Partner Spotlight: God's Love We Deliver
DY2 PP2 New Contracting Methodology | MSPPS Launches Consumer Focus Group 
Issue #070 | January 17, 2017

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Mount Sinai PPS Contracting Metrics Follow Movement from Project Planning to Implementation 

As Mount Sinai PPS moves from project planning to implementation, partners will see a change in their contract metrics as we enter into Performance Period 2 contracting for Demonstration Year 2.  Partners of varying patient attribution numbers will participate with the PPS in different ways. Some partners will focus more on achieving key performance measures and demonstrating clinical outcomes, while others may focus on providing the PPS with key operational information. This new methodology helps to ensure that partners can successfully participate with the PPS in a way that is best suited for their organization.
 
MSPPS partners can expect to receive their DY2 PP2 amendment packets and reporting templates in mid-January. For more information about upcoming dates, partners can join us for the DY2 PP2 webinars on Wednesday, January 18th or Friday, January 20th.  Please email [email protected]  
for registration information or with any questions.
New Members Welcome to Join the Audit and Compliance Committee  

The MSPPS Audit and Compliance Committee is recruiting additional members for 2017. Interested organizations should reach out to Nina Bastian in the DSRIP Project Management Office at [email protected] for more information.

For additional details on the Committee and responsibilities of membership, please visit here: http://partner.mountsinai.org/web/mt-sinai-pps/committees/audit-compliance-committee
Mount Sinai PPS Launches its First Consumer Focus Group 

The Mount Sinai PPS held its first consumer focus group meeting on Thursday, December 15th at Edwin Gould Family Services in Brooklyn. The main goal of the focus group was to provide MSPPS an opportunity to understand the patient's experience through first hand discussions in healthcare directly from consumers/patients. The consumer/patients views will be utilized to assist the PPS on a statewide initiative to provide better communication, education and access for their medical needs. 
Matt Baney helped facilitate the first MSPPS consumer group

The focus group was led by MSPPS Project 4.c.ii co-lead, Matthew Baney and Mount Sinai Consultant, Instructor, and Chef Corrine Matthews to help inform our population of how changes in healthcare could impact care quality and access. Patients/consumers from AIDS Service Center of Lower Manhattan, Mount Sinai Hospital, and New Directions attended the session and received a brief overview on DSRIP, the Triple Aim of Healthcare and the different social determinants affecting our communities. All participants' responses will be aggregated by the PPS and remain confidential. 
 
Participants received free metro cards, T-shirts and bags. MSPPS plans to hold more consumer focus groups across various geographical locations in 2017. If you're interested in planning for future focus groups as a member of our Consumer Advisory Council (CAC), or have any patients/consumers that would be interested in participating, please contact Tara Partovi, Senior Manager for Stakeholder Engagement at [email protected]. 
Partner Spotlight

For over 30 years, God's Love We Deliver, a nonsectarian, not-for-profit provider, has delivered meals and provided nutritional counseling to those with severe, life-threatening illnesses in New York City. 

Policy Grants Coordinator, Danielle Christenson, Dorella Walters, and Karen Pearl are looking forward to collaboration with MSPPS partners. 
While God's Love We Deliver is heavily involved in the community with over 200 partnerships with medical and so cial services, by becoming part of MSPPS, they discovered an opportunity to share their unique services with a variety of new partners. According to Dorella Walters, Senior Director of Program Services, "We un d erstand that our core competency is providing the best food  and nutrition, but we also realize that  patients may need other supports  such as housing and medical support. This is where the partnerships are  able t o p rovide a solution for our clients due to the referrals that we make."

God's Love's  staff began presenting its ideas to as many project workgroups as possible, with the hope of bringing awareness to the various and wide-spread effects of malnutrition. One of the goals of these presentations was to change the screening process that occurs when a patient is discharged to include screening for malnutrition and discharge with a referral to a nutrition provider if necessary. According to Karen Pearl, President and CEO, "If we're able to change the way healthcare providers screen, we will be able to pick up the clients who are in need of and can benefit from home delivered meals and, in turn, fewer and fewer people will need to be hospitalized."

The Impact God's Love has on DSRIP 

God's Love We Deliver's heavy involvement with DSRIP and MSPPS greatly impacts their relationship with partners. Previously, they presented at the Stakeholder Engagement meeting i n April 2016. They since have been featured at both the Mount Sinai Stakeholder Engagement Group as well as during the DSRIP Project Approval and Oversight Panel review, as an example of a successful DSRIP CBO partner. The next goal for  God's Love We Deliver is to present at th e Care Coordination Workgroup meeting   to educate participants
Photo Courtesy of God's Love We Deliver
on how their services can help PPS patients be successful in addressing their illnesses and preventing hospitalization. Through presentations to the PPS, God's Love has been able to demonstrate that their services are integral. For example, when a patient is prescribed a new medication, a medically tailored meal can help a p atient better adhere to their medication. Dorella shares, "I think our   biggest impact   has been to  demonstrate that we are a key partner in addressing serious life altering illnesses. The most exciting thing we've seen is how Mount Sinai PPS has evolved in its awareness of our key role in the healthcare story. It is very exciting to bridge this gap between the hospital and the community."
Photo Courtesy of God's Love We Deliver

The Difference of God's Love We Deliver 

God's Love We Deliver measures its success in numerous ways. The organization sets daily,  monthly, and annual measures around numbers of meals, number of clients, distribution, managed-long term care contracts , etc. The organization also conducts focus groups and satisfaction surveys to understand what is changing in their client base and how they need to evolve as an organization   Lastly, they are in the process  of developing scientific research projects to prove that their services work. Karen share s, "We're currently working on a study centered on cancer care and another that focuses on chronic illnesses. Each looks at different outcomes, but both demonstrate the efficacy of our medically tailored model."

