“The Role of Primary Care”

Collaboration • Catalyst • Community

May, 2016

PRESENTED BY:

RuthAnn Craven, MS, PCMH CCEPractice Transformation Services Manager

• Project 2.a.ii – Advancing primary care

• Project 3.a.i – Integration of primary care & behavioral health

• Project 3.g.i – Integration of palliative care into primary care

The Role of Primary Care in DSRIP

An augmented patient-centered medical home (PCMH) that provides

patients with timely, well-organized and integrated care, and enhanced

access to teams of providers – as the foundation for a high performing

health system.

New York State Health Innovation Plan – December, 2013

Advanced Primary Care

• Ensure all primary care practices meet NCQA PCMH 2014 Level 3 and/or state-

determined criteria for Advanced Primary Care models

• Identify a physician champion

• Identify care coordinators at each practice who are responsible for care

connectivity

• Ensure providers are actively sharing health information (RHIO / SHIN-NY)

• Ensure EHR systems are certified and meet Meaningful Use and PCMH Level 3 or

APC standards

Project 2.a.ii – Advancing Primary Care

• Perform population health management

• Ensure all staff are trained on PCMH or APC, including evidence based

preventive and chronic disease management

• Implement preventive care screening protocols including behavioral health

screenings to identify unmet needs; assure referrals to appropriate care as

needed

• Implement open access scheduling

Project 2.a.ii – Advancing Primary Care (con’t)

Timeline: the last date to submit PCMH 2014 survey tools is 09/30/2017

• Patient Centered Access

• Team Based Care

• Population Health Management

• Care Management and Support

• Care Coordination and Care Transitions

• Performance Measurement and Quality Improvement

PCMH 2014 Level 3

• Outreach to patients for Population Management

• Measure performance improvement

Clinical quality performance

Resource use & care coordination

Patient/family experience

• Utilize clinical decision support / point of care reminders

PCMH Annual Requirements

• Practice transformation is a journey, not a destination.

• NCQA is looking for evidence of ongoing patient-centered activities; less

emphasis on form than substance

Practice Transformation

Milestones

• Co-locate behavioral health services at primary care sites (Model 1) or co-locate

primary care services at behavioral health sites (Model 2)

• Develop collaborative evidence-based standards of care, including medication

management & care engagement process

• Conduct preventive care screenings, including behavioral health screenings to

identify unmet needs

• Use EHRs to track patients engaged in this project

3.a.i Integration with Behavioral Health

Objectives

• Ensure coordination of care

• Identify behavioral health needs early

• Ensure treatments for medical and behavioral health conditions are compatible

and not counter-productive

• De-stigmatize treatment for behavioral health needs

• Care for all conditions delivered under one roof by known health care providers

3.a.i Integration with Behavioral Health (con’t)

Milestones

• Integrate palliative care into advanced primary care practices

• Develop partnerships with community and provider resources to bring palliative

care supports and services to the practice

• Develop and adopt clinical guidelines, including services and eligibility

• Engage staff in trainings to increase role-appropriate competence in palliative

care skills and protocols

• Engage with Medicaid managed care to address coverage

• Use EHRs to track patients engaged in this project

3.g.i Integration of Palliative Care

Objectives

• Ensure care and end of life planning needs are understood, addressed and met

prior to decisions to seek further aggressive care or enter hospice

• Pain and symptom management while patients pursue disease directed

treatment to maximize function, independence and quality of life for as long as

possible

• Maintain the trusted relationship with your patients; the primary care team is

accessible, has knowledge of the patient and family,

as well as psychosocial influences that may affect the patient’s

choices

3.g.i Integration of Palliative Care (con’t)

• Project 2.a.ii – Advancing Primary Care

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-2-a-ii/

• Project 3.a.i – Integration with Behavioral Health

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-i/

• Project 3.g.i – Integration of Palliative Care

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-g-i/

Additional Information

Questions

www.ahihealth.org | 518.480.0111

RuthAnn Craven, MS, PCMH CCErcraven@ahihealth.org

Community Based Behavioral Health

Collaboration • Catalyst • Community

May, 2016

• Project 3.a.ii – Community Crisis Stabilization Services

• Project 3.a.iv – Development of Withdrawal Management

Capabilities & Appropriate Enhanced Abstinence Services

Community Based Behavioral Health Projects

Objective

• To provide readily accessible behavioral health crisis services that

will allow access to appropriate level of service and providers,

supporting a rapid de-escalation of the crisis

Community Crisis Stabilization Services

• Providing readily accessible crisis services, supporting a rapid de-

escalation of the crisis

• Provide a single source of specialty care management for these

complex patients

Crisis Stabilization Program

• Observation monitoring and ready access to inpatient psychiatric

care if short term monitoring does not resolve the crisis

• Mobile crisis team to assist with moving patients safety from the

community to services, and follow up after stabilization

Crisis Stabilization Program (con’t)

