Download DSRIP Domain 2-4 Projects for FQHCs

DSRIP Domain 2-4 Projects for FQHCs
In this document, CHCANYS presents information on select DSRIP projects from Domains 2, 3, and 4. These are projects that FQHCs should or could play
a leadership or central role in designing and implementing. The following three tables provide information on “Top Projects for FQHCs” as well as a few
alternates to consider. Click here for New York State’s DSRIP Project Toolkit, which includes more detailed project descriptions:
http://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_project_toolkit.pdf
Domain 2
Strategy Area and
Project
Valuation Score
FQHC attributes
that would
support this
project
Population that
project targets
System Transformation Projects
 Performing Provider Systems can submit up to 4 projects from Domain 2 for valuation scoring purposes.
 All DSRIP plans must include at least two Domain 2 projects based on their community needs assessment.
 REQUIRED: At least one project must be from Strategy A. Create Integrated Delivery Systems (IDSs)
AND at least one project must be from Strategy B. Implementation of Care Coordination and Transitional Care Strategies OR
Strategy C. Connecting Settings
FQHC Project
FQHC Project
FQHC Project
B. Care Coordination and
B. Care Coordination and Transitions
B. Care Coordination and Transitions
Transitions
2.b.iv
2.b.i
2.b.ii
Care transitions intervention model to
Ambulatory ICUs
Development of co-located primary reduce 30-day readmissions for chronic
care services in the ED
conditions
40
43
36
Patient mix with diabetes, asthma,
High patient mix of elderly, people with
Patient mix with diabetes, asthma, CHF, COPD,
CHF, COPD, other ambulatory
behavioral health (BH)/ substance abuse other ambulatory sensitive conditions; linkages
sensitive conditions; linkages with
(SA) conditions; linkages with hospitals,
with community supports
regional hospitals
psych hospitals, SNFs
Patients without a medical home;
Patients with history/risk of readmission Patients with history/risk of poorly managed
Patients with history/risk of poorly
for poorly managed BH/SA and/or
chronic conditions
managed chronic conditions or with
health conditions
mental/substance abuse comorbidity
DSRIP Domain 2-4 Projects for FQHCs
System Transformation Projects
 Performing Provider Systems can submit up to 4 projects from Domain 2 for valuation scoring purposes.
 All DSRIP plans must include at least two Domain 2 projects based on their community needs assessment.
 REQUIRED: At least one project must be from Strategy A. Create Integrated Delivery Systems (IDSs)
AND at least one project must be from Strategy B. Implementation of Care Coordination and Transitional Care Strategies OR
Strategy C. Connecting Settings
FQHC Project
FQHC Project
FQHC Project
Strategy Area and B. Care Coordination and
B. Care Coordination and Transitions
B. Care Coordination and Transitions
Project
Transitions
2.b.iv
2.b.i
2.b.ii
Care transitions intervention model to
Ambulatory ICUs
Development of co-located primary reduce 30-day readmissions for chronic
care services in the ED
conditions
Evidence to reduce Mixed to strong; some evidence to
Mixed to strong; managing transitions
Limited; some evidence for improving clinical
(inappropriate or
reducing future preventable ED visits linked with cutting readmissions,
outcomes for people with diabetes and
avoidable)
and avoidable hospital admissions
especially after psych/ SA discharges
improving satisfaction
hospitalizations
Existing models to Voices of Detroit Initiative; General
Care Transitions Intervention (CTI)
Union Health Center (in NYC)
build on
Practitioners embedded in UK EDs
Transitional Care Model (TCM)
Interdependence
Medium to high
Medium to high
Low
with other entities
Key entities
FQHC, Hospital
Hospital, FQHC, SNF
FQHC
involved in project
design
Likely FQHC
Clinical and/or care coordination
Clinical and care coordinators to
Patient care assistants (PCAs), health coaches;
staffing
staff embedded at ED
participate in Interdisciplinary Care
“floor” coordinators, patient support service
requirements
Teams (ICTs) with other provider-site
staff, and greeters
staff
HIT requirements
Functional EHR; HIE capability
Functional EHR; HIE capability across
Functional EHR; HIE capability across settings,
between ED and FQHC; instant
settings, providers; near real-time alerts providers; near real-time alerts to PCP/ICT
messaging
to PCP/ICT when admission occurs
when admission occurs
Domain 2
CHCANYS
2
DSRIP Domain 2-4 Projects for FQHCs
Domain 2
Strategy Area and
Project
Considerations,
challenges
CHCANYS
System Transformation Projects
 Performing Provider Systems can submit up to 4 projects from Domain 2 for valuation scoring purposes.
