DSRIP Call Center: 1-844-674-7463
Upcoming Events:
Please visit
http://mountsinaipps.org/calendar/
for the most updated information and contact the project managers to participate. The below includes only a few of our events.
5/11 - Finance Committee Meeting
5/17 - IT Committee Meeting
5/25 - Clinical Quality Committee Meeting
5/26 - Town Hall - Save the Date! Contracting, project updates and more!
5/26 - Workforce Committee Meeting
Resources: Have you checked out our external resources page (with RFPs info and more)? Click here
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Issue #064 | Monday, May 02, 2016
Click on these links to jump to their sections (Best on desktop)
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Recently, the Clinical Quality Committee approved the 2biv project discharge summary enhancement recommendations and the 3ci project diabetes protocol. Below are a few additional project highlights:
Project 3ai: Highlighted at April All PPS Meeting
MSPPS Project 3ai* Co-Lead, Lolita Silva-Vazquez from the Lower Eastside Service
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MSPPS Project 3ai co-leads speaking at the All PPS Meeting in Albany. |
Center presented with MSPPS co-leads Dr. Sabina Lim, Dr. Lauren Peccoralo and Dr. Brian Wong at the April 2016 All PPS Meeting in Albany. During the meeting, the team presented their five pronged approach in the development of their programs with their project partners and the challenges through the development process.
The approach includes ensuring project goals aligned with the MSPPS mission, standardizing group protocols, encouraging knowledge sharing across project participants, and developing a consistent process. As the group discussed their success in working together with their project partners, they also presented on their strategy to sustain these efforts even after the DSRIP program. Next steps for their strategy include:
- Promoting the integration between primary care, mental health, and substance use treatment within the PPS network.
- Collaborating with existing and new partners to share best practices and provide partners with training and support (Train the trainer model)
- Further integration of CBOs & their services within 3ai - creative approaches
- Development of standardized referral MH/SUD processes beyond integrated sites to other needed levels/sites of MH/SUD services
For more information, please
click here for the presentation.
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Project 3ai's goal: To integrate mental health and substance abuse services with primary care services to promote access and ensure coordination. For more information, click here: http://mountsinaipps.org/3-a-i/
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Project 3ci: MSPPS Participates in Statewide Diabetes Coalition
MSPPS attended the first meeting of the reconstituted New York Diabetes Coalition. The 2016 NY Diabetes Coalition has undergone few transformations since first initiating in 1999 as the Westchester Diabetes Coalition. Due to the implementation of DSRIP, the Diabetes Coalition has reconvened and this year, the main goal is to update and endorse the NYS Diabetes Treatment Guideline Summary. The group will meet to: (1) Come to a consensus on an evidence-based clinical guideline available to New York State's health care providers, (2) Establish a uniformed approach to Diabetes treatment across PPS networks in support of the implementation of Project 3ci, and (3) Ensure that all of the coalition's resources are available statewide to create clinical decision support tools, protocols for practices, and workflows in EMRs.
Participants include the 10 PPS implementing Project 3ci, NYSDOH, and Public Consulting Group, but other experts such as other clinicians, MCOS, NYCDOHMH, etc. could potentially be involved in the future.
Project 3ci's goal is to support the implementation of evidence-based best practices for disease management in medical practices for adults with diabetes.
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Project 4cii: MSPPS Participates in Citywide Coalition to Improve HIV Care
MSPPS is one of the several PPSs participating in the DSRIP HIV Coalition, organized by the New York City Department of Health and Mental Hygiene. The purpose of the Coalition is for PPSs to leverage collective experience and knowledge by sharing best practices, foster collaboration, and alignment among PPSs and other community partners on HIV-related DSRIP Projects (including MSPPS' 4cii project*), and to engage with city and state agencies to coordinate and utilize HIV resources.
To date, the Coalition has been formulated and passed by-laws and elected two co-chairs, a role which will be shared on a rotating basis by representatives from the seven PPS members.
The Coalition is now forming workgroups to explore effective approaches to:
- Data Usage
- PrEP Implementation
- Peer Workforce
- Messaging & Social Marketing
- Viral Load Suppression Best Practices
* Project 4cii (Increase Early Access To, and Retention in, HIV Care) has two goals: (1) To increase the percentage of HIV-infected persons with a known diagnosis who are in care by 9% to 72% by December 31, 2017, and (2) To increase the percentage of HIV-infected persons with known diagnoses who are virally suppressed to 45% by the same date.
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MSPPS Members at Healthfirst and Mount Sinai Icahn School of Medicine Event
MS
PPS m
embers, Dr. Danielle Milano from Boriken Neighborhood Health Center
Medical Director and Dr. Jeremy Tolbert from Mount Sinai Hospital, spoke at the latest April "Hypertension Mana
gement and Control: Pragmatic Strategies for Primary C
are" CME Conference hosted by Icahn School
of Medicine at Mount Sinai and Healthfirst. Dr. Milano's presentat
ion was about using data from the CPCI data warehouse to target patients with uncontrolled blood pressure and to find the highest risk patients while Dr. Tolbert spoke on the importance of managing Medicaid patients who are at high risk of cardiovascular disease conditions.
