The CCB PPS network includes 3 (Wyckoff, Interfaith, Kingsbrook Jewish) of the 4 hospitals which are part of the Brooklyn Transformation Study report. Robust primary care network and significant practice transformation resources devoted to assisting practices in attaining PCMH recognition as well as behavioral health integration. Demonstrated funds flow budget allocation to support primary care of $11.2 million.

Overall Assessment: Very strong plan with many activities well in progress.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • CCB has extensive contracting with 5 hospitals employing 400 PCPs, 6 FQHCs with 83 PCPs, 2 IPAs with 74 PCPs and 102 PCPs in community practices.
  • CCB´s approach is to increase primary care capacity by expanding network and supporting increased visit and patient capacity through practice transformation focused on efficiencies and effectiveness. It is encouraging practices to expand office hours and availability of primary care during evenings and weekends.
  • CCB has a major commitment to community primary care practices because of their central role in integrated delivery system in Brooklyn and plans to add another 100–200 PCPs in next network change opportunity. CCB staff have also met with community PCPs in their offices as part of assistance.
  • Capital awards to Wyckoff, Maimonides, and Kingsbrook to increase PCP and urgent care space.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • CCB has retained 4 organizations to provide assistance with PCMH designation and other practice transformation. Priority has been given to 400 PCPs in more than 55 locations with the largest Medicaid practices organizations over the next 12 months potentially impacting more than 250,000 Medicaid members.
  • In addition, Institute for Family Health has been providing training and technical support to PCPs in behavioral health integration.
  • CCB has engaged with workforce (NYAC and CUNY) resources to train medical assistants and MA–level staff to become Health Coaches to work with primary care practices on care coordination activities. Contracted with 1199TEF for care coordination training for a variety of staff positions.
  • Centralized services to support access to web–based collaborative care plan, provide Health Coaches to small practices through contracts with two care management agencies and a project helpline for PPS providers.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • PCMH is the foundation for the integrated delivery system. The Care Transitions, ED Triage, and Health Home projects all promote the central role of PCPs.
  • To promote PCP connectivity to other health care providers, PCPs will have access to Dashboard, the web–based care coordination platform where community–wide care plans are available and encourage to join Healthix, the regional RHIO to receive admissions alerts on their consented patients. CCB provides training on both to the PCPs to make full use of tools.
  • Governance – the three chief positions (CEO, CMO, Chief of Clinical Programs/Network) are primary care physicians and/or versed in practice transformation. Primary Care is "well– represented" on Governance Committees.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Increase PCP´s understanding of the reimbursement environment, including VBP and positioning to succeed in that environment; and to increase the attractiveness of primary practices to MCOs by assisting them in achieving MCO standards for access, preventive screening, quality, and patient outcomes and satisfaction.
  • Development of trainings, including topics that are important for PCPs and their staff to understand and to be successful in VBP arrangements. VBP orientation sessions have already been attended by CBOs and primary care organizations.
  • Provide resources such as Health Coaches to small practices that will expand and eventually include services more directly linked to VBP arrangements, including training on strategies to optimize coding/billing practices.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • As of August 2016, $11 million budgeted directly to flow to support primary care with approximately $5.6 million as direct payments to primary care providers. Additional commitments to be made in the future.
  • Funds support a variety of activities including resources to primary care practices and care management agencies to hire Health Coaches, payments to MJHS Institute for Innovations in Palliative Care to provide primary care team training.
  • Centralized support and contracts for training and technical assistance to providers for PCMH recognition and assistance to support implementation of behavioral health integration models.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • CCB is implementing all three models of 3.a.i. and retained IFH to provide training
  • Providing a care coordination platform (the Dashboard) to facilitate communication between primary care, behavioral health providers, and Health Homes.
  • Addressing behavioral health integration in the Care Transition and ED Care Triage projects and implementing Critical Time Intervention for SMI population.
  • Working with other PPS on a population–based school health initiative as Domain 4/Prevention Agenda project.
  • Collaborating with the NYC Mayor´s Office to implement of a model of community–based depression screening and referrals.
  • Implementing a MAX program at Interfaith MC and a HARP VBP pilot at Maimonides MC.
  • 4 CCB FQHCs have been selected to participate in the NYS Collaborative Care Medicaid program and will receive a PMPM payment to provide care.
  • The use of telepsychiatry as part of implementation of IMPACT and BH co–location into primary care settings when a psychiatrist is not available to provide services on–site.