Last revised: 5/7/15

Project 2.a.i: Create an Integrated Delivery System Focused on Evidence Based Medicine and Population Health Management

Domain 2: System Transformation Projects

Problem Statement: Across the FLPPS region, widespread system-level gaps have led to inappropriate utilization of services and poor health outcomes for the Medicaid population.

Summary Statement: Implement an Integrated Delivery System (IDS) of healthcare providers, which provides a coordinated continuum

of care across several treatment modalities and provider types, while agreeing to be accountable for the health

outcomes of those patients. All providers in the PPS will participate in the IDS.

Objective: The goal of this project is to create an IDS facilitating increased access to care and population management via a

healthcare delivery system that is balanced to the needs of the community.

Core Components and Deliverables: Incentives aligned with population health outcomes across all modalities of care.

An integrated care network that coordinates services across the continuum of care, including medical and

behavioral health, post-acute care, long term care, and public health services.

Value based payment arrangements

High level of continuity of care, supported by evidenced based practices and Health Information

Technology (HIT) tools

Implementation of Patient Centered Medical Home processes and workflows by DY3 (01/2017)

Local RHIO/SHIN-NY connectivity and active sharing of information by DY3 (01/2017)

An EHR system that supports population health management

Targeted patient engagement

FLPPS Design Elements: Developing partnerships with Accountable Care Organizations (ACO) and Health Homes to provide care

management services.

Establishing a centrally-managed Community Health Worker (CHW) program, and contracting with

culturally competent Community Based Organizations (CBO).

Ensuring patients receive appropriate health care and community support through the expansion of

primary care, co-location of services, redesign of acute ambulatory campuses, expansion of telehealth, and

partnership with CBOs.

Ensuring interoperability by providing technical assistance toward the successful recognition of

participating providers as Level 3 PCMH (across 147 PCP sites) and achievers of Meaningful Use.

Last revised: 5/7/15

Ensuring the widespread provision of population health management through the development of an

integrated care management platform and expanded bidirectional information exchange between partners.

Engaging MCOs on FLPPS operational committees to facilitate sharing of information, guidance on

performance improvement and development of value-based contracts that support the delivery of high-

value services such as telemedicine, care navigation and transportation. Aligning compensation with patient outcomes.

Target Population:

All patients

All PPS partners

Assets: Culture of collaboration among PPS providers

Existing RHIO infrastructure (HealtheLink, Rochester RHIO, HealtheConnections)

Experience with Telehealth among PPS partners

Commitment to increasing primary care capacity

Expertise in development and implementation of care coordination resources

Two Accountable Care Organizations (GRIPA and AHP)

Challenges: Communicating effectively with all PPS providers

Capital funding from NYS

Cultural competency and health literacy

Transportation

Aligning incentive payments

Provider workflow changes, especially for PCMH

Last revised: 5/7/15

Project 2.b. iii: ED Care Triage for at-risk Populations

Domain 2: System Transformation Projects

Problem Statement: The emergency department (ED) is being used for the treatment of conditions which could be effectively treated in

lower cost setting, such as primary care offices or urgent care centers. The FLPPS region has a higher rate of

Potentially Preventable Visits (PPV) as compared to the rest of NYS.

Summary Statement: The ED is often utilized for non–emergencies and minor medical concerns for many reasons, including real and perceived barriers to primary care for health management. The goal of this project is to link patients, who arrive at the ED with minor conditions, to primary care providers who can meet their immediate healthcare needs. The project also aims to increase patient awareness of alternative service options and

address other barriers to primary care access, reserving ED utilization for true emergencies. Objective: Develop transitional care programs to link patients with primary care providers (PCP), thereby matching health care needs with healthcare resources more appropriately. Through education and the removal of barriers to access, a patient can more effectively engage with their primary care provider and become better equipped to manage their own health.

Core Components & Deliverables:

Emergency Departments establish linkages to community based primary providers who have open access and will meet PCMH level 3 by end of 2017.

Patient Navigators in Emergency Departments will work with patients who present to ED for minor medical issues to:

Link to PCP - schedule a timely appointment with PCP and ensure attendance through addressing any barriers

Transfer information to receiving outpatient provider and care manager in real time Provide patient education about how, where, and when to access health care services and the

roles of primary care, urgent, care and the emergency room

FLPPS Design Elements:

Implementation of on campus extended hours primary care and urgent care, particularly at highest volume EDs

Leverage FQHCs and PCMHs located throughout PPS to increase open access scheduling and patient capacity

Co-locate EDs with primary care and FQHCs, where possible Explore option for call triage process to potentially re-direct non-emergency EMS calls to alternative

sites

Last revised: 5/7/15

Target Populations: Medicaid patients with no PCP, Pediatric patients with guardian, Frequent/repeat ED utilizers,

patients in ED for non-emergency needs All PPS partner hospital Emergency Departments

Assets: Partnerships between hospitals and primary care Workforce – size and expertise Model programs and experience throughout the PPS IT infrastructure

Challenges: Primary Care Provider capacity Need for PCMH Level 3 designation IT variability Transportation Behavior change

Last revised: 5/7/15

Project 2.b.iv: Care Transitions Intervention Model to Reduce 30 day Readmissions for Chronic Health Conditions

Domain 2: System Transformation Projects

Problem Statement: The rates for potentially preventable hospital readmission in the FLPPS geography are higher for Medicaid patients

than for the general population. In addition, rates for many chronic diseases are higher in the FLPPS region than

the NYS average.

