DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP)

Transcription

1 DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) Palliative Care Projects by Performing Provider System (PPS) HPCANYS 2 Computer Drive West, Suite 105 Albany, NY

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3 INTRODUCTION On February 3, 2014, Governor Andrew Cuomo announced that he had reached an agreement in principle with the Centers for Medicare & Medicaid (CMS) to fund an $8 billion five-year waiver focused on redesigning the way Medicaid services are provided in New York State. A key feature of the plan is the Delivery System Reform Incentive Payment program or DSRIP. DSRIP is a state-wide initiative open to a wide array of safety net providers, with a focus on reducing inappropriate hospitalizations. Payments are performance based and providers chose from a menu of CMS-approved projects. Providers were strongly encouraged to work together across traditional health care silos to develop proposals that reflected a collaborative approach. Up to $6.42 billion dollars have been allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health. Performing Provider Systems (PPSs) came together in late 2014 and submitted project plans which were scored for dollar value and approved in late March In the array of optional project, PPSs could choose up to two projects addressing palliative care. Of the 25 approved PPSs, 11 systems chose to implement a palliative care project. This report describes those projects and the characteristics of the PPS involved. It is important to note that while other hospices in New York State may be part of a PPS that has not chosen to select a palliative care project, this report focuses solely on those PPSs that have chosen Project 3.g.i or 3.g.ii. The information contained in this report is taken from documents posted to the New York State Department of Health website and is current through July 31, ACKNOWLEDGEMENTS Special thanks to Albany College of Pharmacy interns Kelsey Hennig and Leanna Murphy for their contributions to this report. Information in this document originated from the Project Plan Applications submitted by each respective PPS; the Project Plan Applications can be found at: 1

4 Table of Contents DSRIP Description of Projects Involving Palliative Care Adirondack Health Institute Alliance for Better Health Care (Ellis and St. Peters) Bassett Medical Center Maimonides Medical Center Sisters of Charity Hospital of Buffalo (Catholic Medical Partners) Southern Tier Rural Integrated PPS (United Health Services Hospital) Staten Island PPS (Richmond University Medical Center) ** The New York and Presbyterian Hospital The New York Hospital Medical Center of Queens ** Central New York Care Collaborative New York City Health and Hospitals Corporation ** indicates the PPS chose to complete the 3.g.ii project instead of the 3.g.i 2

5 DSRIP Description of Projects Involving Palliative Care DSRIP 3.g.i Integration of Palliative Care into the Patient Centered Medical Home (PCMH) Model Objective: To increase access to palliative care programs in PCMHs Description: This project seeks to increase access to palliative care programs for people with serious illnesses and those at end of life. The goal is to endure care and end of life planning needs are understood, addressed, and met prior to decisions to seek further aggressive care or enter hospice. Requirements: The project must demonstrate the following Integrate Palliative Care into appropriate primary care practices that have, or will have, achieved NCQA PCMH certification. Develop partnerships with community and provider resources including Hospice to bring the palliative care supports and services into the practice. Develop and adopt clinical guidelines agreed to by all partners including services and eligibility. Engages staff in trainings to increase role-appropriate competence in palliative care skills. Engage with Medicaid Managed Care to address coverage of services. Use EHRs or other IT platforms to track all patients engaged in this project. DSRIP 3.g.ii Integration of Palliative Care into Nursing Homes Objective: To increase access to palliative care programs in Nursing Homes. Description: To ensure that end of life planning needs are understood, addressed, and met prior to decisions to seeks further aggressive care or enter hospice. This can help with making sure pain and other comfort issues are managed and further health changes can be planned for. Requirements: The project must demonstrate the following Integrate Palliative Care into practice model of participating Nursing Homes. Develop partnerships with community and provider resources, including Hospice, to bring the palliative care supports and services into the nursing home. Develop and adopt clinical guidelines agreed to by all partners including services and eligibility. Engage staff in trainings to increase role-appropriate competence in palliative care skills and protocols developed by the PPS. Engages with Managed Care to address coverage of services. Use EHRs or other IT platforms to track all patients engaged in this project. 3

