DOH REVIEW AND EXECUTIVE SUMMARY OF PPS PRIMARY CARE PLAN

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CARE COMPASS NETWORK

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DSRIP MIDPOINT FEED BACK

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TO:               THE INDEPENDENT ASSESSOR, PCG

FROM:         CARE COMPASS NETWORK

SUBJECT:   MIDPOINT REPORT – PUBLIC COMMENT PERIOD

DATE:           WEDNESDAY DECEMBER 21, 2016

____________________________________________________________________________________

In accordance with the DSRIP timetable and following the publication of the MidPoint report and Companion Document on November 29, 2016, Care Compass Network (CCN) has gathered feedback to the Independent Assessor (IA) MidPoint report on behalf of the PPS and its partners. Through review of the documents provided during the MidPoint process, Care Compass Network has compiled comments into two categories on behalf of the network: (1) administrative / clarifications and (2) substantive feedback. With regard to both, a detailed overview document has been attached hereto. Given information available to the PPSs there were few questions raised by the PPS with regards to methodology, with comments more geared towards attributes of the reports such as accuracy, validity, and completeness.

The scope of administrative edits and clarifications identified indicate to the PPS that, amidst the effort to effectively evaluate and score PPSs based largely on written reports, the IA was not sufficiently able to characterize core organizational elements of the PPS. To promote ail enhanced communication from the PPS to the IA, the PPS would support establishment of additional on-site meetings to meet directly witl1 PPS representatives and conduct dialogue surrounding the current operational and performance matters of the PPS. These administrative edits and clarifications have been detailed in the attached and should not impact substantive elements of the report such as overarching conclusions or recommendations.

Following review and digestion of the MidPoint Report and supporting documents, Care Compass Network also gained new insights and clarity as to how various reports and standardized templates provided quarterly to the IA are being leveraged for analysis and conclusion. Examples include organizational reporting in MAPP/PIT at the enterprise level having direct results on conclusions drawn regarding partner/ provider engagement, attention to MAPP/PIT partner classifications, attention to MAPP budget reporting methodology to more accurately delineate "PPS PMO" versus other spending categories, and enhanced need for cross–pollination of work across DSRIP Domains. While each of these could also be deemed as administrative / clarifying in nature, there were several instances where these elements drove initial recommendations for the PPS to address and as such were categorized as substantive feedback for this open comment period. There were also several instances identified where recommendations solicited the performance of tasks which have previously been completed and reported by the PPS. Each of these examples has been commented on individually by the respective recommendation. In total, Care Compass Network identified 18 of 22 recommendations for which documentation and clarification points to the support of existing PPS achievements and respectfully requests reconsideration of these recommendations. The remaining four recommendations received minor comment or edit.

Lastly, Care Compass Network appreciates the overall feedback provided and approaches leveraged by the IA. Active discussion has occurred throughout the PPS in several open forums to date with critical CCN stakeholders, including the PAC Executive Council, PAC/Stakeholders, Coordinating Council, Board of Directors, CCN staff, and multiple Regional Performance Unit operating groups. This process has resulted in the provision of valuable insights, feedback, and validation to many of the processes established over the past two years. The PPS has received the MidPoint report comments with great consideration and has already realigned several efforts to begin to address items identified within the documents to achieve critical short team objectives.

Thank you for your consideration.

Respectfully,

Mark Ropiecki,
Executive Director


Document Ref Published Document Proposed (New) – key edits in red font
Midpoint Assessment Report Page 3 "Care Compass Network PPS (Co–led by UHS and CRMC)" " The Care Compass Network PPS is a PPS lead by the newco company Care Compass Network."
Midpoint Assessment Report Page 3 "Serves six counties in the Southern Tier of New York: Broome, Chemung, Chenango, Cortland, Delaware, Schuyler." "Serves nine counties in the Southern Tier of New York: Broome, Chemung, Chenango, Cortland, Delaware, Schuyler, Steuben, Tioga, and Tompkins."
Midpoint Assessment Report Page 4 Figure 2: All PPS 360 Survey Results by Partner Type and Organizational Area Question: Can you elaborate how the Partner Type was selected for Partners in the PIT that have multiple types? For example, one of our Partners that received the survey and completed it, is listed as Hospital, All Other, Clinic, Case Management/Health Home, Mental Health and Substance Abuse. How was it determined which Provider Type they were categorized as when there were more than one?
Midpoint Assessment Report Page 6 0/1 Hospital Partners responded to the survey Note: A hospital partner did confirm response to the survey but was categorized as another partner type.
Midpoint Assessment Report Page 8 "The PPS Governance structure includes a Board of Directors that includes 3 hospitals, one FQHC, the chairs of their committees, and a number of Community Based Organization representatives." "The PPS Governance structure includes a Board of Directors that includes representation from each of the five health systems, one FQHC, and five Community Based Organization representatives."
Midpoint Assessment Report Page 8 "During the IA On–site visit, it was noted that the staff leading the Project Management Office are drawn from various partners within the PPS, and have responsibilities at both the partner organization as well as the PPS." The PMO is comprised of FTEs which work exclusively at CCN, as well as Subject Matter Experts who CCN has acquired services from professionals of partner organizations. CCN Staff do not have responsibilities at partner organizations, however these subject matter experts do.