Summary Statement: Hospital readmission rates are often related to non-adherence to post discharge care instructions, which can be the

result of lack of health literacy, barrier to basic needs (i.e., transportation), non-compliance with medications and

follow up appointments, and poor engagement with community based services.

Objective: Provide a transition care manager to patients for a period of 30 days after hospitalizations for chronic ambulatory

care sensitive conditions. The care manager can assist the patient in better understanding discharge plans and

increase likelihood of adherence to that plan, thereby reducing preventable readmissions.

Core Components and Deliverables: Development of protocols that follow the Care Transitions Intervention Model to include:

o Early notification of planned discharges

o Pre – discharge meeting between patient and care manager

o Transition of care records to patient’s providers

o 30 day transition of care period

o Engagement of key partners in protocol development and service delivery, including:

Medicaid Managed Care

Health Homes

Primary care/high risk primary care

Required network social and home based services

Target Populations:

Primary: Adult Medicaid patients being discharged to home care or self-care following admission for

chronic conditions including diabetes, respiratory diseases, cardiac and circulatory conditions.

Secondary: Adult Medicaid patients with medical comorbidities, limited social supports, secondary

behavioral health conditions, and more than one recent admission.

Last revised: 5/7/15

Assets:

Existing collaborations between hospitals and various community based providers

Existing standards and protocols for identification and referral to care transitions and health homes

Strength of the workforce – care transitions trained professionals

Existing practices for sustainability – to leverage for widespread MMC coverage

IT infrastructure

Challenges:

Information Technology variations

Workforce expansion and training needed

Regional variations in population density impact potential caseload sizes

Transportation

Need for cultural competency

Last revised: 5/7/15

Project 2.b.vi: Transitional Supportive Housing

Domain 2: System Transformation Projects

Problem Statement: Homelessness and poor transitions of care are known risk factors for readmissions and increased health care utilization. Mental illness and substance abuse disorder prevalence among the homeless exacerbate these patterns. Lack of affordable housing and transportation, poor health literacy and limited social support make it difficult to develop relevant solutions to support care transitions following hospital discharge for people experiencing homeless or housing instability. As a result hospitals in the FLPPS region are often faced with limited options to discharge patients with housing instability to appropriately supportive environments that will enable them to safely stabilize, rehabilitate and transition back into the community.

Summary Statement: Develop transitional supportive housing for high-risk patients who have difficulty transitioning safely from a hospitalization back into the community.

Objective: Strengthen coordinated care transition and management through protocols and partnerships between

participating hospitals, community housing providers and care management services (including health homes and

home care). Streamline access and use of inventories across housing continuum.

Core Components & Deliverables: • Develop transitional supportive housing for high-risk patients. Develop medical-respite look alike in 24hr

emergency shelter sites to provide short term rehabilitative and recuperative care for patients capable of discharge and facing housing instability, homelessness risk or delays in transition to a long term care program.

• Establish partnerships, policies and procedures to coordinate transition with relevant short and long-term care management that meets patient medical and behavioral health needs and social conditions

• Establish partnerships between FLPPS, community housing/home care service providers, and hospitals, which develop transitional housing and allow for in-hospital transition planning

• Policies/Protocols/Procedures in place to: o Identify high-risk super users and implement integrated population health management strategies

to appropriately meet their medical, behavioral health and social needs o Prioritize access to transitional supportive housing for high-risk super users o Connect patients with Health Homes by engaging/assigning a care manager

• Coordination of care strategies with MCOs to ensure relevant services (e.g. medical/behavioral) are covered and available in transitional supportive housing site

• Timely transfer of patient medical records to PCPs and specialists occurs and is documented

FLPPS Design Elements: Move the region toward a Housing First approach, which is an evidence-based practice that focuses on providing

people with housing quickly and then setting up services as needed. By partnering with community based housing

providers, many of whom also provide a range of care management services for medical and/or behavioral health

needs, FLPPS takes this model further by simultaneously coupling support services and housing through care

transitions and coordination. FLPPS proposes a variety of scattered site and congregate living structures across the

region to provide a transitional supportive setting that will be utilized by patients capable of transitioning out of

acute care but requiring additional time for recovery or processing before movement into more permanent

Last revised: 5/7/15

adequate and affordable housing is possible. Combined with strengthened protocols and partnerships for care

coordination and management that will better ensure continued patient access to relevant medical and behavioral

health services. FLPPS will collectively advocate to increase affordable permanent housing.

