Refuah PPS consists of 4 FQHCs that service Rockland and Orange counties. In addition, they include a medical group affiliated with Good Samaritan Hospital and Jawanio, an OPWDD provider that provides primary care to its clients.

Most of network are FQHCs where primary care is strong. Refuah is actively expanding and integrating mental health services on–site. Refuah PPS has been an active participate in mid– Hudson collaboration with other PPS, local counties and providers on BH initiatives notably crisis stabilization.

Overall Assessment: Strong elements for BH integration. Other areas require more specificity and timing. Integrating into larger continuum of care with external partners such as hospitals and connectivity with RHIO/SHIN–NY are less specific but are key PPS strategies. Lack of specifics on funds flow.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • Refuah PPS´s primary care capacity is 100% FQHC and hospital–based providers. Their strategy is to:
    • Expand capacity and increase efficiencies through workforce strategies promoting top of license practice
    • Integrate PCP operations into continuum of care including BH integration to reduce inefficiencies and promote well–being
    • Expand administrative infrastructure and resources for the practices
    • Target EHR development and expansion
  • Refuah has no community–based independent primary care providers in the PPS network
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • Refuah plans to establish a funds flow model for primary care organizations based on attribution for their use in operational enhancements, etc.
  • Two of the primary care practices do not yet have PCMH 2014; however, these two practices have recently become part of larger systems and Refuah will provide assistance as needed.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • Create integrated primary care hubs – integrated medical and BH services with robust care management and navigation services.
  • Comprehensive data–sharing network with RHIO/SHIN–NY alerts and other information when patients have admission events or transitions between points of care enhanced collaboration with local hospitals and access to specialists on–site at its primary care locations.
  • RCHC Executive Governing Body has 11 members, 3 are FQHC CEOs. The PPS CMO who is a primary care provider also attends the Executive Governing Body meetings.
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • Because the PPS is FQHC–led, its PCP VBP strategy is synonymous with its overall VBP strategy. The VBP strategy will be largely contingent upon integration of behavioral health into primary care. Key aspects will be:
    • Development of data–sharing based on RHIO/SHIN–NY platforms for partners to share info and alerts for events and transitions between points of care.
    • Scale existing efficiencies and leverage longstanding MCO relationships
    • Identify gaps, fill with additional systems and partnerships; continue workforce training.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • As FQHC–led, the PPS funds flow model was developed to meet project goals and expand primary care capacity. The model will allocate funds for its partners based on 1. Project infrastructure and requirements; 2. Patient engagement; 3. Attribution and performance. Since the FQHC partners drive 90% of the attributed lives, the vast majority will flow to the FQHC partners.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • Refuah believes true holistic approach is necessary for full benefit of primary care and BH integration.
  • Physically dispersed all existing BH providers to more accessible patient services departments.
  • Doubled the number of social workers from 4 to 8 for an "on–call" mental health providers to cover evaluations and warm hand–offs during all operating hours
  • Expanded standardized mental health screening in primary care for all ages and women´s health
  • Invested in education of its primary care providers including gynecologists in the diagnosis and management of routine mental health diagnoses, thereby cutting waiting lists for BH specialists
  • Offering non–pharmacological adjuvant programs for ADHD treatment including parenting skill sessions for caregivers
  • Primary care providers provide routine substance abuse screening during well visits and will monitor best practices such as SBIRT.