Callen-Lorde Community Health Center 
Cultural Competency Event | Call Center Services 
Issue #068 | October 18, 2016

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Mount Sinai PPS' Strategy with Pay for Performance Reporting for State Rewards  

As DSRIP moves from pay for reporting to pay for performance, Mount Sinai PPS will be responsible for meeting specific performance measure targets in order to achieve financial rewards from the state. MSPPS selected performance measures based on the ease of implementation, pay for performance potential, strategic alignment to long-term PPS goals including the value-based payment roadmap. These measures include Adult Access to Preventive or Ambulatory Care - 45 to 64 years;  Diabetes Monitoring for People with Diabetes and Schizophrenia; and Percentage of adults who receive a colorectal cancer screening based on the most recent guidelines - Aged 50- 75 years.

To achieve these performance metrics, we will be integrating clinical work and operations across the 10 DSRIP projects. Project groups would collaborate to allow projects to integrate and align  process and outcome workflows to impact the priority performance metrics.  These project "clusters" are divided into three groups based on the DSRIP three domains: 
  1. System Transformation Projects which would include care transitions, hospital- home care collaboration (2ai, 2biv, 2bviii, 2ci);
  2. Clinical Improvement Projects which would include behavioral health and primary care integration, behavioral health medication adherence,evidence-based strategies for disease management of high risk populations with Diabetes and Cardiovascular disease (3ai, 3aiii, 3bi, 3ci), and 
  3. Preventive Projects (access to quality preventive screenings and access and retention to HIV care (4bii, 4cii). The community-based health navigation services are embedded in three groups to identify the patient navigation and care management needs and to ensure that all patients have access to those services. 
Partners can expect to hear more about this and review the full list of priority performance measures in future project workgroup meetings and the November Town Hall. 
Partners Discuss Cultural Competency at September MSPPS Event 

The MSPPS Cultural Competency & Health Literacy Workgroup held a special event to introduce the new role of the partner Cultural Competency Health Literacy (CC/HL) Site Champion on Thursday, September 22nd at Mount Sinai West. The event included an overview of the CC/HL strategy as well as a presentation on the expectations and responsibilities of the Site Champion role. Each partner organization is expected to have a site champion who would ultimately serve as a liaison between the MSPPS CCHL workgroup and the partner organization.

Callen-Lorde's, Finn Brigham, Director of Project Management, presented on "LGBT Cultural Competence in Healthcare." 
Additionally, Callen-Lorde Community Health Center's Finn Brigham presented on "LGBT Cultural Competence in Healthcare" and discussed strategies to manage the diverse health concerns of LGBT patients. Partners found value in the presentation, giving them insight to consider new approaches to becoming more culturally competent with their patients. Finn shared the Center's approach to creating a comfortable and welcoming environment for their patients including providing supportive resources to meet patients' needs. For example, the Center uses intake forms with inclusive language such as "partner" and not "spouse" and "transgender" or "other" as an option for gender.  To learn more about Callen-Lorde's approach, please read the story below or download event materials here .

Attendance at the event was a DY2 contract metric for partners. All questions can be directed to dsrip_workforce@mountsinai.org.  
MSPPS Presents at September DSRIP Learning Symposium    

Members of the Mount Sinai PPS, Project Management Office recently presented at the DSRIP Learning Symposium in Syracuse, New York last month.

Dr. Kevin Munjal presented the Community Paramedicine Program in Syracuse.

