Central New York Care collaborative (CNYCC)

1. Central New York Care collaborative (CNYCC) Regional Project Advisory Council Meeting Meeting 1

2. AGENDA • Welcome and Introductions • DSRIP Goals, Principles and Timeline • Description of DSRIP Work Streams • Advisory Structure • Domains and Preliminary List of Projects • Review of Needs Assessment Data • Discussion: Confirm or Add to List of Projects • Discussion: Regional Gaps and Strengths Impacting Implementation • Draft Agenda Items Next Meeting

3. Welcome and introductions • JSI Staff • Interim CNYCC Staff • RPAC Members

4. DSRIP Goals, Principles and Timeline • Goals: Delivery System Reform Incentive Payment Program’s (DSRIP) purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid Program with the primary goal of reducing avoidable hospital use by 25% over 5 years.Operating Principles: System Transformation, Clinical Improvement, Population-wide ProjectsTimeline: 5 ½ year project, currently in Year 0

5. DSRIP Goals, Principles and Timeline • Guiding Principles • Collaboration • Project Value • Application of Data Driven, Evidence-based Practices • # and types of project and # Medicaid patients served • Sustainable, long-term transformation • Collaborative Planning and Implementation • Integration of Health Care and Public Health Systems • Application quality

6. DSRIP Goals, Principles and Timeline

7. DSRIP Planning and Workstreams • Additional Resources: DSRIP Workstreams

8. Project Management Project Management • Establish PPS Steering Committee • Establish Project Management Team • Establish Working Groups

9. Governance, Infrastructure & Systems • Governance structure for PPS • Metrics to track performance • IT requirements and infrastructure • Funds flow and pay for performance

10. Project and Partner Selection • Qualitative and quantitative data collection and analysis • Stakeholder engagement and communication • Development of evidence based approaches with clear partners • Assuring workforce capacity

11. Advisory Structure and Charters • Development Council • Regional Project Advisory Council • Technical Work Groups

12. Advisory Structure and Charters

13. System Transformation Projects • Create Integrated Delivery Systems that are focused on Evidence-Based Medicine/Population Health Management • Health Home At-Risk Intervention Program • Care transitions intervention model to reduce 30 day readmissions for chronic health conditions • Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services

14. Clinical Improvement Projects • Integration of primary care and behavioral health services • Integration of palliative care into nursing homes • Behavioral health community crisis stabilization services

15. Population-wide Projects • Prevent Substance Abuse and other Mental Emotional Behavioral Disorders – 2 of the following • Identify and implement evidence-based practices and environmental strategies to prevent underage drinking, substance abuse and other MEB disorders. • Consider evidence based strategies to reduce underage drinking such as those promulgated by the U.S. Surgeon General and the Centers for Disease Control and Prevention. • Increase understanding of evidence-based practices for smoking cessation among individuals with mental illness and/or substance abuse disorder.

16. Population-wide Projects • Strengthen Mental Health and Substance Abuse Infrastructure across Systems – 3 of the following • Participate in MEB health promotion and MEB disorder prevention partnerships. • Expand efforts with DOH and OMH to implement 'Collaborative Care' in primary care settings throughout NYS. • Provide cultural and linguistic training on MEB health promotion, prevention and treatment. • Share data and information on MEB health promotion and MEB disorder prevention and treatment.

17. Needs Assessment Approach

18. Who is at risk? • What are the population demographics? (age, poverty level, education, race/ethnicity) • What are the characteristics of Medicaid members? • What are the services most commonly provided to Medicaid members?

19. What are the risks? • How often do people visit the ER/primary care provider/inpatient care? What are the three-year trends? • What are the leading causes of death and morbidity in the area? What geographies have high rates? • What areas have the highest rates of potentially avoidable services (PQI indicators)? • What areas have the highest rates of root causes of disease (tobacco, nutrition/physical activity) • What racial/ethnic, age, or other demographic disparities exist in utilization and health status indicators?

20. Where is the need? • Where are health care resources located? • Where are social services located? • Where are the areas with limited capacity or service gaps both in health care resources and social services? • What specific type of resources are lacking (e.g., addiction clinic, early education program)?

21. How will PPSs maximize impact? • Given who is at-risk, the specific priority health conditions, and the existing service gaps where should PPSs focus their efforts to maximize impact? • What strategies will have the greatest impact, based on an integration of need and best practice?