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| Project 3bi co-lead Dr. Tolbert speaking on disease management for Medicaid patients with cardiovascular conditions |
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| Project 3ci and 4bii's Dr. Milano speaking on data usage to target patients with uncontrolled blood pressure. |
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| City Health Works, Community Based Organization Collaborating with Hospitals
Inspired by community health solutions from across Africa, Manmeet Kaur adapted a global health model and brought it to Harlem.
During her time in South Africa, she witnessed the unique impact community health workers play in improving the health of individuals with chronic conditions. This inspired Manmeet to launch City Health Works, an organization focused on leveraging the power of peers by training and hiring local individuals to serve as Health Coaches. "A key strength of locally hired Health Coaches is that they have shared life experiences and can quickly build trust in their communities," remarked Manmeet.
Working within the Local Community
The core of their organization is made up of a team of health coaches, who are trained and supervised by a clinician. These coaches are longtime residents of the neighborhoods they serve. Most have personally experienced some of the same challenges and concerns faced by patients, making them uniquely qualified to serve as bridges to the health care system
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City Health Works staff from left to right: Camilo Matos (Health Coach); Manmeet Kaur (Executive Director) Tenisha Dewindt (Health Coach); Anita Hernandez (Health Coach); Marisillis Tejeda (Health Coach); Destini Belton (Health Coach); Leny Rivera (Health Coach); Stacie Gutierrez (Health Coach); David Strefling (Health Coach Supervisor); Jamillah Hoy-Rosas (Director of Health Coaching) ; Elsa Haag (Operations Analyst).
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"We hire people who are from the neighborhood, train them to help their peers better manage their health, navigate the complicated healthcare system and utilize the resources available in the community. We have a powerful ability to work closely with patients, primary care teams, and social service providers. Together, we work to achieve population health goals, reduce healthcare spending, and create more resilient neighborhoods, explained Jamillah Hoy-Rosas, Director of Health Coaching and Clinical Partnerships.
Jamillah, a Registered Dietitian & Certified Diabetes Educator, is the architect behind the training program used with the coaches and the self-management education curricula used with clients. "Our health coaching model is grounded in Motivational Interviewing, designed to help clients increase their internal motivation to adopt realistic, culturally-appropriate lifestyle changes to improve their health." The program uses evidence-based curriculum elements from the American Association of Diabetes Educators (AADE), the American Heart Association (AHA), the American Lung Association (ALA) & the National Institute of Digestive and Diabetes and Kidney Disorders (NIDDK).
"I have learned so much about diabetes, high blood pressure and asthma and in turn it's helped me with my own health and allowed me to help my family and friends living with chronic illnesses," said one of the first health coaches hired, Leny Rivera.
With this experience and understanding, each coach meets with their clients at their homes or in various community settings. Together, they go through a flexible curriculum, tailored to the individual needs of each person. They discuss self-management strategies to empower clients to achieve successful health outcomes and stay out of the hospital.
When teaching medication reconciliation and adherence, patients are asked to take out all of their medications. Coaches check expiration dates and dosage instructions, help patients understand the purpose for each of their medications and identify whether or these medications are being taken as prescribed.
"We help identify barriers to medication adherence and address them. If Pharmacy A can't deliver medication or has too high of a co-pay, the coaches help patients find a pharmacy that delivers and work with them and their providers to find ways they can afford their meds" said Jamillah.
The coaches are always available to their clients by phone to provide social support and answer any questions they may have. "I like getting to know people and helping them overcome barriers that aren't just clinical. They may need help filling out an application for food stamps, finding a senior center or talking to their landlord about repairs needed in their apartment to improve their asthma, we can help with that," said Health Coach Destini Belton.
Working Closely with Hospitals
City Health Works recognizes that it can have the greatest impact in the home if it is closely connected to the primary care clinic and hospitals to ensure its efforts are aligned with the provider. "The coaches serve as eyes and ears for the health system in the community. With unique insight into the homes and lives of clients, our Health Coaches and Care Team help bridge the gap between doctors and patients. For one in every two clients, we identified and escalated a medical, medication or mental health issue that was otherwise unknown, before it became a crisis. Through this collaboration, we jointly ensure patients get the right care at the right time," remarked Manmeet.
The organization uses two referral processes. One is a community-based approach in which the heal
th coaches lead health education workshops at partner community organizations, senior centers, and recreation centers. Patients, who sign up for City Health Works' services in these settings, work with the City Health Works staff to connect with their primary care provider.
The second is a population health based approach where Mount Sinai Hospital generates a list of target patients and providers make referrals based on eligibility. City Health Works reviews complex cases and sends progress reports and medical alerts directly to referring providers. "Keeping the lines of communication open is essential to our success with our clinical partners," says Health Coach Supervisor David Strefling.
