Download DSRIP Care Delivery Transformation – Guidelines for Frontline Staff

DSRIP Care Delivery Transformation
Guidelines for Frontline Staff
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DSRIP Overview
New York State (NYS) received federal approval to implement a Delivery System Reform
Incentive Payment (DSRIP) program that will provide funding for public and safety net
providers to transform the NYS health care delivery system.
Goals:
(1) Achieve the Triple AIM: Better Health, Better Health Care, Lower cost
(2) Transform Delivery and payment system to incentivize value over volume
(3) Ensure delivery system transformation is sustained through movement from
fee-for-service to value-based payment system
Key Program Components:
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Statewide funding initiative for public hospitals and safety net providers
Creates coalitions of community/regional health providers
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DSRIP projects respond specifically to the health needs of Bronx residents
Payments to providers based on their performance in meeting outcome
milestones and achieving statewide metrics
Additional information about the NY State DSRIP program can
be accessed here:
https://www.health.ny.gov/health_care/medicaid/redesign/deli
very_system_reform_incentive_payment_program.htm
The Bronx is Ready for DSRIP
The Bronx is home to:
A large Medicaid population: 59% of residents are covered through
Medicaid over the course of the year
A large base of providers spanning the continuum of care
Support from diverse organizations with deep roots in the
community
DSRIP provides an opportunity for the Bronx to
transition to a truly integrated delivery system.
Bronx Partners for Healthy Communities
Bronx Partners for Healthy Communities (BPHC) is implementing DSRIP
in the Bronx
The BPHC network includes a wide array of organizations and services:
 Hospitals
 Primary and specialty care services
 Behavioral health and substance abuse
services
 Long term care and assisted living facilities
 Home care agencies
 Health homes
 IPAs
 Unions
 Community-based organizations (e.g.,
services for the developmentally disabled,
housing, adult day care centers, advocacy,
foster care, meal delivery, food banks, legal
aid, counseling, youth development)
 Educational institutions
 Pharmacies
 Health plans
The Central Services Organization (CSO) supports the work of BPHC
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Learn More About DSRIP!
This presentation explains what DSRIP projects ask of
you and your team members
For more information on DSRIP:
 Ask your organization’s DSRIP Program Director about the Implementation Guidelines
section of the BPHC Clinical Operations Plan
 DSRIP 101 video:
– https://www.youtube.com/watch?v=YyobdAU60fU&feature=youtu.be.
 DSRIP 101 e-course:
– http://www.hwapps.org/1199tef/courses/bphc-dsrip-101/
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Project-Specific DSRIP Requirements
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Health Home At-Risk Intervention Program
This program aims to:
• Deliver time-limited patient navigation and care coordination services for patients considered “Health Home At-Risk”
through Care Coordinators embedded in primary care practices.
•
Health Home At-Risk patients are those who need more care navigation assistance than is regularly provided
by the primary care team, but lacking the complexity of Health Home patients who are managing multiple
uncontrolled chronic conditions.
• Intervene early to stabilize patient health status and reduce health risks /avoidable service utilization.
• Increase referrals of eligible patients into Health Home care management services.
• Increase connections to community-based services to address social determinants of health.
Primary Care Team Roles and Responsibilities:
• Assist with warm-handoff to Care Coordination Team for patients in need of care coordination services (Health Home
or Health Home At-Risk).
• PCP reviews and provides feedback on patient care plans.
• PCP (and other designees, as relevant) participates in regular case conferences to assess patients’ progress towards
their goals.
• Involve Care Coordinators in care team huddles.
• Maintain communication, as needed, with Health Home Care Managers regarding Health Home enrolled patients.
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Health Home At-Risk Intervention Program
Care Coordination Team Roles and Responsibilities:
• Conduct assessment to determine care coordination needs (clinical care navigation, as well
as housing, entitlements, legal representation and other social services).
• Work with patient and Primary Care Team to create a comprehensive care plan that includes
problems, goals (especially patient self-management goals) and interventions/referrals.
Provide a copy of the care plan to the patient.
• Participate in regular case conferences and huddles with the primary care team to assess
patient progress towards their goals and prepare for patient visits.
• Coordinate with hospital-based staff to ensure follow-up appointments and support are in
place following an emergency room visit or in-patient stay.
• Refer patient to needed services (medical, behavioral health, social service, Health Home,
etc.).
