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DSRIP Meeting Agenda
PAGE 1
Date & Time 11/17/17 @ 9:00 – 10:00AM Meeting Title IT – Clinical Operations Committee
Location NYP Milstein 1HN-144
Facilitator Alvin Lin & Elaine Fleck
WebEx https://nyp.webex.com/nyp/j.php?MTID=m0080f465e5176394053d95ece446f2ae
Conference Line Dial: 415-655-0001 Access Code: 855 960 356
Invitees
Chair: Elaine Fleck (NYP) Chair: Alvin Lin (NYC DOHMH PCIP/REACH)
Gil Kuperman (NYP) Terri Udolf (St. Christopher’s Inn)
Alissa Wassung (God’s Love We Deliver) Sandy Merlino (VNSNY)
Susan Wiviott (The Bridge) Amy Shah (NYC DOHMH)
David Chan (City Drug & Surgical) Maria Lizardo (Northern Manhattan Improvement Corp.)
Jean Marie Bradford, MD (NYPSI) Catherine Thurston (SPOP)
Genevieve Castillo (Methodist) Stuart Myer (VillageCare)
Dan Johansson (ACMH, Inc.) Renato Leonel (Isabella)
Julissa Nunez (IT – VNSNY) Mitze Amoroso (ArchCare)
Theo Figurasin (NYSNA) Todd Rogow (Healthix)
Steven Lam (CBWCHC) Priscilla Pena (1199 SEIU)
Andres Pereira, MD Patricia Hernandez (NYP)
Nelson Mesa (NYP) Andrew Missel (NYP)
Linda Reid (Workforce – VNSNY) Rachel Naiukow (NYP)
Dodi Meyer (NYP) Sarah McNabb (NYP)
Meeting Objectives Facilitator Time Start End
Welcome & Roll Call Alvin Lin 10 min 9:00 9:10
Presentation by God’s Love We Deliver
Treating Nutritional Needs of Medically Complex Patients
Challenges with Getting Data for CBOs
Alissa Wassung 15 min
(+10 min Discussion)
9:10 9:35
Screening for Social Determinants of Health
Program Overview
Planned Process for Managing Referrals Using NowPow
Opportunities for CBOs to Serve on AHC Workgroups
Dodi Meyer 10 min
(+10 min Discussion)
9:35 9:55
Next Steps
Governance Committee Transition Process Andrew Missel 5 min 9:55 10:00
Action Items
Description Owner Start Date Due Date Status
DSRIP Meeting Agenda
PAGE 2
Food Is MedicinePresentation to NYP PPS
Alissa Wassung, Director of Policy & Planning
God’s Love We Deliver
Outline
• Mission in Action
• Medically Tailored Meals (MTM)
• Research
• MTM in Medicaid
• Data Issues
• DSRIP – The Laboratory for VBP
NYP Participation
• Member since the beginning
• Clinical Operations/IT Committee
• MAX Series Member
• Planning Committee
• ED Quality Improvement Retreat
• CMMI/AHC Advisory Group
Mission in Action
• 1.7 million individually-tailored
meals delivered this year
• 7,000 people and 200+
diagnoses
• All 5 boroughs, plus Westchester
County, Nassau County, and
Hudson County, NJ
• 7,000 meals prepared and
delivered each weekday
• Unique focus on severe and
chronic illness
• Meals individually-tailored for
specific medical circumstances
• 7 RDNs with Chefs
• Support trajectory of illness
– Soft, minced, and pureed
• Flexible service plans and
delivery
• No preservatives, starters or fillers
Medically Tailored Meals (MTM)
Meal
Modifications
Low Sodium
Renal (Kidney Disease)
Low Sugar
VegetarianAnd More!
Acid/Bland
Fiber/Gas
Alzheimer's/Neurological
9%
Cancer17%
Cardiovascular16%
Diabetes5%
HIV/AIDS17%
Kidney12%
MS/Musculoskeletal
8%
Other diseases11%
Pulmonary 5%
Secondary Diagnosis
15% behavioral health
35% diabetes
26% obesity
DIAGNOSIS
Target Populations for MTMTOO SICK TO SHOP OR COOK FOR THEMSELVES
• Medically at-risk
• In danger of being institutionalized (in hospitals, nursing homes or long term care
facilities)
• Significantly limited in their activities of daily living that affect shopping and cooking
(standing, carrying, lifting, etc.)
