Click Here to Download PDF

MPA Reference Guide

1.Master Participation Agreement Resources

This site is intended to be used by providers affiliated with the Millennium Collaborative Care PPS (“Millennium”) and to offer guidance around DSRIP projects and achievement of associated metrics.

This site was created as an accompaniment to the Master Participation Agreements (MPAs) for DY3 (April 1, 2017 through June 30, 2018) to provide helpful resources and best practice recommendations relating to achievement of MPA deliverables and overall DSRIP goals. The site will be updated with additional resources and best practice recommendations through the year.

Click on a provider type to see the related requirements and resources:

Please note: This site is not meant to serve as a comprehensive list of all activities required under the MPA. Partner expectations, responsibilities, and deliverables have been provided in the MPA exhibits and associated billing templates.

Last updated on December 5, 2017

2.Provider Types

2.1.Primary Care Practices

This page pertains to primary care practices (all sizes). See also: Pediatric practices

Engagement and Reporting

Category Participant Activity Substantiation
Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually).
Data Provide updated roster of providers on annual/biannual basis. Submission of updated provider roster (annually/biannually).
Data Execute MCC-developed managed care organization data consent form (small, medium, and large practices). Provide copy of signed data consent form.
Data Provide claims data (extra large practices). Submission of electronic claims to MCC for PPS attributed lives.
Data Implement CCDAs. CCDAs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard.
Engagement Provide quarterly engagement reporting for behavioral health and cardiovascular disease (“CVD”). Successful upload of all quarterly engagement reports as indicated by MCC project managers.
Engagement Meet with MCC at least quarterly (all practice locations).  Topics for discussion may  include Patient Activation Measure (“PAM”) training (if applicable) and behavioral health best practices. Provide sign-in sheets, meeting minutes, and workflows (if applicable).
Value-Based Payments (“VBP”) Create a VBP transition plan to include the following required minimum elements:

1. Technology and analytics
2. Utilization and care management tactics
3. Staffing expertise
4. Financial feasibility and impact
5. Timeline for implementing VBP
Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type.

Transformation

Category Participant Activity Substantiation
Health Literacy and Survey Participate in MCC PCP office training and workgroup sessions on MCC specific CG-CAHPS survey measures.

Develop and implement work plan including strategies for improvement based on survey results.

Revise patient facing materials to improve and enhance patient literacy according to CG-CAHPS standards.
Minutes from training and working session that include identification of strategies to improve results.

Provide copy of work plan.

Provide revised patient-facing materials.
Medical Record Review Attend MCC-led education on documentation requirements.

Provide evidence of appropriate documentation and at least 75% documentation accuracy of blood pressure control and depression screen with follow-up.
Sign-in sheets reflecting training attendance.

MCC shall conduct initial medical review audit. If original findings by MCC indicate less than 75% documentation accuracy, then MCC will re-audit again at a later time.
Non-Utilizer Management Contact Non-Utilizers via new phone call or letter to attempt to schedule preventative appointment.

If outreach is unsuccessful and/or scheduled Non-Utilizer fails to show for new preventative appointment, provide a list of outstanding Non-Utilizers to MCC-contracted community-based organizations (“CBOs”).

Accept Non-Utilizer referrals from MCC-contracted CBOs. 90% of Non-Utilizer referrals must be scheduled for appointments within 30 days of referral.

Non-utilizers are patients with no preventive visit in previous 12 months
Provide Non-Utilizer list to MCC.

Completion of MCC sampling audit on documentation of Non-Utilizer outreach efforts.

Non-Utilizer referral appointments substantiated by MCC-contracted CBO reports.
Screening, Brief Intervention and Referral to Treatment (“SBIRT”) Train at least one  clinical staff member per site. Demonstrate completion of training (e.g., certificates or sign-in sheets).
Screening, Brief Intervention and Referral to Treatment (“SBIRT”) Implement SBIRT. Provide workflow and quarterly reporting on number of screenings.
PAM Administer PAM surveys in PCP offices. Participants must perform PAMs on a minimum of 10% of Medicaid visits. Provide workflow and quarterly reporting on number of PAM surveys administered.

Transformation with Performance

Category Participant Activity Substantiation Type Substantiation
Primary Care Access Adherence Rate Improvement Run 12-month annual visit adherence report and establish baseline.*

Develop management plan for improvement of adherence rate and submit adherence rate reports.

*See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements.
Process Produce report and plan.

Submit reports.
Primary Care Access Adherence Rate Improvement Improve 12 month visit adherence rate over historical baseline.**

**Participants are only eligible for an award for achieving one of the performance benchmarks listed in the “Substantiation” column. So, for example, if at year-end a Participant had achieved 15% improvement, they would be eligible for a single allocation as further outlined in the billing templates.
Outcome Provide evidence of adherence rate improvement >=10% over baseline OR

Provide evidence of adherence rate improvement >=15% over baseline OR

Provide evidence of adherence rate improvement >=20% over baseline OR

Demonstrate overall adherence rate >=94% (over 18 years) and >=98% (under 18 years) with maintenance
CVD Best Practice PCPs will develop the following registry (or develop an alternate reporting/identification process)

Patients with:

HbA1c >= 7%

Blood pressure >= 140/90

ASCVD risk score >= 7.5% OR provide a documented process demonstrating how the practice will calculate the ASCVD risk score and record in EMR
Process Provide evidence of use of registry or alternate process (i.e. Category 2 codes) to automate case identification in electronic medical record.

Produce registries.

Produce documented process/plan to calculate and record the ASCVD risk score (if unable to produce registry only).
CVD Best Practice Improve number of patients with controlled blood pressure by 10%. Outcome Provide evidence of achievement of metric.
CVD Best Practice Improve to or maintain 75% CAD patients on a statin. Outcome Provide evidence of achievement of metric.
Medical Neighborhood Review and revise care coordination policy to include the following:

Address linkages with behavioral health, CBOs, health home, and hospitals;

Confirm bi-directional communication with all relevant hospitals and high-volume specialists;

Evaluate and revise criteria and process for follow-up visits and calls;

Enable ADTs with HEALTHeLINK; and

Incorporate process to act upon and ensure outreach and follow-up.
Process Participate in a facilitated meeting with MCC project manager regarding policy revisions.

Submit revised care coordination policy with all required elements.
Medical Neighborhood Conduct outreach to and schedule follow-up visits for acute inpatients that are discharged from a hospital with one of the following avoidable admission principal diagnoses (“Target Conditions”):

COPD and related complications;

diabetes and related complications;

asthma; and

other practice-specific avoidable admission diagnosis driver as identified by MCC analytics.