6 Adirondack Health Institute Demographics of the Applying PPS: Total Population: 693,954 Largely Rural Area The nine counties involved statistically have fewer children and five of the counties involved have high rates of adults 65 plus Diseases and Disorders of the Cardiovascular System, Diseases and Disorders of the Respiratory System, and Diabetes Mellitus are the most common chronic conditions that required medical attention for Medicaid recipients Justifications of Application: The data collected demonstrated that there is a high prevalence of chronic diseases. Palliative care is beneficial for people suffering from serious and chronic illnesses and as such, the population s health will benefit from better integration of Palliative Care into the Patient Centered Medical Home model. The expansions of Palliative Care services provides an opportunity to focus on symptom relief, which contributes to avoidance of ER visits and potentially inpatient admissions. Target Population: Includes patients with: (1) An unacceptable level of pain or other symptoms of distress (i.e. fatigue, dyspnea, nauseas) (2) A need for help with complex decisions and setting goals of care (including family/care team, and including decisions-making with regards to advance directives) (3) Uncontrolled psychological or spiritual needs (4) Significant medical comorbidities and/or poor baseline functional status (i.e. capable of only limited self-care; confined to bed or chair more than 50% of waking hours) (5) A history of chronic or incurable illness (e.g. advanced respiratory, cardiac, neurologic, or renal disease, metastatic cancer, Stage IV cancer, Stage III lung or pancreatic cancer) (6) Frequent ECC visits (>1 per month for same diagnosis), frequent hospital admissions, or a prolonged hospital stay (7) Moderate to late stage Alzheimer s and dementia conditions (8) Failure to thrive (10% weight loss over the last 6 months or BMI<22 and loss of functional capacity In an Intensive Care setting, the target population includes: (1) Patients 80 years of age and older 4

7 (2) Patients with an acute illness (i.e. anoxic brain injury, intracerebral hemorrhage requiring mechanical ventilation) (3) Patients with chronic critical illness associated with a prolonged ICU stay or prolonged mechanical ventilation (4) Patients considering tracheostomy and/or PEG placement (5) Patients for whom life-sustaining treatments are medically futile (in the clinicians view) and may be inappropriate Who Will Be Involved in the Project: Assets that can be leveraged include: (A) The Palliative Care Workgroup, in the Glens Falls/Queensbury region, will be expanded. The hospital s oncology service has started to review/develop evidenced-based treatment guidelines that will incorporate palliative care, and discussion regarding Survivorship plans is underway. (B) UVM Health Network-Champlain Valley Physicians Hospital (CVPH): inpatient Palliative Care Team, a Home Care-Palliative Care nurse, an ELNEC (End of Life Nursing Education Consortium). The Palliative Care IDT committee will be expanded to include the community Palliative Care Team. (C) Nathan Littauer Hospital and community partners have the operating environments and management staff in place, including primary care, nursing home and homecare. Personnel assets include 2 CHPN s and one palliative certified MD. (D) Hospice and Palliative Care of St. Lawrence Valley has an interdisciplinary palliative care program that provides services to Canton-Potsdam Hospital and Gouverneur Hospitals; the program also has active referral relationships with physician practices. (E) Many providers experience developing standard protocols and palliative initiatives through their involvement in the Upstate New York Hospice Alliance and the Hospice and Palliative Care Associated of New York State. Both of these organizations have access to expert resources that will facilitate the development and implementation of effective palliative care services that our appropriate for each primary care setting. (F) The service area s largest FQHC (Hudson Headwaters Health Network) currently provides palliative care services to some of their patients. The service includes a physician advisor, 1 FTE Nurse Practitioner for Inpatient Palliative Care, a PT Nurse Practitioner for Outpatient/Home Palliative Care and a PT Physician Assistant for Home Palliative Care. (G) Community outreach and education activities are in place throughout the region and can be utilized for palliative care education. 5

