Serving the Patients We Do Not See

“When [marginalized patients] do seek care, it is sporadic,” describes Dr. Dave Chokshi, Chief Population Health Officer, OneCity Health. “They may show up in the Emergency Room (ER), but not to a primary care follow-up appointment. If an ensuing phone call goes unanswered, or their phone is out of service, we label them as ‘lost to follow-up’ and move on to the next patient on the list.”

In his article “The Patients We Do Not See,” recently published by The Conversation, Dr. Chokshi questions the role of the health care system in treating patients who may be sick but don’t seek care.

From social isolation, to the current political climate, to the barriers the health care system itself erects, Dr. Chokshi walks through potential reasons that people don’t actively seek care. One of the most unfortunate aspects, notes Dr. Chokshi, is that the most marginalized patients are those with the greatest unmet needs.

Emphasizing a public health mindset, and moving the locus of accountability for health further into communities, is one solution favored by Dr. Chokshi. Through our transformation initiatives, OneCity Health is actively linking patients to primary care and social services, conducting home visits to kids with asthma and transitioning patients to the community following a stay in the hospital. However, we also need to take the next step, as it is also necessary “to equip patients to be better stewards of their own health,” says Dr. Chokshi.

“Sometimes this involves health care providers, sometimes not. While physicians can’t do it alone, we can lend our voices to those calling for greater outreach, less stigma and protection of the most vulnerable.”

Read the full article here.

Partner Webinar: Recapping and Enhancing Partner Engagement

Thank you to our partners who attended today’s OneCity Health Partner Webinar: Recapping and Enhancing Partner Engagement

For our partners who were unable to view the webinar, the slides are available to view here.

The recording of the webinar will be embedded here as soon as it is available.

Our partners should keep in mind next steps:

  • As soon as possible, but by May 31, 2017: If our partners have not yet completed DSRIP compliance training, please do so immediately. Background on DSRIP compliance, instructions on how to easily meet this requirement and the attestation form to submit are available on our website
  • As soon as possible: Our partners should invoice for all Phase I metrics that they submitted and are approved
  • By May 15, 2017: Partners need to sign their Comprehensive Schedule B and complete the attestation on the Portal, otherwise they will forfeit participation in Phase II contracting
  • Week of May 15: Keep an eye out for our new Project Participation Opportunity (PPO)
  • May 24, 2017: Register for our webinar on the Co-location of Primary Care and Behavioral Health. Details are in our Events Calendar
  • By June 9, 2017: For our partners implementing Project 11, please complete metrics PM031, PM032 and PE03
  • June 13, 2017: Attend our next monthly OneCity Health Partner Webinar. The webinar will be held from 2 – 3:30 p.m. Details are in our Events Calendar
  • By June 30, 2017: Complete metrics PM007 (Phase II Partner Network & Gap Assessment Survey) and PM016 (NPI Survey) in the OneCity Health Partner Portal. We recommend our partners get started on the Network & Gap Assessment Survey when it becomes available in the Portal next week, leaving time in June to complete the NPI survey
  • If our partners have questions about completing metrics or submitting reports, please contact our support desk

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

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.

OneCity Health Partner Reporting Manual Version 2.0 Now Available

To help guide and support our partners, we have developed Version 2.0 of the OneCity Health Partner Reporting Manual. This version details most of the Comprehensive Schedule B metrics and the reporting requirements for the Project 11 Schedule B.

The next version of the OneCity Health Partner Reporting Manual, with all remaining metrics, including those for distinct Schedules B, will be issued early in 2017.

We provided a summary of the OneCity Health Partner Reporting Manual and reporting requirements in our July 13 webinar. To download metric templates and upload reports and invoices, our partners need to first register for the OneCity Health Partner Portal.

Click here to download version 2.0 of the OneCity Health Partner Reporting Manual.

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?”

Developing an Integrated Delivery System

OneCity Health will release Comprehensive Schedules B to each of our partners that completed the Master Partner Data Survey in early July, which begins the process of enhanced cooperation and accountability with our network, and strengthens our ability to provide coordinated, high-quality patient care across a seamless continuum of care.

In short, we are laying the foundation for our Performing Provider System (PPS) to become a fully integrated delivery system (IDS).

The current health care system is institution-based, consisting of fragmented providers and organizations with limited abilities to coordinate, share information, and address the full range of patients’ needs. By caring for our patients in a community-based setting – inclusive of medical, behavioral, long-term care, community-based providers and social service organizations– we can place them at the center and work together to keep them healthy.

