Partner Spotlight: VillageCare  
PPS Care Hub Update | Exclusive Partner Access to Website 
Issue #069 | December 14, 2016 

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 Favorable Midpoint Assessment Results for the Mount Sinai PPS 

Mount Sinai PPS ranked fourth out of the 25 PPS' across New York for strong partner engagement, according to recent results from the Midpoint Assessment conducted by the DSRIP Independent Assessor (IA).  Part of the assessment by the third-party vendor included a 360 survey to randomly-selected partners within the PPS network, a site visit from the IA, and the IA's review of the PPS' quarterly reports to New York State Department of Health (DOH) and the PPS' project and organizational narratives on project implementation.

Most notably, partners provided favorable feedback about MSPPS in the 360 survey. The survey asked partners about their experience with governance, contracting and funds flow, performance management, and information technology solutions. According to the results:
  • 61% of partners returned the survey and had overall positive feedback about being in the MSPPS network. The average return rate for surveys across PPS's was 52%. 
  • Over 90% of partners agreed that MSPPS has engaged them in its governing board, committees, and/or received input from them
  • Over 80% of partners agreed that the PPS has engaged them in project implementation efforts
  • 100% of partners agreed that the PPS has communicated to them about any governance activities or any changes to the governance plan
Overall, partners' responses were 85% positive, which is higher than the average 70% for all PPS'.
Thank you to all of our partners for your dedication and hard work in making MSPPS such a success. Please continue to stay engaged with us through our project workgroups, Town Halls, webinars, and others. We look forward to hearing continuous feedback from you!
Upper West Side Hub Launches! Hub 

At the November Town Hall, Moray Joslyn, Project Manager, provided an overview of Mount Sinai PPS' care hub strategy. A care hub can be defined as a regional group of providers collaborating on the same performance measures to improve patient care. The purpose of these hubs is to group together partners within the MSPPS network in the same geographical region to achieve key clinical requirements. To improve performance measures, MSPPS is looking to implement hub-specific clinical strategies or requirements in a six-step launch process.  

Moray Joslyn discussed the launch strategy for MSPPS' hubs. 
Currently, the Mount Sinai PPS network plans to divide into five hubs based on location. These locations include: the Upper West Side of Manhattan, the Upper East Side of Manhattan, Downtown Manhattan, Queens, and Brooklyn. Each hub will contain at least one hospital and a variety of provider types to coordinate the effort.  Mount Sinai PPS has selected 20 sites for this first pilot launch in the Upper West Side Hub. We anticipate active work around these efforts to begin in January 2017. Partners will be evaluated based on the selected Hub clinical strategies and requirements. Partners not selected to participate may have an opportunity to participate with us in future hubs. Lessons from this first hub will help inform the overall care hub strategy. The work of the PPS committees and projects will continue to be ongoing and will be a vehicle to inform the workflows of the hub. For any additional inquiries, please review our  FAQ or slides from the November Town Hall and email [email protected].
Mount Sinai PPS Launches New Website for Partner Access to Key Information 

MSPPS launched its new website earlier this week.  
We launched  our new website earlier this week! Simply type www.mountsinaipp s.org and you will be redirected to Mount Sinai PPS' new website.

The cleaner, sleeker, and more int uitive features provide network partners access to information about Mount Sinai PPS. Features include:
  • Responsive design for desktop, laptop, tablets, and mobile use
  • A Partnership page highlighting the partners across our robust PPS network 
  • Updated News, Events, and Resources pages highlighting key information on PPS operations, resources, events, and requests to partners
  • A Meet the Team page to learn more about our PPS leadership 
PPS members receive exclusive access to Community Gateway, which is a password protected portal behind the main website. The first application to launch is the Organizational Profile, which gives partners an opportunity to see who is in the network and identify ways for collaboration. Furthermore, partners can review contract metrics and achievement status and payment allocation for each performance period. If you are a partner, please check in with your main contact for more information. As a main contact, check your e-mails from December 12th for details. 

Other applications are scheduled to launch throughout 2017. These features include: 
  • Performance Dashboard - review how the partner performance on specific clinical measures
  • Resource Guide - learn about services of partners within the community 
  • Learn Center - training and key educational resources
  • Clinical applications - improve care coordination efforts for patients through improved access to data. 
We hope you'll join us at www.mountsinaipps.org!
Thank you! Actively Engaged Achievements

We wanted to extend our gratitude to those organizations that helped the PPS meet and exceed its goals for Actively Engaged Patient targets for DY2 Q2.  As the DSRIP program progresses the number of patients targeted to be "Actively Engaged" in the PPS's clinical projects continues to climb higher. By pushing the clinical work forward and diligently capturing the necessary data our partners enabled the PPS to meet its committed targets and qualify for Actively Engaged related payments from New York State.

We acknowledge the amount of work involved in continuing to meet the increasing Actively Engaged Patient targets. Please see below for a list of organizations that contributed to the DY2 Q2 success. We thank you for your hard work and look forward to meeting the Actively Engaged Patient targets for the DY2 Q3-Q4 reporting period.

