavioral health services and an overview of strategies for quality improvement.

Click here to view the slides, or watch the recording below:

Billing Considerations for Co-Location of Primary Care and Behavioral Health Services
This webinar reviewed information needed for billing and compliance for co-location of primary care and behavioral health services. The information presented is also helpful to information technology stakeholders who need to support billing, revenue cycle and compliance. Please note this information only addressed billing considerations for sites that have chosen the licensure threshold, DSRIP waiver or Integrated Outpatient Services (IOS) license as the regulatory option for co-location at their site.

Click here to view the slides, or watch the recording below.

In addition to the webinar, click here to download an accompanying handout – Revenue Cycle Changes Checklist

Screening Tools for Co-location of Primary Care and Behavioral Health Services
This topic was addressed in two separate webinars:

  • Screening Approaches for Co-location of Primary Care Services in a Behavioral Health Setting
    This webinar provided an overview of the use of screening approaches for physical health (e.g. chronic disease, pain, etc.) in the behavioral health setting. It included a discussion of the importance of provider involvement in achieving success of co-location. Click here to view the slides.
  • Screening Tools for Co-location of Behavioral Health Services in a Primary Care Setting
    This webinar provided an overview of the use of screening tools for depression, anxiety as well as alcohol and substance abuse in the primary care setting. It included a discussion of the importance of provider involvement in achieving success of co-location. Click here to view the slides.

Both webinars are available to view in one recording. The presentation begins with a focus on behavioral health screening, and then the discussion on physical health screenings commences at the 31:10 mark. Watch the recording here:

OneCity Health Launches City-wide Program to Better Treat Kids with Asthma and Reduce Avoidable Hospitalizations

NYC Health + Hospitals/OneCity Health today announced the launch of a population health and care management program designed to reduce hospitalizations among New York City children who suffer from frequent or severe asthma attacks. The home-based environmental management program assigns community health workers to visit homes to identify asthma triggers, reinforce strategies to help patients and their families maintain control over asthma, and supply free pillow cases, special cleaning supplies, and professional pest control services as needed.

OneCity Health—a subsidiary of NYC Health + Hospitals focused on population health, care management, and implementation of the State’s Delivery System Reform Incentive Payment (DSRIP) program—is aligning the public health system and its community partners, having already completed its first 500 home assessments, with plans to expand the program to hundreds more children and families this year.

“Asthma is the third-leading cause of hospitalization among children under the age of 15 in the United States, and oftentimes it’s because families may not understand how to reduce triggers or may struggle to address underlying determinants of health, such as substandard housing conditions,” said Dr. Luis Rodriguez, Chief of Pediatrics at NYC Health + Hospitals/Woodhull. “Controlling asthma requires getting to the root of the issue, including triggers in the home, and ensuring patients have access to the proper medications.”

“Through these transformation initiatives, which were enacted through the DSRIP program, we are connecting primary care physicians with community health workers and home remediation services, helping professionals across these organizations work together to care for patients with asthma,” said Andrew Kolbasovsky, Chief Program Officer, OneCity Health. “Our goal is to improve the quality of life for affected children, making sure they don’t miss school or avoid physical activity due to their asthma. That begins with creating a care plan focused on prevention, making sure patients don’t need to come to the emergency department or spend the night at the hospital because of asthma attacks.”

“Community partners and community health workers are essential to engaging patients,” said Janise Germosen, LMSW, Community Health Worker Supervisor and Social Work Care Manager at Asian Community Care Management, a OneCity Heath community partner. “We know our communities well and have done outreach before, so patients are more comfortable allowing us into their homes, which is an important element of support in the program.”

The home-based environmental management program for children with asthma is run by the following OneCity Health partners:

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The program’s initial focus is on pediatric patients with poorly controlled asthma, defined as overuse of “rescue” medications, use of systemic corticosteroids two or more times in the last six months, two or more asthma-related emergency department visits in six months, or hospitalization related to asthma in the past year. Program data will be tracked, including the impact on the proper use of medication and reduction in asthma-related hospitalizations, both DSRIP priorities.