8 (H) The region has successfully embedded Care Management services at many primary care sites; behavioral health organizations also offer care management. (I) High Peaks Hospice and rth Country Hospice are additional assets. Additional community resources that need to be developed or re-purposed: Additional Hospice and/or Hospice-like service providers are needed to meet anticipated increases in referrals to both palliative care and hospice providers. There is a need to develop alternate settings for end-of-life care. Need to develop and/or expand Community Palliative Care teams (many of the palliative care services and teams described above are for inpatient settings). Need for more community outreach and education resources, and training/education for providers & staff. Anticipated Challenges or Issues: Lack of qualified and credentialed professional personnel in palliative care. This will be addressed through workforce development activities to provide training and assistance with recruitment. A Lack of what palliative care is, and is not. Historically there had been a low utilization of inpatient palliative care consultations and late/short LOS hospice referrals. This will be addressed by an extensive education program (education for staff and providers about the benefits of hospice, and outreach for the community). There will need to be evidence of return on investment to successfully negotiate adequate payment for the services. This will be addressed through working with an evaluator to develop a statistical model for demonstrating outcomes from the palliative care project, including cost avoidance, relative to the investment. The smaller practices are challenged by the lack of bandwidth to engage in clinical change processes and do not have adequate patient volume t hire dedicated staff to support the changes. To address this problem we will develop centralized training support, provide feedback to clinicians on relevant performance measures, and assist with workflow re-design. Independent Assessor Comments: significant identified weakness 6

9 Hospice Information Counties in PPS Certified Hospice PPS Member Clinton Hospice of the rth Country Essex High Peaks Franklin High Peaks Hospice of the rth Country Fulton Mountain Valley Hospice Hamilton High Peaks St. Lawrence Mountain Valley Hospice High Peaks H&PC of St Lawrence County Hospice of Jefferson County Saratoga The Community Hospice Mountain Valley Hospice Warren High Peaks Washington The Community Hospice High Peaks 7

10 Alliance for Better Health Care (Ellis & St. Peters; also called ihany) Demographics of the Applying PPS: Most hospital admissions are due to hypertensions, cardiovascular disease, respiratory disease, and asthma. Justification of Application: In response to gaps identified in the Ellis PPS CNA, the PPS will meet DSRIP requirements for project 3.g.i. through interventions including: The Ellis PPS will ensure that 100% of all PCP practices are recognized as NCQA Level 3 by the end of Year DY3. The PPS will educate providers on the benefits of palliative care and deploy palliative care coaches in PC practices to increase provider comfort and willingness to offer palliative care interventions. The Ellis PPS will partner with community based organizations including hospice providers to incorporate CBO services and supports that offer and strengthen the delivery of culturally and linguistically appropriate coordinated care that includes palliative care. Target Population: The target population for this project is individuals who are advanced in their disease severity, and who s health status has devolved, additionally individuals that have co-occurring issues such as cardiovascular disease and diabetes. To target patients the health severity assessment (screening) will be used to assist in targeting patients with a chronic condition. The hope is that early interventions can be used in order to reduce avoidable hospital care among those individuals with highest need and disease severity. Who Will Be Involved in the Project: Current Assets: Ellis PPS includes three major health systems: Ellis, St. Peter s Health Partners, and St. Mary s Healthcare Amsterdam Ellis PPS has a certified hospice program that provides end-of life care, and they will strengthen their palliative care competencies through peer to peer consultation (sharing the knowledge that each other have obtained). Anticipated Challenges or Issues: Many PCPs do not currently provide palliative care interventions Ellis PPS will provide incentives, and training in palliative care along with palliative care coaches Independent Assessor Comments: significant identified weakness 8

11 Hospice Information Counties in PPS Certified Hospice PPS Member Albany The Community Hospice Fulton Mountain Valley Hospice Montgomery The Community Hospice Mountain Valley Hospice Rensselaer The Community Hospice Saratoga The Community Hospice Mountain Valley Hospice Schenectady The Community Hospice 9