Discharge Planning:

o Include both hospital and care management staff (health home or home care services)

o Centralized (or at least NOCN regional) housing inventory management and referral processes to facilitate engagement of relevant housing providers

Transitional = <90 days. Target average length of stay of 30 days for medical respite model.

o Care Transitions Coach and/or Health Home Care Manager ensures delivery of medical care and

behavioral services outlined in patient discharge plan

o Housing provider provides personal assistance/supervision and support, identifies and arranging

longer term affordable and adequate housing option

o Care team assesses medium-long term care and support service needs and ensure those will

continue to be accessible by patient after movement out of transitional housing

Delivery mechanisms for supporting medical and behavioral services will combine the following models:

o Built in, for example via community housing provider staff (e.g. on-site counseling, medication

adherence, nutrition/meal support)

o Pushed in, for example via home care service providers or tele-health

o Wrap around via referrals and transportation or accompaniment to partner practitioners and

outpatient services for mental, emotional and behavioral health conditions, work training, etc.

Target Populations: Medicaid enrolled or eligible patients transitioning from inpatient admission, identified as eligible for 30 Day Care Transitions project and at least 18 years old with unstable housing. Patients who are high-risk, meeting health home eligibility requirements (SPMI or HIV or 2+ chronic conditions) and/or has post-acute recuperative needs but no available alternative offering appropriate level of care/support.

Assets: Existing collaborations between hospitals and various community based providers

Opportunity to position this as a pilot project - requires data driven evidence of cost savings to Medicaid

Challenges:

Transitional housing services (room, board, personal assistance) are currently not billable to Medicaid

High risk for bottlenecks due to insufficient affordable permanent and long-term housing (including

Medicaid ALP)

Potential workforce shortages (health home, home care) for adequate and consistent care management

services

IT infrastructure: Variable EHR connectivity among care management and housing providers

Need for cultural competency and sensitivity to health status/conditions and impact of chronic housing

instability

Last revised: 5/7/15

Project 2.d.i.: Implementing Patient Activation Activities to Engage, Educate and Integrate the Uninsured and low/non-utilizing Medicaid Populations into Community Based Care

Domain 2: System Transformation Projects

Problem Statement: The New York State (NYS) Prevention Agenda goal of 0% uninsured recognizes that

even one uninsured individual (UI) is unacceptable, yet 8% of the FLPPS target population lacks coverage. Of the

approximately, 400,000 (300,000 Medicaid Members, 100,000 Uninsured) lives attributed to the Finger Lakes PPS,

approximately 50% fall into the category of underutilizes, and disengaged from the health system. This project

seeks to address this by engaging, educating and linking these persons to essential community based services

through intimately understanding their barriers to engagement and addressing them in meaningful, patient-

centered ways.

Summary Statement:

This project is focused on persons not utilizing the health care system and works to engage and activate those

individuals to utilize primary and preventative care. Through evidence-based patient activation activities, the PPS

will identify those individuals not utilizing the health system and measure and improve their health literacy and level

of activation, thereby encouraging active management of their personal health.

Objective:

To engender and implement PPS patient activation activities across FLPPS region, particularly for the uninsured

and low and non-utilizing Medicaid beneficiaries engaging them to seek primary and preventative services.

Core Components and Deliverables:

Patient Engagement: Develop activities that promote community activation and engagement

o Identify “Hot Spots”; Establish team of Patient Activation Measure (PAM) experts, Train key

community stakeholders in PAM, including providers, ED staff, CBO’s, Care Navigators, etc.; Work

with MCO’s to define Non-utilizer and Low-Utilizer Medicaid Members, Measure and intervene with

defined cohort; Track cohort 5 year project period.

Linkages to Financially Accessible Health Care Resources: Provide community bridges that allow

access to health coverage resources

o Ensure access to primary, behavioral and dental care for uninsured and newly activated Low-

Utilizing Medicaid Beneficiaries.