We wish to thank the following partners: ACMH, Advantage Care Physicians, AMC IPA, ArchCare, Argus Community, Inc., Betances Health Center, Callen-Lorde, CASES, Children's Aid Society, Community Care Management Partners, Community Healthcare Network, Coordinated Behavioral Care, Damian Family Care, Goodwill NYNJ, HANAC, Housing Works, Institute for Family Health, Isabella Care at Home, Lighthouse Guild, Lott Community Home Health Care, Mental Health Providers of Western Queens, Mount Sinai Beth Israel Opioid Treatment Program, Mount Sinai Health System, Mount Sinai Health Home, Prominis Medical Services, Queens Coordinated Care Partners, Ryan Center, Settlement Health, The Brooklyn Hospital Center, The Door, Union Settlement, West Midtown Medical Group, and VNSNY. 
Clinical Integration Readiness Survey Update

The Clinical Integration Readiness Survey (CIRS) was distributed to partners to capture a baseline understanding of each organization's sites in key in clinical domains. The survey was distributed in two groups and was a DY2 metric. The goal of the CIRS is to inform the PPS in decision making including hub development, PPS network development, and the overall DSRIP Clinical Integration strategy.

Neil Patel and Alana MacGregor shared CIRS' results from Group 1 partners. 
Neil Patel, Senior Project Manager, and Alana MacGregor, Project Manager, provided an update to partners about some of the results received from the CIRS distribution to the first group. Some of the findings include the following results:
  • Depression, diabetes, and HIV are some of the quality improvement programs partners are focused on for their target populations.
  • Of the 80% that indicated that they were able to confirm whether a patient/client made it to a referred appointment (which consistently or not,) over 90% indicated that they received feedback from the external organization regarding those patients. 
  • 43% of sites that indicated they have a PCP or specialist referral process felt they need further access to Behavioral Health Services for their patients, while 31% of partners selected Other services which can include Optometry, Podiatry, Radiology, and Dental services
We will continue to share more data with the network as it becomes analyzed. To review some of the preliminary results click here.
Partner Spotlight

For nearly 40 years,VillageCare has been providing services to the frail and chronically ill in New York. VillageCare offers a multitude of services for its patients and clients across three service lines: post-acute services, managed care, and community programs.  
 
Hira Ruskin, VillageCare Health Home Director, prides herself in the expansion of VillageCare's Health Home over the past two years. She said, "We're almost always selected for every single pilot in any lead health home we're in, because we have the ability to stack up quickly and we have the ability to execute."

While VillageCare offers a myriad of different programs to its patients, its Health Home program has truly transformed over the last few years. According to Hira there were 500 patients, 40 employees, and few formal quality initiatives when she started as Director of the Health 
Photo Courtesy of VillageCare
 
Home program. In two short years, she and her team were able to completely expand and enhance the program. Currently there are over 5,000 p atients enrolled and 200 employees. The Health Home program works hard to close gaps in care for patients by putting a care team in place and using the HEDIS measures, members receive preventative primary care services thereby reducing ER utilization and avoiding hospitaliza tions.  "Seeing the growth of the program, as well as the value that we provide to our members is extremely satis fying and gives us the capacity and competency to step up for DSRIP projects," said Hira. Vill ageCare's Health Home program is unique because there is a registered nurse that works directly with the Health Home and oversees the care management department. "We are different than most care management agencies," she said, "Other agencies focus on social determinants- which we do as well, but we've also educated our staff on the use of diagnosis-based action plans which we implement at the point of enroll ment."

Photo courtesy of VillageCare 

Joseph LoPiccolo, RN and Clinical Director of VillageCare's Health Home, oversees many of VillageCare's DSRIP  employees. Joseph makes an effort to communicate the DSRIP initiatives to his staff. "When there is something new on the Health Home horizon, particularly DSRIP, we see an opportunity to bring it back to the staff a nd analyze it from a global perspective and help our employees understand what's going on in the community and how their jobs impact the overall goals of DSRIP", said Joseph. "The more engaged our staff is, the better they understand how their work impacts the success of DSRIP and the more committed they are to ensuring  they meet DSRIP goals."

In fact, education such as this began in 2015 when leadership met with staff to inform them of what exactly DSRIP was. "We told our staff that by creating a relationship with our clients, we can help remove obstacles to achieving better health
Randi Roy,  Hira Ruskin, Michael Martin, and Joseph LoPiccolo discuss the success of VillageCare's Health Home.
and wellness.  We knew that our staff's relationship with members, along with our care plans, would in turn help the PPS  to meet its goals of reduced ER utilization," said Hira.  She credits the transformation of the program to her dedicated and extremely well-trained staff. B efore beginning employment, staff must attend a two-week orientation program and then a re-orientat ion program after 60 days of working at VillageCare to provide feedback on how the organization can better meet the needs of the  employees. The leadership is dedicated to its staff members, as well as demonstrated by the implementation of an  employee engagement program, the holding of monthly meetings, and availability of a leadership developm ent program.
 