12 Bassett Medical Center (Mary Imogene Bassett Hospital) Justification of Application: Many patients do not enter into hospice care until their finals days of life and others do not have discussions about palliative care choices until the last two months before death. According to previous data, many of the terminally ill patients die in the hospital due to lack of access to hospice services. Therefore as a part of the project, social workers will provide training to PCPs and other staff to increase competence in palliative care skills. Leatherstocking Collaborative Health Partners (LCHP) PPS will pursue coverage of Hospice within the Medicaid MCOs to improve the patients access to care. They are going to assemble a palliative care support team trained to follow the Aspire Health model that will be instrumental. It will track patient outcomes and give a systematic approach to outpatient palliative care, so that there is a better management of end of life care. Target Population: Adults 18 and older that are Medicaid beneficiaries that are in the LCHP area, who receive PCP services for a serious medical condition Those with a serious medical condition and a limited life expectancy Who Will Be Involved in the Project: 40 primary care sites will be involved Two hospice and palliative care agencies have joined the LCHP PPS, the Hospice and Palliative Care of Chenango County; and Catskill Area Hospice and Palliative Care, Inc. The staff from these agencies will train PCPs, as well as patients and community groups. Patients will be educated in how to engage their families and practitioners in conversations about their wishes for end of life care Anticipated Challenges or Issues: Physician and Clinical Engagement This will be enhanced through training and education on having endof-life conversations with patients, but also by engaging palliative care professional in the care early enough so to develop trusting relationships with the patients. Independent Assessor Comments: More specificity in terms of patient's social needs or demographics is expected Identified challenge refers to general IT issues affecting multiple projects and not specific palliative care challenges Response describes intent to collaborate, however unclear how this plan fits with other PPS coordination plans 10

13 Hospice Information Counties in PPS Certified Hospice PPS Member Chenango Hospice & PC of Chenango Cty Delaware Catskill Area H&PC Lourdes Hospice Herkimer Hospice & Palliative Care, Inc Madison Hospice & Palliative Care, Inc Hospice of Central NY Oneida Hospice & Palliative Care, Inc Otsego Catskill Area H&PC Schoharie Catskill Area H&PC The Community Hospice 11

14 Maimonides Medical Center Justification of Application: The use of palliative care and Hospice was shown to be decreased compared to national averages. One of the barriers that was identified, as to why hospice is not utilized more often is because of lack of provider knowledge and expertise concerning the matter and about having conversations with patients regarding the subject. They hope to integrate palliative care into PCP practices, through training that would train physicians to have end-of-life conversations with patients and help them understand and use the resources that are available to patients, such as MOLST. They also hope to expand coverage so that palliative care services are covered. Target Population: Patients with at least one of a set of chronic conditions including, but not limited to, advanced cancer, AIDS/HIV with high viral load, COPD, Class ¾ heart failure, all dementias, multiple sclerosis, Parkinson s disease, ALS, Cirrhosis, and end stage renal disease. They will also reach out to patients who have at least one hospitalization along with 3 or greater outpatient visits in 3 months or 12 or great outpatient visits a year. Who Will Be Involved in this Project: Their key players will be the Metropolitan Jewish Hospice and Homecare (part of MJHS), Visiting Nurse Service of New York, Calvary Hospice, and Compassionate Care Hospice. Dr. Russell Portenoy CMO of MJHS Hospice, were serve as a special advisor to the program Anticipated Challenges or Issues: Lack of time in the normal 20 minute check-up to address palliative care discussion The PCP s staff will be trained to reduce the burden on the PCPs. Lack of staff to support patients/care-givers between PCP visits. More care managers will be added to partner PCP practices to assist patients and care givers Lack of MDs and mid-level providers with palliative care specialty training, and staff willing to do home visits. There will be a recruitment effort to attract community members willing to get trained and do home visits and there will be incentives for MDs, who wish to become palliative care specialists. 12

15 Independent Assessor Comments: Response does not describe how alignment and coordination with other PPS will occur Hospice Information Counties in PPS Certified Hospice PPS Member Kings Calvary Hospital Hospice Caring Hospice Services of NY Compassionate Care Hospice Hospice of NY MJHS University Hospice VNSNY Hospice & PC Queens Calvary Hospital Hospice Caring Hospice Services of NY Parker Jewish Hospice Care Network Hospice of NY MJHS University Hospice VNSNY Hospice & PC 13