Suggested language update: "During the IA On–site visit, it was noted that the staff leading the Project Management Office are full time staff of the PPS who are supported by Subject Matter Experts drawn from various partners within the PPS. These subject matter experts have responsibilities at both the partner organization as well as the PPS."
Midpoint Assessment Report Page 10 "There was no indication of the extent to which it has surveyed and assessed the readiness of their partner network to implement VBP." This statement is incorrect. An assessment had previously been completed as reported to the IA in DY1, Q4, which the IA recognized as complete. All steps of the milestone related to this endeavor were marked complete with no disagreement from the IA, but the overall milestone was not marked complete as documentation requirements were never given, and the milestone was removed from the implementation plan by DoH.
Midpoint Assessment Report Page 13 Based on the data in Figure 6 above, the IA identified one project that is at risk due to the current status of project implementation efforts; project 3.a.i. has milestones with required completion dates of DY2, Q4 that are currently in a status of ´On Hold´. This status indicates that the PPS has not begun efforts to complete these milestones by the required completion date and as such are at risk of losing a portion of the Project Implementation Speed AV for each project. In addition to the risks associated with the current status of milestones with a DY2, Q4 required completion date for project 3.a.i, there are additional risks associated with milestones with a DY3, Q4 required completion date. For this project, the PPS has multiple milestones that have a status of ´On Hold´. It is true some of the milestones associated with 3.a.i project are ´On Hold´ with the reason being the Model 3 was not selected. Since CCN is only pursuing Model 1 and Model 2 for project 3.a.i, it does not seem reasonable to include any statements relative to the model the PPS is not pursuing and as currently written this section provides an incorrect view of CCN´s implementation of 3.a.i even though the last paragraph tries to fix that. We are requesting that the entire verbiage below the Figure 6 table to be removed since it is associated with 3ai MODEL 3. CCN is not participating in the Model 3 therefore we are not at risk of losing the AV associated with the project.
Midpoint Assessment Report Page 13 Figure 6: CCN Project Milestone Status – Please remove pink status bar from 3ai – 3/31/2017 and 3/31/2018 This milestone is reported as on hold because we are not participating in model 3 therefore it is providing our stakeholders and partners across the PPS with incorrect information. We are requesting that it be removed from the table (Figure 6 table). ** Suggest Recommendation Removal **
Midpoint Assessment Report Page 17 The data presented in the partner engagement tables in the following pages includes the partners engagement across all defined partner types for all projects where the PPS is lagging in partner engagement. We believe the current way the PIT is filled out is not an accurate picture of Provider Engagement within our network. The original guidance for completing the PIT was "Records will exist at both the entity and practitioner levels, depending on the provider category. For example, reporting related to multiple PCPs could be rolled up to a Clinic or Hospital category row. Due to the records potentially existing at both levels, it is possible to report at either the entity level or the practitioner level. The PPS should aim to match reality as closely as possible, which will most likely result in a combination of reporting at both levels." When CCN completed the PIT, only the entity level was used since it was not clear at the time we needed to also report at the practitioner level. An updated approach will be leveraged effective the 1/31/17 report.
Midpoint Assessment Report Page 23 As the data in Figures 15–20 above indicate, the PPS has engaged network partners on a limited basis for each of the six projects highlighted…. As a result of the comment above regarding the PIT we would expect all the information after Figure 20 but before next section on page 24 would also change.
Midpoint Assessment Report Page 23 For Project 3.a.i, the PPS committed to engaging 37 Mental health partners and zero PCP partners – This is incorrect reporting which is pulled directly from the PIT. We have PCP and Mental health partners who are engaged in the project. The number is not zero for PCP engagement as we have primary sites who have implemented the model 1 integration project. Suggest Recommendation be updated for CCN to update to truly demonstrate the actual number of PCPs who are engaged in the project. The PPS will need to update/amend the PIT and capture the required fields to be able to accurately report in the next quarterly report (1/31/17).
Midpoint Assessment Report Page 25 3.g.i.: The PPS identified challenges with the overall reimbursement of providing these services with payers beyond DSRIP funding. Additionally, the PPS expressed challenges with achieving PCMH 2014 Level 3 certification with its PCP partners. Within the mid point narrative for the 3gi project CCN did not express challenges with achieving PCMH 2014 Level 3 certification. We did however express challenges with multiple changes within the 3.g.i project that caused hesitation by CCN Partners for the willingness to participate in a project without knowing what they were officially being held to due to the multiple changes in 3.g.i.