Linkages to Health Systems and PPS: Build linkages to community based primary and preventative

services and community based health education to grow community and patient activation across the

region.

o Develop community Navigators (in collaboration with CBOs), train Navigators in PAM; place

Navigators in community-based Hot Spots; Ensure insurance enrollment, where applicable; Ensure

access to care

Last revised: 5/7/15

FLPPS Design Elements:

Establishing CBO/PPS partnerships to develop resources and expertise in Patient Activation (PA) techniques Ensuring UI, NU and LU representation on development teams to induce PA in a manner that is patient

centered Increasing bilingual workforce capacity Strategic PPS cultural responsiveness training to provider staff Developing and executing media-driven and/or marketing strategies to drive PA activities and linkage to

health resources Developing multilingual health promotion education materials and approaches specific to our LU, NU and UI

populations Facilitating targeted expansion of FQHCs who are already poised to serve the uninsured

Target Populations: Uninsured (UI) and low (LU) and non- utilizing (NU) Medicaid Beneficiaries

Assets:

Higher levels of health care engagement of PPS patients

Sustainable health care, CBO partnerships to create extended linkages to care for patients

Increase in workforce expertise (PAM administration, PA techniques, cultural competency training)

Best practice models of patient activation in various populations in FLPPS region

IT infrastructure

Challenges:

Tracking identified cohort for PAM or PA over time Limited transportation, barrier to care, particularly in rural areas Behavior modification (not engaged to engaged) requires multiple interactions with patients

Significant linguistic and cultural variations across PPS, will require multiple strategies to engage various

groups of patients.

Last revised: 5/7/15

Project 3.a.i: Integration of Behavioral Health & Primary Care Services

Domain 3: Clinical Improvement Projects in Behavioral Health

Problem Statement:

Compared to NYS, the FLPPS region has elevated levels of both mental illness and substance abuse. A larger portion

of the region is also classified as a Health Professional Shortage Area (HPSA) for mental health services. Co-morbid

behavioral and physical health conditions are associated with increased use of the ED and higher inpatient

readmission rates in the FLPPS region. Overall health outcomes for patients with behavioral health diagnoses are

poorer, with more years of potential life lost.

Summary Statement: Integration of behavioral health and primary care services can serve to identify behavioral health diagnoses early

which allows for rapid treatment, ensures compatibility of medical and behavioral health treatment, and de-

stigmatize treatment for behavioral health diagnoses.

Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for

both services. The objective can be achieved by:

Model 1: Integrating behavioral health specialists into primary care clinics or Model 2: Integrating primary care services into established behavioral health sites or Model 3: When onsite coordination is not possible, behavioral health specialists can be incorporated into

primary care coordination teams through the IMPACT model

Core Components & Deliverables: Models 1 & 2 (Co-location):

a. Primary care practices are National Committee for Quality Assurance Patient-Centered Medical

Home Level 3 (or APCM equivalent) certified by the end of 2017

b. Co-location of services

c. Regular, structured meetings are conducted to develop collaborative care practices

d. Coordinated evidence-based protocols (care & medication management, etc.) are established

e. Policies & procedures are established to facilitate and ensure completion of screenings (results are

documented in the EHR)

f. 100% of patients are screened using industry-standard questionnaires

g. “Warm” referrals to behavioral health are documented when screens are positive

h. EHR demonstrates integration of primary care/behavioral health

i. Targeted patient populations (actively engaged, etc.) patients are identifiable for reporting

Model 3 (IMPACT) – d., f., h., & i. from above plus

o IMPACT Model has been implemented at primary care sites

o Policies and procedures include a process for psychiatry consultation

o Qualified depression care manager follows IMPACT Model coaching, counseling, monitoring for

response to treatment & relapse prevention planning

Last revised: 5/7/15

o Patient participants have a designated psychiatrist

o Patients are evaluated and treatment is adjusted at 10-12 weeks after start of their plan

FLPPS Design Elements: All 3 models will be used

Implementation of evidence-based standards around medication management and care engagement

IMPACT model deployment where workforce shortages prevent full physical integration, which includes

collaborative care standards, depression care managers, utilization of consulting psychiatrists, ,and stepped

care

Preventive screenings

Integrated IT solutions to identify/track patients and project-related outcomes

Target Populations: Approximately 110,000 patients

Patients in need of secondary prevention to stop the development of chronic disease or a mental,

emotional, or behavioral (MEB) disorder

Assets: Working examples of all 3 models that can be leveraged

Greater than 50% of primary care practices in the FLPPS are PCMH Level 3 certified

Pre-existing FQHC requirement to screen for depression coupled with non-DSRIP funding in some cases to

complete full integration

Health homes

Tele-health capability/expertise

Challenges: Shortage of licensed healthcare professionals

Current rates of screening for behavioral in primary care) and physical health (behavioral health) issues

isn’t well known due to lack of documentation and/or ability to track through claims data

HIT interoperability required to bring primary care and behavioral health e-records together

Regulatory relief required for project implementation

Last revised: 5/7/15

Project 3.a.ii: Behavioral Health Community Crisis Stabilization Services

Domain 3: Clinical Improvement Projects

Problem Statement: FLPPS has a higher than NYS average prevalence of mental illness and substance use disorders in this region, accounting for half of our ED treat and release visits. We also have a suicide rate that is trending upward, with counties that are significantly below the NYS average for adherence to anti-psychotic medication and antidepressant use. Routine emergency departments and community behavioral health providers are often unable to readily find resources for the acutely psychotic or otherwise unstable behavioral health patient.

