DSRIP QUARTERLY REVIEW PROCESS: Project Requirement - Timeframe. Project Requirement - Unit Level Reporting

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(1)DSRIP QUARTERLY REVIEW PROCESS: PPSs will submit a quarterly report to the Independent Assessor throughout the DSRIP program via the automated MAPP tool which includes Domain 1 DSRIP Project Requirement Milestone and Metrics. Each Project Requirement includes the time period for completion as well the unit level of reporting which are discussed in further detail below.. Project Requirement - Timeframe � PPSs must enter a target completion date against all Project Requirements Milestone and Metrics. Each Project Requirement has been assigned to one of three time periods for completion. Dates cannot exceed the prescribed time period of speed and scale commitments made in the submitted application (this includes prescribed minimum time periods beyond PPS Application Speed and Scale Commitment). Each of the following requirement sections is similarly colorcoded throughout the document. Project System Changes: Based upon the work plan section in Attachment I, NY DSRIP Program Funding and Mechanics Protocol, no more than the first two years will be utilized to implement major system changes related to the project. Example project requirements that fall into this time period cohort include: training for care coordinators, developing systematic approaches like clinical protocols, the identification of key project personnel, performing population health management activities, or using EHRs or other technical platforms to track patients engaged in the project. Project Requirements with Specific Time Periods : A number of project requirements include prescribed end dates for achievement. Example project requirements include: safety net providers actively sharing medical records with RHIO/SHIN-NY by the end of DY 3 or PCPs achieving Level 3 PCMH certification by the end of DY 3. Project Requirements Tied to PPS Speed and Scale Commitments : The due dates for these project requirements are at the discretion of the PPS and should be consistent with commitments each PPS made in the speed and scale sections of the submitted project application. Project requirements within this time period include components like implementing open access scheduling in all PCP practices, deploying a provider notification/secure messaging system, or converting outdated or unneeded hospital capacity into needed community-based services.. Project Requirement - Unit Level Reporting �. Project Unit Level Reporting. Project-Unit Level Reporting - These are Domain 1 requirement metrics/deliverables which will be reported by the PPS lead at the project-wide level demonstrating the PPS’ overall project performance and success. These are requirements not specific to individual provider but rather are requirements that must be organized and administered by the PPS lead through the PPS’ participating providers and partners. Some of these requirements include performing population health management activities, monthly meetings with MCOs, establishing partnerships between primary care providers and participating Health Homes, and developing materials meeting the cultural and linguistic needs of the population.. Provider Unit Level Reporting. Provider-Unit Level Reporting - These are Domain 1 requirement metrics/deliverables for which performance and success must be demonstrated at the provider level. Some of these requirements include PCPs meeting 2014 NCQA Level 3 PCMH standards, EHR meeting RHIO HIE and SHIN-NY requirements or implementing open access scheduling in PCP practices..

(2) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. Data Source(s). PPS includes continuum of providers in IDS, including medical, behavioral health, postacute, long-term care, and community-based providers.. Provider network list; Periodic reports demonstrating changes to network list; Contractual agreements amongst providers in the IDS. Project. PPS produces a list of participating HHs and ACOs. Participating HHs and ACOs demonstrate real service integration which incorporates a population management strategy towards evolving into an IDS.. Updated list of participating HH; Written agreements; Evidence of interaction. Project. Periodic progress reports on implementation that demonstrate a path to evolve HH or ACO into IDS.. Project. Regularly scheduled formal meetings are held Meeting schedule; Meeting agenda; Meeting to develop collaborative care practices and minutes; List of attendees. integrated service delivery.. Project. 1. 2. All PPS providers must be included in the Integrated Delivery System. The IDS should include all medical, behavioral, post-acute, long-term care, and community-based service providers within the PPS network; additionally, the IDS structure must include payers and social service organizations, as necessary to support its strategy.. Utilize partnering HH and ACO population health management systems and capabilities to implement the PPS’ strategy towards evolving into an IDS.. Project ID 2.a.i. Unit Level. Page 2.

(3) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. Data Source(s). Clinically Interoperable System is in place for all participating providers.. HIE Systems report, if applicable; Process work flows; Documentation of process and workflow including responsible resources at each stage of the workflow; Other sources demonstrating implementation of the system. Project. Process flow diagrams demonstrating IDS processes. Project. Contract; Report; Periodic reporting of discharge plans uploaded into EHR; Other sources demonstrating implementation of the system. Project. Written training materials; list of training dates along with number of staff trained.. Project. 3. Ensure patients receive appropriate health care and community support, including medical and behavioral health, post-acute care, long term care and public health services.. PPS has protocols in place for care coordination and has identified process flow changes required to successfully implement IDS. PPS has process for tracking care outside of hospitals to ensure that all critical follow-up services and appointment reminders are followed. PPS trains staff on IDS protocols and processes.. Project ID 2.a.i. Unit Level. Page 3.

(4) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. Data Source(s). EHR meets connectivity to RHIO’s HIE and SHIN-NY requirements.. QE participation agreement; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP, NonPCP, Hospital, BH, SNF). EHR vendor documentation; Screenshots or other evidence of use of alerts and secure messaging; written training materials; list of training dates along with number of staff trained in use of alerts and secure messaging. Project. EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project. PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. 4. 5. Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including directed exchange (secure messaging), alerts and patient record look up, PPS uses alerts and secure messaging by the end of Demonstration Year (DY) 3. functionality.. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of Demonstration Year 3.. Project ID 2.a.i. Unit Level. Provider (SN: PCP). Page 4.

