DOH REVIEW AND EXECUTIVE SUMMARY OF PPS PRIMARY CARE PLAN

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DSRIP Mid–Point Assessment Report

Central New York Care Collaborative (CNYCC)

PPS Response
December 2016

I. Purpose

This document is the Central New York Care Collaborative Inc. (CNYCC) response to the New York State DSRIP Independent Assessor´s Mid–Point Assessment and the subsequent public comment period

II. Overview

On November 29, 2016 the New York State Department of Health´s DSRIP Independent Assessor (IA) released for public comment the Mid–Point Assessment Report. The Mid–Point Assessment provides a detailed overview of program development to monitor the progress each individual PPS across the state has made in meeting DSRIP goals and objectives.

The IA relied on the following key data sources in development of the Mid–Point Assessment Report:

  • Approved DSRIP Project Plans
  • PPS Quarterly Reports - DY1, Q1 through DY2, Q2
  • 360 Survey of PPS Network Partners
  • PPS Project Narratives

The Mid–Pont Assessment findings were presented in the form of three separate reports: 1.) Mid– Point Assessment, 2.) 360 Survey Appendix, and 3.) Partner Engagement Appendix. The following narrative outlines CNYCC´s response to the Mid–Point Assessment.

III. CNYCC Mid–Point Assessment Response

CNYCC has carefully reviewed the full–text of the Mid–Point Assessment Report (including Partner Appendix and 360 Survey) and offers the following response to the topics outlined below:

