Connecting DSRIP & VBP: An Overview

DSRIP Project Areas VBP Priority Areas Leading Causes of ER Visits & Hospitalizations Across Regions

Domain 2: System Transformation Projects A. Create Integrated Delivery Systems 2.a.i Create Integrated Delivery Systems that are focused on Evidence-Based Medicine / Population Health Management 2.a.ii Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP)) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services 2.a.iv Create a medical village using existing hospital infrastructure 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure B. Implementation of Care Coordination and Transitional Care Programs 2.b.i Ambulatory Intensive Care Units (ICUs) 2.b.ii Development of co-located primary care services in the emergency department (ED) 2.b.iii ED care triage for at-risk populations 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions 2.b.v Care transitions intervention for skilled nursing facility (SNF) residents 2.b.vi Transitional supportive housing services 2.b.vii Implementing the INTERACT project (inpatient transfer avoidance program for SNF) 2.b.viii Hospital-Home Care Collaboration Solutions 2.b.ix Implementation of observational programs in hospitals C. Connecting Settings 2.c.i Development of community-based health navigation services 2.c.ii Expand usage of telemedicine in underserved areas to provide access to otherwise scarce services D. Utilizing Patient Activation to Expand Access to Community Based Care for Special Populations 2.d.i Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care Domain 3: Clinical Improvement Projects A. Behavioral Health 3.a.i Integration of primary care and behavioral health services 3.a.ii Behavioral health community crisis stabilization services 3.a.iii Implementation of evidence-based medication adherence programs (MAP) in community based sites for behavioral health medication compliance 3.a.iv Development of Withdrawal Management (e.g., ambulatory detoxification, ancillary withdrawal services)capabilities and appropriate enhanced abstinence services within community-based addiction treatment programs 3.a.v Behavioral Interventions Paradigm (BIP) in Nursing Homes B. Cardiovascular Health—Implementation of Million Hearts Campaign 3.b.i Evidence-based strategies for disease management in high risk/affected populations (adult only) 3.b.ii Implementation of evidence-based strategies in the community to address chronic disease – primary and secondary prevention projects (adult only) C. Diabetes Care 3.c.i Evidence-based strategies for disease management in high risk/affected populations (adults only) 3.c.ii Implementation of evidence-based strategies to address chronic disease – primary and secondary prevention projects (adults only) D. Asthma 3.d.i Development of evidence-based medication adherence programs (MAP) in community settings– asthma medication 3.d.ii Expansion of asthma home-based self-management program 3.d.iii Implementation of evidence-based medicine guidelines for asthma management E. HIV/AIDS 3.e.i Comprehensive Strategy to decrease HIV/AIDS transmission to reduce avoidable hospitalizations –development of a Center of Excellence for Management of HIV/AIDS F. Perinatal Care 3.f.i Increase support programs for maternal & child health (including high risk pregnancies) (Example: Nurse Family Partnership) G. Palliative Care 3.g.i Integration of palliative care into the PCMH Model 3.g.ii Integration of palliative care into nursing homes H. Renal Care 3.h.i Specialized Medical Home for Chronic Renal Failure Domain 4: Population-wide Projects: New York’s Prevention Agenda A. Promote Mental Health and Prevent Substance Abuse (MHSA) 4.a.i Promote mental, emotional and behavioral (MEB) well-being in communities 4.a.ii Prevent Substance Abuse and other Mental Emotional Behavioral Disorders 4.a.iii Strengthen Mental Health and Substance Abuse Infrastructure across Systems B. Prevent Chronic Diseases 4.b.i. Promote tobacco use cessation, especially among low SES populations and those with poor mental health. 4.b.ii Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings (Note: This project targets chronic diseases that are not included in domain 3, such as cancer C. Prevent HIV and STDs 4.c.i Decrease HIV morbidity 4.c.ii Increase early access to, and retention in, HIV care 4.c.iii Decrease STD morbidity

1.Population Health a. Integrated physical and behavioral health to achieve better overall outcomes and reduce costs of care system-wide 2.Focus on sub-populations/ episodes with particular needs: a. Episodic: maternity care, acute stroke, depression, joint replacement, etc. b. Continuous: i. Chronic care of: CHF, Diabetes, Hypertension, Asthma care, Depression, etc. ii. Chronic Kidney Disease iii. AIDS/ HIV iv. Multi-morbid disabled/frail elderly (MLTC/FIDA population) v. Severe BH/SUD conditions (HARP population) vi. Developmentally Disabled population

