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1 DSRIP Meeting Agenda Date and Time 12/18/15, 9-10am Meeting Title NYP PPS Clinical Operations Committee Location Heart Center Room 3 Facilitator Dr. Emilio Carrillo, Sandy Merlino Go to Meeting join/ Conference Line Dial +1 (646) Access Code: Invitees Chair: Sandy Merlino (VNSNY) Alissa Wassung (God s Love We Deliver) David Pomeranz (Hebrew Home) David Chan (City Drug & Surgical) Jean Marie Bradford, MD (NYPSI) Eva Eng (Arch Care) Bill Mead (St. Mary s Hospital for Children) Chair: Emilio Carrillo, MD (NYP) Tamisha McPherson (Harlem United) Lydia Isaac (NYC DOHMH) Maria Lizardo (Northern Manhattan Improvement Corporation) Susan Wiviott (The Bridge) Meeting Objectives 1. Review of action items from last meeting 2. Introduce new NYP PPS Clinical Operations Co-Chair: Sandy Merlino, Vice President, Integrated Delivery Systems, Visiting Nurse Service of New York (Dr. Emilio Carrillo) 3. Project Status Reporting (Tiffany Sturdivant-Morrison) 4. Project Report: Integration of Palliative Care into the Patient-Centered Medical Home (Veronica Lestelle and Felicia Blaise) 5. Cultural Competency/Health Literacy Strategy Update (Dr. Emilio Carrillo) 6. Upcoming organizational deliverables for Clinical Operations Committee (Lauren Alexander) 7. Identify action items for next meeting Time 5 mins 5 mins 15 min 20 min 5 min 5 min 5 mins Action Items Description Owner Start Date Due Date Status Schedule meeting to discuss pharmacy and L. Alexander/E. medication issues as they relate to Healthix Carrillo 11/20/ /18/2015 In progress Form Cultural Competency and Health Literacy Workgroup E. Carrillo 11/20/2015 1/31/2016 In progress Share GLWD nutrition tool across projects T. Sturdivant-Morrison 11/20/ /31/2015 In progress Have T. Sturdivant-Morrison present on project status reporting at next meeting T. Sturdivant-Morrison 12/18/ /18/2015 Complete A. Wassung to share cultural competency training tool with L. Alexander A. Wassung 11/20/ /20/2015 Complete PAGE 1

2 DSRIP Meeting Agenda Date and Time 12/18/15, 9-10am Meeting Title NYP PPS Clinical Operations Committee Location Heart Center Room 3 Facilitator Dr. Emilio Carrillo, Sandy Merlino Go to Meeting join/ Conference Line Dial +1 (646) Access Code: Attendees Chair: Sandy Merlino (VNSNY) Alissa Wassung (God s Love We Deliver) David Chan (City Drug & Surgical) Jean Marie Bradford, MD (NYPSI) Eva Eng (Arch Care) Christine Duffy (St. Mary s Hospital for Children) Felicia Blaise (NYP) Sam Merrick (NYP) Chair: Emilio Carrillo, MD (NYP) Susan Wiviott (The Bridge) Lauren Alexander (NYP) Isaac Kastenbaum (NYP) Tiffany Sturdivant-Morrison (NYP) Adriana Matiz (NYP) Veronica Lestelle (NYP) Meeting Objectives 1. Review of action items from last meeting 2. Introduce new NYP PPS Clinical Operations Co-Chair: Sandy Merlino, Vice President, Integrated Delivery Systems, Visiting Nurse Service of New York (Dr. Emilio Carrillo) 3. Project Status Reporting (Tiffany Sturdivant-Morrison) 4. Project Report: Integration of Palliative Care into the Patient-Centered Medical Home (Veronica Lestelle and Felicia Blaise) 5. Cultural Competency/Health Literacy Strategy Update (Dr. Emilio Carrillo) 6. Upcoming organizational deliverables for Clinical Operations Committee (Lauren Alexander) 7. Identify action items for next meeting Time 5 mins 5 mins 15 min 20 min 5 min 5 min 5 mins Action Items Description Owner Start Date Due Date Status Share new CMS rule regarding discharge I. Kastenbaum 12/18/2015 1/15/2016 Not started MINUTES: Dr. E. Carrillo opened the meeting. Dr. E. Carrillo reviewed the action items from last meeting. o D. Chan commented that he has been in touch with Healthix regarding a pharmacy software vendor to determine if pharmacy data can be imported into Healthix. o Dr. E. Carrillo noted that volunteers are still being sought for the Cultural Competency/Health Literacy Workgroup. o T. Sturdivant-Morrison noted that she shared the GLWD nutrition tool with the Project Managers. Dr. L. A. Matiz inquired whether GLWD provides services to children. Dr. E. Carrillo introduced and welcomed the new NYP PPS Clinical Operations Committee Co-Chair, Sandy Merlino, who is the Vice President for Integrated Delivery Systems at Visiting Nurse Service of New York. T. Sturdivant-Morrison provided an overview of a new project status reporting tool and a proposed feedback loop for the Clinical Operations Committee to provide comments, questions and suggestions to the projects. Dr. PAGE 1