  1. Independent Assessors (IA) Analysis
    • The IA noted in their findings CNYCC´s successful completion of all available Organizational AVs and two (out of two) possible Patient Engagement Speed AVs in DY1, Q2; and four (out of five) available Organizational AVs and six (out of six) possible Patient Engagement Speed AVs in DY1, Q4.
    • The IA also noted that CNYCC failed to earn the Workforce Organizational AV for failing to meet the minimum threshold for Workforce Spending in DY1.
    • CNYCC Response: CNYCC is pleased to have successfully completed activities to meet required milestones for Organizational and Patient Engagement Achievement Values (AVs) in DY1 and will continue to introduce efforts to complete these activities.
    • The AV associated with Workforce is currently evaluated on an "all or nothing" basis. One of the multiple workforce milestones is attainment of a workforce strategy spending target. The spending target is based on projections submitted during the application period of the PPS in December 2014 (based upon our best estimates and guidance available at the time). Unfortunately, subsequent guidance from the State has reduced the kinds of spending that can be counted towards the workforce strategy spending target. As a result, CNYCC missed that target and forfeited the entire workforce AV in DY1 Q4. Since performance against the workforce strategy spending target is evaluated in every Q2 and Q4 report, CNYCC is at high risk of forfeiting the workforce AV and associated PPS payment in every payment–driving quarter for the rest of the DSRIP program despite meeting all other workforce–related milestones, such as completing labor–intensive staff impact reporting and compensation and benefits surveys.
    • Currently in the DSRIP Program, not all AVs are evaluated in this "all–or–nothing" manner with some AVs being eligible for partial payments. CNYCC would greatly appreciate the consideration of allowing the Workforce AV to be a partial payment, rather than the all–or– nothing manner that it is currently assessed. This change would benefit other PPSs that either have or expect to face similar challenges in meeting the workforce strategy spending target in the future. Absent some strategy to address this risk, it will become increasingly difficult for PPSs to justify to partner organizations the commitment of effort and resources in completing other workforce milestones (such as staff impact reporting and compensation and benefits surveys) for which no funding will be earned. A request to this effect has been advanced to the Department of Health for consideration.
  2. Organizational Assessment
    • The IA evaluated CNYCC´s organizational capacity to support successful implementation of DSRIP and in meeting DSRIP goals. The IA reviewed several key organizational areas as part of their review. Below is a summary of these areas and CNYCC´s response to each assessment:
    • PPS Governance
    • The IA noted CNYCC´s overall Governance structure, highlighted by the development of a 22 member Board of Directors and a robust Committee configuration. The IA also noted concerns related to the challenges CNYCC has faced in filling several vacant positions including Chief Medical Officer and Director of Finance positions.
    • CNYCC Response: CNYCC will continue to develop its Board and Committee structure to be representative of the various partner organizations of the PPS. The Board and Committee structure also plays a key role in partner engagement and participation in PPS activities.
    • In regards to organizational efforts to fill key vacancies, since the submission of the Mid– Point Assessment, CNYCC hired Dr. Joseph Maldonado, MD to the position of Chief Medical Officer. Dr. Maldonado has over 25 years of healthcare experience in various organizations across the PPS, including serving as the Immediate–Past President of the Medical Society of the State of New York. Additionally, CNYCC is actively recruiting to fill the Director of Finance vacancy. Over the past few months, CNYCC has interviewed several prospective candidates for the position, even extending a formal offer to a candidate, which was unfortunately not accepted. Currently, CNYCC is working with several recruiting firms to identify qualified applicants and hopes to fill the vacancy shortly.
    • Notwithstanding our on–going recruitment efforts to secure a Director of Finance, since inception of CNYCC, financial management services have been provided by Iroquois Healthcare Alliance, with financial policies and procedures developed to ensure internal financial controls.
    • Formal reporting of CNYCC financial statements are routinely presented to the Board of Directors and Finance Committee. Additionally, an external audit performed by Fust Charles Chambers LLP resulted in a clean audit report for CNYCC for Calendar Year 2015.
    • PPS Administration and Project Management Office
    • The IA reviewed CNYCC´s overall spending related to administrative costs and noted that CNYCC currently spends less per attributed life than the statewide average. The IA further noted the importance of establishing and maintaining an organizational structure to support implementation of DSRIP projects to ensure the success of the PPS in meeting DSRIP goals.
    • CNYCC Response: As mentioned previously, CNYCC has taken steps to fill current administrative vacancies (CMO, Dir. of Finance) that impact overall spending. Additionally, CNYCC will continue to make investments to fully support PPS partners and the administration of the PPS as the DSRIP program moves ahead. This investment is likely to increase CNYCC´s overall spending per attributed life and result in a ratio more reflective of the statewide average.
    • Community Based Organization Contracting
    • The IA report referenced CNYCC´s current activities in finalizing contracts with Community Based Organizations (CBO). The report notes that based on information gathered from the DY2, Q2 PPS Quarterly Report, and IA on–site visit it was not clear as to the status of CBO Contracting with the PPS. The report further notes that based on the amount of money allocated to CBO partners ($6,678.78) that CNYCC needs to expand fund distribution to include all partners to maintain engagement.
    • CNYCC Response: As noted in the IA report, during the on–site visit CNYCC presented an outline of CBO engagement efforts, including successful contracting with CBO partners. CNYCC has developed strong relationships with CBO partners through various engagement efforts and is currently contracted with approximately 20 CBOs. Additionally, CNYCC will continue efforts to engage CBOs for PPS participation and intends to provide a revised status update in the DY2Q3 quarterly report.
    • Regarding funds flow, since the end of DY2 Q2, CNYCC has distributed an additional $1.5M in partner payments, an increase of 20% from the previous quarter. Part of this distribution included an increase in the amount awarded to CBO partners ($41,065.39). This represents an increase of funds flow to CBO partners from 0.07% to 0.48% of total funds distributed to partners. A limiting factor in funding for CBO partners is the non–safety–net designation of the majority of those organizations, which subjects them to participation in a very limited pool of PPS funds (not to exceed 5% of the PPS´s total project earnings).
    • Additionally, CNYCC is actively working to facilitate contracting relationships between Non– Safety–Net and Safety–Net providers to allow increased funds flow opportunities across PPS provider types, including CBO partners.
    • Cultural Competency and Health Literacy
    • The IA report provided an overview of CNYCC´s Cultural Competency/Health Literacy (CC/HL) Strategy and noted the need to develop an action plan to roll–out training to partners and the development of metrics to assess the effectiveness of engagement strategies.
    • CNYCC Response: CNYCC is in agreement with the IA recommendations and intends to develop an action plan that provides clear guidance on the roll–out of CC/HL activities across the PPS, training strategy/implementation to partner organizations, and development of metrics to track the effectiveness and reach of program.
    • Financial Stability and Value Based Purchasing
    • The IA report noted CNYCC´s efforts to assess financially fragile partners (on an annual basis) across the PPS and the development of a process to assist partners identified as "Very Financially Fragile".
    • The report also notes CNYCC´s efforts through an outside consultant to assist PPS partners with strategic planning for Value–Based Payment (VBP). The report also notes the importance of filling the Director of Finance vacancy.
    • CNYCC Response: CNYCC recognizes the importance of supporting financially "At–Risk" organizations providing services essential to the continuity of patient care and to the overall success of the PPS. CNYCC intends to continue these efforts on behalf of network partners, and has already provided assistance to a partner organization experiencing financial difficulty. CNYCC also take seriously its responsibility to prepare its partner network for the transition to Value Based Payment, which up to this point has primarily taken the form of VBP education and assessment of partner readiness. Additionally, CNYCC is actively recruiting to fill the Director of Finance position (as noted previously).
    • Funds Flow
    • The IA report references CNYCC´s distribution of DSRIP funds to– date. Based on the information collected for the Mid–Point Assessment, CNYCC ranked 18th (out of 25 PPS) in percentage of distribution of funds. The report also noted the heavy distribution of funds to Hospitals, the PPS PMO, and Clinics as well as the IA´s concern about lack of payment distribution across PPS providers (particularly Primary Care Physicians).