 All DSRIP plans must include at least two Domain 2 projects based on their community needs assessment.
 REQUIRED: At least one project must be from Strategy A. Create Integrated Delivery Systems (IDSs)
AND at least one project must be from Strategy B. Implementation of Care Coordination and Transitional Care Strategies OR
Strategy C. Connecting Settings
FQHC Project
FQHC Project
FQHC Project
B. Care Coordination and
B. Care Coordination and Transitions
B. Care Coordination and Transitions
Transitions
2.b.iv
2.b.i
2.b.ii
Care transitions intervention model to
Ambulatory ICUs
Development of co-located primary reduce 30-day readmissions for chronic
care services in the ED
conditions
Capacity to embed FQHC staff at ED; Importance of e-notifications; remaining Model has same goals and structure as a
contractual relationships and
as the PCMH post-discharge; capacity to PCMH; requires significant staff training and
reimbursement
make visits to the patient’s home
reorientation to team-based care model;
setting, as needed
requires recruiting and training of PCAs, Health
Coaches; and intense staff training on model
implementation
3
DSRIP Domain 2-4 Projects for FQHCs
Domain 3
Strategy:
Project:
Valuation Score:
FQHC attributes
that would
support this
project:
Population that
project targets
CHCANYS
Clinical Improvement Projects
 Performing Provider Systems can submit up to 4 projects from Domain 3 for valuation scoring purposes
 All DSRIP plans must include at least two projects from Domain 3, based on their community needs assessment
 REQUIRED: At least one project must be from Strategy A. Behavioral health
 Other Strategies are: B. Cardiovascular Health; C. Diabetes Care, D. Asthma, E. HIV, F. Perinatal, G. Palliative Care, H. Renal
Care
FQHC Project (see 4.a.i) FQHC Project
FQHC Project (see
FQHC Project
FQHC Project
4.d.i)
A. Behavioral Health
C. Diabetes
F. Perinatal
D. Asthma
B. Cardiovascular
3.a.i
3.c.i
3.f.i.
3.d.i. Medication
3.b.i
Integration of
Evidence-based
Increase support
adherence
Evidence-based strategies
behavioral health (BH) strategies for disease programs for
programs; 3.d.ii.
for disease management
into primary care
management (DM)
maternal and child
Expansion of asthma
(DM) in high-risk
settings
in high-risk
health (including
home-based, selfpopulations (adults only)
populations (adults
high-risk
management;
only)
pregnancies)
3.d.iii. EBM
guidelines for
asthma
39
30
29
28, 31, 31
30
At least PCMH level 1 or DM experience,
Outpatient OB
DM experience,
DM experience; disease
2 designation; linkages
disease registries;
services; prenatal
disease registries;
registries; linkages with
with LCSWs and CHWs
linkages with
care education;
linkages with
cardiology specialties
in service area
endocrinology
linkages with WIC
pulmonary/allergy
specialties
programs
specialties
Patients with/at-risk for Patients with/at-risk
Women, including
Patients diagnosed
Patients with/at-risk of
depression, or serious
of diabetes, preteens with a high-risk with or at risk for
hypertension, heart disease/
BH/substance abuse
diabetes,
pregnancy; new
asthma (children and
CHF, and/or conditions that
with chronic health
hypertension, heart
mothers at risk for
adults)
risk heart health
conditions
disease/ CHF, COPD
post-partum
depression
4
DSRIP Domain 2-4 Projects for FQHCs
Clinical Improvement Projects
 Performing Provider Systems can submit up to 4 projects from Domain 3 for valuation scoring purposes
 All DSRIP plans must include at least two projects from Domain 3, based on their community needs assessment
 REQUIRED: At least one project must be from Strategy A. Behavioral health
 Other Strategies are: B. Cardiovascular Health; C. Diabetes Care, D. Asthma, E. HIV, F. Perinatal, G. Palliative Care, H. Renal
Care
FQHC Project (see 4.a.i) FQHC Project
FQHC Project (see
FQHC Project
FQHC Project
4.d.i)
Strategy:
A. Behavioral Health
C. Diabetes
F. Perinatal
D. Asthma
B. Cardiovascular
Project:
3.a.i
3.c.i
3.f.i.