Depression Hypertension Drug Abuse Diabetes Asthma Chronic Stress & Anxiety Diagnoses Schizophrenia Maternity-related conditions/

complications Septicemia & Disseminated Infections Chronic Alcohol Abuse COPD & Other Major Chronic Pulmonary

Diagnoses Chronic Mental Health Diagnoses Cardiomyopathy, CHF, etc. Atrial Fibrillation, Cardiac Dysrhythmia, and

Conduction Disorders Bi-polar Disorder Chronic Bronchitis and other Chronic

Pulmonary Diagnoses Coronary Arteriosclerosis PTSD Angina and Ischemic Heart Disease History of Myocardial Infarction Conduct, Impulse Control, and Other

Disruptive Behavior Disorders ADHD *Information gathered from several DSRIP/ PPS Community Needs Assessments

HCA Planning Matrix for Home Care System Programing Needs & Advocacy

Initiatives Underway Areas of Immediate HC Need Mid-Range Need/Merit

Must-Do Immediate

for Long Term Sustainability, Positioning &

Leadership Standardized Coding and Billing Implementation – HCA inputting via state implementation workgroup EPS fix Managed care/payment adequacy – multiple MD order regulatory fix – in process F2F fixes HCA Quality Tool - RFP drafted and going out HIT – partnership initiative with NYeC; NY Health Foundation grant request; HCA legislative and administrative HIT proposal package HCA Bills in Progress:

Payment adequacy & EPS fix (EPS awaiting Gov’s signature)

Regulatory Realignment

Insurance Modernization

AHHA

Quality Innovation

Telehealth Fix

Essential Personnel Bill – HCA legislation awaiting signature and implementation

Implementation/Maximization of Passed Legislation

HCA Hospital-Homecare-Physician Collaboration Program - implementation opportunities; related collaboration initiatives between HCA and other assoc (Iroquois, HANYS, MSSNY, HPA, HPCANY, Behavioral Health, Blue Cross, ACOP)

Special Areas/Home Care “Value”

Sepsis Initiative – Home care screening tool and protocol

Falls Prevention Initiative – collaborative partnership and grant offering to HCA

Palliative Care - implementation of HCA legislation, and related palliative care program support

Maternal and Child Health workgroup

Cardiovascular health initiative (HHQI/IPRO)

Disparities – HCA and MSSNY meeting with legislature next week to seek support for addressing disparities via leveraging of home care, physicians and other partners

HCA data/analytical capability HCA regional “meet-ups” and Boot Camps –technical assistance sessions for providers in critical areas of need Rural Health Summit/Roundtable – legislative and budget planning session with Senator Young and Legislative Commission on Rural Resources (HCA coordinating with Chair) Additional legislative/program areas

HCA Housing Legislation

HCA Veterans Home Care Pilot Bring Home the Vote HCA Website Consumer/Marketing Resource