Summary Statement: This project entails providing readily accessible behavioral health crisis services that will allow access to appropriate level of service and providers. The Behavioral Health Crisis Stabilization Service provide a single source of specialty expert care management for these complex patients, offering observation monitoring in a safe location and ready access to inpatient psychiatric stabilization. A mobile crisis team extension of this service will assist with moving patients safely to health services and support community follow-up after stabilization. These services can better ensure continued wellness with support and empowerment for patients and their families through the recovery process.

Objective: To provide readily accessible behavioral health crisis services in the community that will allow access to appropriate levels of service and providers, supporting a rapid de-escalation of the crisis and preventing the need for emergency and inpatient services.

Core Components and Deliverables An evidence-based crisis intervention program that, at a minimum, includes outreach, mobile crisis, and

intensive crisis services to include access to 48 hour observation units/crisis residences for stabilization

and monitoring.

The program will have clear linkages with Health Homes, ER and hospital services to develop and

implement protocols for diversion of patients from emergency room and inpatient services.

There will be a central triage service with agreements among participating psychiatrists, mental health,

behavioral health, and substance abuse providers to assure coordination, collaboration, ready access and

continuity of care.

EHRs or other technical platforms will be used in the treatment and tracking of all patients engaged in this

project.

Includes at least 1 hospital with Psychiatric and crisis-oriented specialty services.

FLPPS Design Elements:

Collaborative, community-based, behavioral health crisis stabilization services with crisis stabilization

“hubs.”

Each hub will have a Mobile Crisis Team, crisis stabilization beds (both extended observation and other

community stabilization beds), access to care managers and close collaborations with their region’s clinical

and community resources.

Last revised: 5/7/15

Crisis triage will be done primarily at the hub level, with escalation to a centrally supported PPS triage, if

required, e.g., to access inpatient services. The hub infrastructure will be fully supported by the 2.a.i. Integrated Delivery System. Patients will be engaged through walk in, 24/7 phone triage, mobile crisis teams and may also be identified

and referred through Care Managers, PCP’s and other community partners. These hubs are resourced by skilled Behavioral Health teams and will include access to and consultation with

Peer Specialists, Care Managers, and Developmental Disabilities Services.

Target Populations: Current high utilizers of emergency services for behavioral health crises. The general population who currently have low or no utilization of crisis services but who would engage, as

needed, if the services were more accessible, lower cost, culturally and linguistically accessible, and patient, family and community-centered.

Community-based staff and organizations to assure their awareness and collaboration in utilizing community crisis stabilization services in lieu of emergency services, and to provide support and education around the importance of screening and early identification of mental health needs.

Assets: Expertise and resources across the PPS in behavioral health crisis intervention and

stabilization.

A PPS-wide willingness and ability to share expertise, best practices and provide

leadership as needed.

Broad-based partnerships that will help us to think differently and pave the way for

innovative utilization of community resources.

Challenges: Availability of Psychiatric workforce that is culturally, linguistically and ethnically diverse.

IT variability

Transportation

Behavior change

Last revised: 5/7/15

Project 3.a.v: Behavioral Interventions Paradigm (BIP) in Nursing Homes

Domain 3: Clinical Improvement Projects

Problem Statement: Forty percent of Skilled Nursing Facility (SNF) residents in the FLPPS region have a behavioral health diagnosis as compared to 32% statewide. The percentage of SNF residents with depression and/or anxiety symptoms have increased. Readmissions to acute care beds following admission to a SNF account for 16% of all Medicaid readmissions. Many patients in long term care have behavioral health issues as a primary disease or as the result of other ongoing chronic diseases. Despite the prevalence of such problems within the SNF, staff may have inadequate formal training to manage these problems or rely on medication to manage these patients. These patients are a significant cause of avoidable admissions and readmissions to hospitals from SNFs.

Summary Statement: This program provides a pathway to avoid hospital transfers and to ensure better care for the SNF patient with these diagnoses. Interventions that rely on increased training of traditional care staff to identify and address behavioral health concerns have been found to be effective management tools. Resources from other evidence based SNF initiatives to reduce avoidable hospital admissions, e.g., INTERACT, may be integrated into this program.

Objective: To reduce transfer of patients from a SNF facility to an acute care hospital by early intervention strategies to stabilize patients with behavioral health issues before crisis levels occur.

Core Components and Deliverables: Implement the Behavioral Interventions Paradigm (BIP) Model in Nursing Homes using SNF skilled nurse

practitioners (NP) and psychiatric Social Workers to provide early assessment, reassessment , intervention,

and care coordination for at risk residents to reduce the risk of crisis requiring transfer to higher level of

care.

