Download Workforce Coordinating Council

AMCH PPS
PAC Meeting
March 22, 2016
Agenda
•
•
•
•
•
•
CRFP
PAC Deliverables 3/31/16
Committee Updates
Sub-Committee Updates
Clinical Integration
PMO Updates – Staffing Changes and
Announcements
• Questions
Updates
• Capital Restructuring Financing Program
– Only $17 million awarded to our region,
between the two PPSs out of $1.5 billion
across the State
– Concerns about inadequate funding for IT
– Concerns about funding for space renovation
in skilled nursing facilities
Deliverables due 3/31/16
• Workforce Communication and
Engagement Plan
• Performance Reporting Strategy
• VBP Workgroup Mission Statement
• Data Security & Confidentiality Plan
• IT Roadmap
• IT Change Management Strategy
Finance
• Funding to partner organizations continues
– 2ai – Baseline Assessment Addendum: Check
requests for $114K have been submitted for 20
partnering organizations
– 2di – PAMs: Check requests for $42K have been
submitted for 1 partnering organization
• VBP Workgroup Formed
• The Planning Grant audit information was
submitted to the Independent Assessor on
3/4/2016
• Valuation Consultant – addressing FMV
Finance - Status of Contracts
Survey Complete
Organization
1 820 River St., Inc.
2 Addictions Care Center of Albany
Albany County Department for Children Youth
3 And Families
4 Albany County Department of Mental Health
By 10/16 After 10/16
N/A
N/A
6,000
N/A
N/A
6,000
Date of Contract
Date 2ai
2.a.i Baseline
Comprehensive
Date 2di
Assessment
Baseline
PAM
Addendum/ Assessment - Addendum/
Invoice Sent Addendum 1 Invoice Sent
POA
BAA
2/9/2016
2/9/2016
N/A
N/A
12/21/2015
1/28/16
2/2/2016
2/2/2016
2/23/2016
2/23/2016
N/A
N/A
12/22/2015
12/22/2015
2/2/2016
5 Albany County Nursing Home
5,000
1/27/2016
1/27/2016
2/2/2016
2/19/2016
6 Albany Medical College
5,000
2/18/2016
2/12/2016
2/8/2016
2/12/2016
2/10/2016
2/10/2016
N/A
N/A
7 All Metro Health Care
N/A
N/A
8 Alliance for Positive Health
6,000
2/1/2016
2/1/2016
2/24/2016
9 Arc of Ulster-Greene
6,000
1/26/2016
1/26/2016
2/2/2016
2/16/2016
3/8/2016
10 Belvedere Health Services
5,000
1/27/2016
1/27/2016
2/24/2016
11 Capital Care Medical Group
5,000
2/2/2016
2/2/2016
2/24/2016
1/11/2016
1/11/2016
N/A
N/A
12 Capital District Psychiatric Center -OMH
N/A
N/A
13 Catholic Charities
6,000
1/12/2016
12/16/2015
2/2/2016
2/2/2016
14 Center for Disability Services
6,000
12/21/2015
12/21/2015
2/2/2016
2/2/2016
Columbia County Community Healthcare
15 Consortium, Inc.
6,000
2/25/2016
2/25/2016
3/4/2016
2.d.i
2/25/2016
3/9/2016
2/25/2016
3/2/2016
Finance - Status of Contracts
Survey Complete
Organization
By 10/16 After 10/16