(5) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. Data Source(s). PPS identifies targeted patients through patient registries and is able to track actively engaged patients for project milestone reporting.. Sample patient registries; EHR completeness reports (necessary data fields sufficiently accurate to conduct population health management). Project. Primary care capacity increases improved access for patients seeking services particularly in high-need areas.. Status reporting of recruitment of PCPs, particularly in high-need areas; Demonstration of improved access via CAHPS measurement. Project. 6. 7. Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers.. Achieve 2014 Level 3 PCMH primary care certification and/or meet state-determined criteria for Advanced Primary Care Models for All practices meet 2014 NCQA Level 3 PCMH and/or APCM standards. all participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standards by the end of DY 3. EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria.). Project ID 2.a.i. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Unit Level. Provider (PCP). Project. Page 5.

(6) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. 8. Contract with Medicaid Managed Care Organizations and other payers, as Medicaid Managed Care contract(s) are in appropriate, as an integrated system and place that include value-based payments. establish value-based payment arrangements.. 9. Establish monthly meetings with Medicaid MCOs to discuss utilization trends, performance issues, and payment reform.. 10. Re-enforce the transition towards valuebased payment reform by aligning provider compensation to patient outcomes.. Project ID 2.a.i. PPS holds monthly meetings with Medicaid Managed Care plans to evaluate utilization trends and performance issues and ensure payment reforms are instituted.. Data Source(s) Documentation of executed Medicaid Managed Care contracts; Report demonstrating percentage of total provider Medicaid reimbursement using value-based payments Meeting minutes; agendas; Medicaid MCO attendee list; meeting materials; process of reporting meeting outcomes/recommendations to stakeholders and PPS leadership. Unit Level. Project. Project. PPS submitted a growth plan outlining the strategy to evolve provider compensation model to incentive-based compensation. VBP Growth Plan; Compensation model; consultant recommendations. Project. Providers receive incentive-based compensation consistent with DSRIP goals and objectives.. Contract; Report; Payment reconciliation documentation; Other sources demonstrating implementation of the compensation and performance management system. Project. Page 6.

(7) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain. System Transformation Projects (Domain 2). Project ID. 2.a.i Create an Integrated Delivery System focused on Evidence Based Medicine and Population Health Management. Project Title Index Score = 56. Definition of Actively Engaged. Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent).. Project Requirement. Metric/Deliverable. Data Source(s). Community health workers and communitybased organizations utilized in IDS for outreach and navigation activities.. Documentation of partnerships with community-based organizations; Evidence of community-based health worker hiring; Colocation agreements between community health workers and CBOs; Job description of the community health workers; Report on how many patients are engaged with community health worker. 11. Engage patients in the integrated delivery system through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations, as appropriate.. Project ID 2.a.i. Unit Level. Project. Page 7.

(8) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)). Index Score = 37. Definition of Actively Engaged. Project Requirement Ensure that all participating PCPs in the PPS meet NCQA 2014 Level 3 PCMH accreditation 1 and/or meet state-determined criteria for Advanced Primary Care Models by the end of DSRIP Year 3.. 2. The number of participating patients who receive preventive care screenings from participating providers to identify unmet medical or behavioral health needs from participating PCPs. Metric/Deliverable. Data Source(s). Unit Level. All practices meet NCQA 2014 Level 3 PCMH and/or APCM standards.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Provider (PCP). Role description of the physician champion; CV (illustrating NCQA PCMH certification, PCMH and/or APCM content expertise, and/or significant population health experience); Contract; PCMH certification and/or APCM documentation. Provider (PCP practice). Identify a physician champion with knowledge PPS has identified physician champion with of PCMH/APCM implementation for each experience implementing PCMHs/ACPMs. primary care practice included in the project.. Project ID 2.a.ii. Page 8.

(9) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)). Index Score = 37. Definition of Actively Engaged. The number of participating patients who receive preventive care screenings from participating providers to identify unmet medical or behavioral health needs from participating PCPs.. Project Requirement. Metric/Deliverable. Data Source(s). Care coordinators are identified for each primary care site.. List of names of care coordinators at each primary care site. 3. 4. Care coordinator identified, site-specific role established as well as inter-location Identify care coordinators at each primary care coordination responsibilities. site who are responsible for care connectivity, internally, as well as connectivity to care managers at other primary care practices. Clinical Interoperability System in place for all participating providers and document usage by the identified care coordinators.. EHR meets connectivity to RHIO’s HIE and Ensure all PPS safety net providers are actively SHIN-NY requirements. sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including direct exchange (secure PPS uses alerts and secure messaging messaging), alerts and patient record look up functionality. by the end of Demonstration Year (DY) 3.. Project ID 2.a.ii. Role description of the care coordinator; Written training materials. Unit Level Provider (PCP practice) Provider (PCP practice). HIE Systems report, if applicable; Process work flows; Documentation of process and workflow including responsible resources at each stage of the workflow; Other sources demonstrating implementation of the system. Project. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP). EHR vendor documentation; Screenshots or other evidence of use of alerts and secure messaging; written training materials; list of training dates along with number of staff trained in use of alerts and secure messaging. Project. Page 9.

(10) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)). Index Score = 37. Definition of Actively Engaged. The number of participating patients who receive preventive care screenings from participating providers to identify unmet medical or behavioral health needs from participating PCPs.. Project Requirement. Metric/Deliverable. Data Source(s). EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. PPS identifies targeted patients through patient registries and is able to track actively engaged patients for project milestone reporting.. Sample patient registries; EHR completeness reports (necessary data fields sufficiently accurate to conduct population health management). 5. 6. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of Demonstration Year 3.. Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers.. Project ID 2.a.ii. Unit Level. Project. Provider (SN: PCP). Project. Page 10.