3.d.i. Medication
3.b.i
Integration of
Evidence-based
Increase support
adherence
Evidence-based strategies
behavioral health (BH) strategies for disease programs for
programs; 3.d.ii.
for disease management
into primary care
management (DM)
maternal and child
Expansion of asthma
(DM) in high-risk
settings
in high-risk
health (including
home-based, selfpopulations (adults only)
populations (adults
high-risk
management;
only)
pregnancies)
3.d.iii. EBM
guidelines for
asthma
Evidence to reduce Mixed; best results
Mixed; strongest for
Some for: reducing
Mixed; strongest for
Mixed; strongest for self(inappropriate or
limited to reducing ED
self-management
pre-term births, esp. self-management
management programs for
avoidable)
visits
programs for highest associated with
programs for highest
highest risk patients
hospitalizations
risk patients
specific medical
risk patients
interventions (e.g.,
17 OHP), when highrisk is identified
early; reducing rate
of elective deliveries
before 39 weeks; see
project 2.c.ii
Domain 3
CHCANYS
5
DSRIP Domain 2-4 Projects for FQHCs
Domain 3
Strategy:
Project:
Existing models to
build on
Interdependence
with other entities
Key entities
involved in project
design
CHCANYS
Clinical Improvement Projects
 Performing Provider Systems can submit up to 4 projects from Domain 3 for valuation scoring purposes
 All DSRIP plans must include at least two projects from Domain 3, based on their community needs assessment
 REQUIRED: At least one project must be from Strategy A. Behavioral health
 Other Strategies are: B. Cardiovascular Health; C. Diabetes Care, D. Asthma, E. HIV, F. Perinatal, G. Palliative Care, H. Renal
Care
FQHC Project (see 4.a.i) FQHC Project
FQHC Project (see
FQHC Project
FQHC Project
4.d.i)
A. Behavioral Health
C. Diabetes
F. Perinatal
D. Asthma
B. Cardiovascular
3.a.i
3.c.i
3.f.i.
3.d.i. Medication
3.b.i
Integration of
Evidence-based
Increase support
adherence
Evidence-based strategies
behavioral health (BH) strategies for disease programs for
programs; 3.d.ii.
for disease management
into primary care
management (DM)
maternal and child
Expansion of asthma
(DM) in high-risk
settings
in high-risk
health (including
home-based, selfpopulations (adults only)
populations (adults
high-risk
management;
only)
pregnancies)
3.d.iii. EBM
guidelines for
asthma
IMPACT model;
National Diabetes
Nurse Family
Home-based selfMillion Hearts campaign;
DIAMOND model for
Prevention Program; Partner-ship;
management
dedicated DM for CHF;
adults with depression
Diabetes selfMaternal and Infant
programs;
medication management
or Dysthymia.