22. Needs Assessment Methods - Data Collection / Community Engagement • Quantitative Data Activities • .Leading causes of death and illness • Primary care, ED, and inpatient utilization rates • Prevention indicators / risk factors • Resource Inventory Activities • Health and community resources • Service area, scope of service, and capacity • Qualitative Data Activities • Key informant interviews • Community listening sessions • Consumer Focus Groups

23. Data Integration and Analysis • Descriptive, comparative/benchmarking and mapping/”Hot Spot” analyses to identify: • Leading causes of morbidity and mortality • Population segments most at-risk • Service gaps / capacity gaps • Barriers to access • Factors associated with morbidity and mortality • Leading determinants of health or illness • Identification/prioritization of high impact strategies

24. Preliminary Findings County members as a percentage of State Medicaid members

25. Preliminary Findings Average number of hospital admissions visits per Medicaid member State average: 0.16

26. Preliminary Findings Average number of emergency room (ER) visits per Medicaid member State average: 0.49

27. Preliminary Findings Zip Codes with highest admission rates, and total number of admissions

28. Preliminary Findings • Potentially Preventable ER Visits (PPV) per county Nine of the 11 counties have rates of PPV that are higher than overall New York State (36.1), with St. Lawrence, Jefferson, Madison, Cayuga, and Lewis being the top 5 with the highest rates.

29. Preliminary Findings • PQI: Overall Composite Eight of the 11 counties had higher overall PQI than NYS. Cortland, Oneida, and Cayuga had the highest rates, when compared to the 11 counties.

30. Preliminary Findings • Pediatric Quality Indicator: Overall Composite The overall, acute, and chronic Pediatric Quality Indicator composites for Cortland and St. Lawrence were higher than overall New York State. Cortland had the highest score followed by St. Lawrence. The other counties’ rates were lower than the State overall..

31. Preliminary Findings

32. Preliminary Findings • PQI: All Circulatory Composite Six counties had composite circulatory rates higher than the state average. Cortland, Cayuga, and Oneida had the highest rates, when compared to the other 11 counties.

33. Web Mapping Apps • Explore demographics and health statistics through maps • 3 Different Apps • Demographics • Preventable Indicators • Access to Health Care

34. Web Mapping App: Demographics • ZCTA Level • Layers: • % Age 65+ • % Minority Race • % Hispanic • % Under 138% FPL • % Under 200% FPL • % Foreign Born • % LEP (Limited English Proficiency) maps.jsi.com/cnydemographics/map.html

35. Web Mapping App: Preventable Indicators • Zip Code Level • Layers: • Medicaid PQI Overall Composite • Subcategories • Medicaid PDI Overall Composite • Subcategories • ER PPV - Potentially Preventable Visits maps.jsi.com/cnypreventable/map.html

36. Web Mapping App: Access to Health • County Level • Layers: • % Adults with Regular Health CareProvider • % of Adults with Health Insurance • % women aged 40+ who had mammograms in the past 2 years • % of adults aged 50+ who ever had sigmoidoscopies or colonoscopies maps.jsi.com/cnyaccess/map.html

37. Demo of web mapping Maps maps.jsi.com/cnydemographics/map.html maps.jsi.com/cnypreventable/map.html maps.jsi.com/cnyaccess/map.html Demo: Regional overview, close look at Onondoga/Cayuga Counties

38. Progress Reports / Key Deliverables • Final Workplan and JSI Scope of Work (Aug. 5 - 8) • Phase I - Initial Progress Report (Sept. 5) • Phase II - Preliminary Review of Quantitative Findings (Sept. 17) • Phase III - Preliminary Review of Service Inventories and Initial Integrated Review of Health Status Issues, Service Gaps, and Barriers to Care (Oct. 1) • Phase IV - Comprehensive Report of Findings (Oct. 15) • Phase V - Summary Report of All Findings (Oct. 30) • Phase VI - Final Narrative Report of Findings by Region / PPS (Jan 15)

39. Discussion Discussion Goal: To provide guidance regarding reduction of avoidable hospital use. To understand this will require a discussion of: • Major segments of the low income, Medicaid insured and uninsured target population • Leading health issues, barriers to care, service needs/gaps, and major determinants of health • Root causes of inappropriate utilization • Input on evidence-based and best practice approaches to reducing inappropriate utilization

40. Discussion • What segments of the low income Medicaid and uninsured populations should be targeted? • What are the leading health issues, barriers to care, and service needs/gaps? • What are the major determinants of health?

41. Discussion • What are the root causes of inappropriate hospital emergency department and inpatient utilization? • What behaviors, attitudes or care seeking behaviors need to be addressed? • What are the leading factors associated with lack of follow-up and fragmentation of service?

42. Discussion • What approaches should be initiated to address the issues described previously? • Are there examples of these initiatives locally, regionally or nationally? • What seems to be most effective in addressing the root causes of inappropriate utilization?

43. Discussion • What will need to be done in order to successfully implement these approaches? • New clinical practice approaches? • New partners – including those outside the conventional health services realm? • System enhancement and infrastructure development?