(11) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)). Index Score = 37. Definition of Actively Engaged. The number of participating patients who receive preventive care screenings from participating providers to identify unmet medical or behavioral health needs from participating PCPs.. Project Requirement. Metric/Deliverable. 7. 8. Ensure that all staff are trained on PCMH or Advanced Primary Care models, including evidence-based preventive and chronic disease management.. Implement preventive care screening protocols including behavioral health screenings (PHQ-2 or 9 for those screening positive, SBIRT) for all patients to identify unmet needs. A process is developed for assuring referral to appropriate care in a timely manner.. Project ID 2.a.ii. Data Source(s). Policies and procedures related to standardized treatment protocols for chronic Practice has adopted preventive and chronic disease management; agreements with PPS care protocols aligned with national guidelines. organizations to implement consistent standardized treatment protocols. Project staff are trained on policies and procedures specific to evidence-based preventive and chronic disease management.. Documentation of training program; Written training materials; List of training dates along with number of staff trained. OQPS Reporting Requirements; claims Preventive care screenings implemented reporting; number and types of screenings among participating PCPs, including behavioral implemented; number of patients screened; health screenings (PHQ-2 or 9, SBIRT). number of providers trained on screening protocols. Protocols and processes for referral to appropriate services are in place.. HIE Systems report, if applicable; Process work flows; Documentation of process and workflow including responsible resources at each stage of the workflow; Other sources demonstrating implementation of the system. Unit Level. Project. Provider (PCP practice). Provider (PCP). Project. Page 11.

(12) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or Advanced Primary Care Models (as developed under the New York State Health Innovation Plan (SHIP)). Index Score = 37. Definition of Actively Engaged. The number of participating patients who receive preventive care screenings from participating providers to identify unmet medical or behavioral health needs from participating PCPs.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. PCMH 1A Access During Office Hours scheduling to meet NCQA standards established across all PPS primary care sites.. Scheduling standards documentation; Report showing third next available appointment, which could include a 1.) new patient physical, 2.) routine exam or 3.) return visit exam [Institute for Healthcare Improvement measures]; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation; Other Sources demonstrating implementation. Provider (PCP Practice). PCMH 1B After Hours Access scheduling to meet NCQA standards established across all PPS primary care sites.. Scheduling standards documentation; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation; Other Sources demonstrating implementation. Provider (PCP Practice). PPS monitors and decreases no-show rate by at least 15%.. Baseline no-show rate with periodic reports demonstrating 15% no-show rate reduction. Provider (PCP Practice). 9. Implement open access scheduling in all primary care practices.. Project ID 2.a.ii. Page 12.

(13) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services. Index Score = 46. Definition of Actively Engaged. The number of participating patients who completed a new or updated comprehensive care management plan.. Project Requirement. Metric/Deliverable. Data Source(s). A clear strategic plan is in place which includes, at a minimum: - Definition of the Health Home At-Risk Intervention Program - Development of comprehensive care management plan, with definition of roles of PCMH/APC PCPs and HHs. Complete strategic plan; Reports on progress in implementation that demonstrate a path to successful implementation within the timeframe committed to in the application. 1. Develop a Health Home At-Risk Intervention Program, utilizing participating HHs as well as PCMH/APC PCPs in care coordination within the program.. 2. Ensure all primary care providers participating in the project meet NCQA (2011) accredited Patient Centered Medical Home, Level 3 All practices meet NCQA 2014 Level 3 PCMH standards and will achieve NCQA 2014 Level 3 and APCM standards PCMH and Advanced Primary Care accreditation by Demonstration Year (DY) 3.. Project ID 2.a.iii. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Unit Level. Project. Provider (PCP). Page 13.

(14) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services. Index Score = 46. Definition of Actively Engaged. The number of participating patients who completed a new or updated comprehensive care management plan.. Project Requirement. Metric/Deliverable. Data Source(s). EHR meets connectivity to RHIO’s HIE and SHIN-NY requirements.. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. 3. 4. 5. Ensure that all participating safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including PPS uses alerts and secure messaging direct exchange (secure messaging), alerts and functionality. patient record look up.. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM.. Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers.. Project ID 2.a.iii. Unit Level Provider (SN: PCP, Non-PCP, HH). EHR vendor documentation; Screenshots or other evidence of use of alerts and secure messaging; written training materials; list of training dates along with number of staff trained in use of alerts and secure messaging. Project. EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project. PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.. Certification documentation. PPS identifies targeted patients through patient registries and is able to track actively engaged patients for project milestone reporting.. Sample patient registries; EHR completeness reports (necessary data fields are populated in order to track project implementation and progress). Provider (SN: PCP). Project. Page 14.

(15) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services. Index Score = 46. Definition of Actively Engaged. The number of participating patients who completed a new or updated comprehensive care management plan.. Project Requirement. Metric/Deliverable. Data Source(s). Procedures to engage at-risk patients with care management plan instituted.. Documentation of process and workflow including responsible resources at each stage; Written training materials; List of training dates, including number of staff trained; Sample care management plans; Sample engagement with at-risk patients; Number of patients engaged with care management plan. Project. Information-sharing policies and procedures; Number of patients provided care management services. Provider (PCP, HH). Policies and procedures; List of active partner providers and agencies; written agreements with partner providers and agencies; care coordination processes and services; clinical team's policies and procedures related to group decision-making. Provider (PCP, HH). 6. Develop a comprehensive care management plan for each patient to engage him/her in care and to reduce patient risk factors.. 7. Establish partnerships between primary care providers and the local Health Home for care Each identified PCP establish partnerships management services. This plan should clearly with the local Health Home for care delineate roles and responsibilities for both management services. parties.. 8. Establish partnerships between the primary care providers, in concert with the Health Home, with network resources for needed services. Where necessary, the provider will work with local government units (such as SPOAs and public health departments).. Project ID 2.a.iii. PPS has established partnerships to medical, behavioral health, and social services.. PPS uses EHRs and HIE system to facilitate and EHR vendor documentation; protocols for use document partnerships with needed services. of EHR vendor documentation for referrals. Unit Level. Project. Page 15.