 
Project 2biv MD Champion, Dr. Kevin Munjal, presented the Community Paramedicine Program, a Care Transitions innovation Mount Sinai PPS is launching over the next few months. Dr. Munjal's presentation highlighted the need for patients to move away from unnecessary 9-1-1 calls and emergency room visits. The goal of the Community Paramedicine Program is to reduce unnecessary ER visits and hospitalizations by allowing for urgent EMS assessments in the field to be conducted by paramedics in coordination with emergency and primary care specialists. For more information about Project 2biv, please visit here.  
Dennis Lumbao and Patti Cuartas presented at the NY DOH DSRIP Annual Statewide Learning Symposiu m


Senior IT Director Patti Cuartas and Care Coordination Project Manager Dennis Lumbao co-presented during a breakout session at the Statewide Learning Symposium. The session called "Piloting Care Plan Exchange" and facilitated by Greater New York Hospital Association (GNYHA) highlighted lessons learned from  early -stage piloting of care plan exchange. Patti and Dennis shared MSPPS experiences with panelists from other PPSs' and a Qualified Entity (QE) or Regional Health Information Organization (RHIO) where a region's electronic health information is stored. 

The MSPPS has identified a select group of partners with varying levels of IT capabilities. These partners will receive phone calls in which the PPS will gather insight around care plan development, management, and sharing. Feedback will be used to help drive the PPS care management strategy. Stay tuned for more information on this project.   
Partner Spotlight

Callen-Lorde Community Health Center's serves the LGBT community within New York City and provides a voice for these individuals to improve the quality of care they receive. 

In 2015 New York State fee-for-service Medicaid and Medicaid Managed Care began covering "transition-related care and services for persons diagnosed with gender dysphoria."* Gender dysphoria is a diagnosis given to an individual whose gender assignment at birth does not match the gender they identify with. These services  include counseling, hormone therapy, and gender reassignment surgery.  
Finn Brigham and Anthony Fortenberry both sit on MSPPS Projects and Workgroups. 

 
For an organization like Callen-Lorde Community Health Center, this was monumental. Callen-Lorde is a health center that provides supportive services to New York's lesbian, gay, bisexual, and transgender commu nit ies. The Transgender Health Services Program serves 3,000 to 4,000 patients who identify as either transgender or gender non-conforming. The coverage of trans-gender services from Medicaid provides patients with opportunities to receive these services that they were previously unable to afford. According  to Finn Brigham, Director of Project Management, "This has been a wonderful development for our patients who would have to pay out of pocket for these services."
 
While this is a step in the right direction, Finn is aware that those who identify as trans-gender or gender non-conforming are still uncomfortable in medical settings and specifically some are afraid to go to the emergency room. He feels that the implementation of DSRIP will help alleviate these fears among Callen-Lorde's patients.   Finn said, "DSRIP is a great opportunity to solidify best practices around trans-care and essentially train other healthcare providers."

The Effects of DSRIP within Callen-Lorde
Callen-Lorde offers a variety of services to its patients including dental as pictured above.
Callen-Lorde is involved with Projects 2.c.i., 3.a.i., and 4.c.ii and has tried to implement these projects' strategies to improve its services. For example, Anthony Fortenberry, Chief Nursing Officer, explains  that within the LGBT population there are higher rates of depression and suicide. Being involved with Project 3.a.i, Integration of Primary Care and Behavioral Health Services, has allowed them to utilize depression screenings. In fact, Callen-Lorde h as even hired mental health professionals to conduct these assessments. If a patient tests positive for depression, a warm hand-off will be conducted in the moment to these mental health professionals to determine if this is an urgent n eed. Depression screenings have increased in Callen-Lorde by 30% in one year and it's hoping to expand. In fact, Anthony credits the success of this implementation to those involved within the 3.a.i workgroup . He said, "It has been a great opportunity for us to learn from organizations who have integrated similar types of models." 

DSRIP has also helped Callen-Lorde re-structure its data collection strategy. Anthony shares that Callen-Lorde has had its own electronic medical records (EMRs) for the past 20 years. He said, "We had to create a really customized electronic medical record to ensure we could record more information on gender than just sex assigned at birth. It's limiting for us. We want to bridge the gap, but it's been a particular struggle for our organization in regards to the data we're collecting. The data we're collecting is actually much more robust than the system allows for."


Due to DSRIP, Callen-Lorde has enhanced its population health team to really focus and analyze its data. The organization is now able to pull out data by demographics such as, income, gender identity, and race which allows the organization to target its quality improvement around the specific data.
 