Maintain hospital patient follow-up log.
Process Provide hospital patient follow-up log substantiated by MCC sample audit of logs.
Medical Neighborhood Enroll and/or refer patients eligible for care coordination and/or health home services consistent with internal policies and applicable health home guidelines. Process Report number and percentage of patients with target conditions enrolled in care coordination.

Report number and percentage of patients referred to health homes. Report can be satisfied by practice or health home.
Medical Neighborhood Reduce practice-specific avoidable admission rate (including readmissions) for Target Conditions by 5% when compared to historical baseline. Outcome Provide evidence of achievement of metric.
Medical Neighborhood Reduce practice-specific preventable emergency department visit rate by 10% when compared to historical baseline. Outcome Provide evidence of achievement of metric.
Depression Best Practice Participate in MCC-facilitated education and training on depression best practices.

Develop and implement practice workflow to care manage newly diagnosed depressed patients prescribed an anti-depressant.
Process Sign-in sheets for education and training sessions.

Report on number and percent of patients that were care managed.
Depression Best Practice Improve patient Major Depression Medication Adherence to anti-depressant medications, acute phase (12 weeks). Outcome Provide evidence of improvement in patients’ Major Depression Medication Adherence to anti-depressant medications, acute phase (12 weeks) by 10%; OR

If current Major Depression Medication Adherence is at or above 60%, maintain.
Depression Best Practice Improve patient Major Depression Medication Adherence to anti-depressant medications, chronic phase (6 months). Outcome Provide evidence of improvement in patients’ Major Depression Medication Adherence to anti-depressant medications, chronic phase (6 months) by 10%; OR

If current Major Depression Medication Adherence is at or above 44%, maintain.
Last updated on December 18, 2017

2.2.Pediatric Practices

Engagement and Reporting

Category Participant Activity Substantiation
Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually).
Data Provide updated roster of providers on annual/biannual basis. Submission of updated provider roster (annually/biannually).
Data Execute MCC-developed managed care organization data consent form. Provide copy of signed data consent form.
Data Implement CCDAs. CCDAs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard.
Engagement Provide quarterly engagement reporting for behavioral health. Successful upload of all quarterly engagement reports as indicated by MCC project managers.
Value-Based Payments (“VBP”) Create a VBP transition plan to include the following required minimum elements:

1. Technology and analytics
2. Utilization and care management tactics
3. Staffing expertise
4. Financial feasibility and impact
5. Timeline for implementing VBP
Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type.

Transformation

Category Participant Activity Substantiation
Medical Record Review Attend MCC-led education on documentation requirements.

Provide documentation evidencing at least 75% of patients with full immunization panel and percentage of two-year-olds with lead screenings.
Sign in sheets reflecting training attendance.

MCC shall conduct initial medical review audit. If original findings by MCC indicate less than 75% documentation accuracy, then MCC will re-audit again at a later time.
Non-Utilizer Management Contact Non-Utilizers via new phone call or letter to attempt to schedule new preventative appointment.

If outreach is unsuccessful and/or scheduled Non-Utilizer fails to show for new preventative appointment, provide a list of outstanding Non-Utilizers to MCC-contracted community-based organizations (“CBOs”).

Accept Non-Utilizer referrals from MCC-contracted CBOs. 90% of Non-Utilizer referrals must be scheduled for appointments within 30 days of referral.

Non-utilizers are patients with no preventive visit in previous 12 months
Provide Non-Utilizer list to MCC.

Completion of MCC sampling audit on documentation of Non-Utilizer outreach efforts.

Non-Utilizer referral appointments substantiated by MCC-contracted CBO reports.

Transformation with Performance

Category Participant Activity Substantiation Type Substantiation
Primary Care Access Adherence Rate Improvement Run 12-month annual visit adherence report and establish baseline.*

Develop management plan for improvement of adherence rate and submit adherence rate reports.
Process Produce report and plan.

Submit reports.
Primary Care Access Adherence Rate Improvement Improve 12-month visit adherence rate over historical baseline.** Outcome Provide evidence of adherence rate improvement >=10% over baseline OR

Provide evidence of adherence rate improvement >=15% over baseline OR

Provide evidence of adherence rate improvement >=20% over baseline OR

Demonstrate overall adherence rate >=98% with maintenance
ADHD Best Practice Produce registries for children 6–12 years with ADHD on ADHD medication. Process Produce registry.
ADHD Best Practice Develop process for ADHD-related bi-directional communication with behavioral health practices.
Establish workflow with behavioral health providers for provision of care for patients with ADHD.
Process Provide policies and workflows.
ADHD Best Practice Improve to or maintain at least 52% patients with behavioral health visit within 30 days of starting ADHD medication. Outcome Provide evidence of improvement or maintenance.
ADHD Best Practice Improve to or maintain at least 61% patients with behavioral health visit within 9 months of starting ADHD medication. Outcome Provide evidence of improvement or maintenance.
Hospital Utilization and Reducing Avoidable Admissions Review and revise care coordination policy to include the following:

1. Confirm bi-directional communication with all relevant hospitals.
2. Evaluate and revise criteria and process for follow-up visits and calls.
3. Enable ADTs with HEALTHeLINK.
4. Incorporate process to act upon and ensure outreach and follow-up.
Process Participate in a facilitated meeting with MCC project manager regarding policy revisions.

Submit revised care coordination policy with all required elements.
Hospital Utilization and Reducing Avoidable Admissions Conduct outreach to and schedule follow-up visits for acute inpatients that are discharged from a hospital with one of the following avoidable admission principal diagnoses (“Target Conditions”):

asthma;
dehydration; and
other practice-specific avoidable admission diagnosis driver as identified by MCC analytics.
maintain hospital follow-up log.
Process Provide evidence of achievement of >=75% metric.

Hospital patient follow-up log substantiated by MCC sample audit of logs.
Hospital Utilization and Reducing Avoidable Admissions Enroll and/or refer patients eligible for care coordination and/or health home services consistent with internal policies and applicable health home guidelines. Process Report number and percentage of patients with target conditions enrolled in care coordination.