POA
BAA
Date of Contract
Date 2ai
2.a.i Baseline
Comprehensive
Date 2di
Assessment
Baseline
PAM
Addendum/ Assessment - Addendum/
Invoice Sent Addendum 1 Invoice Sent
16 Columbia County Dept. of Human Services
6,000
2/24/2016
2/10/2016
3/4/2016
17 Columbia Memorial Health
6,000
12/21/2015
12/21/2015
2/2/2016
2/1/2016
2/1/2016
2/24/2016
18 Community Care Physicians
5,000
19 Community Caregivers, Inc.
20 Community Health Center
21 Eddy Visiting Nurses Assoc
5,000
6,000
N/A
N/A
2/26/2016
2/26/2016
3/4/2016
12/29/2015
12/29/2015
2/2/2016
12/23/2015
12/23/2015
N/A
2/24/2016
3/7/2016
2/24/2016
N/A
ENS Health Care Management, LLC d/b/a Interim
22 HealthCare of the Capital Region
5,000
12/23/2015
12/23/2015
2/2/2016
23 Equinox
5,000
1/8/2016
1/8/2016
2/2/2016
12/17/2015
12/17/2015
12/21/2015
12/21/2015
2/2/2016
2/2/2016,
3/4/2016
12/23/2015
12/23/2015
N/A
N/A
12/29/2015
12/29/2015
2/2/2016
2/2/2016
24 Fulton Center for Rehabilitation and Healthcare
6,000
25 Harmony Mills Pediatrics
26 Hospitality House
27 In Our Own Voices
5,000
N/A
N/A
6,000
2/29/2016
28 Jewish Family Services of NENY
N/A
N/A
1/27/2016
1/27/2016
N/A
N/A
29 Kee to Independent Growth
N/A
N/A
2/10/2016
2/10/2016
N/A
N/A
1/26/2016
1/26/2016
2/2/2016
2/2/2016
30 Koinonia Primary Care, Inc.
6,000
2.d.i
3/16/2016
3/16/2016
Finance - Status of Contracts
Survey Complete
Organization
By 10/16 After 10/16
31 Lighthouse Guild -JGB Health Facilities Corp
POA
BAA
Date of Contract
Date 2ai
2.a.i Baseline Comprehensive Date 2di
Assessment
Baseline
PAM
Addendum/ Assessment - Addendum/
Invoice Sent Addendum 1 Invoice Sent
5,000 12/23/2015
12/23/2015
2/2/2016
6,000
2/16/2016
2/16/2016
3/4/2016
33 Living Resources Corporation
6,000
2/16/2016
2/16/2016
3/4/2016
34 Living Resources Home Care Agency, Inc.
6,000
2/16/2016
2/16/2016
3/4/2016
Mental Health Association of Columbia-Greene
35 Counties, Inc.
6,000
12/23/2015
12/23/2015
2/2/2016
2/8/2016
2/1/2016
2/1/2016
N/A
N/A
Living Resources Certificated Home Health
32 Agency, Inc.
36 Mental Health Empowerment Project
N/A
N/A
37 Northern Rivers Family of Services
6,000
12/17/2015
12/17/2015
2/2/2016
38 NY Statewide Senior Action Council, Inc.
6,000
12/28/2015
12/28/2015
2/2/2016
2/29/2016
39 NYSARC, Columbia County Chapter
40 Planned Parenthood Mohawk Hudson
6,000
6,000
2/1/2016
2/1/2016
2/24/2016
2/24/2016
12/10/2015
12/10/2015
2/2/2016
2/3/2016
12/21/2015
12/21/2015
N/A
N/A
12/30/2015
12/30/2015
2/2/2016
2/9/2016
41 Promesa, Inc.
N/A
N/A
2/24/2016
42 Rehabilitation Support Services, Inc.
6,000
43 Saratoga County Public Health Nursing Service
44 Saratoga Hospital
1/13/2016
did not receive