Health Homes and VBP Implementation
Along with the involvement within workgroups and projects, Anthony and Finn are also optimistic about other improvements implemented by the state. For example, the implementation of the Health Home Program and Value-Based Payment fits right in at Callen-Lorde. Callen-Lorde had coincidentally started a small case management program for patients who have mental health issues, but did not have the resources to support  the program. Finn shares, "When the Health Homes Program was implemented, we were already trying to  work with these folks and now there is a program created to supporting them with the same goals we had."

Health Outreach to Teens (HOTT) provides medical services to teens.   
Also, Anthony is excited about the value-based payment (VBP) implementation. Currently, Callen-Lorde uses fee-for-service and Anthony said, "VBP is acknowledging and supporting the needs to address social determinants of health in a general sense. Whether it's through the state DSRIP funding or incentive programs through insurers, there's a real focus on quality improvement."   In fact, now with value-based payment, those in the LGBT community can have a focused voice in this discussion.

T o read the full article please click here.  For more information on Callen-Lorde please visit here.  

*"Department of Health." Medicaid Update. Web. 17 Oct. 2016.
Updates for PPS Partners Updates
Download a flier today! 
Mount Sinai PPS Introduces New Health Home Eligibility Service at Call Center 

Mount Sinai PPS is rolling out new services as a part of its care management strategy across the PPS network. Now we can help partners connect their patients to care management services within the PPS network. Our call center team can:
  • Find out if your patient is eligible for a dedicated Health Home care manager
  • Provide you with information to help you connect your patient with a Health Home
  • Find out if your patient is already assigned to a Health Home care manager
In November, partners can expect to hear more about the Resource Entitlement Advocacy Program (REAP) service.
 
To connect with our call center, call 1-844-MSHS 4ME (1-844-674-7463). Don't forget! We are available to answer questions about DSRIP, make appointments at a Mount Sinai Health System location, and connect you with our partner relations team. 
Partners Encouraged to Join Healthix for Data Sharing 

This diagram depicts the information exchange process from Healthix to Community Gateway. 
During the September Healthix webinar, Mount Sinai PPS highlighted the importance of partners sharing data to the PPS. As the PPS moves towards a more performance-based approach for partners, the use of Healthix will be increasingly important. Healthix ensures the appropriate aggregation of patient information across the PPS network. Partners who connect with Healthix would receive access to patient clinical data across the Healthix network (over 400 health organizations in the New York area) as well as the Performance Metrics application within Mount Sinai PPS Community Gateway, which would offer partners insight to progress on performance measures as guided by State and PPS targets. Partners would also be able to review their patient's data as it relates to DSRIP measures. 

Partners are encouraged to engage with Healthix as their primary regional health information organization. Mount Sinai PPS is available to assist partners through the process. For more information about this, please contact hiequestions@mountsinai.org. To contact a Healthix representative, please e-mail Jason Thaw at JThaw@healthix.com
MSPPS Partner To Manage Housing Units Serving Those with HIV/AIDS 
 
A Mount Sinai partner, Gay Men's Health Crisis (GMHC), a non-profit organization, was recently awarded $450,000 from the city Department of Health and Mental Hygiene's Housing Opportunities for Persons with HIV/AIDS. GMHC used this money to take over a contract which manages 25 units of housing across the city in Brooklyn, Queens, and the Bronx serving those living with HIV/AIDS.

GMHC will offer many services to these residents units including job training, access to a food pantry, mental health services, and transportation assistance.  GMHC applied for Article 31 mental health clinic and Article 32 chemical dependence treatment clinic licenses and anticipates to open these clinics in January 2017. 

To read more about the article please click here

The mission of GMHC is to end the AIDS epidemic and help all those who have been affected. Please click here to learn more about Gay Men's Health Crisis.
  • Call 1-844-674-7463 to reach our Call Center for assistance on questions about DSRIP & Health Home Eligibility 
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