Report number and percentage of patients referred to health homes. Report can be satisfied by practice or health home.
Hospital Utilization and Reducing Avoidable Admissions Reduce practice-specific avoidable admission rate (including readmissions) for Target Conditions by 5% when compared to historical baseline. Outcome Provide evidence of achievement of metric.
Hospital Utilization and Reducing Avoidable Admissions Identify patients with preventable emergency department diagnoses and develop workflows and processes to manage these patients. Process Provide copies of workflow and process documents.
Hospital Utilization and Reducing Avoidable Admissions Reduce practice-specific preventable emergency department visit rate by 10% when compared to historical baseline. Outcome Provide evidence of achievement of metric.
Increase Well Visits within 15 Months Identify number of children that had five or more well visits within their first 15 months and establish this as practice baseline.* Process Produce report and plan.
Increase Well Visits within 15 Months Improve practice-specific rate of five or more well visits. Outcome Improvement in practice-specific rate of five or more well visits in first 15 months.
Last updated on December 18, 2017

2.3.Behavioral Health

Engagement and Reporting

Behavioral Health Provider Type Category Participant Activity Substantiation
Outpatient Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually).
Outpatient Data Submit performance data (e.g., PSYCKES and/or managed care organization data) to MCC. Submission of required data.
Outpatient Engagement Provide quarterly engagement reporting for behavioral health. Successful upload of all quarterly engagement reports as indicated by MCC project managers.
Outpatient Value-Based Payments (“VBP”) Create a VBP transition plan to include the following required minimum elements:
1. Technology and analytics
2. Utilization and care management tactics
3. Staffing expertise
4. Financial feasibility and impact
5. Timeline for implementing VBP
Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type.
Inpatient Participation in Regional Behavioral Health Workgroups Attend and participate in MCC regional behavioral health workgroups. Sign-in sheets evidencing workgroup attendance.

Transformation

Behavioral Health Provider Type Category Participant Activity Substantiation
Outpatient Participation in Regional Behavioral Health Workgroups Attend and participate in MCC regional behavioral health workgroups. Sign-in sheets evidencing workgroup attendance.
Outpatient Non-Utilizer Management Link closed/discharged cases with primary care, health home, or other provider; or, if no linkage, provide name of patients to MCC-contracted community-based organizations (“CBOs”).
Provide monthly list of closed patients with linkages requiring HbA1c or LDL lab work to follow-up provider.
Non-utilizers are patients with no preventive visit in previous 12 months
Provide MCC with monthly list indicating number of Non-Utilizer patient referrals to MCC-contracted CBO.
Provide MCC with monthly list indicating number of patients requiring HbA1c or LDL lab work sent to follow-up provider.

 Transformation with Performance

Behavioral Health Provider Type Category Participant Activity Substantiation Type Substantiation
Outpatient 7- and 30-Day Follow-Up for Outpatients Attempt outreach utilizing the Sinnissippi model for patients discharged from acute care prior to appointment.
Perform outreach for 75% or more patients.
Process Provide report of number of attempted contacts vs. scheduled patients. Report must evidence 75% or more outreaches attempted.
Outpatient 7- and 30-Day Follow-Up for Outpatients Produce historical show rate for 7- and 30-day follow-up appointment* Process Provide PSYCKES and/or internal report to MCC.
Outpatient 7- and 30-Day Follow-Up for Outpatients Improve show rate for 7-day follow-up appointments over historical baseline.** Outcome Provide evidence of show rate improvement >=5% over baseline OR
Provide evidence of show rate improvement >=10% over baseline OR
Provide evidence of show rate improvement >=15% over baseline OR
Exceed/maintain current rate if baseline number already shows >=74%.
Outpatient 7- and 30-Day Follow-Up for Outpatients Improve show rate for 30-day follow-up appointments over historical baseline.** Outcome Provide evidence of show rate improvement >=5% over baseline OR
Provide evidence of show rate improvement >=10% over baseline OR
Provide evidence of show rate improvement >=15% over baseline OR
Exceed/maintain current rate if baseline number already shows >=74%.
Outpatient Substance Abuse Treatment Participate in MCC best practice workgroup and implement workflows created in workgroup. Process Sign-in sheets evidencing workgroup attendance and documentation of employee training and distribution of training materials.
Outpatient Substance Abuse Treatment Produce historical compliance rate for substance abuse treatment metrics.* Process Provide PSYCKES and/or internal report to MCC.
Outpatient Substance Abuse Treatment Increase number of patients with timely initiation of substance abuse treatment (within 14 days) over historical baseline.** Outcome Provide evidence of improvement of >=5% in number of patients with timely Substance Abuse Treatment initiative OR
Provide evidence of improvement of >=10% in number of patients with timely Substance Abuse Treatment initiative OR
Provide evidence of improvement of >=15% in number of patients with timely Substance Abuse Treatment initiative OR
Exceed/maintain current number if baseline number already shows >=57%.
Outpatient Substance Abuse Treatment Increase number of patients engaged in ongoing substance abuse treatment (2 or more visits over 30 days) who have a diagnosis of substance abuse issues over historical baseline.** Outcome Provide evidence of improvement of >=5% in number of patients with timely Substance Abuse Treatment initiative OR
Provide evidence of improvement of >=10% in number of patients with timely Substance Abuse Treatment initiative OR
Provide evidence of improvement of >=15% in number of patients with timely Substance Abuse Treatment initiative OR
Exceed/maintain current number if baseline number already shows >=57%.
Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Produce historical compliance rate for HbA1c and LDL testing among schizophrenic patients.* Process Provide PSYCKES and/or internal report to MCC.
Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Improve compliance rate for HbA1c testing for patients with schizophrenia and diabetes over historical baseline.** Outcome Improve compliance rate >=5% over baseline OR
Improve compliance rate >=10% over baseline OR
Improve compliance rate >=15% over baseline OR
Exceed/maintain current compliance rate if baseline number already shows >=90%.
Outpatient Cardiovascular and Diabetic Monitoring for Patients with Schizophrenia Improve compliance rate for LDL testing for patients with schizophrenia and diabetes or CVD over historical baseline.** Outcome Improve compliance rate >=5% over baseline OR
Improve compliance rate >=10% over baseline OR
Improve compliance rate >=15% over baseline OR
Exceed/maintain current compliance rate if baseline number already shows >=92%.
Outpatient Medication Adherence for Patients with Schizophrenia Participate in MCC best practice workgroups and implement workflows created in workgroups. Process Sign-in sheets evidencing workgroup attendance and documentation of employee training and distribution of training materials.
Outpatient Medication Adherence for Patients with Schizophrenia Produce historical compliance rate for Medicaid schizophrenia-diagnosed patients 19–64 years who remained on antipsychotic medication for 80% of treatment period.* Process Provide PSYCKES and/or internal report to MCC.
Outpatient Medication Adherence for Patients with Schizophrenia Improve compliance rate over historical baseline.** Outcome Improve compliance rate >=5% over baseline OR
Improve compliance rate >=10% over baseline OR
Improve compliance rate >=15% over baseline OR
Exceed/maintain current compliance rate if baseline number already shows >=76%.
Inpatient Substance Abuse Patient Follow-up Secure follow-up appointment with mental health facility at discharge within 14 days for 80% or more of substance abuse patients. Process Provide number of monthly discharges with log of patient appointments.
Inpatient 7- and 30-day Follow-up Secure follow-up appointment with mental health facility at discharge within 7 days for 80% or more of patients.
Implement “warm handoff” workflow to engage patient during discharge process.
Process Provide monthly log of patient follow-up visits
Provide workflow and process that includes patient participation in scheduling of appointment (e.g., participation in call with follow-up agency or discussion and documentation of patient input and/or feedback regarding appointment).
Inpatient 7- and 30-day Follow-up Successful outreach/handoff to designated outpatient mental health facility relationship manager for 90% or more of patients.
Develop patient-facing material to include comprehensive information relating to follow-up appointment:
Name of provider;
Full address;
Date and time;
Why the appointment is important.
Process MCC shall substantiate via audit (e.g., evidence of email, fax or phone call).
Provision of patient-facing material that includes these elements.