• Close the loop on referrals: follow up with patient and provider post-referral to ensure that
the patient has connected to and received necessary services.
• Where available, use a Care Coordination Management System (CCMS) IT platform to
document and track patients’ care planning and progress towards goals.
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ED Care Triage
This program aims to:
• Reduce avoidable ED use by patients with non-emergent needs that could be addressed by their
community PCP or behavioral health provider.
• Connect patients to their primary care provider and/or Health Home Care Manager with an appointment.
• Improve communications between ED and primary care teams.
Hospital-Based Roles and Responsibilities:
ED Navigator
• Receive patients from work list of eligible patients; perform assessment to identify clinical and social
supports to reduce avoidable ED visits
• Make an appointment with PCP or Health Home Care Manager; share information with provider, as
relevant.
• Make referrals as appropriate to community-based organizations (CBOs) and/or Behavioral Health (BH)
providers including the Parachute NYC program, a provider of BH crisis respite services. Provide warm
handoff to receiving clinician/organization.
• Perform (or handoff to support team to perform) closed-loop referral tracking to ensure patient went to
appointment(s).
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ED Care Triage
Outpatient Roles and Responsibilities:
Outpatient Care Coordinator (e.g. Health Home Care Manager, Health Home At-Risk
Care Coordinator and/or PCMH Patient Navigator) and/or Primary Care Team
• Respond to Bronx RHIO alert (“Encounter Notification System”) that patient was recently in the ED and
perform necessary assessments based on this trigger.
• Retrieve ED discharge summary and/or ED Navigator assessment through Bronx RHIO, synthesize ED
Navigator recommendations, and update physician/care team.
• Contact the ED Navigation program office at hospital where patient was seen if clarification or additional
information needed to coordinate care and incorporate any recommendations from ED Navigator.
• Remind patient of scheduled appointment, or schedule a follow-up PCP appointment.
• Assign a Care Coordinator, if relevant and the patient is not yet assigned.
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Care Transitions
This program aims to:
• Provide a 30-day supported transition period after hospitalization to ensure discharge directions are understood and
implemented by patients at high risk of readmission, particularly those with cardiac, renal, diabetic, respiratory and/or
behavioral health disorders.
Hospital Roles and Responsibilities:
Inpatient Care Transitions Clinical Coordinator (CTCC) and/or support team.
• Prioritize patients to be engaged in intervention from daily “high risk for readmission” list.
• Provide initial and pre-discharge visits to educate patients (and caregivers) about managing their conditions, review
discharge summaries and care plans, and perform teach back.
• Reinforce the importance of RHIO consent. Share information with and respond to any questions from outpatient Care
Coordinator(s) and/or physician practices.
• Complete assessments to populate Transitional Care Plan (TCP) and/or discharge summary.
• Participate in interdisciplinary care team rounds and coordinate with social workers, discharge planners and PDCCs on
TCP recommendations and referrals that need closed-loop follow up.
• Make referral and warm hand-off to PCP (confirm RHIO connectivity), outpatient care coordinator, community-based
organizations and specialists needed for patient to remain healthy in the community.
• Transmit TCP to the Outpatient Care Coordinator and/or PCP receiving referral.
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Care Transitions
Post-Discharge Roles and Responsibilities (Hospital-based):
Post-Discharge Care Coordinator and/or support team (PDCC)
• Receive risk stratified discharges within 1-2 business days for patients with completed TCP.
• Review TCP, inpatient assessments and any available outpatient care plan information; contact CTCC or
Outpatient Care Coordinator for clarification, as needed.
• Perform post-discharge assessment with patient within 72 hours of discharge, including PHQ-2 and, if
needed, PHQ-9. Perform second assessment within 14 days.
• Execute Problems, Goals and Interventions (PGIs) listed on TCP and review with patient.
• Determine and execute any additional PGIs identified through post-discharge assessments (e.g.,
intervention for positive PHQ9).
• Communicate additional PGIs to Outpatient Care Coordinator.
• Review scheduled appointments and perform medication reconciliation if needed.
• Track referrals to medical and community-based services made on TCP and during post-discharge
assessment to completion.
• Continue tracking for 30 days, until handoff made to Outpatient Care Coordinator can be made, or after 3
unsuccessful rescheduling attempts.
• Hand off any unresolved PGIs to Outpatient Care Coordinator. Confirm receipt of tasks.