(16) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iii Health Home At-Risk Intervention Program: Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services. Index Score = 46. Definition of Actively Engaged. The number of participating patients who completed a new or updated comprehensive care management plan.. Project Requirement. Metric/Deliverable. Data Source(s). PPS has adopted evidence-based practice guidelines for management of chronic conditions. Chronic condition appropriate evidence-based practice guidelines developed and process implemented.. Documentation of evidence-based practice guidelines; Process and workflow including responsible resources at each stage; Written training materials; List of training dates; Chronic condition evidence-based practice protocols; Training materials. Project. Meeting schedule; Meeting agenda; Meeting minutes; List of attendees. Project. Meeting minutes; List of attendees; agreements with social services agencies. Project. Educational materials; evaluation of materials for cultural competence. Project. 9. Implement evidence-based practice guidelines to address risk factor reduction as well as to ensure appropriate management of chronic diseases. Develop educational materials consistent with cultural and linguistic needs of the population.. Project ID 2.a.iii. Regularly scheduled formal meetings are held to develop collaborative evidence-based care practices. PPS has included social services agencies in development of risk reduction and care practice guidelines. Culturally-competent educational materials have been developed to promote management and prevention of chronic diseases.. Unit Level. Page 16.

(17) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iv Create a medical village using existing hospital infrastructure. Index Score = 54 �. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village in a year.. Project Requirement. Metric/Deliverable. Data Source(s). A strategic plan is in place which includes, at a minimum: - Definition of services to be provided in medical village and justification based on CNA - Plan for transition of inpatient capacity - Description of process to engage community stakeholders - Description of any required capital improvements and physical location of the medical village - Plan for marketing and promotion of the medical village and consumer education regarding access to medical village services. Complete strategic plan; Reports on progress in implementation that demonstrate a path to successful implementation within the timeframe committed to in the application. Project. Project must reflect community involvement in the development and the specific activities that will be undertaken during the project term.. Meeting minutes; List of attendees and organizations represented. Project. 1. Convert outdated or unneeded hospital capacity into an outpatient services center, stand-alone emergency department/urgent care center or other healthcare-related purpose.. Project ID 2.a.iv. Unit Level. Page 17.

(18) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iv Create a medical village using existing hospital infrastructure. Index Score = 54 �. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village in a year.. Project Requirement. Metric/Deliverable. Data Source(s). PPS has bed reduction timeline and implementation plan in place with achievable targeted reduction in "staffed" beds.. Certificate of Need (CON) for bed reduction; Bed reduction timeline; Baseline bed capacity; Periodic progress reports documenting bed reduction.. Unit Level. 2. Provide a detailed timeline documenting the specifics of bed reduction and rationale. Specified bed reduction proposed in the project must include active or “staffed” beds.. 3. Ensure that all participating PCPs meet NCQA 2014 Level 3 PCMH accreditation and/or meet All practices meet NCQA 2014 Level 3 PCMH state-determined criteria for Advanced and/or APCM standards. Primary Care Models by the end of DSRIP Year 3.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Provider (PCP). 4. Ensure that all safety net providers participating in Medical Villages are actively sharing EHR systems with local health EHR meets connectivity to RHIO’s HIE and information exchange/RHIO/SHIN-NY and SHIN-NY requirements. sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up.. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP, Non-PCP, Hospitals, BH). Project ID 2.a.iv. Project. Page 18.

(19) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.iv Create a medical village using existing hospital infrastructure. Index Score = 54 �. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village in a year.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. 5. PPS identifies targeted patients and is able to Use EHRs and other technical platforms to track actively engaged patients for project track all patients engaged in the project. milestone reporting.. Sample data collection and tracking system; EHR completeness reports (necessary data fields are populated in order to track project implementation and progress). 6. EHR meets Meaningful Use Stage 2 CMS Ensure that EHR systems used in Medical requirements (Note: any/all MU Villages meet Meaningful Use Stage 2 requirements adjusted by CMS will be incorporated into the assessment criteria).. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project (Medical Village Sites). 7. Ensure that services which migrate to a different setting or location (clinic, hospitals, etc.) are supported by the comprehensive community needs assessment.. Migration plan; Justification for migration as evidenced by CNA; Policies and procedures regarding frequency of updates to guidelines and protocols. Project. Project ID 2.a.iv. Strategy developed for migration of any services to different setting or location (clinic, hospitals, etc.).. Project. Page 19.

(20) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure. Index Score = 42. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village within a year.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. 1. Transform outdated (underperforming) Execute project to reduce outdated nursing nursing home capacity into a stand-alone home capacity into a stand-alone, "medical emergency department/urgent care center or village" other healthcare-related purpose.. Implementation plan to provide improved access; Reports on progress in implementation that demonstrate a path to successful implementation.. Project. 2. Provide a clear statement of how the infrastructure transformation program will promote better service and outcomes (service volume, occupancy statistics, etc.) for the community based upon the community needs assessment including, evaluation of specific planning needs for any Naturally Occurring Retirement Community (NORC) occurring within the PPS.. Implementation Plan; Reports on progress in implementation that demonstrate a path to successful implementation.. Project. Project ID 2.a.v. PPS has completed evaluation of community needs, including planning needs for NORCs, and has developed goals to provide improved access to needed services.. Page 20.

