DOH REVIEW AND EXECUTIVE SUMMARY OF PPS PRIMARY CARE PLAN

DECEMBER, 2016

PPS NAME: SISTERS OF CHARITY HOSPITAL OF BUFFALO, NY/AKA COMMUNITY PARTNERS OF WNY (CPWNY)

Catholic Medical Partners (CMP) IPA is part of the Catholic Health System (CHS) and the PMO for the PPS as well as an ACO that brings its resources to PPS project implementation. The PPS covers Erie, Niagara and Chautauqua counties that include HPSAs and MUAs. Active collaboration with Millennium PPS for coordination with overlapping network providers.

Overall Assessment: Strong primary care plan with active project implementation. Expansion of CMP resources and partnership to Chautauqua County Health Network, strengthening regional primary care networks and providing practice transformation resources to community-based providers.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • There are two physician teams in the PPS – 1) CMP with 990 independent primary care providers and specialists including 98 community–based primary care practices. 2) Chautauqua County Health Network (CCHN) has partnered with CMP to support 7 large community practices that service large portions of Medicaid patients.
  • Both provider groups are using workforce strategies to recruit primary care providers– signing bonuses by CMP into CHS clinic sites. Also, use of National Health Service Corps and Doctors Across NY. Six PCPs, 4 PC residents and 27 mid–level practitioners recruited in 2015 by CHS.
  • Chautauqua has activities to foster "home–grown" professionals and 4 home–grown physicians returned to practice in the county.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • CMP resources provided to the PPS include a mobile team of practice transformation staff trained to assist practices in achieving PCMH recognition, achieve meaningful use and transition to a population health management model of care.
  • The PMO project teams employ staff educators and trainers experienced in teaching rapid cycle improvement, case/chronic care management for high–risk conditions, palliative care and BH.
  • CPWNY has engaged key behavioral health partners to work with primary care sites to provide training, consultation, care coordination, and triage.
  • PPS has partnered with NYS Smokers Quitline to provide training to CMP and CCHN primary care practices on cessation resources and counseling services.
  • CCHN has applied for Practice Transformation Technical Assistance Services funding through the NYS DOH in order to assist small rural providers.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Primary care is central to CMP and CCHN activities as ACOs and applies the same approach to the PPS network. CMP provides centralized resources to strengthen PCPs in the IDS such as social work, care management, data sharing, performance management, training and other education efforts.
  • CMP providers establish referral agreements between PCP practices and specialty providers, including communication channels, contact information, and best practice on warm handoffs. Trainings also provided to encourage cross–specialty communication and efficient use of specialty services.
  • In the future, communication tools in a care management module accessed by the CMP Social Work team will support coordination among inpatient teams.
  • CCHN works with Health Managers and Guided Care Nurses within the PCPs to strengthen care coordination and chronic disease management with their patients.
  • CCHN's two Clinical Transformation Coordinators hold monthly Learning Community meetings with PCPs in attendance.
  • Practitioner professional committees and stakeholder groups represented in the PPS governance structure. 3 community–based (non–hospital) primary care providers and 2 hospital–based providers within the 19 person–voting member of the EGB board. Three community–based (non– hospital) primary care providers within the 12–person voting member roster of the CGC board.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • CMP and CCHN currently participate in VBP arrangements with CMP targeting the Medicaid managed care population. CCHN is working with its physician partners to obtain VBP arrangements for their Medicaid populations. CMP meets regularly with MCOs.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • CMP has 6 full–time employees working as clinical transformation staff to support practices pursuing PCMH. DSRIP funds support 1 FTE spread among 6 full–time employees to allow for flexibility in resource planning. This staff supports approximately 84 primary care practices.
  • CCHN has 2 full–time employees working as clinical transformation staff with DSRIP funds supporting 1 FTE spread among the 2 full–time employees. 7 primary care practices are supported by this staff with 2 practices PCMH recognized.
  • $1.1 million to 228 primary care practitioners in 99 CMP primary care practices.
  • Approximately $110 thousand paid to 7 primary care practices in Chautauqua County.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • CPWNY has developed a model for behavioral health partners to establish a counselor at designated primary care practice sites to do initial screenings and consultations, and connect patients with the appropriate level of BH care.
  • Pilot model using community health workers to offer care management for behavioral health patients and connections with primary care services.
  • Exploring to integrate satellite clinic at a large primary care practice to offer a full range of mental and behavioral health services at the primary care site.
  • 65% of CPWNY PCPs are PCMH recognized and have adopted PHQ–2/9 screenings.
  • 77 CMP practices hold referral agreements with CMP behavioral health providers, covering around 240 primary care providers and 5 behavioral health partners.
  • Under Model 1, CPWNY has contracted or is contracting with 9 behavioral health satellite clinic sites to collaborate at primary care practices.