2/24/2016
6,000
12/10/2015
12/10/2015
2/2/2016
2/3/2016
45 Senior Hope Counseling, Inc.
6,000
2/9/2016
2/9/2016
2/2/2016
2/9/2016
5,000
2.d.i
2/29/2016
3/7/2016
2/25/2016 2/26/2016
Finance - Status of Contracts
Survey Complete
Organization
46 Senior Services of Albany
47 The Altamont Program, Inc.
48
The Philmont Hearth, Inc.
49 Transistional Services Assoc., Inc.
50
51
By 10/16 After 10/16
6,000
N/A
N/A
N/A
N/A
6,000
Trinity Alliance
Twin County Recovery Services, Inc.
52 Upper Hudson Planned Parenthood
5,000
N/A
N/A
6,000
Date of Contract
Date 2ai
2.a.i Baseline Comprehensive Date 2di
Assessment
Baseline
PAM
Addendum/ Assessment - Addendum/
Invoice Sent Addendum 1 Invoice Sent
POA
BAA
2/3/2016
2/3/2016
2/24/2016
2/9/2016
2/9/2016
N/A
N/A
2/1/2016
2/26/2016
N/A
N/A
2/11/2016
2/11/2016
2/24/2016
2/24/2016
2/4/2016
2/3/2016
2/24/2016
2/24/2016
2/24/2016
2/24/2016
N/A
N/A
1/6/2016
1/6/2016
2/2/2016
2/1/2016
2/1/2016
2/24/2016
12/23/2015
2/2/2016
53 VNA Home Health
5,000
54 Wildwood Programs
5,000 12/23/2015
2/26/2016
2.d.i
Finance Committee
•
•
•
•
•
Next Meeting 3/28/2016
Status of Contracts
June 2016 Deliverables
VBP Learning Workgroup
Budget by Project – DY1 & DY2 /
Valuation Consultant
Audit and Compliance Committee
Update
• Next Audit and Compliance Committee
4/21/16
• Compliance Training underway
• BHNNY Compliance Documents – in process
Compliance Plan
Code of Conduct
Fraud Waste and Abuse Policy
Anti-Trust Policy
Conflict of Interest
Performance Reporting Workgroup
• Project staff have completed the
Performance & Data Reporting Strategy
• Strategy incorporates expectations for
data reporting for both the PMO and
funded participating organizations
• Will be presented for final approval and
submitted to DOH with quarterly report
12
Workforce Coordinating Council
• The WCC recently disseminated an email to partnering providers introducing them
to the Compensation and Benefits Survey being conducted by Iroquois.
 Invitation letter was sent out by Iroquois to PPS partners with survey link and details, a username
and password to access the survey.
 Deadline to complete the survey is April 18, 2016. Once completed, Iroquois will compile the
information and send the aggregated data to the AMCH PPS.
 Aggregated data will help determine another Milestone, “Define a Target Workforce State”.
• Workforce Communication and Engagement Plan was endorsed by the WCC on
March 21, 2016.
 Plan will be presented to PAC Leadership this Thursday, and the PPS Board on Friday for approval.
• Last WCC meeting was combined with the AFBHC and was held on March 21st
 Agenda items included:

