DOH REVIEW AND EXECUTIVE SUMMARY OF PPS PRIMARY CARE PLAN

DECEMBER, 2016

PPS NAME: MONTEFIORE HUDSON VALLEY COLLABORATIVE (MHVC)

MHVC is contracting with 69 key partner organizations in seven counties that include 984 PCPs (78% of total amount of PCPs in the MHVC network), serving over 242,000 Medicaid members. 42% of MHVC´s PCPs have a panel size greater than 100 and 15% have a Medicaid panel size of zero. 55% of MHVC´s total Medicaid membership are served by physicians with a panel size of over 500. 21% of MHVC´s PCPs offer extended hours of care to patients, and PCPs in the MHVC network provide an average of 30 hours of care per week.

Overall Assessment: Plan is extensive and thorough. MVHC has a strong commitment to the PCMH model and a robust plan for an IDS and BH integration. PCPs are involved in Governance and other Committees and are recognized as the backbone of MHVC´s healthcare transformation model.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • MHVC has 205 organizations in its network that have a minimum of 1 PCP
    • 10 organizations have obtained PCMH 2014 Level 3 certification, including 456 PCPs.
    • 2 organizations, representing 10 PCPs, are currently PCMH 2011 certified.
  • MHVC plans to expand PC by focusing on 5 key areas:
    • Increasing access to primary care by supporting the PCMH model;
    • Optimizing CRFP awards to expand PC capacity in the Hospital´s service area;
    • Deployment of the medical village to address inefficient resource usage & improve access;
    • Assisting providers to transition to the VBP model, through training; and programmatic enhancements to infrastructure that will support VBP; and
    • Exploring the opportunity to partner with the urgent care and retail clinics in Hudson Valley.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • PCDC conducting Network Assessment and Practice Readiness Assessments.
  • Worked with WMC PPS to divide up practices based on actual member attribution.
  • 2 approaches to TA:
    • 1:1 coaching model
    • Group TA
  • In collaboration with the National Council of Behavioral Health and North Shore–LIJ, MHVC was granted a competitive Practice Transformation Network award to improve primary care and behavioral health outcomes for adults with Serious Mental Illness.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Developing a model of an IDS where the PCP is at the center, supporting:
    • Connection to broader networks of care, including CBOs, MH providers and others;
    • Involvement in VBP arrangements, in accordance with the NY State Roadmap;
    • PCP education and resources such as IT for data analytics; and
    • Care management support for PCP success in a VBP reimbursement environment
  • Governance structures and Committees include community and institutional PCPs. Inclusion of PCPs with varying levels of infrastructure critical to the design of IDS, development of shared service models and creating standards for clinical projects.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Providing consistent & meaningful message to PCPs: "What does VBP mean for me?"
  • Engaged diverse stakeholder groups in a facilitated activity that led to creation of a series of process maps of the patient journey through care continuum per project.
  • Leveraging Montefiore´s existing experience with risk–based contracting and care management activities to educate providers on VBP arrangements and the benefits of IPA membership.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • MHVC focused on the MHVC partners that represented more than 90% of its network attribution.
  • To date, approximately $4.8m of $11m for partner activities have been distributed through January 2017, with $2m to PCPs/clinics.
  • $1.7m to PCDC to support PCMH transformation.
  • $500k annually of MHVC´s personnel budget supports PCMH efforts.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • 19 organizations (13 – Model 1; 2 –Model 2; 6 –Model 3)
  • More than 40 unique sites and more than 300 PCPs participating in BHI activities.
  • Every DSRIP project to consider the behavioral health needs of all members.
  • Launched 18 month BHI learning collaborative starting November 1, 2016.
  • Contracting with the University of Washington so provider partners will have access to the UW registry to guide efficient case reviews.
  • Screening for SU as part of the initial 5 item BH screen administered to all patients
  • Ability of staff to support patient self–management is foundational to all of MHVC´s DSRIP projects and achievement of Performance Metrics. Partnered with the Centre for Collaboration, Motivation & Innovation (CCMI) to provide an opportunity for select staff at network partner sites to become trainers in Brief Action Planning and Motivational Interviewing.
  • Exploring use of tele–health as a method for the delivery of healthcare via consultations and other collaboration, when co–location is not a viable option.