Augment skills of the clinical and non-clinical staff in identifying & managing behavioral health issues.

Enhanced environmental and holistic interventions to promote the mental health of SNF residents.

EHRs or other technical platforms used in the treatment and tracking of all patients engaged in this project.

Assignment of NP with BH training to coordinate care with interdisciplinary team.

Engagement of key partners in protocol development and service delivery.

Development of a medication reconciliation and reduction program.

Telehealth services where access to psych specialists is limited.

FLPPS Design Elements: Employ early assessment, reassessment and intervention strategies with NPs and psychiatric social

workers to stabilize patients with behavioral health issues before crisis levels occur.

Modify facilities, as needed, to ensure adequate recreation and holistic interventions can be carried

out.

Implementation of a medication reduction and reconciliation process across all partnering SNFs

within the PPS.

Last revised: 5/7/15

Build an education & training infrastructure to facilitate education and training for SNF clinical and

non-clinical staff using local, online and web-based training.

Use EHR and other documentation to develop algorithms that identify patients in need of

intervention before a crisis requiring a transfer occurs.

Improve access to psychiatric expertise along with enhanced mental health care at our SNFs

Target Populations: SNFs that do not have access to consistent and effective psychiatric expertise (most of them).

SNFs with high rates of acute psychiatric hospitalizations for their residents.

Patients across all SNFs in the PPS.

Assets: Expertise and resources across the PPS in the successful implementation of the INTERACT Model,

in the use of Telehealth and Telementoring.

A PPS-wide willingness and ability to share expertise, best practices and provide leadership as

needed.

Broad-based partnerships with partners that have had to do more with less that will help us to

think differently and pave the way for innovation.

Challenges: Availability of Psychiatric providers especially those with geriatric expertise.

IT variability and variability in data-tracking resources.

Communication especially around transitions with acute services.

Behavior change of the workforce and sustainability of these changes.

Finding adequate time & space for training across the SNF workforce

Last revised: 5/7/15

Project 3.f.i: Increase Support Programs for Maternal and Child Health (including high risk pregnancies)

Domain 3: Clinical Improvement Projects

Problem Statement: The Infant mortality rate in the FLPPS region has marginally improved over the last two decades, moving from 7.3

deaths per 1,000 births in 1994 to 6.4 deaths per thousand births in 2011. There are current service gaps that

impact maternal and child health including the lack of coordinated services for high risk mothers and lack of

attention to the casual factors of toxic stress (of which poverty is an indicator). Poor perinatal outcomes are the 4th

leading cause of Years of Potential Life Lost in the FLPPS region, a rates higher than the upstate NY average.

Summary Statement: Provide women with high risk pregnancies additional support, beyond obstetrical care to ensure the birth of a

healthy child. Provide families access to functional parenting skill advice to assist them in the crucial first two years

of a child’s life.

Objective: To reduce avoidable poor pregnancy outcomes and subsequent hospitalization as well as improve maternal and

child health through the first two years of the child’s life.

Core Components and Deliverables: Implementation of an evidence based home visiting model for pregnant high risk mothers including high

risk first time mothers.

o Develop a referral system for early identification of woman who are or may be at high risk.

o Establish a quality oversight committee of Ob/Gyn and primary care providers to monitor quality

outcomes and implement new/changes activities as appropriate.

Establish a care/referral community network based upon a regional center of excellence for high risk

pregnancies and infants.

o Identify and engage a regional medical center with expertise in management of high risk

pregnancies and infants (must have Level 3 NICU services or Regional Perinatal Center)

o Develop a multidisciplinary team of experts with clinical and social support expertise who will co-

manage care of the high risk mother and infant with local community obstetricians and pediatric

providers. Service availability will be pregnancy through at least the first year of life.

o Utilize best evidence care guidelines for management of high risk pregnancies and newborns.

o Ensure EHR and HIE/RHIO connectivity are in place to ensure real time data sharing, analytic

capabilities, and implementation of uniform clinical protocols based upon evidence based

guidelines.

o Establish Clinical Quality Committee composed of community practitioners and regional medical

center experts to oversee quality of program.

Implementation of a Community Health Worker (CHW) program on the model of the Maternal and Infant

Community Health Collaborative (MICHC) program.

o Access NYSDOH-funded CHW training program.

Last revised: 5/7/15

o Employ a Community Health Worker Coordinator responsible for supervision of 4 – 6 community

health workers. Duties and qualifications are per NYS DOH criteria.

o Identify appropriate candidates for Community Health Worker.

o Establish protocols for deployment of CHW.

o Coordinate with the Medicaid Managed Care organizations serving the target population.

Target Populations: Medicaid Expecting mothers. Mothers participating in the program during pregnancy and up to the first 2

years of child’s life.

