Building Sustainable CBO and Health System Partnerships

under Medicaid Delivery System Reform

October 23, 2018

Part of the Aging and Disability Business Institute

Series- a collaboration of n4a and ASA

The “Business Institute”

The mission of the Aging and Disability Business Institute (Business Institute) is to successfully build and strengthen partnerships between community-based organizations (CBOs) and the health care system so older adults and people with disabilities will have access to services and supports that will enable them to live with dignity and independence in their homes and communities as long as possible.

aginganddisabilitybusinessinstitute.org

Partners and Funders

Partners:

• National Association of Area Agencies on Aging

• Independent Living Research Utilization/National Center for Aging and Disability

• American Society on Aging

• Partners in Care Foundation

• Elder Services of the Merrimack Valley/Healthy Living Center of Excellence

• The National Council on Aging (NCOA)

• The Evidence-Based Leadership Council (EBLC)

• Meals on Wheels America (MOWA)

Funders:

• Administration for Community Living

• The John A. Hartford Foundation

• The SCAN Foundation

• The Gary and Mary West Foundation

• The Colorado Health Foundation

• The Marin Community Foundation

Objectives:

• Seek reasons why healthcare systems would develop partnerships with community-based organizations to achieve desired outcomes;

• Better understand different services and payment structures that healthcare systems may pursue while engaging community-based organizations; and

• Identify challenges that community-based organizations will likely encounter and must address when partnering with healthcare organizations.

Overview

• Welcome and introductions

• New York State’s DSRIP and OneCity Health • Opportunities for CBOs

• New York City Department for the Aging • Care Transitions

• Successes and Lessons Learned

• Q&A

Welcome & Introductions

• Ishmael Carter • Senior Assistant Vice President, Hub Executive Director,

OneCity Health Services

• Carin Tinney • Director of Program Development, NYC Department for the

Aging

• Meghan Shineman • Healthcare Planning Specialist, NYC Department for the Aging

New York State DSRIP Overview

The Delivery System Reform Incentive Payment (DSRIP) program comprises the largest portion of the 1115 Medicaid Waiver. DSRIP is a $6.42B performance-based program that will fund public and safety net providers to transform the NYS health care delivery system.

Goals:

1. Transform the safety net system

2. Reduce avoidable hospital use by 25% over 5 years (admissions & readmissions by 2020)

3. Concurrent pursuit of the Triple Aim (better care, improved health, reduced cost)

4. Ensure delivery system transformation continues beyond the waiver period through managed care payment reform

OneCity Health – Key Program Components

• Statewide funding initiative for public hospitals and safety net providers

• Only coalitions of community/regional health providers are eligible (to create a Performing Provider System – PPS)

• DSRIP projects based on a menu of interventions approved by CMS and NYS

• Payments to providers based on their performance in meeting outcome milestones and the State achieving statewide metrics

What is a Performing Provider System (PPS)?

Hub-Based Model Designed to Meet Local Needs

OneCity Health Overview: Background

• OneCity Health PPS is the largest in New York State, the only public hospital-led PPS in New York City

• Serves one of the most diverse population in the state

• 657,000 DSRIP attributed Medicaid patients

• Over 240 organizational-level partners with approximately 1,200 provider sites in four (4) Hubs across the city

• Implemented 11 of the 44 DSRIP projects in NYS

OneCity Health PPS Objectives

• We seek to change the way health and social services are delivered for all New Yorkers

• Our strategy is to build upon the strengths and infrastructure of our largest partner, NYC Health and Hospitals, while partnering for community expertise and capacity in primary care, social services

• Effectively re-engineer the care management processes across the continuum of care at NYC Health + Hospitals and New York City

• Enable the full integration of social services in the care management process to reduce avoidable hospitalizations and readmission

DSRIP Projects Translated to Care Continuum

Community Based Organizations Engagement - Objectives

• OneCity Health values CBOs’ grassroots approach. They provide a level of insight, expertise and access to our underserved and priority population

• OneCity Health Engage CBO Partner more extensively in healthcare transformation efforts

• Support the achievement of required DSRIP milestones

• To foster greater accountability and measured value of CBO initiatives and efforts

• To encourage collaboration between CBO

• To build and establish more meaningful relationships between CBOs and PPS

OneCity Health CBO Capacity Building

• OneCity Health is committed to forging sustainable partnerships amongst PPS partners that are focused on improving health outcomes

• Our CBO capacity building experience has been lauded by the NYS DOH as a best practice and continues to be recognized at the local, state and national levels—congratulations to all of our CBO partners

• Support the development of a value proposition

• CBO partners that completed their value propositions have utilized them to support conversations with various potential funders

Strategic Advisory Workgroup

• OneCity Health seeks the advise of community-based organizations in order to meet our DSRIP program goals

• The Strategic Advisory Workgroup is comprised of CBOs that provide direct social services to our patient population

• OneCity Health collaborates with the Workgroup on some of the following topics:

• CBO Contracting

• Network Development

• Expanded use of social service referral platforms

• Integration of social determinants of health screenings

• VBP readiness and value proposition training

CBO Technical Assistance

OneCity provides ongoing technical assistance (TA) to build Community Based Organizations (CBO’s) capacity for Value-Based contracting

• TA Vendor was secured by OCH to access CBO capacity

• CBOs complete an online survey help OCH to tailor the TA to the CBO specific needs

• Learning Collaboratives and training on VBP, Creation of Value Proposition

Expansion of co-location services across hospitals and clinics • Care Transitions Teams

• Asthma Community Health Workers

• Food Insecurity – SNAP. Food insecurity is one of top areas of focus.