16 Sisters of Charity Hospital of Buffalo (Catholic Medical Partners) Justification of Application: To decrease the cost associated with the end-of-life care through utilizations of palliative care (mentioned patients with COPD and cardiovascular diseases specifically). Target Populations: The target population is patients with COPD and cardiovascular diseases. Patients that live at home or alternative settings like assisted living and long term care will be focused upon. Who Will Be Involved in this Project: Current assets that are mobilized are physicians, registered nurses, social workers, spiritual care staff, and other outreach staff Initially training and will be provided to partner organizations via webinars. Anticipated Challenges or issues: The most significant challenge will be understanding of the word palliative care, as it is traditionally associated with end of life care, and not attainment of everyday quality of life. They will utilize a phone call campaign, faith based approach in communities, libraries, shelters, clinics, and food pantries. Independent Assessor Comments: Response needs a stronger discussion of project design Overly general discussion of existing assets and resources will be mobilized Needs fuller discussion on the challenge of growth of PCMH offices that will be addressed Hospice Information Counties in PPS Certified Hospice PPS Member Chautauqua Hospice of Chautauqua County Erie The Center for H&PC Niagara Niagara Hospice 14

17 Southern Tier Rural Integrated PPS (United Health Services Hospitals) Justification of Application: There is inconsistent availability of formal palliative care programs in the STRIPPS region There are no clearly define goals for patients in advanced directives Pain and symptom management is lacking in patient care plans The goal of the project is to introduce palliative care services in every community, with the aim to: Reduce emergency department visits, hospitalizations, and readmissions Determine safe, sustainable, and effective caregiving arrangements for each patient Centering the care in the PCMH to assure more consistent and coordinated management than is currently available Target Population: Patients with: (A) chronic and advanced disease with limited health prognosis (i.e. cancer, ALS, multiple organ system failure, advanced COPD and CHF) (B) Poorly controlled pain or symptoms that accompany serious disease (i.e. cancer, digestive issues, and any condition or disease in which pain, dyspnea, anxiety or nauseas is a significant or persistent symptom (C) end stage disease (i.e. end-stage renal disease) Who Will Be Involved in this Project: Both inpatient and outpatient palliative care programs What is needed are more mid-level providers with palliative care expertise and there will be implementation that raise awareness of the benefits of palliative care. Anticipated Challenges or Issues: Coordination with other DSRIPP programs An algorithm will be put into place so that patients can move through the health system appropriately Independent Assessor Comments: The response needs a fuller grounding in data developed from the CAN Summary of current assets is too high level and does not clearly identify specific resources that will be mobilized Hospice Information Counties in PPS Certified Hospice PPS Member Broome Lourdes Hospice 15

18 Chemung CareFirst (formerly Southern Tier H/PC) Chenango Hospice & PC of Chenango Cty Cortland Hospicare & PC of Tompkins Cty Delaware Lourdes Hospice Catskill Area Hospice & PC Schuyler CareFirst (formerly Southern Tier H/PC) Steuben CareFirst (formerly Southern Tier H/PC) Tioga Lourdes Hospice Tompkins Hospicare & PC of Tompkins Cty 16

19 Staten Island PPS (Richmond University Medical Center) ** 3.g.ii Justification of Application: Staten Island PPS wants to integrate palliative care programs into it 10 skilled nursing facilities. Staten Island has the highest mortality of the five boroughs with the leading cause of death being heart disease and cancer. There is hope that end of life care will decrease the cost for Medicaid. During a workgroup session it was identified that perceptions surrounding palliative care for patients and caregivers needed to change. Patients and Caregivers associate palliative care with forgoing treatment. This program would focus on educating the public about what palliative care is and broadly educating the public and health care teams and staff about the benefits of palliative care. Target Population: Patients with serious illness that would benefit from receiving palliative care services at skilled nursing facilities Who Will Be Involved in this Project: The 10 skilled nursing facilities and Nurse Educators will be part of the staff trained in palliative care skills and protocols. Anticipated Challenges or Issues: One of the big problems is reimbursement for palliative care Staten Island PPS will work with the MCOs in order to restructure reimbursement models Other things that Staten Island PPS will do is implement training for the staff and doctors, and educate the patients and their families (while being conscientious about the cultural diversity that exists). Independent Assessor Comments: significant weakness identified for the project Hospice Information Counties in PPS Certified Hospice PPS Member Bronx Calvary Hospice Richmond University Hospice VNSNY Hospice & PC 17