Episodic Payment System fix – Stop DOH from implementing full rebasing cut; hold any cut to no more than budget agreement; secure Gov’s signature on HCA EPS Hannon/Gottfried bill; HCA working directly and with coalition; working with Gov’s new health secretary 9/22. Payor/Managed care issues – Payments must cover core costs of operation, service, mandates, labor. Problems with managed care must also be fixed. HCA pursuing payment adequacy legislation for MLTC and home care agencies. HCA working with Assemblyman Morelle on fix to MC problems, conducting/ gathering data from HCA MC survey; participating in MC uniform billing/coding implementation. Wage parity and QIVAP – HCA to intensify and garner wider support (including hospitals, managed care plans, consumers, workers) for adequately funding and distributing wage parity adjustments and QIVAP. HCA conducting direct and multi-association advocacy with DOH. DSRIP/PPS engagement – Support provider engagement through outreach, technical assistance, information/data; HCA advocating with Administration and Legislature for flow of funds and operation of DSRIP/PPS in manner inclusive/supportive of home care; HCA mapping out current DSRIP/PPS inclusion of home care and vice versa to further support strategies for assistance and advocacy. Infrastructure Investment – Advocate funds (direct to agencies and in managed care premiums/rates) for core agency operational and service needs, including HCA Payment Adequacy bill and HCA Technology Investment bill drafts currently with Senate and Assembly health chairs. Infrastructure/Workforce - Support for workforce and service capacity expansion to meet demand and new system seeds per DSRIP, VBP, Hospital Readmissions, etc. HCA working to support via: AHHA proposal, HCA “Collaboration” program implementation, HCA payment adequacy legislation, DOH advocacy on MLTC premiums and provider rates, EPS sustainability, and other. HIT/HIE Capacity – HCA undertaking multi-tier efforts (e.g., partnership, legislative, budgetary and education/technical assistance) to support provider HIT/HIE and capital for clinical technology. Opportunities/Threats to Home Care Space – Intensify both offense and defense. HCA and individual agencies must undertake proactive efforts to advance home care standing/positioning – local/market, state, federal. HCA working on provider “strategies” document to support agencies. HCA also working to modify current bills and/or ward off other actions/vulnerabilities that usurp article 36 or other home care space. HCA also looking to work with health plans, physicians, hospitals and others for proactive home care partnering and positioning. Rebasing/Federal Rule Mitigation – HCA working with NAHC,VNAA, state association partners and others to advocate responsible changes to Federal Medicare payment rules and Federal value based payment/bundled care models. F2F Fix – HCA working on federal fix and on state-level streamlining of F2F. (HCA F2F workgroup) MD orders Fix – HCA regulatory revisions have been drafted and are in process at DOH; advocate expeditious adoption; Hannon/Gottfried bill provides vehicle for timeliness, if needed. Business Line clarifications – Need to clarify and expand business line opportunities for home care agencies. HCA advocating opportunities via VBP, DSRIP, other. HCA has also passed the “Collaboration” program and working to secure funding and implementation. HCA will propose further legislative flexibility in 2016. HCA working with DOH on regulatory clarifications and flexibility to support business lines for home care agencies. LTHHCP Clarifications/Waiver Status – Urgently needed and requested by HCA members. HCA has scheduled meeting to address with DOH division leaders. HCA has conducted a statewide survey of LTHHCP sponsors to invite their input into the meeting issues and recommendations. VBP Preparation – Need for a workable state/managed care structure for home care’s participation. Need for expeditious, proactive work by agencies to position with health plans and key partners (esp hospitals and physicians) re home care value proposals, including bundles. Critical for agencies to proactively bring proposals to these tables. HCA advocating for home care on state’s VBP steering committees, and with Legislature. HCA continuing to provide education, intel and technical assistance to providers on VBP and VBP strategies. HCA to further ramp up provider assistance. AHHA – Develop solutions to legislative impasse as well as language to address implementation needs. HCA has met with Senate higher education staff and currently preparing language to hit goal. Connect with Elected Officials – Need to secure increased state/federal legislative recognition and direct support for home care. Home care agencies must ramp up activity to connect with their elected officials to inform/education them on home care agency and patient needs, and their value to their communities and local health systems. HCA has established a Legislative Action Center to facilitate broader input by providers on key issues. HCA developing “bring the vote home” initiative. HCA to conduct direct provider education/training to assist in comfort and success with legislative outreach. Executive Order 38, FSLA, and Other Labor Rulings – Need to turn back, mitigate or help agencies cope (in that order) with fiscal, resource and operational consequences of these rulings. HCA continues to 1) support litigation challenges to these rulings, 2) advocate funding and operational accommodation if rules are implemented, 3) provide extensive education and technical assistance to providers to assist implementation and compliance.

Quality tool adoption, data analysis, market use – Tool and RFP drafted; RFP ready to go. Quality metrics – Need for alignment with other parts of system; correction of state/federal misrepresentation via Home Health Compare, Star Rating, and other; HCA has initiated. HCA also pressing alignment need at VBP tables. Commercial Coverage/Insurance Modernization –Need to update, expand commercial coverage of home care to align with and further encourage home care role. Pursue passage of HCA home care insurance modernization bill sponsored by Seward/Cahill; reach out to insurers to try to bring aboard. Health Personnel/Workforce Development – Need to support health personnel evolution in skill sets, flexibility, scope, etc., compatible with changing system (state + federal) – HCA working on garnering legislative approval for approach to AHHA. HCA “Collaboration” program provides additional avenues for personnel development and use; HCA working to secure funding and implementation. DSRIP waiver authority and VBP are additional sources for personnel /workforce support. HCA will continue advocating its payment adequacy legislation which would support personnel/ workforce payment needs and investment. Compliance (state + federal) – Critical in the changing environment (managed care, DSRIP, VBP, ACO, FIDA); HCA working with DOH and OMIG on alignment of audit rules and procedures with the roles and responsibilities under these new systems; advocating similar change at federal level. Regulatory Alignment (state + federal) – essential in the changing environment. HCA legislation (Hannon/Gottfried) provides for home care/MLTC regulatory coordination, and waivers and emergency regulatory changes to support. HCA further working administratively with DOH on alignment and mitigation of excessive/conflictory requirements. HCA working federal changes to reconcile regulatory conflicts between COPs and other federal policies (bundles, managed care, DSRIP, etc) Mandate relief (state + federal) – Same as above Increased Efficiency – rising demand and pressure on agencies to become increasingly efficient, especially in environment of VBP, managed care, and continuous restraints in payment. HCA pursuing mandate relief, regulatory flexibility, technology, education/technical assistance and other supports for assisting providers with efficiency efforts. Audit relief – audits expensive, exploitive, drain to agency resources and wearying to staff. Relief critical! DOH asserting audit relief is an accompanying goal of VBP; HCA will work to advocate this within VBP as an express goal, and otherwise advocate with NAHC and other partners for federal audit relief. TPL – need to pursue both interim and permanent TPL fix. HCA will work with DOH and OMIG to see if relief can be accomplished via the system now operating for duals under MLTC, and will also continue to advocate relief at CMS Grant opportunities – HCA pursuing grant opportunities to support priority and progressive areas for agencies (examples of grant proposals in pipeline: HIT/HIE grant, falls prevention programing, HCA sepsis initiative, veterans home care program)