Discussion of job titles, descriptions and educational requirements.

DSRIP projects that both PPSs have chosen to implement.

Learning collaboratives that AMCH and AFBHC could collectively roll out to partnering providers.
Consumer and Community Affairs
• Last Meeting: Tuesday, March 8th-1275 Broadway, Albany
• Survey outcomes from Regional Meeting reviewed
• All 3 PPS Collaboration Meeting with AFBH and AHI in
Saratoga. Tentative meeting date: May 5th 6PM-8PM
• RFP issued to eligible organizations requesting facilitation of
consumer listening sessions, 2 responses approved for
funding; extended RFP until March 29th for consumer-facing
listening sessions to increase number of participating
organizations and sessions
• Conceptual agreement to continue to hold joint regional
meetings with overlapping PPSs
• Next Meeting: Tuesday, April 12th-Location TBD
Technology and Data Management
• 3 Milestones Complete for 3/31/2016
• Committee Endorsement and approval for
submission:
– IT Roadmap
– IT Change Management Strategy
– Data Security & Confidentiality Plan
• EHR Subcommittee in formation
• Leadership change
– George Hickman elected as new Chair, filling slot created
by Mary Hand’s resignation
• De-duplication of data new DOH requirement
• Next meeting 4/20/2016
AMCH PPS: Clinical and Quality
Affairs Committee Updates
• Project Updates
• Clinical Integration Project
– Accenture Engagement
AMCH PPS: Project Sequence - Update
Project name
Project
ID
Start date
1. Integrated Delivery Systems
2.a.i
Nov/Dec 2015
2. ED Care Triage
2.b.iii
Nov/Dec 2015
3. Patient Engagement – PAM & CFA
2.d.i
Nov/Dec 2015
4. Asthma Evidence-Based Guidelines
3.b.iii
Dec 2015/Jan 2016
5. Cardiovascular - Hypertension
2.a.iii
Dec 2015/Feb 2016
6. Integration of PC & BH – Part I (Models 1 & 3) 3.a.i
Jan 2016/Feb 2016
7. Health Home At-Risk Intervention Program
3.b.i
Jan 2016/Feb 2016
8. BH Community Crisis Stabilization
3.a.ii
Jan 2016/Feb 2016
9. Integration of BH & PC – Part II (Model 2)
3.a.i
Jan 2016/Mar 2016
10. Medical Village – SNF
2.a.v
Apr 2016/Mar 2016
11. Tobacco Cessation
4.b.i
Jun 2016
12. Cancer Screening
4.b.ii
Jun 2016
SC
2.a.iii – Health Home At-Risk Intervention
• Project Objective:
Expanded access to community primary care services (PCMH 2011
Level III certified sites) and develop integrated care teams to meet
the individual needs of higher risk patients who do not currently
qualify for NYS Health Home services.
• Key updates:
– Introductory webinar held on Feb 19th
– Strong interest among our HH care management downstream
organizations
• Next steps:
– First Sub-committee meeting scheduled for March 29th at 1 PM
– Project summary and other documents will be sent prior to the meeting
– Sub-committee will establish roles and responsibilities and begin reviewing
the project implementation plan
18
2.b.iii – ED Care Triage
• Project Objective:
–
–
To develop a care coordination/care transition program that will assist
patients to link with a PCP
To provide supportive assistance to transitioning members to the least
restrictive environment
• Key Updates:
– ED Care Triage Subcommittee meeting held on March 7th
• Discussion of current ED triage process and narcotic prescription guidelines
• Workflow for Patient Navigators
– Chaired by Denis Pauze, MD
– Meeting with EmUrgent Care Leadership on March 4th
– ED Diversion and Crisis Stabilization Project Meeting in Hudson on February
29th
• Next Steps:
– Next ED Care Triage Subcommittee meeting on Monday, April 4th at 10am
– Presentation to the CMH ED department on March 23rd
19
3.a.i: Integration of PC and BH Services
• Project Objective: Integration of mental health and substance abuse with
primary care services to ensure coordination of care for both services.
Model 1: Co-locate Behavioral Health services at Primary Care practice sites
Model 2: Co-locate Primary Care services at Behavioral Health practice sites
Model 3: Implement the “Improving Mood - Promoting Access to Collaborative
Treatment” (IMPACT) model of depression management at Primary care sites
• Key updates:
– Webinars have been concluded for the project, well received
– First subcommittee meeting is scheduled for Thursday, March 24th with
participation from PC Providers, BH Providers, and other key stakeholders
– Co-Chaired by Brendon Smith, PhD & Keith Stack, Executive Director, ACCA
– Project summary and other documents sent out on 3/21
• Next steps:
– Sub-committee will establish roles and responsibilities
– Address upcoming milestone deliverables
20
3.a.ii: BH Community Crisis Stabilization Services
• Project Objective:
To provide readily accessible behavioral health crisis stabilization services,
that allow access to appropriate levels of care and support rapid deescalation of the crisis.
• Key updates:
– Webinars have been concluded for the project
– First formal subcommittee meeting is scheduled for Thursday, March
31st with participation from Primary Care Providers, Behavioral Health