• Dealing with serious behavioral health issues that impede their ability to take care
of their nutritional needs
• In the progressive stages of dementia that require dietary modifications (pureed or
minced)
• On the cusp of developing to severe diabetes, or those who need temporary
support to recover from a relapse of diabetes-related complications
• Being discharged from the hospital after an acute episode with no supports in home
High Risk, High Need, High Cost
Healthcare Spending
Food is Medicine
While adequate food and nutrition is
important for all people, proper
nutrition is critical for the
management of chronic illness.
The Problem The Solution
Food Insecurity Leads to:
• Poor medication adherence
• Reduced control of chronic conditions
• Poor engagement in medical care
• ER/inpatient/institutional use
Malnutrition Results in:
• 50% more likely to be readmitted
• More than 2 million hospital stays annually (nationally)
For People with Serious Illness
Medically Tailored Meals =
• 28% drop in healthcare costs
• 50% fewer hospital admissions
• 23% more likely to be discharged to home and not an institution
For People with HIV = More Likely to:• Adhere to medication• Achieve viral suppression• Have better health functioning
Research Summary
Citations and studies available
NO DEDICATED FEDERAL BENEFIT
for medically tailored food for critically ill people
State by state by state etc.
INNOVATION
RESULT
NYS Reimbursement: Medicaid
Fully Reimbursable:
• Medicaid Managed Long Term Care (MLTC)
• Fully Integrated Duals Advantage Plans (FIDA) –Medicaid/Medicare
Reimbursable through DSRIP Direct Contract:
• Mainstream Medicaid Managed Care (MMC)
3,0819,397
24,76751,780
57,871
66,80194,131
121,767
150,901
201,506
231,359
263,121
312,543
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017
Me
als
pe
r FY
MLTC Community Partner Program Growth FY2005-FY2017
Our Process
Identify
• NYSDOH Balancing Incentives Program (MLTC) – We used
the UAS to develop an MTM Referral Tool
• NYP MAX Series (Mainstream Medicaid) – As a member of
the MAX Series team, I co-developed an HU SDOH screen
• NYP CMMI/AHC Project – CMS has developed a 10 question
screen
• National Malnutrition Blueprint – God’s Love was co-author
with AARP, NANASP and others. Recommends the:
– Malnutrition Screening Tool
– The Mini Nutritional Assessment
Authorize
We work to provide:• Flexibility with delivery days and requested service adjustments
• Customized menu based on diagnosis, medication interaction and dietary
needs
• Streamlined authorization process
• Responsive customer service care for all clients
We:• Are fully HIPAA compliant
• Utilize HCFA 1500 billing forms (to bill per meal per service day) that are
sent electronically to each provider
Nourish
We provide meals by addressing a combination of restrictions,
resulting in almost infinite meal variety for members.
• All meals are low in sodium and balanced for other nutrients.
Meal restrictions include:
• Pork, Beef, Fish, Vegetarian
• Sugar, Fat, Dairy
• Renal, Minced, Pureed
• Acid/Bland and Fiber/Gas
• More…
Outcomes Data?
Data and Closed Loop Referrals
Data NeedsBarriers to Providing Quality CBO Interventions in DSRIP
• Medical field lacks a comprehensive assessment of SDOH
• If there is an assessment, and it is positive, staff are unsure where to refer
• If staff understand where to refer, referrals contain incomplete data, or may be inappropriate
• Staff turnover
• Lack of payment for additional services
Barriers to CBOs Being Effective Partners in DSRIP
• Outcomes data medical field hopes to track is not available to CBOs
So: CBOs are being asked to prove the efficacy of services in particular populations without access to outcomes data.
Positive Screen for Malnutrition
In-Depth Intake and Diet Prescription***Client is MLTC
Contact Case Manager
MLTC
If Yes = Reimbursed ServicesAuthorization
Identify
Authorize
Nourish
1. MLTC2. MMC
2 Referral
Pathways
In-Depth Intake and Diet Prescription***Client MMC
MCO
Medical Outcomes and Utilization
• Clinical nutrition data• Medication reconciliation• Contextual data on life of
the client that ensures success of treatment
• Client surveysHealthcare Cost and Utilization Data
Data
Pathways
Rx
Healthcare Cost
Billing/Encounters
Outcomes Data
Outcomes Data
?