• Implement a crisis intervention program, including outreach, mobile

crisis and intensive crisis services

• Establish linkages with Health Homes, ER and hospital services to

implement protocols for diversion of patients from emergency room

& inpatient services

• Establish agreements with Medicaid managed care organizations to

provide coverage for the services under this project

Crisis Stabilization Project Milestones

• Develop written treatment protocols

• Include at least one hospital with specialty psychiatry services and

crisis oriented services

• Expand access to observation for stabilization monitoring (up to 48

hours)

• Deploy a mobile crisis team to provide stabilization using evidence

based protocols

Crisis Stabilization Project Milestones (con’t)

• Ensure all providers are actively sharing health information among

clinical partners (RHIO/SHIN-NY)

• Establish central triage service

• Ensure a quality committee is established for oversight and

surveillance of compliance with protocols and quality of care

• Use EHRs or other platforms to track patients engaged in this project

Crisis Stabilization Project Milestones (con’t)

Objective

• To develop withdrawal management services for substance use

disorders (ambulatory detoxification) within community based

addiction treatment programs that provide medical supervision and

allow transfer of stabilized patients into treatment, and to provide

link with care management services to assist with addressing related

life disruption related to substance abuse

Withdrawal Management Services

• Outpatient monitoring programs, with a primary care integrated

team

• Care management services to support abstinence and improved

function within the community

• Programs to address alcohol, sedative and opioid dependency, and

access to ongoing medication management treatment

Withdrawal Management Program

• Develop community based addition treatment programs that include

PCP integration teams, stabilization services, and social services

• Establish referral relationships between community treatment

programs and inpatient detox services

Withdrawal Management Project Milestones

• Identify a medical director, board certified in addiction medicine,

with training for use of buprenorphine, and other withdrawal

management agents

• Link to providers approved for outpatient medication management

of opioid addiction, for continued maintenance therapy

• Collaborate with treatment program(s)/care manager(s)

Withdrawal Mgmt Project Milestones (con’t)

• Develop community based withdrawal management (ambulatory

detoxification) protocols based on evidence-based best practice

• Develop care management services within the SUD treatment

program

Withdrawal Mgmt Project Milestones (con’t)

• Form agreements with Medicaid managed care organizations to

provide coverage for the services under this project

• Use EHRs or other platforms to track patients engaged in this project

Withdrawal Mgmt Project Milestones (con’t)

Project 3.a.ii – Community Crisis Stabilization Services

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-ii/

Project 3.a.iv – Development of Withdrawal Management Capabilities

& Appropriate Enhanced Abstinence Services

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-3-a-iv/

Additional Information

Questions

“Prevention Projects”

Collaboration • Catalyst • Community

May, 2016

PRESENTED BY:

• Project 4.a.Iii – Strengthen Mental Health & Substance Abuse

Infrastructure Across Systems

• Project 4.b.ii – Increase Access to High-Quality Chronic Disease

Preventive Care and Management (COPD)

Prevention Projects

Objective

• To collaborate with traditional and non-traditional providers to

promote mental, emotional, behavioral (MEB) wellbeing

Strengthen Infrastructure

• Participate in MEB health promotion and disorder prevention

partnerships

• Provide cultural and linguistic training on MEB health promotion,

prevention and treatment

• Offer poverty training, trauma informed care training, SEDL (social,

emotional, developmental learning) training and cross training of

medical & behavioral health providers

Program Services

• Participate in MEB health promotion and MEB disorder prevention

partnerships

• Obtain evidence-based MEB promotion and prevention resources

• Have an MEB integration plan

Project Milestones

• Provide MEB health promotion and disorder prevention trainings

• Share data and information on MEB health promotion and MEB

disorder prevention and treatment

Project Milestones

Objective

• Increase access to high quality chronic disease preventative care and

management in both clinical and community settings for COPD

Chronic Disease Preventive Care (COPD)

• Deliver high-quality chronic disease preventative care to lessen the

burden of chronic disease or avoid related complications

• Provide cost-effective care including screening tests, counseling or

medications used to prevent disease, detect health problems early

and prevent disease progression and complications

Program Services

• Print media campaign to build public awareness about COPD

prevention and programs

• Care teams are staffed/trained and have necessary patient education

tools & materials in place

• Home monitoring equipment is acquired and fully deployed

Project Milestones

• Adoption of primary care evidence-based diagnosis and treatment

guidelines for COPD

• Embedded clinical decision supports for evidence based care are in

place in EHRs and/or population health management tools are

utilized as applicable

Project Milestones (con’t)

• Adoption by skilled nursing facilities of evidence-based guidelines for

COPD

• Supportive resources are established or enhanced

Project Milestones (con’t)

• Primary care sites are equipped with adequate spirometry testing

• Opportunity to bring additional COPD services to more patients

• Current pulmonary fitness programs are expanded or developed, as

necessary

Project Milestones (con’t)

Project 4.a.iii – Strengthen Mental Health & Substance Abuse

Infrastructure Across Systems

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-4-a-iii/

Project 4.b.ii – Increase Access to High-Quality Chronic Disease

Preventative Care and Management (COPD)

http://www.ahihealth.org/ahipps/dsrip-projects/dsrip-project-4-b-ii/

Additional Information

Questions

www.ahihealth.org | 518.480.0111

@ahihealth.org