3 DSRIP Meeting Agenda E. Carrillo noted that this tool can aid the Clinical Operations Committee in its function of providing clinical oversight to the projects. The tool shows whether projects are on track in meeting their operational goals and the NYS milestones, at both the individual project-level and cross project-level. The status report presented provided data through December 4, The following questions/discussion took place with regard to the report: o Dr. E. Carrillo asked T. Sturvidant-Morrison to speak in more detail to the indicators listed at-risk. o S. Merlino asked how often this report is produced. T. Sturdivant-Morrison commented that the report is produced bimonthly and that this Committee will see it monthly. o o A. Wassung asked for more detail about the status of the indicators for the HIV projects. As it relates to the development of unified plan of care, which was identified as a cross-project challenge, there were several comments : Dr. E. Carrillo noted that GNYHA is working to develop a unified plan of care across PPSs. A. Wassung inquired about the new discharge rules recently released by CMS. She asked whether the Hospital was commenting on it and if it fits into the work of developing a unified care plan. Dr. J. Bradford inquired about what s entailed in the new rule. I. Kastenbaum said he would share a summary of the rule, which outlines what should be included in the discharge process. o With regard to the recently-approved offsite and home visit waivers: o Dr. L. Matiz inquired about the impact of the waivers and what they will allow the projects to do. o A. Wassung asked whether healthcare organizations can bill under the waivers. o Dr. J. Bradford asked how the BH Mobile Crisis Team has been operating in the absence of the recently-approved waivers. o V. Lestelle inquired if the waivers only apply to the Medicaid population. o Dr. L.Matiz asked if the waivers are effective immediately. o E. Eng commented that the new status reporting tool is an excellent framework. V. Lestelle and F. Blaise provided a presentation on the Integration of Palliative Care into the Patient-Centered Medical Home project. The presentation covered the following: NYP Vision of Palliative Care DSRIP Palliative Care Overview DSRIP Palliative Care Baseline Measures Palliative Care Team for DSRIP Key Components of the DSRIP Program How the Patient Population is Identified Defining Prioritization for Palliative Care Screening Maximizing Palliative Care Referrals and Meeting Palliative Care Needs Project Pilots Integrated Educational Interventions Priorities for January 2016 Challenges and Wins o Dr. L. Matiz asked about the potential of the project providing support to the pediatric population. V. Lestelle inquired of I. Kastenbaum about whether a project can change their focus to include another population. o o Dr. L. Matiz inquired about how the palliative care screening is presented to the family/patient. As it relates to cultural competency, E. Eng asked about patient education in the context of explaining what pallitative care is. Ensuring appropriate cross cultural communication is key with regard to this topic. o Regarding the screening tool, A. Wassung inquired about the mechanism that exists to address unmet community needs that may surface as a result of the screening. L. Alexander reviewed the upcoming organizational deliverables assigned to the Clinical Operations Committee. Dr. E. Carrillo closed the meeting. PAGE 2

4 DSRIP Palliative Care Project Overview December 18 th, 2015 Veronica Lestelle, LCSW Felicia Blaise, MPH, MA 1

5 NYP Vision of Palliative Care Specialized medical care for those facing advanced illnesses Not just for End of Life Care To provide relief from the symptoms, pain and stress of serious illnesses To improve quality of life for both the patient AND the family Specialized multidisciplinary team provides an extra layer of support Can be provided along with curative treatment The Center for Advanced Palliative Care (CAPC) 2