      Figure 5: PPS Funds Flow (through DY2, Q2)
      Total Funds Available (DY1) $25,082,462.72
      Total Funds Earned (through DY1) $24,630,798.16 (98.20%of Available Funds)
      Total Funds Distributed (through DY2, Q2) $10,008,030.79 (40.63%of Earned Funds)
      Partner Type Funds Distributed CNYCC (% of Funds Distributed) Statewide (% of Funds Distributed)
      Practitioner – Primary Care
      Physician (PCP)      		 $0.00 0.00% 3.9%
      Practitioner – Non–Primary Care
      Physician (PCP)      		 $0.00 0.00% 0.7%
      Hospital $4,927,906.27 49.24% 30.4%
      Clinic $1,160,921.82 11.60% 7.5%
      Case Management/Health Home $97,003.25 0.97% 1.3%
      Mental Health $215,758.44 2.16% 2.4%
      Substance Abuse $45,343.55 0.45% 1.0%
      Nursing Home $146,193.49 1.46% 1.2%
      Pharmacy $4,164.35 0.04% 0.0%
      Hospice $12,874.15 0.13% 0.2%
      Community Based Organizations $6,678.87 0.07% 2.3%
      All Other $303,596.24 3.03% 5.8%
      Uncategorized $19,914.05 0.20% 0.5%
      Non–PIT Partners $71,318.31 0.71% 0.6%
      PMO $2,996,358.00 29.94% 42.0%
      Figure 1 – PPS Quarterly Reports DY1,Q2, – DY2, Q2
    • CNYCC Response: A key factor impacting funds flow for CNYCC were delayed payments from the Department of Health. In addition to not receiving its first DY1 payment until late summer 2015, CNYCC receives the greatest share of its total funding (nearly half) of any PPS through the Equity Programs, which were significantly delayed in their roll–out and resulted in another delay in payment. Unfortunately, these delays prevented timely funds flow to partner organizations for activities completed in DY1.
    • CNYCC´s DY1 Board–approved payment policies were originally designed to disburse payment only upon completion of key deliverables by partner organizations. Many of these deliverables were complex in nature, requiring the investment of significant time and resources by partner organizations during the start–up period before receipt of payment. Recognizing the importance of funds flow on partner engagement, CNYCC expedited payments to partners via an "Accelerated Payment" program. CNYCC has also distributed an additional $1.5M in partner payments since the submission of the Mid–Point Assessment (as noted above).
      Eligible Partner Type Funds Distributed %
      Community–Based Organizations $41,065.39 0.48%
      Health Home/Care Management Agency $176,955.45 2.09%
      Home Health/Visiting Nurse/Hospice $161,749.57 1.91%
      Hospitals $2,865,579.08 33.83%
      Outpatient Mental Health & Substance Use $1,532,986.58 18.10%
      Primary Care Practices $3,362,921.61 39.70%
      Pharmacy $126,395.22 1.49%
      Skilled Nursing Facilities/Long–Term Care $202,478.65 2.39%
      Total $8,470, 131.54  
      Figure 2 – CNYCC Funds Flow Distribution – Updated Dec. 2016
    • A detailed view of funds by CNYCC– defined partner type eligible for specific payments reveals a more diverse distribution across network providers. For example, payments to a partner organization that both provides outpatient mental health services that is also a downstream Health Home care management agency would be split between both of those categories.
    • Further, under CNYCC´s current payment policies, individual providers (Primary Care Physicians or Non–PCPs) are not paid directly, instead payments are directed to practices, practice plans, or health systems that employ providers. This approach often skews funding allocations and attributes payments to hospitals that are actually the result of their role in providing primary care services.
    • Finally, CNYCC and its Board of Directors are committed to accelerating and enhancing the flow of funds to partner organizations to remove barriers to meaningful system transformation. CNYCC is redesigning its ongoing funds flow model to ensure incentives are clear, adequate, timely, inclusive, and simpler to administer across the entire partner network.
  3. Project Assessment
    • The IA evaluated CNYCC´s progress towards implementing DSRIP projects (through the Project Plan Application process). The IA relied on common data elements including: quarterly report information on completion of project milestones; meeting patient engagement targets; and PPS efforts to engage network partners for the completion of project milestones. Below is a summary of these areas and CNYCC´s response to each assessment:
    • PPS Project Milestone Status
    • The IA evaluated the current status of PPS Project Implementation based on information submitted as part of the DY2, Q2 Quarterly Report. The status indicators ranged from ´Completed´ to ´In Progress´ to ´On–Hold´. Based on CNYCC´s submission, the IA identified two projects; ED Care Triage for At–Risk Patients (2.b.iii), and Integration of Primary Care and Behavioral Health Services (3.a.i), as "At–Risk" due to current reporting status of implementation efforts in the DY2, Q2 Quarterly Report.
    • CNYCC Response: As noted in the IA report, the "At–Risk" designation for both projects were related to an optional milestone requirement in Project 2biii and the PPS not pursuing Model 3 for Project 3.a.i. Based on this additional information, the IA subsequently concluded that neither project was truly "At–Risk" for on–time completion.
    • Patient Engagement AVs
    • The IA evaluated current patient engagement targets through information submitted via the Quarterly Report. Based on this information, the IA identified two projects that missed patient engagement targets in at least one PPS quarterly report. The two projects in questions are: 2.a.iii (Health Home At–Risk Intervention Program), and 2.d.i (Implementation Patient Activation).
    • CNYCC Response: CNYCC recognizes the challenges in reaching patient engagement targets for each project and has developed a strategy to increase participation.