The Solution
• DSRIP is a laboratory to test new models that drive down the cost of care
• Opportunity for reimbursed pilot projects to evaluate community based interventions on medical outcomes and utilization
• Pilots should be predicated on existing SDOH impact data; but also acknowledge the field is being built as we go
• Opportunity to work in collaboration on new data structures –as data pathways do not yet robustly exist
• Remember: VBP requires:– One Tier One CBO
– One SDOH project
Q and A
God’s Love We Deliver Contacts
Alethea Hannemann
Chief Operating Officer
212-294-8136
Dorella Walters
Senior Director of External Program Affairs
[email protected]; 212-294-8123
Lisa Zullig
Director of Nutrition Services
[email protected]; 212.294.8157
Danielle Christensen
Policy & Grants Coordinator
[email protected]; 212-294-8185
Alissa Wassung
Director of Policy & Planning
212-294-8171
Karen Pearl
President & CEO
212.294.8194
God’s Love We Deliver
166 Avenue of the Americas
New York, NY 10013
glwd.org
Accountable Health Communities GrantCenter for Medicare and Medicaid Innovation
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Health Related Social Needs
• Housing
o Quality
o Stability
• Food insecurity
• Utility Needs
• Transportation Needs
• Interpersonal Violence
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Target Population
• 51% community-dwelling Medicaid and/or
Medicare beneficiaries
• Must live in zip codes 10031, 10032, 10032,
10034, 10040
• Goal is to screen 75,000 community-dwelling
beneficiaries per year
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Screening Algorithm
Risk Stratification
Low-Risk: Stable• Low-Risk AHC (+ need, no ED visits)• Negative screens
High Risk (5%)• High
Utilizers• Unstable
Medium Risk: Stable• High-Risk AHC (+ need plus 2
ED visits)• Positive screens w/
Depression, DV, already engaged
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Utilization of Screeners Impact the Rate of Identified Resource Needs: Work to Date
• Selected IT platform for screening and referral: NowPow
• Building IT infrastructure for interface with EMR, screening and referral
• Identifying downstream screening referral sites
• Identified social needs of patients served by NYP at pilot sites
• Goal
Align model partners to optimize community
capacity to address health related social needs
• Objectives
• Identify resource gaps and develop strategies
to address them
• Align with existent community wide initiatives
• Explore Collective Impact Model
24%
40%
15%
7%
2% 9%
0%1% 1% 1%
Months 14 & 15 (Aug & Sept) -Families' Most Common Resource
Needs (n=215 needs)
Physical Activity
Early Literacy
Early Education
Food Insecurity
Other
Nutrition
Adult Literacy
Early Intervention
Housing
Legal Aid
17%
10%
18%31%
5%
14%
1%1% 2% 1%
Month 16 (October) - Families Most Common Resource Needs (n=211
needs)
Physical Activity
Early Literacy
Early Education
Food Insecurity
Other
Nutrition
Adult Literacy
Early Intervention
Housing
Legal Aid
• Completed pilot which involved universal screening for social needs, waiting room
education and referral to one CBO
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Work to Date
• Selected IT platform for screening and referral: NowPow
• Building NYP IT infrastructure for interface with EMR, screening and referral
• Identifying downstream screening referral sites
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Community Collaborator Alignment
• Selected IT platform for screening and referral: NowPow
• Building IT infrastructure for interface with EMR, screening and referral
• Identifying downstream screening referral sites
• Identified social needs of patients served by NYP at pilot sites
• Goal
Align model partners to optimize community
capacity to address health related social needs
• Objectives
• Identify resource gaps and develop strategies
to address them
• Align with existent community wide initiatives
• Explore Collective Impact Model
Housing
– Quality
– Stability
Food insecurity
Utility Needs
Transportation Needs
Interpersonal Violence
Example: Food Insecurity
Outcome Measures:Increase screening for food insecurity NYP Primary Care and Emergency Room sites
Ensure that those who screen positive are referred to appropriate entitlement programs (SNAP/WIC) and emergency food resources
Primary Driver/System Change:
Work with Citywide Food Coalition to enhance # of emergency resources in Northern Manhattan and the South Bronx
Work with CBO’s to address capacity issues secondary to increase number of referrals
Implement training for faculty and trainees in sites where screening will take place: ED,OBGYN, internal medicine and pediatrics by 3rd quarter 2018
GLOBAL AIM: Ensure that every community member has adequate, healthy sources of food
Questions?