News from Advocate Community Providers (ACP)

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December 6, 2016            Vol. 2, No. 13

Achieving Year-End Engagement Targets and Full DSRIP Funding

With a few simple steps, we can achieve our DSRIP engagement targets and ensure full incentive funding for the quarter ending December 31, 2016.

  • Follow and document the Engagement guidelines (below).
  • Provide access once a quarter for reporting, until ACP is able to run reports directly from your EMR.
Below is a summary of our DSRIP projects, their respective engagement goals and – very importantly – the coding that enables us to document your activity for DOH.

Project 3.a.i: Integration of Primary Care and Behavioral Health
Every patient age 12 and above seen by the PCP
Engagement: Every patient age 12 and above must have a PHQ2 screening at every visit.  If positive, administer a PHQ9.
Action: Use CPT code G8431 (Positive) or G8510 (Negative) when screening patient.
Project 3.b.i: Evidence-Based Strategies for Cardiovascular Disease
Target: Patients with Cardiovascular disease or Hyperlipidemia
Engagement: Every patient age 18 and above must have a lifestyle modification counseling documented.
Action: Implement Million Hearts Campaign - Use ACP reporting code LSM01

Project 3.c.i: Evidence-Based Strategies for Diabetes
Patients with Diabetes
Engagement: Every patient age 18 and above must have a documented HgbA1C in the quarter.
Action: Monitor HgbA1C - Lifestyle modification counseling documented
Project 3.d.iii: Evidence-Based Medicine Strategies for Asthma
Every patient with Asthma
Engagement: Every patient must have an Asthma action plan in place
Action: School/Work and Home Asthma action plan in place - Use ACP reporting code AST01

Project 2.a.iii: Health Home At-Risk Intervention Program
Patients with one progressive chronic disease, serious mental Illness or traumatic brain injury
Engagement: Every patient has a documented comprehensive care plan. Patient needs to be referred to care management/coordination services.
Action: Use ACP reporting code CP001

Project 2.b.iv: Care Transitions To Reduce 30-Day Readmissions
Every patient with a hospital admission
Engagement: Every patient has a pre-discharge planning and transitional care visit 7 - 10 days in office or at home
Action:  Use ACP reporting code PD001

Read about ACP's DSRIP Projects here...

Reducing Avoidable Hospitalizations:
Healthier Patients, Healthier Practices

ED Care Triage for At Risk-Populations tackles a problem that may seem to be beyond the control of a community physician: Reducing the reliance of Medicaid patients on hospital emergency departments (EDs) for routine care.

DSRIP Project 2.b.iii is focused on reducing preventable ED visits by identifying the root causes, including social determinants of health, and addressing these causes with appropriate triage and referral. To achieve our DSRIP metrics, patients must see a PCP within 30 days of discharge – and that’s a good thing for your practice.

As we move toward value-based payments,reimbursement will be based on keeping patients healthy, which requires a strong doctor-patient relationship. Completing appointments with these at-risk patients – some of whom may not have had a check-up in 12 months or more, others who are high utilizers, and those whose care is complicated by a chronic condition, behavior health or substance abuse – will generate revenue beyond the PMPM capitation. Where chronic conditions are diagnosed, your practice will be in a position to provide comprehensive preventive care and, very likely, put a Medicaid member on track for a healthier future!

Hospital Partnerships
ACP is working with partner hospitals – Jamaica Hospital Medical Center, Flushing Hospital, Forest Hills Medical Center, and Lenox Hill Hospital – to ensure that Medicaid patients who visit the ED for a non-urgent matter are discharged with a scheduled follow-up appointment with their PCP or are connected with a Health Home care manager. We’re approaching the problem from several directions:

  • Patient Navigators are being stationed in EDs to educate patients and to schedule the follow-up appointment.  
  • ACP Community Health Workers (CHWs) are making follow-up telephone calls to ensure patients are able to keep their appointment, such as by coordinating transportation or helping to reschedule if necessary.
  • For those who are discharged from the ED without an appointment, the CHWs are helping to connect the patients with their PCP.

Role of the Primary Care Physician
We only achieve this goal when the patient completes an appointment. The CHW needs a contact in your office who can schedule appointments or a block of time for walk-in appointments.

  • Reserve time for emergency follow-ups to capture your lost patients
  • Work with hospitals to give appointments to lost patients
  • Help educate patients on why visiting a PCP is preferable to the ED 

Nurturing the relationship of Primary Care Providers (PCPs) and their patients, with a focus on preventive, comprehensive care, is at the heart of this initiative to transform health care delivery. ACP is here to help your practice thrive in this new environment, through care management and care coordination as well as financial support to ensure your practice is PCMH Level 3 certified by December 31, 2017.