    • For Project 2.a.iii (Health Home At–Risk Intervention Program), CNYCC is establishing a joint Health Home/Primary Care Practice workgroup to identify co–location opportunities and address process issues within the project to improve coordination and communication.
    • CNYCC is also working with partner organizations to provide additional guidance on identification of eligible patients.
    • For Project 2.d.i (Implementation of Patient Activation), CNYCC is engaging additional partner organizations to participate in the project and looking at alternative ways to have screenings conducted remotely. CNYCC is also developing additional training opportunities for partner organizations with staff that have not yet been trained to deliver screenings.
    • Finally, for both projects CNYCC is working with partner organizations across the network in several venues to problem solve and obtain input and feedback to address current engagement, including Board and Committee meetings, Regional Project Advisory Committee meetings, and Learning Collaborative sessions.
    • A more detailed outline of mitigation strategies for both 2.a.iii (Health Home At–Risk Intervention Program; and 2.d.i (Implementation of Patient Activation) will be provided as part of CNYCC´s Action Plan for the Mid–Point Assessment (March 2017).
    • PPS Partner Engagement
    • The IA reviewed PPS engagement across the partner network relative to project implementation and Speed and Scale targets. The IA paid particular attention to engagement of Practitioners (Primary Care Providers) and Behavioral Health partners. Based on their review, the IA did not identify any limited partner engagement efforts. The IA does note some concern relative to the level and continuation of engagement given the limited funds flow distribution the PPS has awarded.
    • CNYCC Response: Comprehensive engagement efforts will continue across the entire partner network to ensure participation in PPS activities from various constituents. In addition, CNYCC is developing extensive modifications to funds flow to accelerate payments to partner organizations across all provider types.
    • PPS Projects At–Risk
    • The IA reviewed each project based on an analysis of project milestone status, Patient Engagement AVs and Partner Engagement. The IA also took into account the PPS Narratives for Projects "At–Risk" in its evaluation. Based on these factors, the IA identified the following projects "At–Risk":
    • Health Home At–Risk Intervention Program (2.a.iii) – The IA identified concerns for this project based on patient engagement reporting and provided the following recommendations:
    • Recommendation 1: The IA recommends that the PPS develop a training plan to educate PCPs on the care coordination requirements for this project.
    • Recommendation 2: The IA recommends that the PPS develop a care coordination resource to support PCPs.
    • Recommendation 3: The IA recommends that the PPS establish a system for identifying the targeted patients to assist the PCPs for this project as part of overall PPS population health strategy in working with its network partners.
    • Implementation of Patient Activation (2.d.i) – The IA identified concerns for this project based on patient engagement reporting and provided the following recommendations:
    • Recommendation 1: The IA recommends that the PPS finalize the contracts with partners participating in this project.
    • Recommendation 2: The IA recommends that the PPS increase the trainings available to assist partners in implementing this project.
    • CNYCC Response: CNYCC previously identified these two projects as being potentially "At– Risk" based on level of patient engagement in quarterly reporting. CNYCC´s Project Management Office has been working with partner organizations on project education, increased awareness and participation in both projects. Several presentations have already been made in various settings including Regional Project Advisory Committees, CNYCC Board of Directors and Committees, and in one–on–one meetings to solicit feedback from across the partner network. While a more formal strategy will be outlined as part of the Mid–Point Assessment Action Plan, CNYCC will continue to recruit participation in each project to improve participation and outcomes.
  4. 360 Survey
    • As part of the Mid–Point Assessment the IA prepared and disseminated a survey to PPS network partners to assess level of engagement with CNYCC. The survey was distributed to a random sample of CNYCC partners, across provider types, with a focus on specific areas of engagement including: governance, contracting/funds flow, project management, and information technology solutions. The IA noted that CNYCC partner participation in the "360 Survey" was relatively low compared to PPS counterparts, with only 31% participation. Additionally, results from the survey highlighted the need for continued development of fund flow across the network and additional partner engagement that focuses on project implementation and performance.
    • CNYCC Response: Since the submission of the survey and Mid–Point Assessment, CNYCC launched a Learning Collaborative (LC) series to support project implementation efforts and broad system transformation. The Learning Collaborative are monthly meetings that bring together organizations by specific affinity areas including: Hospital/Acute, Outpatient, CBO, and Post–Acute. The LC sessions are an opportunity to review and discuss DSRIP performance measurements across each project. LC sessions also provide an opportunity to identify best practices and introduce rapid cycle improvement techniques to assist partners in developing strategies for process/workflow changes. The Learning Collaborative Series will play a key role in addressing performance challenges, project implementation efforts and increasing engagement across the partner network.
    • Additionally, CNYCC is developing extensive modifications to funds flow to accelerate payments to partner organizations across all provider types.