*See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements.

** Participants are only eligible for an award for achieving one of the performance benchmarks listed in the “Substantiation” column. So, for example, if at year-end a Participant had achieved 10% improvement, they would be eligible for a single allocation as further outlined in the billing templates.

Last updated on December 18, 2017

2.4.Acute Care

Engagement and Reporting

Category Participant Activity Substantiation
Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually).
Data Provide claims data. Submission of electronic claims to MCC.
Data Implement CCDAs.

Continue to consent patients with HEALTHeLINK consistent with developed workflows and HEALTHeLINK utilization.

Implement ADT messaging for admission, discharge or transfer to HEALTHeLINK.
CCDAs and ADTs successfully implemented as evidenced by activity on the HEALTHeLINK monthly reporting dashboard.

Provide evidence of active consenting and query activity as per MCC HEALTHeLINK reports.
Value-Based Payments (“VBP”) Create a VBP transition plan to include the following required minimum elements:

1. Technology and analytics
2. Utilization and care management tactics
3. Staffing expertise
4. Financial feasibility and impact
5. Timeline for implementing VBP
Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type.
Emergency Department Care Triage (“EDCT”) Create lists of PCPs accepting EDCT referrals and appointments. Listing of PCPs must include physician name, license number and address. Provide required lists.

Transformation

Category Participant Activity Substantiation
Health Literacy (“HL”) and Survey Identify H-CAHPS/HL Champion.

Participate in MCC training and workgroup sessions on H-CAHPS survey measures.

Develop and implement work plan for improvement based on survey results.

Revise patient-facing materials to improve and enhance patient literacy according to H-CAHPS standards.

Report results to MCC of the following survey questions:

#23: Staff took preferences of patient/caregiver into account in deciding patient’s health care needs for discharge.

#24: Upon discharge patient had good understanding of responsibilities and discharge instructions.

#25: Patient clearly understood purpose for taking each of patient’s medications.
Documentation identifying an H-CAHPS/HL Champion.

Sign-in sheets reflecting attendance at workgroup sessions.

Submission of H-CAHPS work plan and updated patient-facing discharge material.

Evidence of distribution of workflow and training of key staff.

Report ongoing survey results to MCC as available.
Enhanced Primary Care–Acute Linkage Create enhanced linkages to PCPs for patients discharged from acute care. Provide workflow and processes demonstrating patient linkage with PCPs.
Enhanced Primary Care–Acute Linkage Revise patient-facing materials to include written documentation of when/where follow-up appointment is and reason for appointment.

Provide copy of materials to patients when PCP visit is scheduled.
Provide copies of revised patient-facing materials.
Non-Utilizer Management Refer patients who fail to follow up with PCP visits after EDCT intervention or an acute admission to MCC-contracted community-based organizations (“CBOs”).

Non-utilizers are patients with no preventive visit in previous 12 months
Provide total number of patients referred to MCC-contracted CBOs
Crisis Stabilization: Attend MCC-led workgroups focused on:

Identifying accessible behavioral health crisis services that allow access to appropriate level of service and providers.

Developing and implementing protocols to divert patients from emergency department (“ED”) and inpatient services when medically appropriate.
Sign-in sheets reflecting attendance at workgroup sessions.

Copy of protocols, date of training, and material distribution to relevant staff.

 Transformation with Performance

Category Participant Activity Substantiation Type Substantiation
Emergency Department Care Triage (EDCT) Implementation Implement EDCT program if not already established.

Provide patient-facing materials including written documentation of when/where appointment is and reason for appointment.

Identify Medicaid patients with low acuity triage levels in the ED.

Enhance Primary Care Linkage for ED patients via assistance and scheduling of immediate follow-up appointment after discharge with outreach to PCP office.

Review monthly EDCT program report from MCC and report improvement opportunities to MCC.
Process Copy of materials distributed to patients when PCP visit is scheduled.

Provide monthly report of Key Performance Indicators with the following:

Number of patients with EDCT acuity triage level 3–5.

Number of EDCT patients engaged with Patient Navigator.

Number of patients completing Patient Activation Measure survey.

Number of patients linked to primary care and percentage of patients who attended their PCP appointment.

Minutes of meetings evidencing improvement opportunities.
Emergency Department Care Triage (EDCT) Implementation Hospitals with existing EDCT programs must increase engagement of Medicaid patients by at least 5%.

Hospitals that are new participants in EDCT programs must engage at least 5% of Medicaid low-acuity patients.
Outcome For hospitals with existing EDCT programs: year-end report demonstrating increased engagement of low-acuity Medicaid patients by at least 5% over previous year.

For hospitals that are new participants in EDCT programs: year-end report demonstrating engagement of at least 5% of low-acuity patients.
Health Home Integration Prepare workflow supporting health home’s clinical integration within hospital ED. Process Provide documentation of workflow.
Health Home Integration Integrate health homes within hospital setting.

Increase health home referrals by 10% over previous year.
Outcome Report on number of patients referred to health homes the previous year demonstrating increase.
Medical Neighborhood Participate in MCC-led workgroups and develop an “at risk” process or tool, to include both medical and social factors, that identifies patients at risk for readmission. Process Sign-in sheets reflecting attendance at workgroup sessions.

