Central New York Care CollaborativeTown Hall Meeting

Oswego CountyWednesday October 2, 2019

Agenda

• Welcome & Introductions 

• Phase Four (IV) Funds Flow Update 

• Update on the CNYCares PHM System

• Unite Us SDOH Platform Updates

• DSRIP Waiver Renewal Application • Best Practice Discussion 

• Network Updates

• Questions

Phase Four (IV) Funds Flow

Phase IV Funds Flow Framework

4

Total Eligible DSRIP Funds

Baseline Budget

Phase IV Partner Share of Funds (80%) ‐ $60.4M

VBP

PAs

Total Eligible DSRIP Dollars

Establish Baseline Budget

Partner Share of Funds

Allocate funds for VBP Pool

Allocate funds for Performance Activities (PAs)

Allocate funds for Innovation & Revenue Loss Rev. LossDetermine distribution methodology to eligible Partner Organizations

Innovation/                             IDS Improvement 

Phase IV Funds Flow – Approved PAs

5

PA # PA Language Complete By: Report By:

PA_01 Demonstrate timely and successful completion of SSL Certification by the organization and DRA Certification, if applicable.  12/31/2019 12/31/2019

PA_02 Attend Annual Compliance Webinar. Selected attendee must be a DSRIP Coordinator, Compliance Officer, or person whose job duties play this role within the organization.

12/31/2019 12/31/2019

PA_03_A Attend and participate in at least 80% of partner‐focused meetings in Quarter 1 and disseminate information and materials to DSRIP related staff within the organization. Such meetings include, but are not limited to Town Halls, LCs, Coalitions, webinars, VBP meetings, & the Annual Meeting. 

9/30/2019 12/31/2019

PA_03_B Attend and participate in at least 80% of partner‐focused meetings in Quarter 2 and disseminate information and materials to DSRIP related staff within the organization. Such meetings include, but are not limited to Town Halls, LCs, Coalitions, webinars, VBP meetings & the Annual Meeting. 

12/31/2019 12/31/2019

PA_03_C Attend and participate in at least 80% of partner‐focused meetings in Quarter 3 and disseminate information and materials to DSRIP related staff within the organization. Such meetings include, but are not limited to Town Halls, LCs, Coalitions, webinars, VBP meetings & the Annual Meeting. 

3/31/2020 3/31/2020

PA_03_D Attend and participate in at least 80% of partner‐focused meetings in Quarter 4 and disseminate information and materials to DSRIP related staff within the organization. Such meetings include, but are not limited to Town Halls, LCs, Coalitions, webinars, VBP meetings & the Annual Meeting. 

6/30/2020 6/30/2020

PA_04_A Report the total number of staff hired, redeployed or retrained to complete DSRIP related activities from April 1, 2019 to September 30, 2019. 9/30/2019 9/30/2019

PA_04_B Report the total number of staff hired, redeployed or retrained to complete DSRIP related activities from October 1, 2019 to March 31, 2020.   3/31/2020 3/31/2020

PA_05_A Report the total workforce strategy spending for DSRIP related activities from April 1, 2019 to September 30, 2019. 9/30/2019 9/30/2019

PA_05_B Report the total workforce strategy spending for DSRIP related activities from October 1, 2019 to March 31, 2020. 3/31/2020 3/31/2020

PA_06 Complete the DY5 Compensation and Benefits Survey.   12/31/2019 12/31/2019

Phase Four (IV) Performance Activity Reporting Page

$60.4M for Phase IV Baseline Budget approved by the CNYCC Board of Directors$5.7M for PA_401 - 412, 415

Six Required PAs (assigned to all partners) 

PA_401, PA_402, PA_403_A‐D, PA_404_A‐B, PA_405_A‐B, PA_406

One DSRIP Project Program Evaluation PA (assigned to partners with past AEP)

PA_407_2aiii‐3gi

Four IBM Watson implementation & adoption PAs (assigned to specific cohorts)

PA_410, PA_411, PA_412, & PA_415

Two Patient Centered Car Recognition PAs (assigned to partners via service types)

PA_408 (NYS PCMH) & PA_409 (Patient Centered Specialty Care Recognition) 

$1.5M - $2.3M for PA_413 & PA_414 $18M for Innovation/Integrated Delivery System (IDS) Improvement FundPhase IV Advance Payment to partners - $50K for VBP implementation per partner

CNYCC’s Priority: Distribute Funds to Partners

7

Phase IV PA 80% Threshold

CNYCC recommended that the Phase IV PA Threshold be set at 80% of the Universal PAs (assigned to all partners)

