Conference Line. Steven Kaplan & Niloo Sobhani (Data/IT Governance)

Transcription

1 DSRIP Meeting Agenda Date and Time 5/16/16, 8am-9am Meeting Title NYP PPS Executive Committee Location Milstein Hospital 1HN-144 Facilitator David Alge, Betty Cheng Go to Meeting / Conference Line Dial +1 (872) Access Code: Invitees Betty Cheng (CBWCHC) Ashanti Chimurenga (NMPP) Sharen Duke (ASCNYC) Jay Gormley (MJHS) Ellen Harnett (Isabella) David Alge Emilio Carrillo (Clinical Operations) Brian Kurz (Finance) Steven Kaplan & Niloo Sobhani (Data/IT Governance) Anne Sperling (PAC) Meeting Objectives 1. Review Action Items from Last Meeting 2. Palliative Care Project Presentation, Veronica Lestelle/Felicia Blaise 3. Updates NYS DSRIP NYP PPS Projects 4. Meeting logistics Frequency Topics 5. Identify Action Items for Next Meeting Time 5 mins 30 mins 10 mins 10 mins 5 mins Action Items Description Owner Start Date Due Date Status F/U at next Finance Committee Meeting regarding suggestion of reimbursement for administrative activities Send inactive status letters to collaborators without executed Participation Agreements Finance Co-Chairs L. Alexander 4/18/2016 5/13/2016 Not started 4/18/2016 5/16/2016 In progress PAGE 1

2 DSRIP Meeting Agenda Date and Time 5/16/16, 8am-9am Meeting Title NYP PPS Executive Committee Location Milstein Hospital 1HN-144 Facilitator David Alge, Betty Cheng Go to Meeting / Conference Line Dial +1 (872) Access Code: Attendees Betty Cheng (CBWCHC) Isaac Kastenbaum (NYP) Sharen Duke (ASCNYC) Jay Gormley (MJHS) Ellen Harnett (Isabella) Veronica Lestelle (NYP) David Alge (NYP) Emilio Carrillo (Clinical Operations) Anne Sperling (PAC) Meeting Objectives 1. Review Action Items from Last Meeting 2. Palliative Care Project Presentation, Veronica Lestelle/Felicia Blaise 3. Updates NYS DSRIP NYP PPS Projects 4. Meeting logistics Frequency Topics 5. Identify Action Items for Next Meeting Time 5 mins 30 mins 10 mins 10 mins 5 mins Action Items Description Owner Start Date Due Date Status Keep a running list of inactive collaborators Lauren Alexander 5/16/2016 Ongoing In progress Connect Palliative Care team with CMP Reschedule Executive Committee Meeings to be monthly via GoTo and quarterly in-person Isaac Kastenbuam Lauren Alexander/Carmen Juan 5/16/2016 6/24/2016 Complete 5/16/2016 6/24/2016 Complete PAGE 1

3 DSRIP Palliative Care Project Overview Outpatient Palliative Care Services (OPCS) May 16 th, 2016 Veronica Lestelle, LCSW Felicia Blaise, MPH, MA 1

4 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 Is provided along with disease-modifying treatments The Center for Advanced Palliative Care (CAPC) 2

5 DSRIP Palliative Care Overview Project Goals: 1. Enhance generalist-level Palliative Care as Standard of Care in the Ambulatory Care Network (ACN), Associates in Internal Medicine (AIM), and community-based practices. 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. 4. Enhancing Information Systems enabled support. 3

6 Palliative Care Team for DSRIP A Multidisciplinary Team Model Clinical Services Physician Nurse Practitioner Social Worker RN Care Manager Administrative Leadership and Support Physician Director of NYP/CU Adult Palliative Care Services Program Manager for NYP Palliative Care Services Physician Director of NYP/ACN Adult Palliative Care Services Project Manager for DSRIP Palliative Care Program Assistant for DSRIP Palliative Care (Currently Recruiting) 4

7 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 Educational modules to Ambulatory Care Network Providers 5

8 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 Stroke 1+ admission (in the past year) with the above diagnoses and diagnosis code of pain and/or dyspnea

9 Maximizing Referrals & Meeting Palliative Care Needs 1. Telephonic Screening Process 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 Discussion of highest risk population and eligibility for palliative care Patient is contacted, screened and scheduled for an appointment 3. Direct Referrals via SHM or 7

10 Defining Prioritization for Palliative Care Screening Pain/Symptom Assessment: (Based partially on Brief Pain Inventory MD Anderson) Psychosocial/Social/Spiritual: (Based partially on PHQ2) Understanding of illness/prognosis/goals of care/advanced care planning (Scored on a scale of 1-5)

11 Defining Prioritization for Palliative Care Screening

12 Where Are We Located? Associates in Internal Medicine (AIM East) 1150 St. Nicholas Avenue New York, NY Hours: Tu 9-12PM We 1-5PM Columbia Presbyterian Specialties Clinic Vanderbilt Building 622 West 168th Street, 3rd Floor New York, NY Hours: TH 9-12 PM Herman Denny Farrell, Jr. Community Health Center 610 West 158th Street New York, NY Hours: M 1-5 PM Washington Heights Family Health Center 575 West 181st Street New York, NY Hours: F 9-12 PM 10

13 Integrated Educational Interventions 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

14 Priority for May 2016 Engage hospice collaborators in focused workgroups for development of protocols and workflows. To include: Calvary Hospital Visiting Nurse Service of New York Metropolitan Jewish Health System Determining additional need for other services Electronic referral process Revisiting current clinical model Develop 2016 education mission and plan 12

15 Challenges Creating New Clinic Identification Codes Soarian Templates/ Superbilling Clinical and Administrative space HIM documentation / Scanning Wins Hiring our full multidisciplinary team Rolling out program before the end of DY1 March 31 st, 2016 Beginning integration and providing services at the clinics Establishing relationships across disciplines Developing marketing materials and educational tools Creation of Outpatient Palliative Care Notes Tandem Intervention Model 13

16 Questions and Discussion? Thank You Contact Us: Veronica Lestelle Felicia Blaise 14