Provide copy of “at risk” process or tool development materials.
Medical Neighborhood Develop comprehensive care transition policy with the following minimum required elements:

Address linkages and confirm bi-directional communication with post-acute entities (including behavioral health, home care, skilled nursing facilities, PCPs, and specialists), health homes, and CBO partners.

Expand CBO integration guidelines and linkages with key agencies identified in facilitated workgroups.

Utilize thorough Medication Reconciliation Process including patient and family education on medication prior to discharge.

Incorporate process to act upon and ensure outreach and follow-up.
Process Provide care transition policy with all required elements.
Manage Hospital Utilization Establish Medicaid-specific reports and baselines for the following:*

30-day readmission rate (PPR);

PPV visits (ambulatory sensitive conditions); and

PQI measures.
*See Section 1.2 of Exhibit A for additional details on establishing baselines and reporting requirements.
Process Provide ongoing monthly report to MCC, including principal diagnosis (and DRG for acute discharges) for PQI, PPV, and PPR (including both the initial admission and the 30-day readmission).
Medical Neighborhood Reduce PPV rate by 10% compared to historical baseline. Outcome Provide reports evidencing reduction.
Medical Neighborhood Reduce PQI admission rate by 5% compared to historical baseline. Outcome Provide reports evidencing reduction.
Medical Neighborhood Reduce 30-day readmission rate by 5% compared to historical baseline. Outcome Provide reports evidencing reduction.
Last updated on December 18, 2017

2.5.Post-Acute Care

Engagement and Reporting

Category Participant Activity Substantiation
Workforce Enter required staffing impact data into HWApps on biannual basis. Successful upload of practice workforce data in HWApps (biannually).
Data Execute MCC-developed managed care organization data consent form. Provide copy of signed data consent form with all participating payers.
Value-Based Payments (“VBP”) Create a VBP transition plan to include the following required minimum elements:

1. Technology and analytics
2. Utilization and care management tactics
3. Staffing expertise
4. Financial feasibility and impact
5. Timeline for implementing VBP
Submission of report. For entities with multiple provider types, each shall be required to provide either a separate report or to have a specific portion of the report dedicated to each provider type.
Engagement Provide quarterly engagement reporting for INTERACT relating to emergency department and inpatient utilization impact. Successful upload of all quarterly engagement reports as indicated by MCC project managers.
Last updated on December 18, 2017

3.Engagement and Reporting

3.1.Workforce

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Current workforce statistics must be compiled and given to the state to measure the effect DSRIP initiatives are having on the healthcare workforce over the time of the program. Projections on staffing need, bed reductions (or additions), and utilization trends are generated from workforce data.

In addition to meeting state requirements, workforce data collected from participants is used for the following objectives:

  • To inform education and training requirements for PPSs and their partners
  • To guide retraining for redeployed workers and employee support programs
  • To advance healthcare workforce research and policy development while demonstrating DSRIP impact

Partners will enter required workforce staffing impact data into HWApps.

The purpose of the Compensation and Benefits Survey is to capture a snapshot in time and examine workforce trends within each PPS. The survey was first conducted in DY1, and NYS requires PPS to repeat the survey in DY3 and DY5. This data is collected and “aged” in accordance with antitrust regulations. The Workforce Compensation and Benefits Survey was sent to each partner by Millennium’s workforce vendor, Rural AHEC.

Resources

Last updated on November 22, 2017

3.2.Value-Based Payment

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

One of the key objectives of DSRIP is to prepare for the transition from fee-for-service (FFS) to value-based payment (VBP) arrangements.

Partners will create a VBP Transition Plan which will include the following required elements:

  • Type of agreement(s)
  • Technology and analytics
  • Utilization and care management tactics
  • Staffing expertise
  • Financial feasibility and impact
  • Timeline

Additional outreach and support, as well as a template, will be provided.

Last updated on November 22, 2017

3.4.Patient Engagement

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Participants must provide Millennium with regular documentation and reports showing the success of their patient engagement throughout the course of DSRIP. Patient engagement criteria are determined by NYS and outlined in Exhibit B of the DY3/MY4 Master Participation Agreement.

Patient engagement registries must be in the approved Millennium standard format (using the correct Microsoft Excel template).

Since these registries contain protected health information (PHI), they must be transmitted to Millennium using a secure file transfer method. Millennium’s approved secure file transfer platform is WatchDox.

Submissions are always due the 15th of the month following the end of the DSRIP quarter: July 15, October 15, January 15, and April 15.

Resources

Last updated on December 8, 2017

4.Transformation Requirements

4.1.Health Literacy Survey

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Partners will develop an organizational plan that will focus on reducing health disparities and improving health outcomes with at-risk populations. This will be done through effective and culturally sensitive communication with patients across the health disciplines. Emphasis will be placed on improving patient health literacy and the use of health literacy interventions by providers, such as the teach-back method. Ultimately, this strategy will support the pay-for-performance measures related to Clinics & Groups Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS), and care transitions.

Primary Care Practices

The DSRIP measures related to the CG-CAHPS survey span several patient experience and quality of care topics, which include two composite measures and eleven individual questions.

CG-CAHPS composite measures and questions:

  • Percent with always/usually timely access, composed of the following CG-CAHPS questions:
  • Question 6: In the last 6 months, when you contacted this provider’s office to get an appointment for care that you needed right away, how often did you get an appointment as soon as you needed?
  • Question 8: In the last 6 months, when you made an appointment for a checkup or routine care with this provider, how often did you get an appointment as soon as you needed?
  • Question 10: In the past 6 months, when you contacted this provider’s office during regular business hours, how often did you get an appointment as soon as you needed?
  • Percent with care coordination, composed of the following CG-CAHPS questions:
  • Question 13: In the last 6 months, how often did this provider seem to know the important information about your medical history?
  • Question 22: In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?
  • Question 24: In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

CG-CAHPS individual questions:

  • Question 2: Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
  • Question 3: How long have you been going to this provider?
  • Question 18: In the last 6 months, how often were the provider’s instructions easy to understand?
  • Question 19: In the last 6 months, how often did this provider ask you to describe how you were going to follow these instructions?
  • Question 20: In the last 6 months, how often did this provider explain what to do if this illness or health condition got worse or came back?
  • Question 30: Have you had a flu shot or flu spray in the nose since September 1, 2015?
  • Question 32: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health care provider?
  • Question 33: In the last 6 months, how often was medication recommended or discussed by a doctor or health care provider to assist you with quitting smoking or using tobacco?
  • Question 34: In the last 6 months, how often did your doctor or health care provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco?
  • Question 35: Do you take aspirin daily or every other day?
  • Question 37: Has a doctor or health care provider ever discussed with you the risks and benefits of aspirin to prevent heart attack or stroke?