6 DSRIP Palliative Care Overview Focus 1. Enhance PCP s competencies to integrate generalist-level palliative care in ACN/AIM and community-based practices as standard of care. 2. Develop a new capacity to provide specialized palliative care services by expert team in the ACN. 3. Model of care to include care management oversight and collaboration with external providers Commitment: Completion of DSRIP Year 2 Palliative care procedures to 2,565 unique patients annually. 3

7 DSRIP Palliative Care Baseline Measures Advanced Directives - Talked about Appointing for Health Decisions Depressive feelings - percentage of members who experienced some depression feeling +/- Percentage of members who had severe or more intense daily pain +/- Percentage of members who remained stable or demonstrated improvement in pain Percentage of members whose pain was not controlled +/- 4

8 Palliative Care Team for DSRIP A multidisciplinary team model Clinical Services: Physician Nurse Practitioner Social Worker Care Manager Community Health Worker Administrative Leadership and Support Physician Director of NYP/CU Adult Palliative Care Services Program Manager for NYP Palliative Care Services Program Manager for DSRIP Palliative Care Project STATUS: Team essentially in place. MD to start in January. 5

9 Key Components of Program Screening of patients with Palliative Care Needs /Risk Stratification Care Manager Outreach and follow up of patients Team participation in Interdisciplinary Rounds Provide specialized Palliative Care Services Develop protocols with key collaborators to facilitate appropriate and timely transition to hospice services and home based palliative care services Integration of Community Health Worker for follow up of at risk population Educational modules to Ambulatory Care Network Providers 6

10 How Do We Identify Our Patient Population? Established/recognized methodology in field to identify patients likely to have unmet palliative care needs. To identify not just patients at end of life, but facing advanced illnesses 2+ admissions (in the past year) within the following disease categories End stage renal disease Chronic CHF COPD Sickle Cell disease Cerebral infarction Malignancies 1+ admission (in the past year) with the above diagnoses and diagnosis code of pain and/or dyspnea

11 Defining Prioritization for Palliative Care Screening Highest Priority: Prior criteria + recent discharge within last 30 days Medium Priority: Prior criteria + missed clinic appointment and/or ED T&R visit Low Priority: Prior criteria + with no ED visits or hospitalizations

12 Maximizing Palliative Care Referrals & Meeting Palliative Care Needs 1. Telephonic Screening Process / Tool Developed Focus: Symptom Management, Depression/Anxiety Goals of care, including advanced directives 2. Interdisciplinary Rounds List of patients are sent to providers prior to IDT rounds WHFHC Tuesdays (8:30-9:30AM) Will expand to other IDT rounds in the future Discussion of highest risk population and eligibility for palliative care Patient is contacted, screened and scheduled for an appointment. 3. Direct Referrals via SHM 9

13 Project Pilots WHFHC (12/4) a. Registry Data/Reports b. Interdisciplinary Rounds c. Direct Referrals (In-person or SHM) Pilot on Module 207 (in conjunction with Adult Amb. ICU) (1/5/16) a. Registry Data/Reports b. Interdisciplinary Rounds c. Integrated Palliative Care Visit 10

14 Integrated Educational Interventions Options: Direct clinical care (residents to join Pall Care MD in clinic) Residency program didactics (already being implemented) Web-based modules and other educational resources via secure health messages Offer of Monthly Palliative Care Program /based on established Interdisciplinary Palliative Care Champion Program 11

15 Priority for January 2016 Engage our collaborators in focused workgroups for development of protocols and workflows. To include: Calvary Hospital Visiting Nurse Service of New York Metropolitan Jewish Health System 12

16 Challenges Creating New Clinic Identification Codes Soarian Templates/ Superbilling Wins Hiring the Team Creation of Palliative Care Note Ambulatory Palliative Care Initial Consult Ambulatory Palliative Care Follow Up Identification of IT Needs ACD + SCM Integrating into ACN sites via IDT Piloting at WHFHC Establishing relationships across disciplines 13