Collaboration, Network Affiliation, Partnerships – Collaboration essential with partners and models, esp hospitals, physicians/PCMHs, behavioral health, housing, managed care plans, etc. HCA working to support through association-to-association collaboration (HCA, MSSNY, HANYS, HPA, other), conferencing/education sessions, implementation of HCA “Collaboration” legislation, VBP/DSRIP venues, and other. Marketing/presentation – Imperative that home care be viewed with fuller understanding and desirability in all markets (consumer/general public, health plan, health systems, government, media). Broader and more integrated role of home care in primary medical management, functionality of the continuum, addressing public health priorities, promoting population health, and other advanced roles must be successfully conveyed at the provider and HCA levels. HCA has convened provider “boot camps” and other education sessions to support this goal, is conducting initiatives that greatly widen the view of home care (e.g., insurance modernization legislation, collaboration program, sepsis, veterans health, falls prevention, and other), created and circulated advocacy documents which broadly convey home care’s roles and capability, is working to expand the view of home care in multi-association and state policy venues (e.g., VBP, DSRIP), and supporting in other ways. HCA to plan and implement major marketing strategy to support home care recognition and positioning. Value Based Offerings – Critical that home care agencies expeditiously compile and bring to the market their portfolio on specific areas and ways they can contribute to VBP. The list below are such areas where home care is currently positioned to demonstrate excellence, and/or where agencies can look to program for the VBP marketplace. HCA will work to assist agencies through information, technical assistance, collaboration with state association partners, education/conferencing, legislation and policy initiatives.

Prenatal/Perinatal care

Primary Care

Population Health – immunizations, health education, self-management

Behavioral health

Other medical management

Cardiovascular Health

Clinical pathways

Joint Replacement

Telehealth

Wound care

CHF

COPD

Diabetes

Mental Health

Care Transitions

ER Intervention

Repaid Response

Specialty Aide Training/technology` to Avert Rehospitalization

Palliative Care

Sepsis

Falls

Disparities Technology investment and development - same as stated Payment adequacy - same as stated Restructuring or flexibility in home care model – HCA to explore with a workgroup of the board recommendations whether and how restructuring of the home care model in New York State should be fashioned to best function in the evolving health care system and marketplace. Innovation, new business lines, cultivate new roles - same as stated Research/Data demonstration – Empirical demonstration of effectiveness, efficiency and value are imperative in the evolving system. Providers must take major, proactive steps to compile and utilize data for their own clinical and operational excellence, as well as for their market positioning and value. HCA’s initiatives to support providers in this activity and goal include: the HCA Quality Tool, HCA’s various HIT/HIE initiatives, HCA’s established data base and resources provided to the membership via HCA web, HCA access to the Salient database and other. HCA will continue to work with governmental and other collaborating sources to make data available to providers, to directly conduct research on accessible data in support of performance and needs, and to apply for research grant opportunities to further the same.

1

HCA Draft Legislative Proposal

Collaborative Models of Community Paramedicine

(for purposes of discussion-only with HCA Board 12-3-2015)