Hospitals

The three DSRIP performance measures related to the H-CAHPS survey fall under the Care Transitions section, questions 23–25 as stated below:

  • Question 23: During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
  • Question 24: When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • Question 25: When I left the hospital, I clearly understood the purpose for taking each of my medications.

Each acute care partner will identify at least one H-CAHPS champion to represent the organization. The H-CAHPS champion must participate in monthly workgroup meetings (subject to change as H-CAHPS scores increase). Intended audience for workgroup meetings include but are not limited to identified H-CAHPS project champions.

Each hospital and primary care practice will develop and implement an individualized work plan for improvement based on survey results.

Hospitals and primary care practices will revise patient-facing material to improve and enhance patient literacy according to H-CAHPS/CG-CAHPS standards.

Hospitals will report H-CAHPS results as they relate to transitions of care according to the following schedule:

  • July 1–September 30: Scores are due no later than November 15
  • October 1–December 31: Scores are due no later than January 15
  • January 1–March 31: Scores are due no later than April 15
  • April 1–June 30: Scores are due no later than July 15
Last updated on November 22, 2017

4.2.Enhanced Primary Care Linkage from Acute Care

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Ensuring definitive, timely linkages are made to primary care following a hospital stay is crucial for follow-up and maintenance of health conditions in the community setting. Primary care needs to be the center of care coordination strategies. Patients must be given appropriate resources to be successful in their linkage to primary care.

Partners are expected to develop a workflow and process demonstrating patient linkage with PCP.

  • Acute care partners will create timely linkage to primary care for patients prior to discharge
  • Revise patient-facing materials that demonstrate components of health literacy with inclusion of written documentation of when/where follow-up appointment is and reason for appointment
  • Provide copy of materials to patient when primary care provider (PCP) visit is scheduled
Last updated on November 2, 2017

4.3.Non-Utilizer Management

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Hospitals

For hospitals, the objective of NU management is to successfully link ED Care Triage patients who fail to attend their primary care follow-up visit to primary care services.

As part of the EDCT program, Medicaid patients are linked with a primary care appointment prior to leaving the ED. The Patient Navigator will follow up with the EDCT patient within 48 hours of upcoming primary care visit. This is to ensure the patient is aware of their appointment and to identify any barriers to getting to their appointment. The Patient Navigator will confirm and document the patient’s compliance to their PCP scheduled appointment.

Hospitals will track patient’s outcome either in SalesForce or their own electronic medical record (EMR):

  • For hospitals using Salesforce for EDCT documentation, Millennium will pull SalesForce data of patients with No Show and submit the patients to the Millennium-contracted non-utilizer (NU) vendor
  • For ECMC hospitals using their own EMR for EDCT documentation, Millennium will assist ECMC with reporting requirements of patients with a No Show to PCP

Primary Care

The intent of non-utilizer (NU) management within primary care is to provide additional support with locating patients that have become disconnected from primary care practices. Millennium’s contracted community-based organizations (CBOs) will be providing that support to primary care.

Millennium recognizes that primary care practices are currently spending significant resources on telephonic outreach and mailings to bring patients in for routine services. The NU management program is intended to attempt another form of outreach for hard-to-reach patients. Once a patient is located, the contracted CBO will navigate the patient back to his or her primary care provider for an appointment.

Primary care practices will partner with one of Millennium’s regional contracted CBOs to receive their NU lists. The practice will run reports which identify non-utilizing patients throughout the engagement and send these reports to Millennium’s vendor. The vendor will attempt additional forms of outreach to connect with the patient and get the patient back to primary care.

Primary care practices must accept referrals from NU vendors and schedule 90% of appointments within 30 days of referral.

Behavioral Health

For behavioral health providers, the objective of NU management is to successfully connect patients with behavioral health diagnoses to primary care.

Behavioral health practices will report (monthly) the number of patients referred to the NU vendor who require HbA1c or LDL lab work.

All Applicable Partners

Participants will report the total number of patients referred to the NU program monthly. Millennium may request an audit at any time.

In order to exchange patient data, participants must execute a Business Associate Agreement with the NU vendor. Patient lists must be exchanged using a secure file transfer method.

Resources

Last updated on November 22, 2017

4.4.Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Provider Types

Description

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a set of guidelines that recognize the important role for primary care services in screening for nicotine, alcohol, and other drug use, fostering healthy changes in use, and in linkage to further services when appropriate. All patients seen in primary care settings should be screened for use and misuse of alcohol, nicotine, and other drugs.

Resources

Last updated on November 22, 2017

4.5.Crisis Stabilization

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

It is imperative that Millennium partners have established diversion management protocols to prevent unnecessary ED visits and hospitalizations for patients with a crisis episode. Diversion management protocols document how readily accessible behavioral health services would be accessed by patients getting them to the most appropriate level of service and provider, supporting a rapid de-escalation of the crisis. Core crisis stabilization services include crisis phone hotline (phone triage), mobile crisis outreach, short-term community respite, and observation. Additional services are emergency departments, behavioral health and community based treatment providers, health homes, and primary care.

Millennium and its partners developed a Mental Health Triage Tool as a base for a community-wide crisis stabilization protocol. Providers adopted this resource to triage and stabilize behavioral health crises in the community. The purpose of the tool is to increase efficiency for identifying and connecting individuals with the right level of care during their crisis. Engage individuals with solutions that influence behaviors by providing the information needed to make informed decisions, better understand their mental health status, and know when to seek which level of care.

Partners are required to participate in behavioral health-led workgroups. The intended audience for these workgroups includes but is not limited to outpatient clinical staff, anyone who works on the warm line or crisis call lines, intake and/or front desk staff at behavioral health agencies, any agency that receives calls for after-hour calls, police officers trained in CIT, peer service providers, EMT staff, firefighters/volunteer firefighters, ED staff, recovery coaches, health home staff, physician office/primary care staff, DSS staff, college counseling centers, mental health associations and substance abuse councils across all eight counties, and 211 staff.

Acute care partners are expected to implement diversion management guidelines and protocols and conduct training on these protocols.