After identifying a patient with frequent or severe asthma attacks, the primary care team develops an Asthma Action Plan and refers the patient to a community health worker. The community health worker meets with the patient and reinforces recommendations from the clinical team, including self-monitoring strategies and instructions on the correct use of medications. In addition, the community health worker conducts a home visit to evaluate the environment for asthma triggers, such as rodents, pests, mold, and dust. Based on the assessment, the community health worker can provide pillow cases and cleaning supplies, instruct families in home-cleaning strategies, and engage with the New York City Department of Health & Mental Hygiene—OneCity Health’s partner providing professional cleaning and pest management—at no cost to the patient.

Community health workers ensure that patients and their families are adhering to the Asthma Action Plan on an ongoing basis, through both home visits and phone calls. The community health workers also communicate with each patient’s clinical care team, using care management software to document interventions and receive alerts when patients are in the hospital.

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.

New in JAMA: A “Moonshot” for High-Need Patients

While “moonshot” efforts may be typically used for curing diseases like cancer, transforming care for high-need patients – improving the outcomes of people with multiple, and often interconnected, medical, social and behavioral health needs – would be just as lofty, and no less impactful. But, as Dr. Dave Chokshi, Chief Population Health Officer, OneCity Health, writes in an article published this week by JAMA, the time might be right for a similar bipartisan push towards this health care goal.

In “A Bipartisan “Moonshot” in Health: Improving Care for High-Need Patients,” Dr. Chokshi notes there are no silver-bullet interventions for patients with complex needs, but health systems and payers could begin by identifying high-need patients and asking themselves how they are improving care for them. He outlines four broad strategies to help:

  • Recognize the whole-person needs of complex patients
  • Build and nurture relationships between patients and care teams
  • Enhance the usual clinical services provided in primary care, particularly with resources to address behavioral health and social needs
  • Renew the focus on caregiving

About 12 million adult patients have three or more chronic conditions as well as functional limitations, such as difficulties with self-care, and could benefit from these improvements. Read the full article to learn more about these strategies, and why now may be the right time for bipartisan policy efforts to improve the care we deliver to high-need patients.

Click here to read the full article.

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.

New York State SBIRT Resources Available to OneCity Health Partners

The New York State Office of Alcoholism and Substance Abuse Services (OASAS) is offering technical assistance resources and trainings to help our partners implement the Screening, Brief Intervention and Referral to Treatment (SBIRT) program.

Below please find complete details about SBIRT and how to access these resources. Our primary care partners that are Integrating Primary Care with Behavioral Health can report on their participation in any of these trainings through metric PM024 in their Phase 2 Comprehensive Schedule B.

SBIRT Technical Assistance Opportunity

What is SBIRT (Screening, Brief Intervention and Referral to Treatment)?
SBIRT is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related health consequences, disease, accidents and injuries. Risky substance use is a health issue and often goes undetected. For more information on SBIRT please visit https://www.oasas.ny.gov/AdMed/sbirt/index.cfm and watch the following video:

What resources are available for SBIRT implementation?
NYS OASAS has a time-limited technical assistance opportunity for hands-on, intensive consultation, guidance, and training to emergency departments, primary care practices, and other health delivery practitioners implementing SBIRT across New York State. Technical assistance supports various stages of implementation and includes:

  • Advice and guidance on all aspects of readiness and practice implementation using OASAS resources and based on best practices;
  • education and training on SBIRT;
  • on-site implementation support, as needed.

NYS OASAS aims to advise individual sites in becoming fully operational and sustainable by:

  • Identifying barriers to implementation;
  • identifying strategies to overcome barriers;
  • assessing current workflows and assisting in reconfiguration;
  • creating and reviewing process maps;
  • gauging readiness;
  • and developing individualized project management tools such as project timelines & work plans.

To request OASAS SBIRT technical assistance and/or training, email SBIRTNY@oasas.ny.gov

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