An Act to amend the public health law in relation to authorizing 1

collaborative programs for community paramedicine services 2

Section 1. Section 2805-x of the public health law as added by 3

Chapter 57 of the laws of 2015 is amended to read as follows: 4

§ 2805-x. Hospital-home care-physician collaboration program. 1. The 5

purpose of this section shall be to facilitate innovation in hospital, home 6

care agency and physician collaboration in meeting the community's health 7

care needs. It shall provide a framework to support voluntary initiatives 8

in collaboration to improve patient care access and management, 9

patient health outcomes, cost-effectiveness in the use of health care 10

services and community population health. Such collaborative initiatives may 11

also include payors, skilled nursing facilities and other interdisciplinary 12

providers, practitioners and service entities. 13

2. For purposes of this section: 14

(a) "Hospital" shall include a general hospital as defined in this 15

article or other inpatient facility for rehabilitation or specialty care 16

within the definition of hospital in this article. 17

(b) "Home care agency" shall mean a certified home health agency, long 18

term home health care program or licensed home care services agency as 19

defined in article thirty-six of this chapter. 20

(c) "Payor" shall mean a health plan approved pursuant to article forty-21

four of this chapter, or article thirty-two or forty-three of the insurance 22

law. 23

2

(d) "Practitioner" shall mean any of the health, mental health or 1

health related professions licensed pursuant to title eight of the 2

education law. 3

(e) “Emergency Medical Services” (EMS) shall mean the services of an 4

entity certified under article thirty of this chapter to provide advance life 5

support first response or ambulance services. 6

3. The commissioner is authorized to provide financing including, but not 7

limited to, grants or positive adjustments in medical assistance rates or 8

premium payments, to the extent of funds available and allocated or 9

appropriated therefor, including funds provided to the state through 10

federal waivers, funds made available through state appropriations 11

and/or funding through section twenty-eight hundred seven-v of this 12

article, as well as waivers of regulations under title ten of the New 13

York codes, rules and regulations, to support the voluntary initiatives 14

and objectives of this section. 15

4. Hospital-home care-physician collaborative initiatives under this 16

section may include, but shall not be limited to: 17

(a) Hospital-home care-physician integration initiatives, including but 18

not limited to: 19

(i) transitions in care initiatives to help effectively transition 20

patients to post-acute care at home, coordinate follow-up care and address 21

issues critical to care plan success and readmission avoidance; 22

(ii) clinical pathways for specified conditions, guiding patients' 23

progress and outcome goals, as well as effective health services use; 24

(iii) application of telehealth/telemedicine services in monitoring and 25

managing patient conditions, and promoting self-care/management, improved 26

outcomes and effective services use; 27

3

(iv) facilitation of physician house calls to homebound patients 1

and/or to patients for whom such home visits are determined necessary and 2

effective for patient care management; 3

(v) additional models for prevention of avoidable hospital readmissions 4

and emergency room visits; 5

(vi) health home development; 6

(vii) development and demonstration of new models of integrated or 7

collaborative care and care management not otherwise achievable through 8

existing models; [and] 9

(viii) bundled payment demonstrations for hospital-to-post-acute-care 10

for specified conditions or categories of conditions, in particular, 11

conditions predisposed to high prevalence of readmission, including 12

those currently subject to federal/state penalty, and other discharges 13

with extensive post-acute needs; 14

(ix) models of community paramedicine, under which hospitals, 15

EMS-employed certified emergency medical services technicians, physicians and 16

home care agencies may develop and implement a plan for the collaborative 17

provision of services in community-settings. In addition to emergency 18

services provided under article thirty of this chapter, models of community 19

paramedicine may include collaborative services to at-risk individuals living 20

in the community to prevent emergencies, avoidable emergency room need, and 21

avoidable transport; community paramedicine services to individuals with 22

behavioral health conditions, or developmental or intellectual disabilities, 23

shall include the collaboration of appropriate providers licensed or 24

certified under the mental hygiene law; 25

(b) Recruitment, training and retention of hospital/home care direct care 26

staff and physicians, in geographic or clinical areas of demonstrated need. 27

Such initiatives may include, but are not limited to, the following 28

activities: 29

4

(i) outreach and public education about the need and value of service in 1

health occupations; 2

(ii) training/continuing education and regulatory facilitation for cross-3

training to maximize flexibility in the utilization of staff, including: 4

(A) training of hospital nurses in home care; 5

(B) dual certified nurse aide/home health aide certification; [and] 6

(C) dual personal care aide/HHA certification; and 7

(D) orientation and/or collaborative training of EMS, hospital, home 8

care, physician and, as necessary, other participating provider staff in 9

community paramedicine; 10

(iii) salary/benefit enhancement; 11

(iv) career ladder development; and 12

(v) other incentives to practice in shortage areas; and 13

(c) Hospital - home care - physician collaboratives for the care and 14

management of special needs, high-risk and high-cost patients, including but 15

not limited to best practices, and training and education of direct care 16

practitioners and service employees. 17

5. Hospitals and home care agencies which are provided financing or 18

waivers pursuant to this section shall report to the commissioner on the 19

patient, service and cost experiences pursuant to this section, including the 20

extent to which the project goals are achieved. The commissioner shall 21

compile and make such reports available on the department's website. 22