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Care Transitions
Outpatient Roles and Responsibilities:
Outpatient Care Coordinators and/or Primary Care Team
• Receive Bronx RHIO alert that a patient has been in the hospital and has documents available.
• Obtain discharge summary / TCP and any assessments from CTCC or PDCC through Bronx RHIO, fax
or secure email.
• Contact the hospital-based Care Transitions Manager (numbers will be provided at a later date) if
clarification needed on TCP. The Care Transitions Manager will connect Outpatient team with
hospital-based CTCCs and/or PDCCs caring for the patient to provide an update and facilitate followup care.
• Remind patient of scheduled appointment, or schedule an appointment within 7 days of hospital
discharge.
• Coordinate with PDCC team at hospital to close the loop on any referrals.
• Note the patient’s record and/or care plan to reflect communications with the hospital and relevant
updates from the TCM.
• Assign a Care Coordinator, if relevant and the patient is not yet assigned. Accept the patient for
longitudinal care management on day 31 or sooner of transitional care period.
• Care Coordinator should go to hospital and visit the patient. Engage in transitional care planning
with inpatient team.
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Primary Care and Behavioral Health Integration
This program aims to:
• Integrate mental health and substance abuse with primary care services to ensure
coordination of care for both services.
• Provide integrated care to patients aged 12 years old and over who visit a projectparticipating primary care provider or behavioral health professional in our PPS network,
with particular attention to patients living in neighborhoods with the highest rates of
residents reporting psychological distress.
• Different models possible: Co-location or IMPACT
Co-location Models:
• Co-location of primary care and behavioral health services enables earlier identification,
increased follow through of referrals, and improved continuum of care.
• Processes and workflows have been developed to guide adoption of effective
communications between primary care and behavioral health providers in co-located
practices, this includes the implementation of new procedures for patient intake,
assessment, and management.
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Primary Care and Behavioral Health Integration
Primary Care Team Roles and Responsibilities (Co-location Models):
• Treat patient’s primary care needs
• Prescribe medication as needed
• Make warm hand-off to and be available for warm hand-off from behavioral health team
• Engage in regular communication with the behavioral health team by connecting in-person, by phone, and
through the shared EHR
• Coordinate and consult on treatment plans with the behavioral health team
• Coach the behavioral health team to monitor physical health problems and conduct physical health
screenings
Behavioral Health Team Roles and Responsibilities (Co-location Models):
• Treat patients’ mental health conditions
• Prescribe medication as needed
• Make warm hand-off to and is available for warm hand-off from primary care team when physical health
needs have been identified
• Engage in regular communication with the primary care team by connecting in-person, by phone, and
through the shared EHR
• Coordinate and consults on treatment plans with the primary care team
• Provide coaching to the primary care team on behavioral health skills/issues
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Primary Care and Behavioral Health Integration
IMPACT Model:
• IMPACT stands for Improving Mood-Providing Access to Collaborative Treatment
• This intervention, an evidence-based model of collaborative care, is the foundation for the
integration of primary care into the behavioral health setting, and behavioral health into the
primary care setting.
• Leverages the role of a depression care manager (DCM), who can implement short term
treatment.
• Documentation of screening, warm hand-offs, and following protocol for escalating a case to
a psychiatric consultant are critical components of adhering to the IMPACT model of care.
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Primary Care and Behavioral Health Integration
Depression Care Managers (or Behavioral Health Specialists) Roles and
Responsibilities (IMPACT Model):
• Coordinate the overall effort of the IMPACT team
• Ensure effective communication among team members
• Provide brief counseling using evidence-based techniques such as Motivational Interviewing, Behavioral
Activation, and Problem Solving Treatment
• Support medication management
• Communicate regularly with the patient
• Provide proactive follow-up of treatment response
• Adjust treatment based on clinical outcomes, according to an evidence-based algorithm utilizing common
depression screening tools
• With every patient contact, the DCM will re-measure the symptoms, using the common screening tools,
identifying whether or not symptoms are improving
• If patient does not demonstrate significant improvement by 10-12 weeks, the DCM must work with PCP
and Psychiatric Consultant to change the treatment plan. This may include, but is not limited to a) a change
in medication and/or medication dosage, b) addition of psychotherapy, c) a combination of the two; or d)
any additional treatments suggested by the consulting psychiatrist.