For example, our early work with Project 11 initiated our efforts to collaborate and engage patients. By working with our community partners to implement additional Delivery System Reform Incentive Payment (DSRIP) projects, we can continue to learn about our partners, share best practices and grow together into an IDS.

Following the release of the Schedules B, we will quickly shift our focus toward these goals by hosting monthly ‘Implementation Webinars’ for our partners. Our first webinar will be held on July 13th from 12:30 p.m. to 2 p.m. Details on the agenda are forthcoming.

In this next phase, we plan to implement our 11 DSRIP projects. While they may seem distinct from one another, they align around our larger transformation efforts to ensure our patients receive high quality care in the right setting at the right time.

Our projects are only a start. To put patients in the center of an IDS, we must work with our community partners on a number of additional components that further align our network and improve care. These include:

  • Utilizing appropriate technology, including electronic health records (EHRs) to share health information and better coordinate care among our partners

We look forward to working with our partners on these initiatives in the coming months. Please view our events calendar for more details on the monthly Implementation Webinars, and continue to visit our website for updates on the development of our IDS.

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.

Project 11 Project Participation Opportunity

We are pleased to announce our latest Project Participation Opportunity (PPO) for Project 11 for our partners who work with uninsured and low- and non-utilizers of Medicaid. This Project Participation Opportunity is intended for OneCity Health community partners only; NYC Health + Hospitals sites should not submit an expression of interest and will be engaged in discussion around implementation through a separate process.

Community partners that participate in this project will help us engage patients in their health care, connect patients to insurance and/or primary care and screen for care management services. Read this Project 11 Project Participation Opportunity for more details.

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.

Interested partners should complete the interest form here by April 15, 2016. OneCity Health will respond to all expressions of interest by April 22, 2016.

An expression of interest through the completion of the interest form will provide OneCity Health with an understanding of interest and resources within our Performing Provider System (PPS) partner network for both early and future roll-out of this program to primary care sites.

We will also hold a webinar to take questions about this opportunity on Wednesday, April 13th, at 3 p.m. The webinar is not mandatory for participation in this project or submission of interest.

Online Access: Click Here
Meeting number: 734 032 514
Join by phone: +1-855-282-6330 US TOLL FREE
Access code: 731 788 715

Questions regarding this Project Participation Opportunity should be sent to DSRIPSupport@nychhc.org with the subject line “Project 11 PPO Questions”. We will respond to your inquiries promptly.

Entering DSRIP Demonstration Year Two

Thank you to everyone who attended our Project Advisory Committee (PAC) meetings last month in one of the four borough-based hubs, as well as those who completed the pre-PAC survey. For those who couldn’t attend, you can view the presentation here. If you did attend one of the recent meetings, please complete this optional post-PAC meeting survey. We value your feedback and use it to shape the agenda at future PAC events.

At both the meetings and in the pre-PAC survey, you emphasized a desire to learn more about Delivery System Reform Incentive Payment (DSRIP) program implementation and funds flow. Since we just concluded DSRIP Demonstration Year One (DY1, April 1, 2015 – March 31, 2016), we feel this is an appropriate time to review our recent milestones and what is on the horizon regarding these two topics.

Project Implementation: We successfully administered over 11,000 Patient Activation Measure (PAM®) surveys as part of Project 11. 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.

In addition, we are also proud to announce that we surpassed our initial goal for our palliative care project, as we successfully engaged over 500 patients with simple advance care planning in the primary care setting. This was just the first wave; moving forward, we’ll continue to implement additional interventions with our community partners aimed at ensuring our patients’ symptoms and advanced illnesses are appropriately managed in the primary care setting.

We have also initiated pilots for multiple other DSRIP clinical projects: 1) ED Care Triage, which begins the effort to connect patients with primary care from the Emergency Department; 2) Care Transitions, for which our goal is to provide a supportive transition to the community for patients who were admitted to the hospital and reduce readmissions; and 3) Health Home At-Risk planning, in which the objective is to extend care management services equivalent to the NYS Health Home program.

You can review the care model webinars on these clinical projects here.

Funds Flow: On April 4, we launched the Master Partner Data Survey to finalize our funds flow. If your organization has signed a Master Services Agreement (MSA) and provides clinical and social services, regardless of whether you bill for Medicaid, then your organization should have received the Data Survey. Please contact us immediately if you believe you should complete the Data Survey. Once it is complete, we will develop a more encompassing Schedule B for your organization, which will detail project deliverables and payments.

Expect more information in the coming weeks on project status and implementation as we advance into DSRIP Demonstration Year Two (DY2, April 1, 2016 – March 31, 2017). As always, if you have feedback or questions, please feel free to email us at DSRIPSupport@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.