Central New York Care CollaborativeRegional Project Advisory CommitteeOswego County DY2 Q1 Meeting

Thursday May 19, 2016 Fulton Alliance Church Fulton, NY 13069

Ice Breaker

Name Generator

B = Skullcrushing

Sept = Creepy Sweatpants

Circus Performer NameEighties Band NameGym Name

Name Generators

RPAC Structure & Roles

RPAC Structure & Roles

Representatives-Membership (continued)

f. Representative requirements:

i. Representatives commit to attending RPAC meetings. Representatives who are unable to maintain regular attendance are replaced.

ii. Organizations that participate in DSRIP projects across multiple counties are encouraged to have a RPAC representative at each relevant regional meeting. If resources are restrictive, such organizations may have one representative who may attend one or more of the relevant RPAC meetings.

iii. RPAC representatives are liaisons for their organizations and CNYCC.

iv. RPAC representatives are responsible for communicating agendas and discussions of the RPAC back to their respective organizations (i.e. their employer).

Source: PAC/RPAC/EPAC Interim Principles & Procedures (September 2015)

EPAC Structure & Roles

EPAC Structure & Roles

• Purpose: The Executive Project Advisory Committee (EPAC) is the liaison between the CNYCC Board, CNYCC staff and the RPACs. The EPAC is responsible for

• Monitoring all aspects of the DSRIP process from the Partner/Regional perspective.• Providing information to the CNYCC Board and staff regarding local priorities and concerns

through communications that are vetted with the RPACs.• Receiving project-specific data and performance indicators and CNYCC-level priorities and

concerns and communicating these to the RPACs.• Responding to queries from the CNYCC Board of Directors and its Corporate Committees.• Facilitating communication among the Board and regions.

• Source: PAC/RPAC/EPAC Interim Principles & Procedures (September 2015)

EPAC Structure & Roles

Structurea. The EPAC is comprised of two (2) representatives from each of the RPACS.b. The EPAC will meet monthly.c. The EPAC maintains minutes of all meetings and disseminates them to the CNYCC

Board, staff and RPACs following each meeting.

Membershipa. Each RPAC will have two (2) representatives on the EPAC

i. The county representative.ii. An additional partner organization representative.

1) Each RPAC will select the EPAC representative through a voting process.2) No one organization can have multiple EPAC representatives.

Source: PAC/RPAC/EPAC Interim Principles & Procedures (September 2015)

Oswego County EPAC RepresentativeTricia ClarkVP/Chief Operating Officer - Northern Oswego County Health Services Inc. (NOCHSI)

• NOCHSI since 2013• Responsible for operations and program management• Federally Qualified Health Center (FQHC)

• Primary Care• Behavioral Health• Dental Services• Medical/School Based Services• 30,000 Unique Patient Visits Annually

• Health Center Locations: Fulton, Mexico, Oswego, Parish, Phoenix and Pulaski

Madison County:Teisha Cook – Madison County ConvenerDenise Hummer – Community Memorial Hospital

Cayuga County:Kathleen Cuddy – Cayuga County ConvenerLiz Smith – Unity House of Cayuga County Inc.

Onondaga County: Mat Roosa – Onondaga County ConvenerMarta Durkin - Liberty Resources, Inc.

Oneida County: Robin O’Brien – Oneida County Convener TBD

Oswego County : Nicole Kolmsee – Oswego County ConvenerTricia Clark - NOCHSI

Lewis County: Penny Ingham – Lewis County ConvenerTBD

Executive Project Advisory Committee Membership

Organizational Spotlight

Oswego County Opportunities

Oswego County Opportunities

Organizational Spotlight

Project Breakout Session(s)

Project Breakout Session(s)

• ED Care Triage (2.b.iii)• Patient Activation (2.d.i)• Behavioral Health/ Primary Care Integration (3.a.i )• Cardiovascular Disease Management (3.b.i)• Palliative Care Integration (3.g.i)