• Facilitate the development of the relapse prevention plan
• Meet regularly with the PCP and Psychiatric Consultant to discuss progress of patients in treatment
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Primary Care and Behavioral Health Integration
Primary Care Provider Roles and Responsibilities (IMPACT Model):
• Oversee all aspects of the patient’s care
• Work in close consultation and collaboration with the DCM
• Prescribe medications, including those recommended by the Psychiatric Consultant
• Treat patient’s primary care needs and co-morbid conditions
• Discuss the patient with the Psychiatric Consultant, when needed
• Make referrals to specialty mental health care when needed
• Work with other care team members to proactively change the treatment plan when necessary
Psychiatric Consultant Roles and Responsibilities (IMPACT Model):
• Support the PCP and DCM in treating patients
• Available to the PCP and DCM for ad hoc consultation as needed
• Provide one hour of supervision with each DCM each week
• Assist with diagnosis, treatment planning and makes recommendations for treatment modification
• Consult on patients who are clinically challenging or may need specialty mental health services
• Have limited patient interaction, do not prescribe medications, and only document in the EMR during the
consultation, alongside the PCP and/or DCM
• Participate in weekly case conferences, focusing on patients who are not improving on current treatment
plan
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Disease Management: Cardiovascular Disease
This program aims to:
• Implement evidence based best practices, including treatment guidelines and Million Heart Campaign strategies, for
disease management in medical practice for cardiovascular conditions.
• Improve population health management
• Increase patient self-efficacy and confidence in self-management for patients with cardiovascular disease
Primary Care Team Roles and Responsibilities:
• Refer to JNC-7 with modifications to achieve age range for evidence based clinical guidelines
• Implement patient self-management goal-setting and documentation at all regular visits as standard practice.
Patients must be provided with a written copy of their goals
• Support at-home blood pressure monitoring for CVD patients, including, at a minimum:
• Prescribing home blood pressure cuffs, educating patients in self-monitoring, performing equipment evaluation,
and implementing a workflow to follow-up abnormal results and alarm values
• Provide opportunities to receive blood pressure checks without a scheduled PCP visit and without a co-pay
• Implement or reinforce existing workflows for population health management and referral tracking for CVD patients
(hypertension and LDL monitoring) and preventative care (flu shots, smoking cessation, and aspirin use)
• Adopt BPHC-recommended Million Hearts patient and provider resources where appropriate
• Support preferred prescribing of once-daily formulations, combination pills and convenience packaging, where
possible
• Facilitate referrals to chronic disease self-management and LEAP programs
• Facilitate referrals to community-based services to assist patients with non-clinical/social need
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Disease Management: Diabetes
This program aims to:
• Implementation of evidence based best practices for diabetes disease management.
• Improve population health management
• Increase patient self-efficacy and confidence in self-management for patients with diabetes
Primary Care Team Roles and Responsibilities:
• Adopt BPHC evidence-based guidelines for diabetes
• Implement/reinforce standard practice of patient self-management goal-setting
• Implement/reinforce existing workflows for PHM and referral tracking for:
• diabetes patients (e.g., HbA1c test, cholesterol screening test, diabetes eye exam, nephropathy exam)
• Utilize standardized patient educational materials and provider support tools
• Facilitate referrals to diabetes self-management and Lower Extremity Amputation Programs (LEAP)
programs (provided by Health People or similar programs)
• Facilitate referrals to community-based services to assist patients with non-clinical/social needs
• Support preferred prescribing of once-daily formulations, combination pills and convenience packaging,
where possible
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Asthma Home Based Self-Management
This program aims to:
• Link patients to with asthma home-based resources for evidence based trigger reduction interventions.
Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests,
mold, and second hand smoke. Implementation of evidence based best practices for diabetes disease
management.
Primary Care Team Roles and Responsibilities:
• Complete Asthma Action Plans for all patients with asthma. Share hard copy (in color) with patient and/or
caregiver. Update plans at least annually.
•
Includes list of medications with direction for use, recommended control measures, details asthma
severity using color coded graphics using patient number, emergency and provider info.