(21) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure. Index Score = 42. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village within a year.. Project Requirement. Metric/Deliverable. Data Source(s). PPS has developed a clear strategic plan, which includes, at a minimum: - Definition of services to be provided in medical village and justification based on CNA - Plan for transition of nursing home infrastructure to other needed services - Description of process to engage community stakeholders - Description of any required capital improvements and physical location of the medical village - Plan for marketing and promotion of the medical village and consumer education regarding access to medical village services. Reports on progress in implementation that demonstrate a path to successful implementation, in the timeframe committed to in the application, which shall include: - project report on status and challenges - status of progress towards achievement of core components based on project metrics in Work Plan. 3. Provide a clear description of how this reconfigured facility will fit into a broader integrated delivery system that is committed to high quality care and willing/able to participate in payment reform.. Project ID 2.a.v. Unit Level. Project. Page 21.

(22) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure. Index Score = 42. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village within a year.. Project Requirement. Metric/Deliverable. Data Source(s). 4. Provide clear documentation that demonstrates housing plans are consistent with the Olmstead Decision and any other federal requirements.. Medical village services and housing are compliant with Olmstead Decision and federal requirements.. Documentation of housing access to or integrated supports for elders and persons with disabilities. 5. Identify specific community-based services that will be developed in lieu of these beds based upon the community need.. PPS increases capacity of community-based services as identified in Community Needs Assessment.. 6. Use EHRs and other technical platforms to track all patients engaged in the project.. PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting.. 7. Ensure that all participating PCPs meet NCQA 2014 Level 3 PCMH accreditation and/or All practices meet NCQA 2014 Level 3 PCMH meet state-determined criteria for Advanced and/or APCM standards. Primary Care Models by the end of DSRIP Year 3.. Project ID 2.a.v. Documentation of new community services available; Baseline outpatient volume with periodic reports demonstrating increase in outpatient visits Sample data collection and tracking system; EHR completeness reports (necessary data fields are populated in order to track project implementation and progress) List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Unit Level. Project. Project. Project. Provider (PCP). Page 22.

(23) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.a.v Create a medical village/alternative housing using existing nursing home infrastructure. Index Score = 42. Definition of Actively Engaged. The number of participating patients who had two or more distinct non-emergency services from at least two distinct participating providers at a Medical Village within a year.. Project Requirement. Metric/Deliverable. 8. Ensure that all safety net providers participating in medical villages are actively sharing EHR systems with local health EHR meets connectivity to RHIO’s HIE and SHINinformation exchange/RHIO/SHIN-NY and NY requirements. sharing health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up.. 9. Ensure that EHR systems used in Medical Villages meet Meaningful Use Stage 2. Project ID 2.a.v. EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).. Data Source(s). Unit Level. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP, Non-PCP, SNF, BH). Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project (Medical Village sites). Page 23.

(24) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.i Ambulatory ICUs. Index Score = 36. Definition of Actively Engaged. The number of participating patients who had two or more distinct services at an Ambulatory ICU in a year.. Project Requirement. Metric/Deliverable. Data Source(s). PPS has recruited adequate specialty resources within the community including medical, behavioral, nutritional, rehabilitation, and other necessary providers to meet the population needs.. List of participating medical, behavioral, nutritional, rehabilitation, and other necessary providers; Evidence of service integration; documentation of staffing. Project (Ambulatory Sites). Standard Clinical Protocol. Project (Ambulatory Sites). 1. Ensure Ambulatory ICU is staffed by or has access to a network of providers including medical, behavioral health, nutritional, rehabilitation and other necessary provider specialties that is sufficient to meet the needs of the target population. PPS has established a standard clinical protocol for Ambulatory ICU services.. Unit Level. 2. Ensure Ambulatory ICU is integrated with all relevant Health Homes in the community.. List of participating Health Homes as well as Each identified Ambulatory ICU has community-based, non-physician participants established partnerships with the local Health (including complex specialty services e.g., Home based on the Nuka Model. housing, rehab, etc.). Project (Ambulatory Sites). 3. Use EHRs and other technical platforms to track all patients engaged in the project, including collecting community data and Health Home referrals.. Sample data collection and tracking system; PPS identifies targeted patients and is able to EHR completeness reports (necessary data track actively engaged patients for project fields are populated in order to track project milestone reporting. implementation and progress). Project. 4. Establish care managers co-located at each Ambulatory ICU site.. PPS has co-located health home care managers and social support services.. Project ID 2.b.i. Documented evidence of health home and social support care managers operating in Ambulatory ICU sites; Attestation. Project (Ambulatory Sites). Page 24.

(25) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.i Ambulatory ICUs. Index Score = 36. Definition of Actively Engaged. The number of participating patients who had two or more distinct services at an Ambulatory ICU in a year.. Project Requirement. Metric/Deliverable. 5. 6. Project ID 2.b.i. Unit Level. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP, NonPCP, Hospitals, BH). EHR vendor documentation; Screenshots or other evidence of use of alerts and secure messaging; written training materials; list of training dates along with number of staff trained in use of alerts and secure messaging. Project. EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).. Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project. PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. EHR meets connectivity to RHIO’s HIE and Ensure that all safety net project participants SHIN-NY requirements. are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including Direct exchange (secure PPS uses alerts and secure messaging messaging), alerts and patient record look up. functionality.. Ensure that EHR systems used by participating providers meet Meaningful Use and PCMH Level 3 standards and/or APCM.. Data Source(s). Provider (SN: PCP). Page 25.