Clinical supervisors also have secure read-only access to medical records for patients who have provided consent. This keeps the City Health Works team informed of their patients' health information and outcomes over time.
Sharing Information
"We would really love to see shared care plans. We're doing all of this work trying to integrate services, but we still can't see what happens when patients visit other clinical partners or CBOs. A centralized location to share data and speak the same language would really help improve continuity of care," said Manmeet.
City Health Works is an active member of the Workforce and Clinical Quality and Clinical Executive Committees, projects 2ai, 3bi, 3ci (where they serve as co-lead), 4bii, and the Care Coordination Cross Functional Workgroup.
"DSRIP brings community based partners to the table so they are a part of an integrated patient experience," said Manmeet. "It is trying to connect the community as a bridge for patients; this is a link that would benefit everyone. We are proud to be a part of this effort"
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Updates for PPS Partners
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Contracting Update
DY1 Participation:
DY1 partners can expect to hear more about the PP2 reporting process during the May 6th and May 11th webinars. To learn more about participating in this process, please
click here
.
DY2 Participation
: For partners who are new to the network and participating in DY2, you will receive the initial DY2 participation survey. Our partner relations team will be in touch with you shortly. For more information or questions, please contact
[email protected]
.
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Pilot Begins for Partner Portal
As mentioned in the last newsletter, MSPPS is developing the Partner Portal with launch scheduled for later this year. This solution will help encourage peer to peer and partner to PPS collaboration across the network. The Portal is undergoing internal review and testing. As a next step, we have reached out to select partners to participate in piloting the portal. Their feedback will help shape the content and user experience for this portal.
If you have not already done so, please send us your organization's logo as a PNG or .EPS file, along with 50-100 words about your organization to
[email protected]
.
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| MSPPS Partners to Connect with Healthix
MSPPS has selected Healthix as the primary health information exchange (HIE) solution to simplify PPS connectivity, increase DSRIP investment sustainability, and reduce barriers to entry for partners who may be connecting with multiple RHIOs or who are already connected with Healthix.
Each partner will be responsible for executing an individual contract with Healthix and paying for any and all one-time and operational costs associated with connectivity and data exchange. Healthix will reach out to partners to initiate the HIE conversation with partners. MSPPS will work closely with Healthix and the partners to help guide the process along. Resources and the slides from our HIE webinar are currently available on our website here
under Committees Materials. For all questions, please e-mail
[email protected]
.
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MSPPS Compliance Education Coming Soon
Please be on the lookout for the MSPPS Compliance Education that you will receive shortly via email! It is a requirement that the Mount Sinai PPS as a Lead to distribute compliance education materials on a periodic basis to all network partners eligible to receive DSRIP funds. Shortly after receiving the MSPPS compliance education, the network providers will be asked to confirm and attest that they have received the MSPPS Compliance Education.
For all compliance questions please call the Confidential DSRIP Compliance Hotline at 1-844-MS-DSRIP (673-7747). Please visit our website:
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Recent Study Highlights Importance for Collaboration Between Community Groups and Hospitals
A recent study, Role of Hospitals in Improving Non-Medical Determinants of Community Population Health, conducted by Weill Cornell Medical College highlights the strength of community programs in New York.
The study features a total of 59 community service plans from New York State hospitals that were reviewed. 27 of those plans included community programs addressing behavioral lifestyle factors such as access to healthy foods, while 17 plans had programs impacting other non-medical community health determinants such as the built environment, housing, education, and crime.
Some analysts feel hospitals should not only focus on the medical care of their patients, but to improve non-medical detriments in their communities as well. In fact, according to David Kindig, MD, PhD, and Greg Stoddart, PhD, there are multiple health determinants besides medical care that are attributed to a patient's health and well-being. They credit social factors such as education, poverty, inequality, and the built environment in the likelihood of a patient's recovery. It has even been estimated that only about 10% of health can even be credited to clinical care, while the remaining 40% has been attributed to social and economic factors, 30% to health behaviors, and 10% to environmental factors.*
DSRIP is one of the ways in which community programs are highlighted to improve patients' overall health. City Health Work's relationship with Mount Sinai Hospital is a prime example of this. Patients work with health coaches to receive health education and tools to navigate the health care system. The program also provides tools focused on self-management and ultimately, to reduce hospital visits and admissions. To read the study, please click here:
http://nyshealthfoundation.org/uploads/resources/community-population-health-report-april-2016.pdf
*Booske BC, Athens JK, Kindig DA, Park H, Remington PL. Different perspectives for assigning weights to determinants of health. Madison: University of Wisconsin Population Health Institute; 2010.
*Kindig, Asada, Booske. Population health framework for setting national and state health goals. JAMA.2008;299(17):2081-2083.
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Resources for Partners
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- Call 1-844-674-7463 to reach our Call Center for assistance on questions about DSRIP or the Medicaid Opt-Out letters
- Click here for external resources that may be helpful for you and your organization
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