management
Community Health
community-based
models
education (DSME)
Collaboratives;
asthma programs
Centering Pregnancy
Medium
Low
Medium
Medium
Low
FQHC, with CMHCs
FQHC
FQHC, with local
public health
agencies
FQHC, with home
health agency
FQHC
6
DSRIP Domain 2-4 Projects for FQHCs
Domain 3
Strategy:
Project:
Likely FQHC
staffing
requirements
HIT requirements
CHCANYS
Clinical Improvement Projects
 Performing Provider Systems can submit up to 4 projects from Domain 3 for valuation scoring purposes
 All DSRIP plans must include at least two projects from Domain 3, based on their community needs assessment
 REQUIRED: At least one project must be from Strategy A. Behavioral health
 Other Strategies are: B. Cardiovascular Health; C. Diabetes Care, D. Asthma, E. HIV, F. Perinatal, G. Palliative Care, H. Renal
Care
FQHC Project (see 4.a.i) FQHC Project
FQHC Project (see
FQHC Project
FQHC Project
4.d.i)
A. Behavioral Health
C. Diabetes
F. Perinatal
D. Asthma
B. Cardiovascular
3.a.i
3.c.i
3.f.i.
3.d.i. Medication
3.b.i
Integration of
Evidence-based
Increase support
adherence
Evidence-based strategies
behavioral health (BH) strategies for disease programs for
programs; 3.d.ii.
for disease management
into primary care
management (DM)
maternal and child
Expansion of asthma
(DM) in high-risk
settings
in high-risk
health (including
home-based, selfpopulations (adults only)
populations (adults
high-risk
management;
only)
pregnancies)
3.d.iii. EBM
guidelines for
asthma
Psychologists and/or
Health educators;
Advanced nurse
Health educators;
Health educators; DM care
psychiatrists in FQHC
DM care managers,
practitioners, CHWs; DM care managers,
managers, coordinators;
setting, peer support
coordinators
linkages to homecoordinators;
linkages to cardiology
specialists
dieticians; linkages
visiting nurses;
linkages to
specialists
to endocrinology
allergy/pulmonary
specialists
specialists
Functional EHR
Functional EHR
Functional EHR, with Functional EHR
Functional EHR w/registry;
w/registry; systems for w/registry; near real- registry; HIE with
w/registry; near realnear real-time HIE to monitor
hot-spotting; near real- time HIE to monitor
hospital providers to time HIE to monitor
prescription adherence
time HIE to monitor
prescription
monitor birth
prescription adherence
prescription adherence adherence
outcomes
7
DSRIP Domain 2-4 Projects for FQHCs
Domain 3
Strategy:
Project:
Considerations,
challenges
CHCANYS
Clinical Improvement Projects
 Performing Provider Systems can submit up to 4 projects from Domain 3 for valuation scoring purposes
 All DSRIP plans must include at least two projects from Domain 3, based on their community needs assessment
 REQUIRED: At least one project must be from Strategy A. Behavioral health
 Other Strategies are: B. Cardiovascular Health; C. Diabetes Care, D. Asthma, E. HIV, F. Perinatal, G. Palliative Care, H. Renal
Care
FQHC Project (see 4.a.i) FQHC Project
FQHC Project (see
FQHC Project
FQHC Project
4.d.i)
A. Behavioral Health
C. Diabetes
F. Perinatal
D. Asthma
B. Cardiovascular
3.a.i
3.c.i
3.f.i.
3.d.i. Medication
3.b.i
Integration of
Evidence-based
Increase support
adherence
Evidence-based strategies
behavioral health (BH) strategies for disease programs for
programs; 3.d.ii.