(26) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.i Ambulatory ICUs. Index Score = 36. Definition of Actively Engaged. The number of participating patients who had two or more distinct services at an Ambulatory ICU in a year.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. 7. Implementation of a secure patient portal that supports patient communication and Secure patient portal supporting patient engagement as well as provides assistance for communication and engagement. self-management.. Evidence of portal development and functionality; Screenshots of patient communication system; staff training documentation. Project. 8. Establish a multi-disciplinary, team-based care review and planning process to ensure Policies and procedures are in place for team that all Ambulatory ICU patients benefit from based care planning. the input of multiple providers.. Documentation of process/procedures and workflow including responsible resources at each stage; Written training materials; List of training dates; Number of staff trained. Project. 9. Deploy a provider notification/secure messaging system to alert care managers and EHR System with Real Time Notification Health Homes of important developments in System is in use. patient care and utilization.. System design; Screenshots of Real Time Notification System; Training Documentation. Project. 10. Sample data collection and tracking system; PPS identifies targeted patients and is able to EHR completeness reports (necessary data Use EHRs and other technical platforms to track actively engaged patients for project fields are populated in order to track project track all patients engaged in the project. milestone reporting. implementation and progress). Project. Project ID 2.b.i. Page 26.

(27) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening.. Project Requirement. Metric/Deliverable. 1. Ensure appropriate location of the co-located primary care services in the ED to be located Relocated PCMH practices located in the ED on the same campus of the hospital. All achieve NCQA 2014 Level 3 PCMH standards relocated PCMH practices will meet NCQA and/or APCM 2 years after relocation. 2014 Level 3 PCMH standards and/or APCM within 2 years after relocation.. Project ID 2.b.ii. Data Source(s). Unit Level. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation; Evidence of appropriate co-location of primary care services.. Provider (PCP). Page 27.

(28) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. All practices meet NCQA 2014 Level 3 PCMH and/or APCM standards.. List of participating NCQA-certified and/or APC-approved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Provider (PCP). Scheduling standards documentation; Report showing third next available appointment, which could include a 1.) new patient physical, 2.) routine exam or 3.) return visit exam [Institute for Healthcare Improvement measures]; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation. Provider (PCP). Scheduling standards documentation; Report showing third next available appointment, which could include a 1.) new patient physical, 2.) routine exam or 3.) return visit exam [Institute for Healthcare Improvement measures]; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation. Provider (PCP). 2. Ensure that new participating PCPs will meet All new practices meet NCQA 2014 PCMH 1A NCQA 2014 Level 3 Medical Home standards scheduling standards. or NYS Advanced Primary Care Model standards by the end of DSRIP Year 3. At start up, the participating PCPs must have open access scheduling extended hours, and have EHR capability that is interoperable with the ED.. All new practices meet NCQA 2014 PCMH 1B scheduling standards.. Project ID 2.b.ii. Page 28.

(29) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening.. Project Requirement. Metric/Deliverable. 3. Care management protocols and procedures, consistent with EMTALA standards, for triage Develop care management protocols for triage and referral to ensure compliance with and referral are developed in concert with practitioners at the PCMHs and/or APCM sites EMTALA standards. and are in place.. 4. EHR supports secure notifications/messaging Ensure utilization of EHR that supports secure and the sharing of medical records. notification/messaging and sharing of medical records between participating local health EHR meets Meaningful Use Stage 2 CMS providers, and meets Meaningful Use Stage 2 requirements (Note: any/all MU CMS requirements. requirements adjusted by CMS will be incorporated into the assessment criteria.). 5. Establish protocols and training for care coordinators to assist patients in understanding use of the health system, and to promote self-management and knowledge on appropriate care.. Project ID 2.b.ii. Care Coordinator and ED policies and procedures are in place to manage overall population health and perform as an integrated clinical team.. Data Source(s). Unit Level. Care Management protocols and procedures; Documentation of process and workflow including responsible resources at each stage of the workflow; Written training materials; List of training dates along with number of staff trained. Project. QE participant agreements; sample of transactions to public health registries; Evidence of DIRECT secure email transactions. Provider (SN: PCP, Hospital). Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project. Policies and procedures; Documentation of process and workflow including responsible resources at each stage of the workflow; Written training materials; List of training dates along with number of staff trained. Project (colocation site). Page 29.

(30) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. Project Requirement Implement a comprehensive payment and billing strategy. (The PCP may only bill usual 6 primary care billing codes and not emergency billing codes.) Develop protocols for connectivity to the assigned health plan PCP and real-time 7 notification to the Health Home care manager as applicable.. 8. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening. Metric/Deliverable. Data Source(s). Unit Level. The PCP bills only primary care, not emergency, billing codes.. Periodic self-audit of procedure codes billed; payment agreements only allowing nonemergency billing codes. Project (colocation site). EHR System with Real Time Notification System is in use.. Protocols; Screenshots of Real Time Notification System; Training Documentation. Project. Program Budget; Protocols; Written attestation or evidence of agreement with Community Organizations; Written training materials. Project. Community awareness program to raise Utilize culturally competent community based awareness of alternatives to the emergency organizations to raise community awareness room is established with community-based of alternatives to the emergency room. organizations.. Project ID 2.b.ii. Page 30.