God's Love We Deliver also has a robust database that moves throughout the entire organization and is part of its entire operations. Through their tracking system, they are able to measure the needs of each patient and how they can focus on ways to better improve their patients' health. The data is shared throughout  many departments in the organization. For example, once a new patient enrolls in the organization their dietary restrictions and medical issues are tracked. This informs the kitchen staff on specific meals needed for  each individual and informs the meal packaging department on the number of mea ls an individual needs.  Lastly, once the meals are packed, this then helps the delivery department on 
Photo Courtesy of God's Love We Deliver
their route for the day. Dorella says of their tracking process, "As a CBO we are able to share our data and understand the importance of it. We've been excited that we've been able to leverage our capacity and technologically we are on par with what the PPS needs." 
 
Metrics and research are not the only ways the CBO measures its success.  While the goal of God's Love is to provide patients with a meal and good nutrition, they're able to do so in a way that brings people care, friendship, and the love that they might not receive when they are sick. The client connection is essential for the success of this organization. All clients receive unlimited nutrition counseling and education and have the opportunity to call at any time for any questions.  According to Karen, "Sometimes people say to us, 'Why should we use God's Love meals instead of a for profit company?' Because you miss the love. You get something at the door, but you don't get people checking on you and talking to you, and the community that comes with God's Love. Patient satisfaction is a huge part of health." 

God's Love We Deliver is able to showcase the importance community based organizations have on the success of DSRIP. Karen said of their success, "I think we're able to demonstrate to the PPS that they can count on CBOs. The PPS understands in a new way that CBOs, while on a much smaller scale than a hospital, are data driven, focused on health and well-being, natural allies, and that we're able to reach people and support them."

For more information on God's Love We Deliver please click here: https://www.glwd.org/  
Project HighlightsProjectUpdates
Project 2.b.viii Update: Community Paramedicine Pilot to Improve Urgent Care for Patients 

The Mount Sinai PPS Community Paramedicine pilot program is anticipated to launch in the coming months! This initiative seeks to reduce preventable emergency department (ED) visits and hospitalizations by utilizing telemedicine technology to coordinate care in our communities between paramedics, primary care specialists and home health nurses. 

In the past, when a patient called providers from home with an acute medical problem, providers didn't have many options other than referring the patient to the ED. Through this pilot, the physician has an innovative resource to dispatch a specially trained paramedic to visit the patient at home without immediately transporting him or her to the hospital. These units will be able to respond to the home within 30-60 min, and with the help of telemedicine technology, the community paramedic will then participate in real-time consultation with the referring clinician and/or the Regional Emergency Medical Advisory Council (REMAC) certified emergency physician to make a coordinated decision as to the appropriate course of action. Paramedics will be trained for this new role and physicians will be certified to work with paramedics. Several PPS partners including Institute for Family Health and Visiting Nurse Services of New York are working with the program to develop workflows for the upcoming pilot. If your organization would like to learn more about the program, please contact Hugh Chapin at  [email protected].  
Project 3.a.i and 3.a.iii Update: PSYCKES Data Usage Training Webinar 

The New York State Office of Mental Health (OMH) will be offering a training webinar to partners in February regarding the usage of the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) application. The goal of this webinar is to showcase how PSYCKES can be utilized by partners and providers to help support DSRIP initiatives and projects. This webinar will also provide an overview of the application, demonstrate how the data can be used to improve DSRIP project implementation, and showcase tools used to help identify DSRIP patient populations. 

PSYCKES is a HIPAA compliant, web-based portfolio that was created by OMH. The application gathers data from the NYS Medicaid claims database and is collected when providers bill Medicaid for services. For additional information on PSYCKES, please click here.

The webinar will be offered on Thursday, February 9th and Monday, February 13th. It will also be recorded for future viewing. If you have any questions about the webinar, please email Natalie Kil at [email protected].
MSPPS Partner Hopes to Receive Approval To Open Health Center in Midtown 
 
Mount Sinai PPS partner, Housing Works, is awaiting the state's final approval in order to open up a health center in Midtown Manhattan through the Capital Restructuring Financing Program (CRFP). The goal of the CRFP is to integrate health systems through $1.5 billion of funds for 162 projects statewide. The goal of this four-story center would be to provide primary care, substance abuse, and mental health treatment services to the community. Construction on the $3.4 million clinic is expected to take about nine months to complete

For more information on the Capital Restructuring Financing Program please click here.  For more information on Housing Works, please click here . 
  • Call 1-844-674-7463 to reach our Call Center for assistance on questions about DSRIP & Health Home Eligibility 
  • MSPPS Partner, St. Mary's Healthcare System for Children is hiring. Attend an Open House Session for more information. Click here for more information. 
Mount Sinai PPS | [email protected] |   www.mountsinaipps.org |  1-844-674-7463