for disease management
into primary care
management (DM)
maternal and child
Expansion of asthma
(DM) in high-risk
settings
in high-risk
health (including
home-based, selfpopulations (adults only)
populations (adults
high-risk
management;
only)
pregnancies)
3.d.iii. EBM
guidelines for
asthma
Role of existing Health
Coordination,
Need to demonstrate Coordination,
Coordination, integration
Homes in service area;
integration with
expansion of MICHC, integration with
with existing health plan DM
BH provider supply;
existing health plan
if already
existing health plan DM programs; requires strong
potential need for
DM programs;
implemented
programs; requires
patient engagement
telepsychiatry
requires strong
strong patient
component, adequate
patient engagement
engagement
specialty capacity
component,
component, adequate
adequate specialty
specialty capacity
capacity
8
DSRIP Domain 2-4 Projects for FQHCs
Domain 4
Strategy:
Project:
Valuation Score:
FQHC attributes that
would support this
project:
Population that project
Targets
Evidence to reduce
(inappropriate or
avoidable)
hospitalizations
Existing models to build
on
Interdependence with
other health care entities
Potential leadership
entity in project design
Likely FQHC staffing
requirements
CHCANYS
Population-wide Projects
 Performing Provider Systems can submit up to 2 projects from Domain 4 for valuation scoring purposes
 All DSRIP plans must include at least one project from Domain 4, based on their community needs assessment
 DSRIP plans are not required to include a project from any one of the four Strategies
 The four Strategies are: A. Promote Mental Health and Prevent Substance Abuse (MHSA), B. Prevent Chronic
Diseases, C. Prevent HIV and STDs, and D. Promote Healthy Women, Infants and Children
Combine with Top 5 3f.i Perinatal project
Combine with Top 5 3.a.i. Integration of behavioral health
D. Promote Healthy Women, Infants and Children
A. Promote Mental Health/Prevent Substance Abuse
4.d.i
4.a.i. Promote mental, emotional and behavioral (MEB) wellReduce premature births
being in communities
24
23
Outpatient OB services; prenatal care education;
Strong community linkages with schools, Agencies on Aging,
telemedicine for women discharged after preterm
SNFs, CMHCs
labor; linkages with hospital-based high-risk pregnancy
programs
High-risk pregnant women; women at-risk for high-risk
At-risk youth; pregnant teens; parents with children involved in
pregnancy
child welfare; children involved in child welfare agencies (foster
care, juvenile justice), frail elderly;
specific medical interventions (e.g., 17 OHP) are
Needs further research
associated with reducing pre-term births, especially
when high-risk is identified early
Nurse family Partnership; Maternal and Infant
Community Health Collaboratives (MICHC); March of
Dimes Centering Pregnancy
Low to medium
SAMHSA-sponsored System of Care communities; Positive
parenting; targeted school-based curricula
FQHC
Low; high for dependence with non-medical agencies and
organizations
FQHC, with a school, AoA or other community partner
Advanced nurse practitioners, CHWs; linkages to homevisiting nurses;
Community relations specialists; CHWs, Peer/family support
specialists
9
DSRIP Domain 2-4 Projects for FQHCs
Domain 4
Strategy:
Project:
HIT requirements
Considerations,
challenges
CHCANYS
Population-wide Projects
 Performing Provider Systems can submit up to 2 projects from Domain 4 for valuation scoring purposes
 All DSRIP plans must include at least one project from Domain 4, based on their community needs assessment
 DSRIP plans are not required to include a project from any one of the four Strategies
 The four Strategies are: A. Promote Mental Health and Prevent Substance Abuse (MHSA), B. Prevent Chronic
Diseases, C. Prevent HIV and STDs, and D. Promote Healthy Women, Infants and Children
Combine with Top 5 3f.i Perinatal project
Combine with Top 5 3.a.i. Integration of behavioral health
D. Promote Healthy Women, Infants and Children
A. Promote Mental Health/Prevent Substance Abuse
4.d.i
4.a.i. Promote mental, emotional and behavioral (MEB) wellReduce premature births
being in communities
Functional EHR, with registry; HIE with hospital
Functional EHR; registry and/or HIE capability to track
providers to monitor birth outcomes
participation and admission outcomes
Need to demonstrate expansion of MICHC if already
Determine whether or how this project may tie into BH
implemented
integration
10
DSRIP Domain 2-4 Projects Most
Relevant to FQHCs - Appendix
CHCANYS
DSRIP Domain 2-4 Projects Most
Relevant to FQHCs - Appendix
CHCANYS
DSRIP Domain 2-4 Projects Most
Relevant to FQHCs - Appendix
CHCANYS
DSRIP Domain 2-4 Projects Most
Relevant to FQHCs - Appendix
CHCANYS