(31) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. PCMH 1A Access During Office Hours scheduling to meet NCQA standards established across all PPS primary care sites.. Scheduling standards documentation; Report showing third next available appointment, which could include a 1.) new patient physical, 2.) routine exam or 3.) return visit exam [Institute for Healthcare Improvement measures]; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation; Other Sources demonstrating implementation. Provider (PCP). PCMH 1B After Hours Access scheduling to meet NCQA standards established across all PPS primary care sites.. Scheduling standards documentation; Report showing third next available appointment, which could include a 1.) new patient physical, 2.) routine exam or 3.) return visit exam [Institute for Healthcare Improvement measures]; Response times reporting; Materials communicating open access scheduling; Vendor System Documentation; Other Sources demonstrating implementation. Provider (PCP). PPS monitors and decreases no-show rate by at least 15%.. Baseline no-show rate with periodic reports demonstrating 15% no-show rate reduction. Provider (PCP). 9. Implement open access scheduling in all primary care practices.. Project ID 2.b.ii. Page 31.

(32) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.ii Development of Co-Located Primary Care Services in the Emergency Department. Index Score = 40. Definition of Actively Engaged. The number of participating patients who presented at the ED but were successfully and appropriately redirected to a PCMH/APCM site, after medical screening.. Project Requirement. Metric/Deliverable. 10. PPS identifies targeted patients and is able to Use EHRs and other technical platforms to track actively engaged patients for project track all patients engaged in the project. milestone reporting.. Project ID 2.b.ii. Data Source(s) Sample data collection and tracking system; EHR completeness reports (necessary data fields are populated in order to track project implementation and progress). Unit Level. Project. Page 32.

(33) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2.b.iii ED care triage for at-risk populations. Index Score = 43. Definition of Actively Engaged. The number of participating patients presenting to the ED, who after medical screening examination were successfully redirected to a PCP as demonstrated by a scheduled appointment.. Project Requirement Establish ED care triage program for at-risk 1 populations. Metric/Deliverable Stand up program based on project requirements. 2. All practices meet NCQA 2014 Level 3 Participating EDs will establish partnerships to PCMH and/or APCM standards. community primary care providers with an emphasis on those that are PCMHs and have EHR meets Meaningful Use Stage 2 CMS open access scheduling. a. Achieve NCQA 2014 Level 3 Medical Home requirements (Note: any/all MU requirements adjusted by CMS will be standards or NYS Advanced Primary Care Model standards by the end of DSRIP Year 3. incorporated into the assessment criteria.) b. Develop process and procedures to establish connectivity between the emergency department and community primary care providers. Encounter Notification Service (ENS) is c. Ensure real time notification to a Health installed in all PCP offices and EDs Home care manager as applicable. Project ID 2.b.iii. Data Source(s) Project description & necessary resources and key challenges. List of participating NCQA-certified and/or APCapproved physicians/practioners (APC Model requirements as determined by NY SHIP); Certification documentation. Unit Level Project. Provider (PCP). Meaningful Use certification from CMS or NYS Medicaid or EHR Proof of Certification. Project. Contract Review of PPS; Encounter Notification Summary; Report; Vendor System Documentation; Other Sources demonstrating implementation of the system. Provider (PCP and Hospital). Page 33.

(34) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2.b.iii ED care triage for at-risk populations. Index Score = 43. Definition of Actively Engaged. The number of participating patients presenting to the ED, who after medical screening examination were successfully redirected to a PCP as demonstrated by a scheduled appointment.. Project Requirement. Metric/Deliverable. Data Source(s). A defined process for triage of patients from patient navigators to non-emergency PCP and needed community support resources is in place.. Protocol documentation; Detailed Steps and Process Flows within the ER; Other Sources demonstrating implementation of the system; list of non-emergent encounters eligible for triage. 3. For patients presenting with minor illnesses who do not have a primary care provider: a. Patient navigators will assist the presenting patient to receive an immediate appointment with a primary care provider, after required medical screening examination, to validate a non-emergency need. b. Patient navigator will assist the patient with identifying and accessing needed community support resources. c. Patient navigator will assist the member in receiving a timely appointment with that provider’s office (for patients with a primary care provider).. Project ID 2.b.iii. Unit Level. Project. Page 34.

(35) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2.b.iii ED care triage for at-risk populations. Index Score = 43. Definition of Actively Engaged. The number of participating patients presenting to the ED, who after medical screening examination were successfully redirected to a PCP as demonstrated by a scheduled appointment.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. Protocol documentation; ED encounter report includes billings algorithm categorization including 1. Non-Emergent 2. Emergent/Primary Care Treatable (CAT Scans or Lab Test) 3. Emergent ED Care Needed/Avoidable (asthma flare-ups, diabetes, heart failure, etc...) 4. Emergent ED Care Needed - Not Preventable/Avoidable. Provider (Hospital). 4. Established protocols allowing ED and first responders - under supervision of the ED practitioners - to transport patients with non- PPS has protocols and operations in place to transport non-acute patients to acute disorders to alternate care sites appropriate care site. (Optional). including the PCMH to receive more appropriate level of care. (This requirement is optional.). 5. Sample data collection and tracking system; PPS identifies targeted patients and is able EHR completeness reports (necessary data Use EHRs and other technical platforms to to track actively engaged patients for fields are populated in order to track project track all patients engaged in the project. project milestone reporting. implementation and progress). Project ID 2.b.iii. Project. Page 35.