PA_401

PA_402

PA_403_A‐D

PA_404_A‐B

PA_405_A‐B

PA_406

PA_413

12 PAs x 80% = minimum of 10 PAs to meet the Phase IV thresholdPhase IV PA threshold governs eligibility for portion of Measurement Year 5 outcomes payments (Phase 3 Appendix 3)

8

Update: CNYCares PHM System

CNYCC and IBM --- Joint Announcement Regarding CNYCaresPopulation Health Management System CNYCC and IBM are committed to providing the highest value to CNYCC partners without further delays. To this end, we have jointly reviewed the IBM solutions being offered to CNYCC partners.

IBM Enterprise Performance Management (EPM) is a best‐in‐class healthcare data consolidation, measurement, and analytics system.  EPM is live in several CNYCC partner enterprises and used to track critical metrics to drive reimbursement and quality.

IBM Phytel Outreach is a best‐in‐class patient engagement solution which directly communicates with patients to close relevant gaps in care. In fact, Phytel significantly helps improve engagement of hibernating patients. Client after client have fast and real ROI from this investment for Care Management.

IBM Watson Care Management (WCM) is not designed for the use case required for provider networks such as CNYCC.  Consequently, WCM workflows do not match consent standards of CNYCC, NYS and the DSRIP program.  

Therefore, after careful review of CNYCC's partner use cases and timelines, both CNYCC and IBM have removed Watson Care Management to re‐direct focus on IBM's EPM and Phytel offerings with highest speed‐to‐value for care management, gap closure, and population health.

Message from the Executive Director

Population Health Analytics as a Service Technology

Supermart:  IBM’s database of all integrated and Medicaid data that CNYCares can use to generate reports and analytics on behalf of network partners

Nascate:  A product CNYCares is piloting to offer AI (Artificial Intelligence) for insight into CNYCC’s patient population (all payors)

Population Health Technology 

IBM Enterprise Performance Manager:  Performance Manager, also known as “EPM” is CNYCares hub for DSRIP and VPB measures and metrics as well as patient registries. This product is used to track performance at your organization and to identify care gaps and opportunities for patients in need.

IBM Phytel Outreach:  (Formerly Engagement Manger), Phytel Outreach is a patient engagement tool that leverages Practice Management data to perform patient outreach based on protocols selected by partner organizations.

Unite Us:  CNYCC’s vendor of choice for a Social Determinants of Health Referral Platform that will help partners across our network better communicate with one another to achieve higher quality outcomes for patients and clients in need.

Unite Us SDOH Platform

Community Need and Project Formation• Stated need for a social referral program that brings community partners together.

• CNYCares is in a unique position to leverage DSRIP funds to provide access to a community utility that can be made available to organizations across the PPS.

• Intention of project is to provide infrastructure that enables grass roots collaboration on Social and Behavioral Determinants of Health between Community Based, Human Service, Mental and Behavioral Health, Substance Use and Clinical Organizations.

• In order to successfully impact the healthcare delivery system in a manner consistent with the goals of the DSRIP program Community Based Organization need an effective way to collaborate, participate, communicate and refer across the healthcare continuum.

• Using the Unite Us platform CNYCares intends to provide a tool and act as a convener of organizations to facilitate projects and reduce barriers of collaboration for organizations and entities that can’t provide this infrastructure, at scale, individually.

Project Overview

Network and Community Impact

Improve patient/client outcomes by addressing social and behavioral needs.

Track and report on efficacy of grants and other funded community programs.

Streamline communication and workflows across organizations and care settings.

Measure impact of Value Based Contracts, including value proposition for CBO participation.

Unite Us Demo Resources

DEMO Recording: https://vimeo.com/359637511/23d1f7fb27

Webinar: https://register.gotowebinar.com/recording/9148970685687358467

CNYCC Distributed Letters of Interest on 09/19/2019

Letters Inform:• Use Cases for Platform• Initial Network Configuration• Project and Engagements Strategy• Funds flow eligibility* 

To‐Date Over 50 Partner Organizations Have Submitted Letter of Interest 

Due: 11/15/2019

Letters of Interest

Planned PhasesBuild a community infrastructure using PPS incentives to build out PPS wide referral network

Allow partners to individually identify their own referral networks and pilot programs

Work with partners to strengthen workflows and partnership by acting as a facilitator and convener.