VillageCare is also involved in Projects 2.b.iv, 2.b.viii, 2.c.i, 3.a.iii, 3.b.i, 3.c.i, 4.b.ii, and 4.c.ii. Read the full story here to learn about VillageCare and their partnership with The Brooklyn Hospital on Project 2.c.i. 

Please click here for more information on VillageCare. 
Project HighlightsProjectUpdates
Goodwill Industries of Greater New York and Northern New Jersey's Integration of DSRIP. 

Goodwill NYNJ presented at the November Town Hall on how they have operationalized their work in alignment with DSRIP to achieve key performance measures. As an active Project 3aiii participant, Goodwill was able t o incorporate a 3aiii self-management goal template into their electronic health record system. This has helped enhance their workflows in establishing self-management and adherence goals and
Effie Tsangalidis, Director of Managed Care Operations, presented on Goodwill's implementation of DSRIP measures. 
discussions between patients and their Recovery Counselors. Goodwill also talked about their strategic decision to participate with Mount Sinai PPS preparation for value-based performance. They talked about how working on 3aiii ha s helped them think about some of the benefits for achieving key behavioral health performance me as ures including adherence to anti-psychotic medications for people with schizophrenia; diabetes  monitoring for people with diabetes and schizophrenia, diabetes screening for people with schizophrenia or bipolar disorder who are using anti-psychotic medication and others. 

For more information on Goodwill NYNJ's presentation,please click here. To learn more about Goodwill, please read their Partner Spotlight Series here.
DOH Selected Partners for Medical Record Review 

Some partners were randomly selected by the NYS Department of Health (NYS DOH) to participate in a Medical Record Review, to collect data essential to quality improvement within the DSRIP program. The NYS DOH and the program's independent assessor have partnered with MedReview Inc. to complete chart abstractions for Mount Sinai PPS partners participating in DSRIP Domains 2 and 3. It's critical to the success of DSRIP that all partners who have been selected for Medical Record Review comply with the requests from MedReview.

If partners were selected, they should have received a letter informing them about this process. Partners had the opportunity to meet with Janet Stieg, Project Director from MedReview Inc. at our November Town Hall. For more information about the Medical Record Review, please click here for the  instruction document and November Town Hall presentation. We greatly appreciate your efforts. 

Diabetes Focused Discussions at Recent Retreat 

Mount Sinai PPS partners interested in diabetes care participated in the 2nd annual Mount Sinai Clinical Diabetes Institute (CDI) Retreat, which took place on Friday, November 11th, at the Icahn School of Medicine at Mount Sinai. The event was planned and hosted by Dr. Ronald Tamler, Director of the Mount Sinai Clinical Diabetes Institute and Project 3.c.i co-lead. The retreat started with an overview of the impactful diabetes work occurring throughout the Mount Sinai Health System, including patient care, groundbreaking research, tele-diabetes, and DSRIP.
The CDI Retreat was open to MDs, DOs, NPs, PAs, RDs, RNs, and administrative personnel. 

Experts provided brief updates on novel insulins and landmark studies. Additio nally, discu ssions were also held on special considerations for diabetes care in the elderly, the HIV-positive, the obese and patients struggling with mental health issues, psychological and financial barriers to medication adherence, neuropathy and kidney disease. Dr. Jerome Tolbert, Project 3.b.i and 3.c.i co-lead, also  highlighted the progress made by the Mount Sinai PPS in terms of diabetes treatment and prevention. Dr. Tolbert further familiarized the attending diabetes care providers with the overall goal of the DSRIP program and the Mount Sinai PPS. Many of the presentations from the CDI retreat will be adapted into short online training modules and made available to partners within the Mount Sinai PPS.  To learn more about the Proj ects 3bi and 3ci, please visit our Projects pages at www.mountsinaipps.org .  
Data Exchange Incentive Program Extended 
Please click here for a flier on this program. 

In coordination with CMS, the New York Department of Health has established The Data Exch ange  Incentive Program (DEIP). The objective of this program is to increase the implementation of HIE usage for Medicaid Eligible Professionals (EPs) so there will be greater and more robust data in the SHIN-NY. Enrollment is open to all organizations that have Medicaid EPs and is on a first-come first-served basis. The program is being extended to September 30, 2017. 

Please click here for additional information regardi ng eligibility requirements and conditions of the program.
MSPPS Partner Awarded Grant to Increase Diabetes Program 
 
The William F. Ryan Community Health Network, a MSPPS partner, was recently awarded a $425,000 grant from the Robin Hood Foundation. With the funding, the organization plans to recruit 1,300 people in Manhattan to join its diabetes management program.  The program will focus specifically on patients residing in Lower East Side, Harlem, and midtown Manhattan neighborhoods who are at high risk for not managing their diabetes.

For more information on the William F. Ryan Community Health Network please click here: http://ryanhealth.org/

For more information on the Robin Hood Foundation, please click here: https://www.robinhood.org/
  • Call 1-844-674-7463 to reach our Call Center for assistance on questions about DSRIP & Health Home Eligibility 
Mount Sinai PPS | [email protected] |   www.mountsinaipps.org |  1-844-674-7463