In Monroe County, the project focus will be on those receiving pre- and perinatal care. Across the rural

counties, the project will target mothers of children age 0-24 months, and will work to improve the rates of

well child visits, immunizations and lead screenings.

Assets: Existing evidence-based programs, MICHC model programming in Monroe and Livingston Counties, and

experience providing this service

Collaborative relationships between existing programs and community resources

Perinatal Network is implementing Peer Place, expecting to be in place in March

Challenges: Toxic Stress

Transportation

Workforce

Cultural Competence

Last revised: 5/7/15

Project 4.a.iii: Strengthen Mental Health and Substance Abuse Infrastructure Across Systems

Domain 4: Population-wide Projects

Problem Statement: Programs and interventions targeted at preventing mental health and substance abuse disorders lack a developed

evidence base and receive an inadequate distribution of healthcare dollars, despite disparities in Mental, Emotional

and Behavioral (MEB) Health across the population.

Summary Statement:

Through activities defined under New York State’s Prevention Agenda, the PPS, in collaboration with MEB providers

and community leaders, will strengthen the infrastructure for MEB health promotion and MEB disorder prevention,

across systems.

Objective:

Develop/Improve the mental health and substance abuse infrastructure to facilitate the implementation of evidence-

based practices and the collection of standardized data to assure the delivery of high value interventions that move

overall program metrics.

Core Components and Deliverables: FLPPS will convene a Partnership focused on MEB health promotion and MEB disorder prevention. This

Partnership will be responsible for developing a body of evidence to support the delivery of population-

based interventions that promote MEB health and prevent MEB disorders, across the integrated delivery

system.

FLPPS will collect and analyze data on the MEB health of the population, stratified by race/ethnicity, age and

geography, to establish a baseline and target appropriate high-risk populations. Examples of existing data

gaps, to be addressed, include: individual and community-based sources of trauma, suicide rate by

comorbidity, use of opiates and benzodiazepines across populations and care settings, and perceived quality

of life.

FLPPS will then work with providers and NOCNs to select and implement targeted, evidenced-based prevention and promotion programs, driven by analysis of newly established datasets. Interventions will focus on primary prevention, reducing stigma, recovery support and trauma. The PPS will monitor and collect outcome data from newly implemented programs and conduct cost-benefit analysis to determine programmatic value. As a result, the PPS will develop and share a compendium of high-value evidence-based interventions to facilitate wide-spread adoption. In addition, the PPS will have created a replicable strategy for identification and implementation of such programs, which can be redeployed as the needs of the target population change, over time. This asset will act as the centerpiece of future MEB health infrastructure improvement.

Concurrently, the PPS will train network providers to assess and address the behavioral health needs of patients in a culturally competent manner. In addition the PPS will define and disseminate best practice interventions in pain and anxiety management, including a compendium of local resources to use as an alternative to medication-based treatment, in an effort to minimize local sources of addiction. Training will be targeted at both the existing and future workforce. The Partnership, as described above, will lead and facilitate these activities for the organization.

Last revised: 5/7/15

Target Population: High-risk families and those impacted by the criminal justice system, with a particular focus on:

1. Individuals, ages 10-24, who are identified as being at high-risk of developing an MEB disorder 2. Individuals currently living with an MEB disorder, diagnosed or otherwise, and those living on the precipice of illness. This target population requires interventions that assess risk and trauma to diagnose and manage potential or existing MEB disorders to prevent crisis and reduce further deterioration

Challenges: Paradigm Shift: A sustained focus on MEB health promotion and disorder prevention represents a substantial

paradigm shift for the health system.

Stigma: Behavioral health disorders are often associated with false stereotypes/ prejudice, making it difficult

to engage the wider population in MEB health promotion and prevention activities

Silos: Tremendous silos still exist between physical health, mental health and substance abuse providers.

Financing and Sustainability: Many of the Evidence-Based Interventions (EBI) are not currently reimbursed.

Community-based providers must implement infrastructure improvements and demonstrate the value of

those EBIs

Workforce: There is a shortage of licensed behavioral health professionals across the PPS region

Regulations: Waivers are needed to share data across provider types

Project Milestones: Establish MEB health Partnerships (DY1 Q1/Q2)

Assess workforce training needs (DY1 Q3/Q4)

Collect and analyze population-based data (through DY2 1/Q2)

Establish “incubator fund” (DY2 Q1/Q2)

Identify IT solutions to support program evaluation (DY2 Q1/Q2)

Develop curriculums for MEB health competency (DY2 Q3/Q4)

Begin roll-out of evidence-based programs (DY2 Q3/Q4)

Begin workforce training initiatives (through DY3 Q3/Q4 and beyond)

Begin cost-benefit analysis of evidence-based programs (DY4 Q1/Q2 and beyond)

Develop compendium of best practices (DY5 Q/1/Q2)

Develop value-based payment methodology for MEB health prevention programs (DY5 Q3/Q4)

Last revised: 5/7/15

Project 4.b.ii: Increase Access to High Quality Chronic Disease Preventative Care and Management in both Clinical and Community Settings

Domain 4: Population-wide Projects

Problem Statement: Individuals lack the knowledge and health literacy to effectively manage chronic diseases, and providers often lack

the knowledge of resources in the community that can support these individuals in this effort, leading to poorer

management of chronic diseases and ineffective behavior modification to reduce the risk of developing chronic

disease.