Grow network to allow for long term sustainability of infrastructure/network

Phase 1:Network Development and Roll Out

Phase 2: Use Case Development and Facilitation

Phase 3: Network growth, Optimization and Integration

Project Approach

Implementation Planning

Next Steps and Timeline

2019 2019Week 1 3 5 7 9 11 13 15 17 19 21 23

Send out RFP6/3/2019

Review RFP Questions6/12/2019

RFP Due6/21/2019

Finalist Demo7/15/2019

Present Vendor of Choice at ITDG7/17/2019

Present Vendor of Choice at Board7/25/2019

August ITDG8/14/2019

August Board8/22/2019

September PHM Steering9/9/2019

September Board9/26/2019

Estimated Project Kick Off11/4/2019

October PHM Steering10/7/2019

October ITDG10/9/2019

October Board10/24/2019

6/3/2019 ‐ 6/14/2019Feedback Demo Sheet

5/30/2019 ‐ 6/21/2019RFP Window

6/21/2019 ‐ 7/1/2019Initial Eval. of Vendors

6/21/2019 ‐ 6/28/2019Request Demo

7/8/2019 ‐ 7/17/2019Compile Finalist Findings

8/1/2019 ‐ 8/14/2019Document Current Use Cases and Areas for Collaboration

7/26/2019 ‐ 8/20/2019Develop Draft Project Charter 

8/14/2019 ‐ 9/6/2019Develop Baseline Budget 

8/5/2019 ‐ 10/16/2019Contracting with Unite Us

9/1/2019 ‐ 11/1/2019Project Planning, Socialization and Use Case Documentation

9/17/2019 ‐ 9/26/2019Partner Engagment & Request for Letters of Interest

8/1/2019 ‐ 9/26/2019Performance Activity Development

DSRIP Waiver Renewal Application

Four‐year Waiver Extension/Renewal (April 1, 2020 through March 31, 2024)• Continuation of DSRIP for the 1‐year balance of the current 1115 waiver ending March 31, 2021 

• Conceptual agreement to an additional 3‐years from April 2021 to March 21, 2024

Support the cost savings and quality improvements by aligning with federal goals and through the DSRIP Promising Practices. 

$8 billion is being requested over this period to be invested as follows:• $5 billion DSRIP performance; • $1billion Workforce Development; • $1.5 billion Social Determinants of Health and;• $500 million Interim Access Assurance Fund. 

DSRIP Waiver Renewal Application 23

Renewal Application Overview

First Public Notice ‐ Week of September 16, 2019Draft Waiver Proposal to CMS ‐ September 30, 2019MRT Public Comment Day ‐ October 25, 2019 – Baruch College (NYC)Upstate MRT Public Comment Day – October 30, 2019 – OnCenter (Carrier Theater)Official Waiver Proposal to CMS ‐ November 27, 2019CMS response – April 1, 2020

All PPS Meeting - DOH Proposal Timeline

New York’s Current DSRIP OUTCOMESPotentially preventable admissions reduced by 21%Potentially preventable readmissions reduced by 17%Combined reductions reduced PMPY cost by 14% (savings of more than $500 million)

DSRIP Waiver Renewal Application

Based on the primary goals of the DSRIP program (25% reduction statewide in PPRs & PPVs by end of MY5), CNYCC consistently performs well in support of the State when compared to other PPSs

• 21% reduction in PPRs from MY0 and MY4 (11th out of 25 PPSs)• 13% reduction in PPVs from MY0 and MY4 (6th out of 25 PPSs)• 23% reduction in PPVs from BH between MY0 and MY4 (2nd out of 25 PPSs) 

CNYCC Performance Outcomes

Measure Improvement MY0 to MY4

Overall rank (25 PPSs)

Rank among6 mid-sized* PPSs

Rank among 7 PPSs w/ similar structures**

Rank among6 neighbor PPSs***

Potentially Preventable Readmissions (PPRs) 21% 11th 4th 1st 3rd

Potentially Preventable ED Visits (PPVs) 13% 6th 2nd 2nd 2nd

Potentially Preventable ED Visits with BH (PPV-BH) 23% 2nd 2nd 1st 1st

CNYCC Key Measure Improvement Performance Comparison

*Mid-Size = 100,000-200,000 attributed Medicaid members**Multiple Unaffiliated Hospital Lead Entity

***Adirondack Health Institute (AHI), Care Compass Network (CCN), North Country Initiative (NCI), Finger Lakes PPS (FLPPS),

Leatherstocking Collaborative Health Partners (LCHP), & CNYCC

3

The State is responding to the request for additional flexibility in the operational structure of the next DSRIP funded entity by proposing new “Value Driving Entities” 

The single overarching goal of the VDE will be to drive the DSRIP promising practices and the additional high‐need projects to the point where they are fully supported by VBP contracts by the close of the third year of the DSRIP extension. 