Resources

Last updated on November 22, 2017

4.6.Participation in Behavioral Health Workgroups

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

Behavioral health partners will work together to identify specific targeted strategies to work on as a community. Workgroups have been developed to support regional and county-wide approaches. The Millennium behavioral health team will oversee the workgroups and ask for participation by partner agencies. Topics include metric-driven targets, best practices,  community crisis stabilization, and others.

Each behavioral health partner will be responsible for sending representatives to the appropriate behavioral health workgroup meetings. Workgroups include but are not limited to Behavioral Health Metrics Workgroup(s), Community Crisis Stabilization Workgroup, and site-specific meetings with the Millennium relationship manager periodically.

The Millennium relationship manager will keep track of ongoing behavioral health meeting minutes, sign-in sheets, and related documentation as evidence of workgroup attendance. No substantiation requirements for behavioral health /developmental disability providers.

Last updated on November 22, 2017

5.Transformation with Performance

This section outlines the Quality Improvement (QI) metrics designed to allow Millennium to measure and monitor outcomes from the baseline (July 2015–June 2016) to the final (July 2018–June 2019) measurement year. The DSRIP QI performance measures focus on the following goals:

  • Identifying program measures that matter in managing ambulatory care services
  • Preparing meaningful indicators to evaluate performance on an annual basis using evidence based quality indicators
  • Building the infrastructure for continuous quality improvement with Millennium’s network partners
  • Evaluating areas related to improving efficiency, access of care delivery and timeliness of care management in the appropriate setting

This annual QI benchmarking will benchmark Millennium and its provider partners against other PPSs in the state to assess provider performance across the region. To meet the final performance measurement goals and achieve maximum DSRIP funding, the Millennium team will guide PPS participants to achieve these goals.

NYS DOH bases DSRIP performance on “Measurement Years,” which lag roughly a year behind Demonstration Years. For example, Measurement Year 2 (MY2) spanned July 1, 2015–June 30, 2016 (while DY2 spanned April 1, 2016–March 31, 2017).

  • MY1 (baseline): July 1, 2014–June 30, 2015
  • MY2: July 1, 2015–June 30, 2016
  • MY3: July 1, 2016–June 30, 2017
  • MY4: July 1, 2017–June 30, 2018
  • MY5: July 1, 2018–June 30, 2019

[link to DSRIP timelines][link to measures documents that include code sets etc – PC, peds, BH][link to reporting parameters spreadsheets – PC, acute]

Last updated on November 2, 2017

5.1.Emergency Department Care Triage Program

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

The goal of the ED Care Triage Project is to develop an evidence-based care coordination and transitional care program for patients following an ED visit. The ED care triage program is designed to connect patients to primary care to avoid future potentially preventable ED visits and readmissions in support of the overall DSRIP program goals of reducing hospital and emergency department visits by 25% by the end of the DSRIP initiative.

This program will allow patients to have a better knowledge of community resources and information relative to their chronic conditions and ensure patients are connected with PCPs. Performing warm handoffs established in the ED will support patients as they transition to the next, more appropriate, level of care.

Community health workers (CHWs) and/or patient navigators (PNs) are embedded in hospital EDs as part of the ED care coordination or discharge planning teams targeting Medicaid patients with lower acuity triage levels. These targeted patients are triage-level patients which most likely could be handled more appropriately by a primary care provider, versus in the acute care setting (ED).

These patients are interviewed by a CHW/PN, who also conducts a Patient Activation Measures (PAM®) assessment. The patient is then scheduled for a primary care appointment within 30 days of their initial ED visit. These scheduled primary care appointments are tracked within the hospital’s EHR or within SalesForce application. (Note: SalesForce is an interim plan until full implementation into acute care site EHR.)

The CHW/PN also conducts a reminder call 24–48 hours prior to the appointment and confirms appointment outcome (i.e., whether patient attended and/or rescheduled as appropriate). Patient barriers to primary care are assessed and CHW/PN connect patients to community resources and/or the next level of care.

  • Develop processes and procedures to establish connectivity between the ED and community PCPs
  • Ensure real-time notification to a health home care manager as applicable

Each hospital will need to develop a process to establish partnership and connectivity between key clinical participants and health homes. For patients presenting with minor illnesses who do not have a primary care provider:

  • PNs will assist the presenting patient to receive an immediate appointment with a PCP, after required medical screening examination, to validate a non-emergency need
  • PN will assist the patient with identifying and accessing needed community support resources
  • PN will assist the member in receiving a timely appointment with that resource

Hospitals will provide the following:

  • Workflow outlining necessary steps for PN to take to link patient to PCP appointment and confirm follow-up
  • Report from SalesForce or hospital EMR on percentage of patients who attended their follow-up appointments
Last updated on November 22, 2017

5.2.Health Home Integration

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

The objective of integrating health home care coordination resources into the hospital (ED and inpatient) discharge planning process is to ensure an effective, appropriate plan is in place prior to discharge and adequate follow-through and transition into the community is established.

Resources

Last updated on November 27, 2017

5.3.Medical Neighborhood Best Practice

Provider Types

The deliverables described in this section are required by the following types of participants:

Description

A “medical neighborhood” is a clinical–community partnership that includes the medical and social supports necessary to enhance health, with primary care serving as the patient’s primary “hub” and coordinator of health care delivery.

A high-functioning medical neighborhood ensures thorough, well-coordinated care transitions are in place for patients which take into account medical, social, and behavioral factors with the goal of ensuring patients health and well- being.

Certain key activities support the creation of medical neighborhoods:

  • Collaborate with various “medical neighbors” to encourage bidirectional flow of information among clinicians and patients, to include hospitals, behavioral health providers, home health, long-term care, health homes, community-based organizations, and other clinical providers.
  • Actively promote care coordination, fitness, healthy behaviors, proper nutrition, as well as health environments and workplaces.
  • Focus on meeting the needs of the individual patient, but also incorporate aspects of population health and overall community health needs. Active collaboration with non-clinical health partners to address social determinants of health is essential.

A high-functioning medical neighborhood relies on improved bidirectional communication and coordination among healthcare providers and institutions. This encourages the flow of information among clinicians and patients and introduces a level of accountability to ensure that clinicians readily participate in information exchange. Other key features of a high-functioning medical neighborhood include:

  • Clear agreements on and delineation of the respective roles of neighbors in the system
  • Sharing of clinical information
  • Care teams, typically anchored by the primary care, to develop individualized care plans for complex patients that describe a proactive sequence of health care interventions and interactions
  • Continuity of needed medical care when patient transitions between settings, with active communication, coordination, and collaboration among all parties involved in the patient’s care, including patients and family
  • Strong community linkages that include both clinical and nonclinical services
  • A focus on patients’ preferences to ensure they are incorporated into decision making process

Outcome of a high-functioning medical neighborhood include patient-centered outcomes, safety, and experience through reduced duplication of services, increased delivery of preventative services, increase in evidence-based patient care.