17 Questions and Discussion Thank You! Contact Us: Veronica Lestelle Felicia Blaise 14

18 Project Status Reporting Tiffany Sturdivant-Morrison, MPH 18 December 2015

19 Contents Project Highlights Slide Legend DSRIP Project Status All Milestones, All Operational Goals Highlights Data Cross Project Challenges 2

20 Slide Legend NYS Milestone Requirement Exact milestone requirement from the state s Minimum Documentation Standards document Some milestones are missing for 2.b.i awaiting feedback from state Milestones to be added for Domain 4 Projects (HIV - Decrease Morbidity and Tobacco Cessation) Operational Goals Taken from last round of charter updates Percentages Represent the % of the project, not % of all projects, all indicators 3

21 Slide Legend Status Definitions Completed On Track In Progress - Challenges No Progress - At Risk Not Started Implementation done. All documentation, processes, etc. are in place. The implementation is "under control" and largely "on track." There may be minor issues and concerns, but the project teams and committees are managing them with no escalation required. There can also be minor slippage of schedule or overspent on resources, but the project teams and committees are comfortable with their ability to resolve them. With the status in "Green," additional comments in the status are optional. Yellow indicates the overall health as "cautious" with challenges and risks that may deteriorate the healthy unless they are addressed quickly. Yellow also signals to the project team that management attention is required and that escalation may be inevitable. With the status in "Yellow", a Mitigation Plan, steps to a solution, is neccessary (with appropriate deadlines). Red indicates the overall health as "unhealthy" with attention required from the Executive Leadership and / or external resources. Depending on the urgency, the attention may be immediate. Red occurs when there are problems requiring escalation and the team should work together quickly to resolve them before the problems impact other areas of the project. With the status in "Red", discussion of the Mitigation Plan and its continued barriers is required. Implementation efforts have not begun. 4

22 DSRIP Project Status All Indicators, All Projects Data Highlights 364 indicators across all projects (and growing) 53% reported On Track 7% reported At Risk 6% reported Issues 9% reported Completed 25% reported Not Started Cross project successes Process for warm handoffs between inpatient and outpatient care coordinators being developed Peds Amb ICU fully staffed as of January 2016 Pilots for Integrated Visits for Adults with Complex Care Needs starting December 2016 (Palliative Care and Adult Amb ICU) Reporting Warehouse being built for all reporting efforts 5

23 DSRIP Project Status All Indicators, All Projects Highlights Continued CBO Engagement Efforts PPS Wide Collaborator Symposium January 11, 2016 CHN Developing process for sharing discharge summaries and scheduling next day appointments for patient discharged from the ED Charles B. Wang Community Health Center (CBWCHC) Implementing systems for post-discharge communications Enhancing CBWCHC current tobacco cessation efforts NYSPI Developing clear process for referring patients between organizations Argus and Create Working with the Behavioral Health Projects to create an effective Team Based Care approach 6

24 100% DSRIP Project Status All Indicators, All Projects As of December 4, % 80% 70% 60% 50% 40% 30% 20% 10% 0% 47% 14% 21% 19% 75% 16% 6% 3% 52% 11% 4% 33% 79% 6% 11% 4% 50% 50% 29% 38% 48% 50% 38% 41% 19% 24% 7% 2% 4% 45% 28% 8% 18% 61% 81% 24% 2% 13% 7% 5% 6% On Track Not Started No Progress - At Risk In Progress - Challenges Completed 7

25 DSRIP Project Status All Indicators, All Projects Cross Project Challenges Care Management / Health Homes Develop process for bottom up referrals and coordination of HH with DSRIP projects Patient Identification Need to create clear process to identify patients across projects/services as to not duplicate efforts Waivers Develop alternative solutions if waivers are not granted HIV and BH Projects Notifications (ED and Inpatient alerts) Plan of Care Developing a universal plan of care, a document that lists all of the clinical and psychosocial needs of the patient Sharing the Plan of Care with team members in various EHR and IS Platforms to enhance care coordination 8

26 Clinical Operations / DSRIP Projects Feedback Project Status Report Shared at Clinical Operations Committee Meeting Managers address feedback (implement change, provide answers, etc.) Committee provides feedback / questions Committee feedback shared with Managers Committee feedback discussed at PMO

27 QUESTIONS / COMMENTS? THANK YOU 10