Remember, the so-called Triple Aim of DSRIP isn’t just to Reduce Costs but also to Improve Care and Enhance the Patient Experience. The ED Triage project will educate patients and encourage stronger relationships with the PCP while contributing toward the overarching goal of DSRIP – reducing avoidable hospitalizations by 25% over five years.

Stanford Model Training for Diabetes Self-Management 

Engaging patients in self-management of their chronic disease is an important step toward improving health outcomes and reducing the cost of health care.
ACP is pleased to offer a comprehensive, evidence-based, chronic disease self-management program for your patients with diabetes, as part of DSRIP Project 3.c.i.
ACP Community Health Workers (CHWs) are being trained and certified in the Stanford Model and will lead community-based self-management workshops. The week-long training, taking place in ACP headquarters, is being facilitated by Health People, a community health agency based in the South Bronx. 

Do you have patients who would benefit from a diabetes self-management program?

  • Type-2 Diabetes
  • A1C greater than 6.4
  • Medicaid recipient
  • Wants to learn how to control their blood sugar

Please contact Angela Lee or Migna Taveras to learn more about the Stanford Model program and to refer patients as candidates.
The Stanford Model is a chronic disease self-management initiative to engage patients in their care. Each workshop covers:

  • Techniques to deal with problems such as frustration, fatigue, pain and isolation;
  • Appropriate exercise for maintaining and improving strength, flexibility, and endurance;
  • Appropriate use of medications;
  • Communicating effectively with family, friends, and health professionals;
  • Nutrition

Healthfirst Conducts Patient Experience Training

Dr. Susan Beane Healthfirst Training
Dr. Susan Beane, Vice President and Medical Director of Healthfirst, led an ACP training session focused on enhancing the patient experience to produce engagement, resulting in higher quality outcomes.

Ten Steps to Achieve DSRIP Cardiovascular Project 3.b.i Goals

Million Hearts® is a core element of ACP’s Cardiovascular protocol (Project 3.b.i), which targets patients age 18 and above who have Cardiovascular disease or Hyperlipidemia.

  1. Implement a Standardized Hypertension Treatment Protocol, including once-daily regimens or fixed-dose combinations to increase compliance and avoid dosing errors.  
  2. Prescribe Medications in the Patient’s Insurance Coverage Formulary, when possible. 
  3. Implement a Refill Protocol and train a designated staff person to manage refill requests and ensure prompt patient medication access.
  4. Implement Lifestyle Modification Plans with Every Patient
  5. Designate a Blood Pressure (BP) Station and train every staff member to take a patient’s blood pressure without appointment or co-pay.
  6. Use an EHR to Track Patient’s Blood Pressure and create alerts to flag patients with Blood Pressures above goal.     
  7. Proactively Contact Flagged Patients to encourage, educate and ensure compliance with appointments and treatment plans. 
  8. Review the Patient’s Record Before an Office Visit to identify ways to improve blood pressure control.  
  9. Indicate and Prescribe Blood Pressure Machines and instruct patients on how and when to perform in-home blood pressure checks.           
  10. Provide a Blood Pressure Logbook for the patient to write down daily readings that can be reviewed periodically by the practice.

Questions about ACP's Cardiovascular project? Contact Project Manager Shariff De Los Santos. Read more here...

Helgerson Addresses Concerns About DSRIP 

All – With the election results, many have raised questions regarding implications for DSRIP.  We wanted to share the following points to help clarify some concerns.

  • DSRIP is not part of the Affordable Care Act (ACA) and would not be affected by legislative attempts related to the ACA.
  • DSRIP is part of a waiver amendment agreement with CMS, authorized through March 2020 and run by the state government.
  • Health care system reform and Value-Based Payment efforts will continue as these are industry drivers for improved quality and sustainability.  Medicare has adopted VBP as part of their program policy and commercial payers are pursuing similar arrangements.  

The tremendous efforts by the State and the PPSs to transform the system under DSRIP will continue.   Please keep focused on the DSRIP goals and projects, and maintain the collaborative and positive work you and your staff have accomplished so far.  Proceed with Fact-based Optimism. 
Jason Helgerson
Medicaid Director

519 Eighth Avenue, 14th Floor, New York, NY 10018

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844-ACP-PPS2 (844-227-7772)
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Advocate Community Providers · 519 Eighth Avenue · 14th Floor · New York, NY 10018 · USA