• Implement workflow for annual spirometry
• Make closed-loop referrals to asthma home-visiting service (a.i.r. bronx)
•
Prioritize patients with three or more PCP visits in past year with asthma as the primary diagnosis
and/or patients with an ED or hospital discharge in the last year with asthma as the primary
diagnosis
• Provide coordinated care to asthma patients under Care Team model
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Cross-Cutting DSRIP Requirements
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Integrated Delivery System
Electronic Health Records (EHR)
• Use EHRs to plan, document, and communicate care
• Participate in various IT related CMS programs such as Meaningful Use
Health Information Exchange (HIE) connectivity
• Review and consider the patient's full medical history, even when the care was not received
with your organization by referring to a broader patient record in the RHIO
• Follow up on referrals and tests completed at other organizations
• Make patients’ medical records accessible to other providers through the RHIO
• Receive and respond to real-time RHIO Alerts regarding patients’ hospital encounters
Care Coordination Management System (CCMS) use
• Use a care coordination management system to document the care coordination activities
performed, This will help with communication and coordination.
• Care coordination management systems need to integrate so care plans can be exchanged,
referrals can be tracked and so we can better perform population health-management.
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Integrated Delivery System, Continued
Connect to Care Beyond the Clinical Setting
• Refer patients to community-based organizations (CBOs) to address wellness needs
and the social determinants of health
•
Track all referrals to completion of services (“closed loop referrals”)
• Work with community health workers (CHWs), Health Home Care Managers and other
care coordinators to reach the patient outside of medical appointments and through
home visits, where appropriate
•
This includes home-based asthma services
• Provide access to self-care resources and increase emphasis on cultural competency,
patient education and health literacy to help the Bronx’s diverse population
understand and take greater responsibility of their own wellness and care
•
This includes diabetes and cardiovascular disease self-management
interventions
• Participate in city- and state-wide population health initiatives, via BPHC-coordinated
efforts
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Patient Centered Medical Home (PCMH)
Participate in PCMH:
• Provide patient-centered appointment access by expanding hours of operation and availability of
appointments during those hours
• Monitor appointments and no-shows
• Provide and document “team-based care”
•
This includes shared goals, clear roles, mutual trust, effective communication, and measurable
processes and outcomes.
• Conduct “population health management” activities
•
Create lists of patients needing services and reach out proactively to fill gaps in care, rather then
waiting for the patient to come in on their own for an appointment.
• Regularly update assessments of patient/family health and social factors
• Develop and provide a patient-facing care plan to the patient/family, describing self-management goals
and plans for improving health and wellness
• Make and actively track patient referrals to specialists and other providers to ensure closed loop referrals
where the PCP is notified of visit results and an action is taken where needed
• Use reminders to communicate with patients regarding mental health or substance use, chronic medical
conditions, acute conditions, unhealthy behaviors, well care and healthcare service
overuse/appropriateness issues
• Provide adequate culturally (e.g. sensitivity to religion, traditions) and linguistically appropriate access
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Workforce Innovation
This program aims to:
• Support and develop a robust and well-trained workforce, rooted in the diverse communities of the
Bronx, and engaged in the transformative change required to successfully implement DSRIP
• Prepare the BPHC workforce for new jobs being created as a result of DSRIP projects, particularly in
primary care, care coordination, and community-based settings
• Provide training opportunities to prepare the BPHC workforce to meet the needs of the future
transformed health care delivery system
•
Training in new methods, approaches, and technology is being made available for existing
and newly hired employees
•
Some training will result in certification/licensing
• Facilitate the hiring of new employees and the redeployment (internal transfer or promotion) of
existing employees at BPHC partner organizations
• Engage the BPHC workforce to take full advantage of the opportunities being created as a result of
DSRIP, including:
•
Increased demand for workers rooted in the community
•
New education and training opportunities
•
Expanded and more clearly defined care roles and career ladders
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Anticipated Workforce Impact
What DSRIP means for the workforce overall:
• DSRIP and other Medicaid Redesign programs are changing the healthcare delivery system in
the Bronx and all over New York State
• New models of care are being introduced through the implementation of several DSRIP
clinical projects (such as Health Home At-Risk, ED Care Triage, Care Transitions, Integration
of Primary Care and Behavioral Health, Disease Management Projects)
• DSRIP aims to improve health for patients in the Bronx and promotes a shift from inpatient
care to primary care and community-based services.
•
A reduction in hospital admissions and beds means fewer hospital staff may be
required. However, this also means increased demand for primary care providers, care
coordinators, community health workers means more outpatient staff.
• These changes bring opportunities for the workforce as new jobs are being created,
particularly in primary care and community-based settings
• BPHC is committed to working closely with our partners in labor and member organizations
to ensure our existing workers are prepared to take full advantage of this opportunity.
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Thank you for all you do
to care for patients in the Bronx!
www.bronxphc.org