Summary Statement:

This project will help to increase access to high quality chronic disease preventative care and management in both

clinical and community settings. Interventions will be targeted toward high-risk patients who will be identified using

a standardized tool and tracked using an integrated IT solution that will be implemented in both clinical and

community settings.

Objective:

The objective of this project is the sustainable delivery of high-quality chronic disease and preventive care and

management in clinical and community settings, which can be accessed, monitored and evaluated using IT solutions

developed through the creation of an integrated delivery system.

Core Components and Deliverables: Identification of high-risk patients using a standardized risk assessment that includes an evaluation of health,

socio-economic and psychological risk factors.

Development of best practices and processes to ensure the appropriate referral and treatment of targeted

patients, based on their level of risk and patient activation

Establishment funding mechanisms that value the prevention and management of chronic disease for

targeted high-risk patients.

FLPPS PCMH-eligible clinical providers will adopt medical home or team-based care models. Medical Homes

will function as the hub for tracking and improving outcomes for high risk patients.

FLPPS partners will adopt and use certified electronic health records, especially those with clinical decision

supports and registry functionality. They will send reminders to patients for preventive and follow-up care,

and identify community resources available to patients to support disease self-management. Success will be

determined by establishing innovative ways to connect with a highly mobile patient population and again,

this can be facilitated by an integrated IT solution.

FLPPS partners will deliver evidence-based preventive services in the clinical setting and connect patients

to community-based preventive resources, including self-care management and support. Appropriate

interventions will be determined based on a standardized assessment of risk and documented and

monitored via an Individual Care Plan that is shared across clinical and community settings.

Through the provision of technical assistance and facilitation of best practices, FLPPS will deliver culturally,

linguistically and ethnically appropriate chronic disease management programs that consider the needs of

the patients and "where they are". There will be "No Wrong Door" to receiving a risk assessment, referral

and chronic disease management support.

Last revised: 5/7/15

FLPPS will document available community-based resources. Using this information, the PPS will work across

its partnership to define and fill gaps, as needed (where are individuals most likely to learn/feel supported

in chronic disease self-management?). In addition, the PPS will create linkages between providers and CBOs

to facilitate referrals to community-based preventive resources.

The PPS will incorporate Prevention Agenda goals and objectives into Hospital Community Service Plans,

and coordinate implementation with local health departments and other community partners. To this end,

implementation will include the growth of programming focused on high-risk patients.

The PPS will adopt and/or grow best practice paradigms for motivational interviewing/health coaching and

self-care/self-management across clinical and community settings, and provide technical assistance for

delivery of model programs across the organization.

The PPS will monitor and provide feedback to clinicians, care teams and community-based partners around

clinical outcomes and benchmarks, incentivizing quality improvement efforts, as appropriate. Incentives will

be targeted at improving the health status and facilitating chronic disease prevention and management

among high-risk patients.

Through contracts with its partnership, the PPS will establish and/or enhance reimbursement and incentive

models to increase delivery of high-quality chronic disease prevention and management services, including

the expansion of reimbursement to community-based disease management and peer support programs

targeting high-risk patients.

The PPS will reduce or eliminate out-of-pocket costs for clinical and community preventive services. This

will ensure access to services for high-risk individuals, particularly those with Low SES.

Target Population: Individuals identified as being “high-risk” for developing chronic illness and those who currently have a diagnosis of

chronic illness and are at “high-risk” for further deterioration.

Challenges:

Paradigm Shift

Coordination across counties

Sustainability

Facilitation of Partnerships

Milestones

Identify target population (DY1 Q1/2)

Develop and test risk assessment (D1 Q3/4)

Map existing resources throughout the PPS (DY1 Q3/4)

Contract with CBO assets serving target population (DY1 Q3/4)

Begin to monitor outcomes associated with interventions delivered to target population (DY2 Q1)

Identify gaps in resources throughout the PPS and work to close the gaps (DY2 Q4)

Update and distribute asset map to include newly developed resources (DY2 Q3/4, ongoing)

Develop cost-benefit analysis to identify high value interventions (DY3 and beyond)

Develop value-based payment methodology (DY5 Q3/Q4)

Facilitate long-term partnerships (DY5 Q3/Q4)