Providers, and crisis-oriented service providers.
• Next steps:
Finalize documents required for the first 3.a.ii subcommittee meeting on
3/31/2016 and continue to address upcoming milestone deliverables as we
work through the early implementation phase of the project.
21
3.b.i - Evidence-Based Strategies for Disease Management in
High Risk/Affected Populations (Adults Only)
• Project Objective:
To support implementation of evidence-based best practices for disease
management in medical practice for adults with cardiovascular
conditions.
• Key updates:
– Subcommittee to launch Friday, March 25, 8-9am (WebEx)
• Chaired by Joseph Wayne, MD, MPH, MACP
• 3/25 Agenda to include:
– Identification of co-chair; Distribution of participant list; Review of draft
Subcommittee Charter; Review of Project Summary and performance
measures; Identification of opportunities for rapid cycle improvement
• Next steps:
– Future subcommittee meetings proposed for 1st Friday, 8-9am,
starting May 6.
22
3.d.iii: Implementation of Evidence Based Medicine
Guidelines for Asthma Management
• Project Objective:
Ensure access for all patients with asthma to care consistent with
evidence-based medicine guidelines for asthma management.
• Key updates:
– Subcommittee to launch Monday, March 28, 8-9am (WebEx)
• Chaired by Ron Dick, MD
• 3/28 Agenda to include:
– Identification of co-chair; Distribution of participant list; Review of
draft Subcommittee Charter; Review of Project Summary and
performance measures; Identification of opportunities for rapid cycle
improvement
• Next steps:
– Future subcommittee meetings proposed for 2nd Friday of the
month.
23
Draft for discussion
Clinical Integration Project
Overview
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24
Draft for discussion
AMCH PPS Clinical Integration
Milestone Requirements, Goals, and Objectives
The CI milestone requires the development of a Clinical Integration (CI) Strategy that needs to
meet the following requirements and submitted to DOH by 6/30/16:
Milestone Requirements
• Specific Care Transitions Strategy that consists of hospital admission, discharge coordination, care transitions, coordination and
communication among Primary Care (PC), Behavioral Health (BH) and Substance Use providers
• Signed off by the Clinical Quality committee
• Clinical and other information for sharing among the PPS affiliates
• Data sharing systems and interoperability
• Implementation plan with a focus on Care Transitions
• Training for providers across settings (ED, inpatient, outpatient) regarding clinical integration, tools and communication for coordination
• Training for operations staff on care coordination and communication tools
Project Goals
Primary:
• Define the CI strategy for the AMCH PPS with a
focus on the Medicaid population and the DOH
requirements
Secondary:
• Define a CI strategy applicable for patient
populations to meet today’s CMS’ VBP /
Readmissions and future VBC requirements for
Care Management / Population Health
Management functions
Project Objectives
AMCH PPS DSRIP Objectives:
• Define Transitions of Care (ToC) strategy
• Outline clinical and other information for sharing
• Outline tools and communication approaches to facilitate coordination
among PPS affiliates and engage patients
• Define training criteria
Additional AMC-Defined Objectives:
• Define the Care Coordination Model (CCM) with governance / structure at the
PPS wide / local level
• Identify CCM functions / processes, protocols, roles and technology enablers
Copyright © 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
25
Draft for discussion
What is DSRIP?
Project Phasing
AMCH has chosen 11 projects from the menu of interventions provided by New York State; the CI
strategy is foundational to the AMCH projects outlined below
Key
Required in 6
Months
Priority
Long-term
AMCH PPS Projects
2.a.i
Create an IDS
2.a.iii
Health Home At-Risk Intervention Program
2.a.v
Medical Village/Alternative Housing using existing
Nursing Infrastructure
2.b.iii
ED Care Triage for At-Risk Population
2.d.i
Patient Activation Activities to Engage, Educate and
Integrate At-Risk Population
3.a.i
Integrate Primary Health and Behavioral Health
3.a.ii
Behavioral Health Crisis Stabilization Services
3.b.i
Evidence-based strategies for Disease Management in
High Risk Populations
3.d.iii
Evidence-based Guidelines for Asthma Management
4.b.i
Promote Tobacco Use Cessation
4.b.ii
Increase Access to High Quality Chronic Disease
Prevention (Cancer)
DY2
DY3
DY4
DY5
2016
2017
2018
2019
Q1/2
Q3/4
Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
Q1/2
Q3/4
Q1/2
Q3/4
Q1/2
Q3/4
26
Draft for discussion
Representative Measures by Project
P4R / P4P / Engagement metrics depend on operational improvements
Care Coordination is critical for all projects to accelerate, achieve the results for a value of $89M
Measures (P4R or P4P and Pt. Engagement)
2.a.i
IDS
2.a.iii
At Risk
2.a.v
Med. Village
2.b.iii
ED Triage
2.d.i
PAM
↓ avoidable ED visits