• Medical-Legal partnership with New York Legal Assistance Group (NYLAG)

• Legal Services (general, immigration)

• Tax preparation and financial capacity building

OneCity Health - CBO Listening Sessions

• OCH hosted four (4) listening sessions to hear from CBOs about the changing landscape of healthcare

• Key Takeaways: • Network Alignment and Sustainability- creating a network that

leverages the strengths of our community partners

• Data Systems – given the variability of systems at CBOs, the PPS needs to access data needs and scalability

• Value Based Payment Environment- a need for training

Hospital - Community Partnerships

• Achieving the goals and objectives of an integrated delivery system requires greater communication and collaboration between the healthcare and social services sectors.

• Hospital – Community Partnerships is mechanism to identify, develop and support piloting of innovative ideas to yield a proof of concept that can be marketed to managed care partners, and that could be scaled to other geographical regions

• Identification of strategic hospital partnership needs

• Input and guidance of structure and management of meaningful engagement with hospitals

• Collaboration and alignment with the NYS DOH Bureau of Social Determinants of Health priorities

NowPow Electronic Directory and Referral Tool

• OneCity Health has made NowRx, available during the first phase of our NowPow rollout

• NowRx offers a comprehensive, accurate and searchable resource directory of New York City organizations that allows staff to find social services that meet an individual’s needs and priorities

• Services are identified and compiled on a HealtheRx that staff can send to patients and clients as referral recommendations via email, text or printed copy

• OneCity Health is initiating the first phase rollout of PowRx starting October 2018

Innovation Fund Projects

• In January 2018, OneCity Health launched the $5 million Innovation Award program

• This program will partners in designing and implementing innovative programs to improve the health of the patients and clients we serve and reduce avoidable use of the health care system

• Eight community partners that will receive funding from its $5 million Innovation Fund

• Partners will use this money to innovate around transformation goals, including reducing avoidable hospitalizations, improving community health outcomes, and addressing social determinants of health, such as food security and health literacy.

NYC Department for the Aging (DFTA)

• There are approximately 1.5 million people 60+ years old in New York City

• Nation’s largest Area Agency on Aging

• Network of over 400 contracted CBOs

DFTA Services

• 249 senior centers = approx. 30,000 people daily

• Case management = approx. 30,000 seniors

• Home care/housekeeping = approx. 3,000 seniors

• 18,500 home-delivered meals delivered daily

• 10 caregiver programs = approx. 10,000 caregivers

• NY Connects = No Wrong Door; Aging & Disability Resource Center

• NORC services = approx. 11,000 residents

Previous Care Transition Experience

• CMS-funded Community-Based Care Transitions Program (CCTP)

• April 2013 -- March 2015

• Queens Collaborative = 5 Queens-based hospitals + 4 DFTA contracted agencies

• Reduction of 4.5% in avoidable hospital readmissions = about 50 readmissions prevented per month

• Estimated $560,000/month savings for CMS

DFTA + OCH Partnership

• DSRIP PPS partner since December 2015

• Care transitions since November 2016 • 2 Queens H+H hospitals

• 2 of DFTA’s contracted CBOs (Selfhelp Community Services and New York Foundation for Senior Citizens)

OCH Care Transitions Program

• Team of 3: Registered nurse, licensed social worker, and community liaison

• Approx. 36 active patients per month

• Hospital rounds & initial bedside assessments prior to discharge

• Post Discharge:

• Home visits within 7 days + weekly follow-ups for 30 days post discharge

• Coordination with PCP & care management

• Medication reconciliation & self-management support

• Linking to community-based resources

Successes

• More than 500 distinct, high-risk individuals (as of 10/1/18) served

• Population served = 54% aged 60 and over ; 95% non-white; 16% uninsured

• Estimated 40% with BH needs; 60% social service needs

• Approximately 58% graduated from the CT program once in the community

Lessons Learned

• True integration & recognition from hospital staff more appropriate and sufficient # of referrals

• Co-location, consistent presence

• Different patient tracking IT databases = duplication of effort & inconsistent information

• Different onboarding personnel procedures

What Does the Future Hold?

• End of DSRIP = March 31, 2020

• Better coordination between NYC’s aging services network with the city’s public hospital system (H+H)

• CommunityCare Link (CCL) • Management Services organization (MSO)

• Bridge between the aging & health sectors

Thank you!

• Ishmael Carter, Senior Assistant Vice President, Hub Executive Director, OneCity Health Services: Ishmael.Carter@nychhc.org

• Carin Tinney, Director of Program Development, NYC Department for the Aging: CTinney@aging.nyc.gov

• Meghan Shineman, Healthcare Planning Specialist, NYC Department for the Aging: Mshineman@aging.nyc.gov

Questions & Answers: Please Submit Using the “Questions”

Box

Please join us for future webinars in the Aging and Disability Business Institute Series

Learn more and pre-register here: http://www.asaging.org/series/109/aging-and-disability-business-institute-

series

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BusinessInstitute@n4a.org