The NYU Lutheran PPS is located in Brooklyn, but also has partners in Manhattan and Queens. The PPS patient base is concentrated around 18 primary care partner organizations (93% of attribution) and approximately 150 providers.

Overall Assessment: Plan focuses on primary care but capacity information not well documented. There are many primary care HPSA areas in Kings County and the primary care plan does not address this aspect. The Plan could have more information provided on numbers of primary care practitioners in the PPS including pediatricians, nurse practitioners, etc.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Plan outlines that all practices offer same or next day appointments and extended hours. Internal survey results of practices revealed nearly all practices have achieved PCMH 2014 Level 3 status, however based on the information in Fundamental #2, it appears this number represents all levels of PCMH certification and a significantly lower number is at 2014 Level 3. The plan is to focus on telehealth and telepsychiatry to improve access to high volume specialists.
  • Some PPS partners are planning to expand PC physical capacity by creating new sites through CRFP or adding square footage to existing sites (e.g., Ezra MC will develop an additional 10k square feet for PC, NYU FGP and UPN practices built Medicaid clinically integrated network, and ODA PHCN has a CRFP grant to expand PC access to 3,112 new patients). The PPS is also working with the RHIO Healthix on EHR.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • The PPS has several different training opportunities for primary care staff including cultural competency/health literacy, compliance, use of HIE/Healthix and other clinical training.
  • The PPS will contract with a consultant to determine which PCPs do not yet meet PCMH standards. According to this section, 150 providers have achieved some PCMH designation, but only five have achieved 2014 Level 3 designation. This appears to contradict what is reported under Fundamental 1.
  • The PPS has implemented an EHR system and is providing training to primary care practices. They have contracted with Salesforce to support practice and workforce transformation around EHR, both developing the partner portal to enable bi–directional communication and supporting the workflows, referral management and community resource tools.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • NYU Lutheran has created a Medicaid–focused IPA and has begun enrolling partners. The IPA will promote improved coordination of care through enhanced IT connectivity, improved transparency and timeliness of information.
  • PCPs will facilitate linkages to patient navigators and/or care coordinators, leading to effective interventions and management of high–risk patient populations.
  • PCPs will be able to facilitate linkages to specialist services with medical information easily accessible through common IT platforms and networks. This will allow PCPs to be able to manage the population within the framework of an integrated delivery system.
  • Optimizing IT strategy will allow for timely information transfer to specialists, ambulatory and inpatient settings.
  • Primary care partners are represented on the governance committees, representing 37% of the governance board and committees. Of those, 87% are community based practitioners.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Creation of the IPA will allow for VBP contracting arrangements and the PPS is preparing to transition from FFS to level 1 or 2 arrangements.
  • The PPS currently has activities underway to prepare for these arrangements, such as assessing partners risk readiness, engaging payers, using analytics to understand the population and cost of care, and developing patient–centered interventions to ensure quality care in the appropriate PC setting. The last will be managed by care coordinators. There is little information on operationalizing technical assistance for partners, e.g., contracting with vendors for TA.
  • The PPS will collaborate with MCOs to receive daily patient data. How the providers will receive data is not detailed.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • The PPS has developed a funds flow to primary care providers that is focused on dispersing funds to primary care facilities, FQHCs, PC physicians and CBOs. To earn payments, the PPS analyzes efforts in several areas including meeting domain milestones and deliverables, accomplishing patient engagement targets, and focusing on P4R and P4P areas, among others.
  • To date, $3.1m has flowed to PPS partners as follows: clinics and outpatient facilities 66.69%; hospitals 21.04%; primary care practitioners 6.52% ($202k); and community based organizations 4.76%. It does not appear that any payments for engagement have been made as of yet.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • The PPS has developed a network of collaborative care, supported through building IT information tracking and exchange. Also developed protocols for warm handoff of patients screening positive for MH or SUD to the appropriate BH providers.
  • PPS has 11 family health centers with some level of BH services at 7 sites. Ezra Medical Center has implemented a culturally competent co–located model and ODA has streamlined its service integration. Will continue this expansion, as well as develop a telepsychiatry program to enhance the access to BH services at the primary care site.