↓ avoidable readmissions




↑ frequency of ambulatory / preventive visits




↓ cost in ED / inpatient / PC / BH




↑ alignment to PCP





↑ patient satisfaction





↑ capture of HCAHPS Care Transition across PPS




↓ % of admissions




3.a.i
I PC / BH

3.a.ii
BH Crisis
3.d.iii
Asthma
4.b.ii
Cancer









↑ pts. with two+ non-ED services at Medical Village

↑ ED pts. with follow-up appointment with PCP

↑ pts. with completed PAM / PAM level 3 or 4
↑ pts. with preventive screening & include BH / SA

↑ pts. receiving PC services at BH/SA sites

↑ pts. screened using PHQ-2 or 9 / SBIRT


↑ medication adherence / mgmt.


↑ post-D/C follow-up / condition monitoring – for BH pts.


↑ % pts. screened for depression with tool / follow-up



↑ pts. receiving crisis stabilization /crisis programs

↑ adoption of substance dependence treatment





↑ Health literacy
↓ Premature deaths
Copyright © 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
Total
4.b.i
Tobacco


↑ pts. with new / updated CM plan / self mgmt. goals
3.b.i
CVD
$12M
$10M
$10M
$9M
$9M
$8M
$8M
$7M
$7M


$5M
$4M
27
Draft for discussion
Governance Structure
New Proposed Structure
Governance structure to support effective affiliate engagement, stakeholder buy-in / adoption
and timely execution of recommendations would consist of:
AMCH PPS
Oversight
Committee
AMCH PPS Oversight Committee:
 Receive monthly CI Project status updates
 Review / approve CI Project recommendations / plans
 Align plans with overall AMCH PPS strategy
Clinical and Quality Affairs Committee:
 Receive monthly CI Project status updates
 Review and approve CI strategy / plans
 Key Clinical Quality committee members serve on CI SC
Clinical and Quality
Affairs Committee
AMCH CI Steering Committee (new committee):
AMCH CI Steering
Committee (SC)
CI Project
Leadership Team
 Receive bi-weekly CI Project status updates / oversee Project
 Review / approve CI strategy / plan, approach / deliverables
 Key Clinical Quality committee members, PPS affiliate Executive
Sponsors (e.g., hospitals, Tier 1 affiliates, Medical Directors of
hospitals, leadership of physician practices, CDPHP, etc.) serve on CI SC
CI Project Leadership Team (new committee):
 Conduct weekly CI Project reviews / status updates
 Manage / monitor Project plan and activities
 Provide Project updates to governance committees
 Plan and execute right messages at right time to affiliate stakeholders
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28
Draft for discussion
Project Logistics and Commitment
Clinical Integration Strategy Timeline
In order to satisfy all milestone requirements by 6/30, the Clinical Integration Strategy
project has already begun and will run through the end of May
Current State
Assessment
Mobilization
Mar 1
Jan/Feb