Consist of PPS (or a subset of PPS), provider, CBO and MCO teams specifically approved by the state to implement the high‐priority DSRIP promising practices. 

• selected based on the history of performance improvement, strength of provider, MCO and community‐based organization partnerships

• inclusive governance structure that includes a range of providers, MCOs and CBOs in executive steerage   • Potential to sustain the overarching goal

27DSRIP Waiver Renewal Application

“Value-Driving Entities” (VDE)

Continue to be assigned specific regions/markets and attributed populations but will have the flexibility to either modify the existing PPS structure to accommodate additional representation from the different sectors (CBO, MCO) or instead propose new teams from a subset of provider/CBO/MCO/QE groups. 

• Required to bring MCOs in the region into the management and operational structure to replicate and scale (and make ready for VBP contracting) 

• Qualified Entities would also be integrated into the collaborative partnerships to be strategic partners in sustaining and enhancing the partners’ bidirectional data exchange capabilities.

• Build upon existing value‐based payment networks including Integrated Delivery Systems, ACOs, IPAs, and NYS Behavioral Health Care Collaboratives (BHCCs) 

“Value-Driving Entities” (VDE)

28

DSRIP Promising Practices

29

Initiatives that demonstrate transformative regional and community collaborations among a diverse set of health system and social service providers that have impacted quality and clinical outcomes and earned PPS the performance‐based DSRIP incentive payments. 

These efforts have been labor‐intensive, requiring the formation of new relationships to better serve consumers and iterative testing as to which innovations yield the best results at the local level. 

DSRIP Promising Practices  CNYCC Promising Practices

Expanding Technology & Using Data Analytics  CNYCares PHM System; Unite Us SDOH; Performance Improvement Support

Transforming Primary Care Lewis County General Hospital; ConnextCare; Community Memorial Hospital; PCMHProgram; Practice Improvement Consulting 

Connecting Clinical & Community Resources Lewis County Coalition; NRCIL; Catholic Charities; CIT Training Program; Innovation Fund Projects

Peer Support: Using Peer Coaches to Support Recovery for SUD Berkana Respite Home (Access CNY); Liberty Resources  

Population Targeting: Managing Care Transitions for At‐Risk Patients  NRCIL; Care Transition Coalitions; MAX Series Pilot Projects

Crisis Stabilization: Preventing Unnecessary Behavioral Health Hospitalizations

Liberty Resources; Neighborhood Center; Access CNY

Integration: Merging Primary Care and Behavioral Health through Investments in Provider Capacity and Co‐Location

MVHS; Planned Parenthood of MHV; Christian Health; Liberty Resources; Upstate Cerebral Palsy

Community Partnerships: Leveraging Local Resources to Promote Heart Health

ConnextCare; Upstate University Hospital; 

Integration: Embedding Nutrition Assistance WithinHealth Care Settings

Nutrition Sub‐Committee; ARISE Innovation Fund 

Population Targeting: Using Community Partnerships to Engage Low Utilizers in Care

Oneida Healthcare

Workforce: Using Community Health Workers to Connect Patients to Health and Social Services

REACH CNY; CHW RFP 

Regional Care Management: Tracking High Utilizers Across Multiple Settings to Bridge Gaps in Coordination

Oneida Healthcare; CNYCC MAX Series; Upstate ITT Group 

31

Network Updates

Annual Meeting

Register Today Keynote Speaker

Bonnie St. John

1115 MRT Waiver Upstate Public Forum Information- Syracuse NY

Public Comment

The New York State Department of Health (the Department) is pleased to announce the date for the upstate public comment day for New York’s 1115 waiver programs.  

The upstate public comment day will be held on October 30, 2019 at The Oncenter’sCarrier Theater, 421 Montgomery Street, Syracuse, NY 13202. 

MRT Public Comment will commence from 11am‐2pm. Any written public comment may be submitted to 1115waivers@health.ny.gov through November 4, 2019. Please include “1115 Public Forum Comment” in the subject line.

11:00am- 2:00pm MRT Public Comment2:00pm - 2:10pm Wrap-Up

The tentative agenda for the day is as follows:

QUESTIONS????