20 The New York and Presbyterian Hospital Justification of Application: There is a big gap in the treatment of pain in the minority groups in the population, there is also a lack of education of the providers as to what palliative care is and how it can benefit patients. The goal of this program is to increase awareness of palliative care and increase access to palliative care for minorities Target Population: Adults with a primary or secondary diagnosis of Congestive heart failure Kidney Failure Dementia COPD Stroke Malignancy Sickle cell Anemia Patients with three or more inpatient admission for patients below age 80 and one or more inpatient admissions for those above age 80 All of these patients will be flagged by the system and further evaluated Who Will Be Involved in this Project: The palliative care intervention will consist of a newly hired, embedded Palliative Care Service (PCS) team comprised of a physician, NP, social worker and RN Care Manager who will provide a palliative plan of care. Additionally they will train community health workers to complete the home visits, patient education, and be able to communicate with the patients in their language Anticipated Challenges or Issues: Creating Registries to identify potential patients Creating effective referral; mechanisms for physicians to refer to the Palliative Care Team Exchange of information between community-based partners They need to address the way reimbursement occurs through the MCOs They need to recruitment palliative care providers Independent Assessor Comments: More specificity in terms of which patients will receive palliative care services based off of screening process Hospice Information Counties in PPS Certified Hospice PPS Member New York Calvary Hospital Hospice Hospice of NY 18

21 MJHS VNSNY Hospice & PC The New York Hospital Medical Center of Queens **3.g.ii Justification of Application: There is an opportunity to expand the use of palliative care in this area. The end-oflife care in this area has been shown to be one of the most expensive. Only 9 of the 26 nursing homes in the area currently use MOLST, meaning that there is a lack of advanced planning for any health care issues that arise. The goal of this project is to improve the quality of life, reduce unnecessary hospitalizations, and deliver person-centered, and family oriented care. They will use public education campaigns in order to raise awareness of palliative care. Target Population: The target population are the Medicaid beneficiaries that reside in the 27 committed nursing homes. The disease states and chronic conditions that will benefit vary greatly. Who Will Be Involved in this Project: The NYHQ has an established Division of Geriatrics and Palliative Medicine, which will serve as a role model for the nursing homes palliative care teams. The nursing homes will develop standards for both services provided and patient eligibility. A pilot project has already begun to implement the use of the MOLST form for all new nursing home transfers (currently the form is paper, but the hope is in the future all communication will become electronic). Anticipated Challenges or Issues: Cultural sensitivity The physician on the case should speak the language of the beneficiary and should reflect an ethnic composition similar to the beneficiary. There will be spiritual support, interdisciplinary teams, and input from family councils. Reimbursement The PPS and nursing home with work with the Medicaid MCOs to discuss issues and identify solutions related to reimbursement for palliative care services. Time for project team participation Nursing home leaders must agree to support team participation and training as a part of their daily routine. Independent Assessor Comments: There is an intention to collaborate but the overlapping PPSs are not known by the PPS and no discussions have occurred 19

22 Hospice Information Counties in PPS Certified Hospice PPS Member Queens Parker Jewish Hospice Care Network MJHS University Hospital Hospice VNSNY Hospice & PC Caring Hospice Services of NY Hospice of NY Calvary Hospital Hospice 20