The following performance measures can be impacted by a successful medical neighborhood:

  • Reduction in readmissions
  • Reduction in preventable admissions
  • Reduction in preventable ED visits
  • Improved patient survey (e.g., H-CAHPS) scores

Hospitals

As a key player in the medical neighborhood concept, hospitals need to ensure a process is in place to inform primary care teams when their patients are in the hospital or have visited the ED. Hospitals must also:

  • Advise the primary care practitioner of patient discharge (timely, informative discharge summary)
  • Assess patient risk for 30-day readmission (medical, social, and behavioral)
  • Develop strong communication and coordination with PCPs in the community (when concerns are noted)
  • Increase communication to PCPs for patients with complex discharge plans (knowledge of the reason for hospital admission, what transpired, and what is the discharge plan—home, post-acute care)

Special attention is paid to care transitions, with interventions focused on discharge planning and post-discharge follow-up and an emphasis on reducing readmission. Activities should be led jointly by hospitals, primary care, relevant specialists, and other clinicians and community partners. Examples of care transition interventions include the following:

  • Post-discharge medication management
  • Communication on pending lab and test results
  • Post-discharge status and instruction, including community linkages and other care management services
  • Systematized care coordination activities within primary care

Simply transferring information from the hospital to primary care is not sufficient. Active collaboration and partnership is necessary for managing care transitions appropriately.

Hospitals should know about available resources for different patient needs, make referrals, and follow-up with patients to ensure they accessed those services. To facilitate this, hospitals may develop a referral bank of social services linkages with key community-based organizations.

Primary Care

As the hub of the medical neighborhood, primary care practices must continue to expand upon the core principles of Patient Centered Medical Home Recognition.  Building upon this foundation is critical to success.  Practices must take active steps in the following:

  • Ensuring clinical partnerships are strong and effective. This includes enhancing collaboration with hospitals, behavioral health providers, and any other high volume specialists that serve their patients. Collaboration should come from ongoing relationship building, and formalized agreements if needed.
  • Assessing their hospital and ED follow up process. Does the practice receive notifications from all area hospitals and EDs? Is there a triage process within the practice’s hospital and ED follow up workflow?
  • Building out bi-directional communication with non-clinical partners, such as health homes and community based organizations. Reaching out to new community based organizations to serve the non-clinical needs of their patients for important services such as housing and transportation
  • Embrace opportunities to receive clinical data that supports risk stratification of their patients. Ensure that the practice is using HEALTHeLINK to its full capacity in support of care coordination and care transitions activities.
Last updated on November 22, 2017

5.4.Behavioral Health 7- and 30-Day Follow-Up

Provider Types

The deliverables described in this section are required by the following types of participants:

  • Behavioral health outpatient
  • Behavioral health inpatient

Description

Improve the rate of 7- and 30-day follow-up following a behavioral health hospitalization.

Outpatient behavioral health partners will attempt outreach for at least 75% of patients using the Sinnissippi Centers Non-Clinical Pre-Admission Customer Service/Motivational Techniques for patients discharged from acute care prior to appointments.

Resources

Last updated on November 2, 2017

5.5.Depression Best Practice

Provider Types

Description

Primary care practices are often responsible for prescribing/managing antidepressant treatment for patients diagnosed with depression. These practices should have workflows in place that reflect current best practices for managing patients with depression.

Partners will participate in best practice education and training sessions facilitated by Millennium, and will implement workflows to care manage newly diagnosed depressed patients prescribed an antidepressant.

Resources

Last updated on November 22, 2017

6.MPA Exhibits

The links below go to the actual Exhibit A “Scope of Work” documents from the DY3 Master Participation Agreements (MPAs). These Exhibits are provider-type specific. Consult your organization’s executed DY3 MPA or Amendment to determine which Exhibits apply to your specific organization.

Last updated on November 2, 2017

7.DSRIP Timeframes

The DSRIP program is based on “Demonstration Years” (DY). Each DY starts on April 1 and goes through March 31.

  • DY 1 (April 1, 2015–March 31, 2016)
  • DY 2 (April 1, 2016–March 31, 2017)
  • DY 3 (April 1, 2017–March 31, 2018)
  • DY 4 (April 1, 2018–March 31, 2019)
  • DY 5 (April 1, 2019–March 31, 2020)

Within each DY, the quarters are as follows:

  • Q1: April 1–June 30
  • Q2: July 1–September 30
  • Q3: October 1–December 31
  • Q4: January 1–March 31

Pay-for-performance metrics are earned during “Measurement Years” (MY) which differ in timing from Demonstration Years. Each MY starts on July 1 and goes through June 30.

The payments related to the performance in each MY come almost a full twelve months after they are earned. The correlation between MYs and DYs and payments are as follows:

MY 1 (July 2014–June 2015)

  • Performance paid out in:
  • DSRIP Year 1 Payment 2 (July 2016)
  • DSRIP Year 2 Payment 1 (January 2017)

MY 2 (July 2015–June 2016)

  • Performance paid out in:
  • DSRIP Year 2 Payment 2 (July 2017)
  • DSRIP Year 3 Payment 1 (January 2018)

MY 3 (July 2016–June 2017)

  • Performance paid out in:
  • DSRIP Year 3 Payment 2 (July 2018)
  • DSRIP Year 4 Payment 1 (January 2019)

MY 4 (July 2017–June 2018)

  • Performance paid out in:
  • DSRIP Year 4 Payment 2 (July 2019)
  • DSRIP Year 5 Payment 1 (January 2020)

MY 5 (July 2018–June 2019)

  • Performance paid out in:
  • DSRIP Year 5 Payment 2 (July 2020)
Last updated on November 27, 2017
Help Guide Powered by Documentor
Suggest Edit

Join Our Quarterly Newsletter

ECMC logo

The Erie County Medical Center (ECMC) is the lead entity in the Millennium Collaborative Care Performing Provider System.

Millennium Collaborative Care

1461 Kensington Ave
Buffalo, NY, 14215

t:  716-898-4950
www.millenniumcc.org

© Millennium Collaborative Care.