(36) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions. Index Score = 43. Definition of Actively Engaged. The number of participating patients with a care transition plan developed prior to discharge.. Project Requirement Develop standardized protocols for a Care Transitions Intervention Model with all 1 participating hospitals, partnering with a home care service or other appropriate community agency.. Metric/Deliverable. Data Source(s). Standardized protocols are in place to manage overall population health and perform as an integrated clinical team are in place.. Documentation of process and workflow including responsible resources at each stage of the workflow; written training materials; training documentation. Project. A payment strategy for the transition of care services is developed in concert with Medicaid Managed Care Plans and Health Homes.. Payment Agreements or MOUs with Managed Care Plans. Project. 2. Engage with the Medicaid Managed Care Organizations and Health Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed.. Coordination of care strategies focused on care transition are in place, in concert with Medicaid Managed Care groups and Health Homes.. PPS has protocol and process in place to identify Health-Home eligible patients and link them to services as required under ACA.. Project ID 2.b.iv. Documentation of methodology and strategies including identification of responsible resources at each stage of the workflow; Periodic self-audit reports and recommendations; Written attestation or evidence of coordination of care transition strategies with Health Homes and the supportive housing site Documentation of process and workflow including responsible resources at each stage of the workflow; Written training materials; List of training dates along with number of staff trained. Unit Level. Project. Project. Page 36.

(37) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions. Index Score = 43. Definition of Actively Engaged. The number of participating patients with a care transition plan developed prior to discharge.. Project Requirement. Metric/Deliverable. 3. 4. Ensure required social services participate in the project.. Transition of care protocols will include early notification of planned discharges and the ability of the transition care manager to visit the patient in the hospital to develop the transition of care services.. Project ID 2.b.iv. Required network social services, including medically tailored home food services, are provided in care transitions.. Policies and procedures are in place for early notification of planned discharges. PPS has program in place that allows care managers access to visit patients in the hospital and provide care transition services and advisement.. Data Source(s) Support Services Lists; Documentation of process and workflow including responsible resources at each stage of the workflow; Written attestation or evidence of agreement; Periodic self-audit reports and recommendations Documentation of early notification of planned discharge process and workflow including responsible resources at each stage; Written training materials; List of training dates; Number of staff trained Contract; Vendor System Documentation; Documentation demonstrating that the care manager has access to visit their patients in the hospital. Unit Level. Project. Provider (PCP, NonPCP, Hospitals). Project. Page 37.

(38) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.iv Care transitions intervention model to reduce 30 day readmissions for chronic health conditions. Index Score = 43. Definition of Actively Engaged. The number of participating patients with a care transition plan developed prior to discharge.. Project Requirement. Metric/Deliverable. Data Source(s). Unit Level. 5. Policies and procedures are in place for Protocols will include care record transitions including care transition plans in patient with timely updates provided to the medical record and ensuring medical record is members’ providers, particularly primary care updated in interoperable EHR or updated in provider. primary care provider record.. Documentation of care record transition process and workflow including responsible resources at each stage; Written training materials; List of training dates; Number of staff trained; Periodic self-audit reports and recommendations. Project. 6. Policies and procedures reflect the Ensure that a 30-day transition of care period requirement that 30 day transition of care is established. period is implemented and utilized.. Policies and Procedures. Project. 7. Sample data collection and tracking system; PPS identifies targeted patients and is able to EHR completeness reports (necessary data Use EHRs and other technical platforms to track actively engaged patients for project fields are populated in order to track project track all patients engaged in the project. milestone reporting. implementation and progress). Project ID 2.b.iv. Project. Page 38.

(39) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.v Care transitions intervention for skilled nursing facility (SNF) residents. Index Score = 41. Definition of Actively Engaged. The number of participating patients with a care transition plan developed prior to discharge.. Project Requirement. Metric/Deliverable. Data Source(s). Partnership agreements are in place between hospitals and SNFs and include agreements to coordinate post-admission care.. Written agreements; Network provider list. Project. SNFs and hospitals have developed care transition policies and procedures, including coordination of thorough and accurate postadmission medical records; ongoing meetings are held to evaluate and improve process.. Policies and Procedures; Meeting minutes. Project. 1. Partner with associated SNFs to develop a standardized protocol to assist with resolution of the identified issues.. Project ID 2.b.v. Unit Level. Page 39.

(40) New York Department of Health Delivery System Reform Incentive Payment (DSRIP) Program Domain 1 DSRIP Project Requirements Milestones and Metrics. Project Domain Project ID Project Title. System Transformation Projects (Domain 2) 2.b.v Care transitions intervention for skilled nursing facility (SNF) residents. Index Score = 41. Definition of Actively Engaged. The number of participating patients with a care transition plan developed prior to discharge.. Project Requirement. Metric/Deliverable. Data Source(s). PPS has engaged with Medicaid Managed Care and Managed Long Term Care or FIDA plans to develop coordination of care and care transition strategies; PPS has developed agreements and protocols to provide post-admission transition of care services.. Written agreements; Policies and Procedures; Documentation of process and workflow including responsible resources at each stage. Project. Covered services, including Durable Medical Equipment, are available for the identified population.. Contract; Report; Other sources demonstrating service availability. Project. A payment strategy for the transition of care services is developed in concert with Medicaid Managed Care and Managed Long Term Care or FIDA Plans.. Documentation of methodology and strategies including identification of responsible resources at each stage of the workflow; Periodic self-audit reports and recommendations; Written attestation or evidence of payment agreements. Project. 2. Engage with the Medicaid Managed Care Organizations and Managed Long Term Care or FIDA Plans associated with their identified population to develop transition of care protocols, ensure covered services including DME will be readily available, and that there is a payment strategy for the transition of care services.. Project ID 2.b.v. Unit Level. Page 40.

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