23 Central New York Care Collaborative Justification of Application: To prevent unnecessary hospitalizations via the appropriate use of palliative care and hospice referrals. Through symptom management the PPS hopes to decrease hospital admissions and emergency department visits. Target Population: The conditions include, but are not limited to; Lung, breast, pancreas, gallbladder, bile ducts, stomach, and metastatic cancer; systolic congestive heart failure; COPD; cirrhosis; dementia; ALS; and stroke The population also includes those with 1 or more ED visits; 1 or more inpatient visits; or 3 or more outpatient visits in 3 months The health severity assessment will be used to identify those most at risk for avoidable ED and inpatient use Who Will Be Involved in this Project: Central New York Hospice; and Hospice and Palliative Care Inc. will both be assets in this project. Anticipated Challenges or Issues: PCPs have been given relevant training on palliative care however, lack the time to conduct such discussions as patients who present with the use for this service usually present with new problems at health care visits. To lighten the load on physicians the hospitals will employ other sources that doctors can refer patients to in order to help give appropriate palliative care referrals for patients. Smaller practices may not have the budget or staff in order to do so, therefore there will be centrally trained personnel who can do so. Independent Assessor Comments: Response contains short description of palliative care needs, but is lacking discussion of project design, sites, and resources Response does not identify the target patient cohort's social needs, demographics or geography Response describes intent to collaborate, however unclear how this plan fits with other PPS coordination plans Hospice Information Counties in PPS Certified Hospice PPS Member Cayuga Hospice of the Finger Lakes 21

24 Comfortcare of Cayuga County Inc DBA Hospice of the Finger Lakes Lewis Lewis County Hospice Madison Hospice & Palliative Care, Inc Hospice of Central NY Oneida Hospice & Palliative Care, Inc Onondaga Hospice of Central NY Hospice of the Finger Lakes The Caring Coalition of Central- NY DBA Hospice of Central NY Oswego Hospice of Central NY Oswego County Hospice 22

25 New York City Health and Hospitals Corporation Justification of Application: There are resources in this area that support hospice and palliative care, however there need to be more resources for patients to manage their health needs on the level of PCPs. Our PPS s approach to develop new or expand existing palliative care resources begins with increasing the availability of palliative care in the PPS service area by developing and deploying training and education for PCPs and staff on palliative care. Using evidence-based guidelines, the training will address: the importance of collecting advance directives and health care proxy data from patients; communication with patients around their palliative care needs (e.g., pain management); and, the transition from primary palliative care to specialty palliative care, including the establishment of referral criteria (see CNA need 1). Target Population: Patients 18 or older, who are eligible for palliative care intervention This is defined as chronic diseases (such as metastatic solid tumor cancers, advanced depression, COPD, generalized pain, stroke) In addition to those criteria the patient population will meet at least one of the following: One hospitalization in a year One ED visit in a year And/or 3 or more outpatient visits in three months or 12 or more outpatient visits in 12 months Who Will Be Involved in this Project: Our PPS has a range of assets and resources to help achieve the goals of this DSRIP project. There are palliative care teams in each of our PPS s 12 hospitals. Their expertise has informed the development of our approach and will continue to support its implementation, in particular by evaluating existing curricula and developing trainings for health care providers and their staff. Our PPS has 26 providers who are board-certified in palliative care or who have certifications pending. Outpatient palliative care services are provided at the following PCMHrecognized clinics in our service area: Bellevue, Metropolitan, Kings, Lincoln. In addition, University Hospital of Brooklyn has a palliative care clinic which provider s services one session per week. Coney Island Hospital has a 19-bed Pain and Symptom Control Palliative Care Unit which can offer lessons learned around care coordination for patients receiving palliative care services. They will also provide training for providers or other members and staff, in addition to tapping into their partners resources. 23

26 Anticipated Challenges or Issues: Short physician visits and workflow changes may be a challenges to incorporating palliative care into PCP visits. To alleviate this the PPS will standardize training and materials available to physicians. The option of hiring additional physician extenders to support the patient s needs. They also want to standardize what the referral process is so that it is optimal, as well as providing training to the practitioners on this referral system. Independent Assessor Comments: Project need is well explained, however the project design and included sites are not identified Hospice Information Counties in PPS Certified Hospice PPS Member Bronx Calvary Hospital Hospice Compassionate Care Hospice Hospice of NY Jansen Hospice & PC MJHS VNSNY Hospice & PC Kings New York Queens Calvary Hospital Hospice Caring Hospice Services of NY Compassionate Care Hospice Hospice of NY MJHS University Hospital Hospice VNSNY Hospice & PC Calvary Hospital Hospice Hospice of NY MJHS VNSNY Hospice & PC Calvary Hospital Hospice Caring Hospice Services of NY Parker Jewish Hospice Care Network Hospice of NY MJHS University Hospital Hospice VNSNY Hospice & PC 24