Define Clinical
Integration project
scope

Identify Tier 1 Affiliates

Kick-off Webinar for
Tier 1 Affiliates

Future State Design
Mar 28
Gain understanding
of current state of
care coordination,
care management
(CM), processes,
data, and staffing

Collect relevant data
and documentation

Conduct analysis

Develop high-level
key findings and
recommendations


May 6
Design and refine
Clinical Integration
processes for discharge
and transitions of care
(ToC)
Convene work group of
stakeholders and
Subject Matter Advisors
to validate and refine
the CI functions /
process standards
June 30th, 2016: Milestone due date; all activities
completed, documented and reported to DOH
Copyright © 2015 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
Training
May 31

Define education
criteria and
implementation /
training plan

Conduct training on
future state for hospital
staff and affiliate
partners
Key

Completed

In progress

Not yet started
29
Draft for discussion
Future State Workgroup
Approach
A series of workgroup sessions will be conducted in order to create the future state functions and
processes
1. Current State
•
•
Assess care coordination current state against the CI/CCM straw model framework
and industry leading practices to identify gaps
Summary findings for the current state validation
Summary findings will be utilized in the future state workgroup session #1
2. Draft Future State
Accenture to draft future state functions and processes based on findings, straw
model and promote cross organizational standardization where possible
3. Finalize Future State
Conduct five workgroup sessions to gather input and validate future state
•
•
•
Begin meeting March 30 for 5 weeks
Webinar option available
Participants to be discussed
Copyright © 2016 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
30
Draft for discussion
Future State Workgroup
Proposed Focus Areas by Session
Work group sessions will cover in scope Care Coordination functions / elements and processes
In scope focus area functions / processes will be covered in two sessions each:
• Initial session: Introduce straw models for focus area, gather input and feedback, make updates
• Consecutive session: Review and validate updated models
Session 1
3/30
Session 2
4/6
Review Current
State & Set Obj.
ED and Acute Admission
Protocols and
Assessments
Focus Areas
Readmission and
Transition of Care
Planning
Session 3
4/13
Session 4
4/20
Session 5
4/27
Each function will include the following (what / when):
1.Elements / interventions
2.Recommended timeframes to complete activities
3.Required data to support communication sharing
4.Potential recommendations for the who
5.Focus on ToC and CC in community settings between
primary care and behavioral health where applicable
Discharge to Post Acute,
Home and Primary Care
Patient Navigation
Barriers to Care
• ED / hospital
• Readmission mgmt. /
Process flows:
• Patient navigation
admission function /
elements /
• DC to home
functions /elements
elements / handoffs /
interventions
• DC to / OP / clinics/
• Barriers to Care
info sharing
• ToC / DC planning
HH / Primary Care
management functions
• Care Plan template /
(process flow)
• DC to PAC (SNF,
elements
Rehab, other facility)
• CM assessments / risk
identification
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Alignment of All
Processes
• Complete any
outstanding processes
• Validate there are no
gaps in the end to end
patient management
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Announcements
• PMO Updates – staffing changes
– Evan Brooksby, deputy director, has accepted
a position with HANYS as director of policy
analysis. He will leave the PMO as of 3/23/16
– Louis Filhour, AMC Sr. Vice President, has
joined the PMO, providing new leadership in
clinical informatics, clinical integration and IT
PMO Announcements - continued
• March 31st is the end of DSRIP Year One
• Quarterly report due to DOH by 4/29/16
• Independent Assessor will conduct a
comprehensive assessment of all 25 PPSs starting
in July 2016
• Numerous important deliverables have to be
completed in the next quarter
• Better Health for Northeast New York incorporated,
but not yet approved as a lead applicant
• Next PAC meeting will be on4/25/16, 11:00 – 2:00
ME-700
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Questions
DSRIP Project Management Office Email: [email protected]
Visit us at: www.AlbanyMedPPS.org
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