Session # 1

Session # 1Session # 2• DSRIP Care Management (2.a.iii) • Reduce Premature Births (4.d.i) • Behavioral Health Community Crisis Stabilization Services (3.a.ii)• Integrated Delivery System (2.a.i)• Care Transitions (2.b.iv )

Project Dashboard Reports

Actively Engaged Patient ReportingDY2 Q1 Targets – April 2016 Rosters

Project Target Actual Gap to Goal

DSRIP Care Management 1650 0 (1650)

ED Care Triage 1600 221 (1379)

Care Transitions 825 737 (88)

Patient Activation 600* 34 (566)

Behavioral Health/Primary Care Integration 5000 846 (4154)

Behavioral Health Crisis Stabilization 3000 1172 (1828)

Cardiovascular Disease Management 1850 7 (1843)

* CNYCC Internal Goal – State Targets do not begin until DY2Q2

DSRIP Care Management Actively Engaged Reporting

DY2 Q1 Targets

New Rosters are due 6/15/2016 for April and May Patients based on updated Reporting Requirements

Q DUE Target Actual Gap to Goal

DY2 Q1 1650 0 (1650)

Orange Text Indicates Participation in Oswego RPAC

ED Care Triage Actively Engaged Patient ReportingDY2 Q1 Targets

Organizations Reporting Actively Engaged Patients• Auburn Community Hospital• Lewis County General Hospital• Oneida Healthcare• St. Joseph’s Hospital Health Center• Upstate University Hospital

Q DUE Target Actual Gap to Goal

DY2 Q1 1600 221 (1379)

Orange Text Indicates Participation in Oswego RPAC

7420 71

56

1379

0

400

800

1200

1600

DY1

Actively Engaged Patients by County*

Onondaga Oneida Oswego

ED Care Triage Actively Engaged Patient Reporting

56

Organizations Participating in Multiple RPACs*

Oneida Healthcare

*If an organization is Participating in Multiple RPACs, the number of Actively Engaged Patients will be attributed to the current RPAC

Care Transitions Actively Engaged Reporting

DY2 Q1 Targets

Organizations Reporting Actively Engaged Patients• Auburn Community Hospital• Crouse Hospital• Lewis County General Hospital• Oneida Healthcare• Oswego Hospital• Rome Memorial Hospital• St. Joseph’s Hospital• Upstate University Hospital

Q DUE Target Actual Gap to Goal

DY2 Q1 825 737 (88)

Highlighted Text Indicates Participation in Oswego RPAC

523

4818

8127

4088

0

100

200

300

400

500

600

700

800

DY1

Actively Engaged Patients by County

Onondaga Oneida OswegoCayuga Madison Lewis

Care Transitions Actively Engaged Reporting

40

Organizations Participating in Multiple RPACs

Oneida Healthcare

*If an organization is Participating in Multiple RPACs, the number of Actively Engaged Patients will be attributed to the current RPAC

Patient Activation Actively Engaged Reporting

DY2 Q1 Targets

Organizations Reporting Actively Engaged Patients• The Salvation Army

Q DUE Target Actual Gap to Goal

DY2 Q1 600 34 (566)

Orange Text Indicates Participation in Oswego RPAC

34

566

0

100

200

300

400

500

600

DY1

Actively Engaged Patients by County

Onondaga Oneida OswegoCayuga Madison Lewis

Patient Activation Actively Engaged Reporting

Behavioral Health/Primary Care Integration Actively Engaged Reporting

Organizations Reporting• ARISE Child and Family Services• Crouse Hospital• Farnham Family Services• Harbor Lights• Hutchings Psychiatric Hospital• Liberty Resources• Oneida Healthcare• Oswego Hospital

Q DUE Target Actual Gap to Goal

DY2 Q1 5000 846 (4154)

