Mt. Sinai PPS network covers the boroughs of Manhattan, Brooklyn and Queens. The primary care capacity of the Mt. Sinai PPS currently includes 1,720 primary care practitioners, of which specialty types include internal medicine, family practice and pediatrics. The current total PPS attributed lives population is 394,789 Medicaid members. The PPS identified that the favorable ratio of primary care practitioner to attributed lives population of the PPS would suggest better clinical outcomes per member, though the Mount Sinai PPS Measurement Year 1 results that are the baseline showed significant community need. Key performance measures, such as Children and Adult Preventive or Ambulatory Care Access and Preventive Quality Indicators were substantially behind and further highlight the need and opportunity for the PPS to explore other drivers beyond expanding primary care capacity as a barrier to access.

Overall Assessment: The Plan seems overall vague and future oriented, suggesting the PPS is behind in its Primary Care activities, with language such as "we have begun exploring" and "the PPS is monitoring FQHCs." That said, 39% of PCP practices are 2011 or 2014 PCMH certified. There is no discussion on use of workforce budget to recruit PCPs.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • While the PPS service areas include Manhattan, with an abundance of primary care providers and other provider types, the two other service areas, Brooklyn and Queens, are the largest geographic area of the PPS and are HRSA–designated Health Professional Shortage Areas (HPSAs).
  • These communities serve a multiethnic and multicultural, medically underserved area with a lower penetration of provider types including primary care providers.
  • Exploring collaboration opportunities with leadership of larger FQHCs by initially assessing their primary care and integrated behavioral health availability, access, and capacity throughout all of the PPS service areas.
  • Monitoring FQHCs and other partners´ innovative models that include talent pipelines to address staffing concerns of primary care physicians, NPs and PAs.
  • Having discussions with Health Home networks to understand, socialize, and optimize the use of Health Home structure for care management & coordination services by PCPs.
  • Utilizing the PPS´ digitized resource guide to generate referrals, track connection to care and services, and monitor performance measures
  • Mt. Sinai is launching the community care hub model, a model whereby many different clinical and social provider types work collaboratively with the PCP at its core, with its first care hub planned to start in upcoming months.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Of the PPS´ safety net and non–safety net PCP providers, 39% are either 2011 or 2014 PCMH certified. The PPS plans to support practices that wish to pursue any practice transformation, and practice transformation vendors have been assessed by the PPS for specific services they can provide practice sites.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • The PPS envisions a community care Hub model that places the PCP at the center of the care team, collaborating and coordinating the care of patients.
  • A care management and IT/Data infrastructure is in development to support and facilitate care coordination and partner communication to be piloted in the first hub and later disseminated to other hubs.
  • Approximately 25 percent of the PPS governance structure, including Clinical committees and Board of Managers, is comprised of PCPs.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • The PPS has socialized and introduced the key principles and concepts of value–based payment arrangements with FQHCs, clinics and other primary care partners.
  • The PPS is messaging VBP arrangement concepts and providing a high–level understanding of Mt. Sinai Health System´s Medicaid IPA strategy
  • Workforce Committee´s strategy includes training and technical assistance resources to help PPS partners understand value–based payment arrangements.
  • Technological platforms that will display the longitudinal view of an attributed patient´s care are under development.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • Assessing the impact of provider types to the PPS prioritized performance measures, since a significant number of performance measures appear to be positively and highly impacted by primary care practitioners, primary care clinics, and FQHCs.
  • $1.9 million distributed thus far to larger PC practices and FQHCs
  • Current contract metrics for distributed dollars include reporting, engagement, and performance.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Implemented a 5–pronged strategic approach to implement key requirements and ensure project success: 1) Connectivity and alignment 2) Team–building 3) Standardization 4) Problem–solving, and 5) Sustainability.
  • Developing an evidence– based protocols´ manual for use by partners across PPS
  • General principles and components around warm handoffs in integrated care have been identified