IV. Conclusion

In closing, the Mid–Point Assessment process has been a valuable tool to help guide our PPS as we continue to implement the DSRIP program. A critical path to our success will be continued development of project implementation, engagement strategies, PHM System Integration, and supporting partners with the transition to Value–Based Payment. The findings of the Mid–Point Assessment confirm the strategic direction for our PPS partners and CNYCC for 2017 and beyond.

CNYCC would like to thank the New York State Department of Health, and the Independent Assessor for all of their hard work. We have found this process to be very helpful and we are truly excited about the future of our PPS as we work together with our partners to improve the health of our community.

Figure # 2 – CNYCC Funds Flow by Partner Type

CNYCC Funds Flow by Partner Type (December 2016)

Eligible Partner Type Funds Distributed %
Community–Based Organizations $41,065.39 0.48%
Health Home/Care Management Agency $176,955.45 2.09%
Home Health/Visiting Nurse/Hospice $161,749.57 1.91%
Hospitals $2,865,579.08 33.83%
Outpatient Mental Health & Substance Use $1,532,986.58 18.10%
Primary Care Practices $3,362,921.61 39.70%
Pharmacy $126,395.22 1.49%
Skilled Nursing Facilities/Long–Term Care $202,478.65 2.39%
Total $8,470, 131.54