• Regional Primary Care Network (RPCN)• St. Joseph’s Hospital

• Syracuse Behavioral Healthcare

• Upstate Cerebral Palsy

DY2 Q1 Targets

Highlighted Text Indicates Participation in Oswego RPAC

62070124

32

4154

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

DY1

Actively Engaged Patients by County*

Onondaga Oneida OswegoCayuga Madison LewisMultiple Counties Gap to Target

Behavioral Health/Primary Care Integration Actively Engaged Reporting

7

74

25

3

Organizations Participating in Multiple RPACs* Oneida Healthcare

Liberty Resources(Oswego CountyParticipant)

*If an organization is Participating in Multiple RPACs, the number of Actively Engaged Patients will be attributed to the current RPAC

Behavioral Health Crisis Stabilization Actively Engaged ReportingDY2 Q1 Targets

Organizations Reporting• ARISE Child and Family Services• Cayuga County Community

Mental Health Center• Hutchings Psychiatric Center• Onondaga Case Management

Services• Oswego Hospital

Q DUE Target Actual Need

DY2 Q1 3000 1172 (1828)

• St. Joseph’s Hospital

• Syracuse Behavioral Health

• The Neighborhood Center

• Unity House of Cayuga County

• Upstate University Hospital

Highlighted Text Indicates Participation in Oswego RPAC

24010

905

161

1828

0

500

1000

1500

2000

2500

3000

DY1

Actively Engaged Patients by County*

Onondaga OneidaOswego CayugaMadison LewisMultiple Counties Gap to Target

Behavioral Health Crisis Stabilization Actively Engaged Reporting

29

563

1

Organizations Participating in Multiple RPACs* ARISE Child and Family

Services (Oswego CountyParticipant)

Onondaga CaseManagement Services(Oswego CountyParticipant)

*If an organization is Participating in Multiple RPACs, the number of Actively Engaged Patients will be attributed to the current RPAC

Cardiovascular Disease Management Actively Engaged Reporting

DY2 Q1 Targets

Organizations Reporting Actively Engaged Patients• Oneida Healthcare

Q DUE Target Actual Need

DY2 Q1 1850 7 (1843)

Highlighted Text Indicates Participation in Oswego RPAC

DY1, 7

1843

0

250

500

750

1000

1250

1500

1750

DY1

Actively Engaged Patients by County*

Onondaga OneidaOswego CayugaMadison LewisMultiple Counties Gap to Target

Cardiovascular Disease Management Actively Engaged Reporting

7

Organizations Participating in Multiple RPACs*

Oneida Healthcare

*If an organization is Participating in Multiple RPACs, the number of Actively Engaged Patients will be attributed to the current RPAC

Questions & Answers

Next Steps & Wrap-Up

Central New York Care Collaborative�Regional Project Advisory Committee�Oswego County DY2 Q1 Meeting �Ice BreakerName Generator Name GeneratorsRPAC Structure & RolesRPAC Structure & RolesEPAC Structure & RolesEPAC Structure & RolesEPAC Structure & RolesOswego County EPAC RepresentativeExecutive Project Advisory Committee MembershipOrganizational SpotlightOswego County OpportunitiesOrganizational SpotlightProject Breakout Session(s)��Project Breakout Session(s)Project Dashboard ReportsActively Engaged Patient ReportingDSRIP Care Management Actively Engaged ReportingED Care Triage Actively Engaged Patient ReportingED Care Triage Actively Engaged Patient ReportingCare Transitions Actively Engaged ReportingCare Transitions Actively Engaged ReportingPatient Activation Actively Engaged ReportingPatient Activation Actively Engaged ReportingBehavioral Health/Primary Care Integration Actively Engaged ReportingSlide Number 27Behavioral Health Crisis Stabilization Actively Engaged ReportingBehavioral Health Crisis Stabilization Actively Engaged ReportingCardiovascular Disease Management Actively Engaged ReportingCardiovascular Disease Management Actively Engaged ReportingSlide Number 32Slide Number 33