New Suggested Language "The PPS identified challenges with the overall reimbursement of providing these services with payers beyond DSRIP funding. Additionally, the PPS expressed challenges with this project as a result of the multiple changes to project 3.g.i. which caused hesitation by several partners who indicated concern with contracting for a program with yet to be finalized revisions."
Midpoint Assessment Report Page 26 Figure 21: Overall Project Assessment. The X in Partner Engagement columns for projects 2biv, 2di, 3ai and 3bi. Suggest removal of Partner Engagement risk for projects 2biv, 2di, 3ai and 3bi. With the updated PIT (to indicate engagement at the entity and provider levels) these projects do not have issues with Partner Engagement.
Midpoint Assessment Report Page 27 Figure 22: Project Risk Scores. Risk score of 3 for project 2ai. This project was given a risk score of 3 due to the limited partner engagement across all of the projects. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 2 instead of 3.
Midpoint Assessment Report Page 27 Figure 22: Project Risk Scores. Risk score of 3 for project 2biv. This project was given a risk score of 3 due to the perceived lack of partner engagement as well as lack of patient engagement. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 2 instead of 3.
Midpoint Assessment Report Page 27 Figure 22: Project Risk Scores. Risk score of 2 for project 2bvii. This project was given a risk score of 2 due to the lack of patient engagement. As of DY2Q2 we have met speed and scale for this project as well as for DY2Q4 and feel this project is more than likely to meet intended goals. We recommend lowering the risk score to 1 instead of 2.
Midpoint Assessment Report Page 27 Figure 22: Project Risk Scores. Risk score of 3 for project 2di. This project was given a risk score of 3 due to the perceived lack of partner engagement as well as lack of patient engagement. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 2 instead of 3.
Midpoint Assessment Report Page 27 Figure 22: Project Risk Scores. Risk score of 3 for project 3ai. This project was given a risk score of 3 due to the perceived lack of partner engagement as well as lack of patient engagement. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 2 instead of 3.
Midpoint Assessment Report Page 28 Figure 22: Project Risk Scores. Risk score of 4 for project 3bi. This project was given a risk score of 4 due to the perceived lack of partner engagement as well as lack of patient engagement. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 3 instead of 4.
Midpoint Assessment Report Page 28 Figure 22: Project Risk Scores. Risk score of 4 for project 3gi. This project was given a risk score of 4 due to the perceived lack of partner engagement as well as lack of patient engagement. As a result of an updated PIT with engagement included at the entity and provider levels we do not feel this project is as high of a risk as indicated. We recommend lowering the risk score to 3 instead of 4.
Midpoint Assessment Report Page 28 While limited partner engagement was the only area of risk identified for project 2.a.i., the IA notes that this issue, when combined with the organizational challenges identified and the limited partner engagements across multiple projects, raises the risk associated with the PPS´ ability to successfully implement this project. As such, the IA has assigned an elevated risk score for this project. As a result of an updated PIT with engagement included at the entity and provider levels the originally identified issue of limited partner engagement across multiple projects is not an issue after all. Please remove this statement. Suggest removal of this statement
Midpoint Assessment Report Page 29 The limited engagement of partners, in particular PCP and behavioral health partners, through the first six quarters of DSRIP presents a major risk to the ability of the PPS to meet its DSRIP goals. Further, when the PPS has successfully engaged partners, it has been in limited portions of the PPS service area, which limits the overall effectiveness of system transformation efforts in the region of the state served by Care Compass. As a result of the providing an updated PIT showing engagement at the entity and provider level we would expect this comment to be removed. Suggest removal of this statement
Midpoint Assessment Report Page 31 Project 3.b.i: The IA considers this project to be at risk and believes the project may fail to meet the intended goals without significant modifications or performance improvements. To date, through DY2, Q2, the PPS has failed to report any figures associated with Patient Engagement in this project. Furthermore, the PPS reports limited to no Partner Engagement in this project. Finally the PPS narrative submitted as part of the Mid–Point Assessment identified a series of overarching challenges which lead the IA to question the ability of the PPS to implement this project. As a result of an updated PIT with engagement included at the entity and provider levels and the earlier suggested edit to change the risk score of this project from 4 to 3 this text should be modified. The IA considers this project to be at risk but this project could meet intended goals with some performance improvements and overcoming challenges. To date, through DY2, Q2, the PPS has failed to report any figures associated with Patient Engagement in this project.
Midpoint Assessment Report Page 32 Project 3.g.i: The IA considers this project to be at risk and believes the project may fail to meet the intended goals without significant modifications or performance improvements. To date, through DY2, Q2, the PPS has failed to report any figures associated with Patient Engagement. Furthermore, the PPS reports limited to no Partner Engagement in this project. Finally the PPS narrative submitted as part of the Mid–Point Assessment identified a series of overarching challenges which lead the IA to question the ability of the PPS to implement this project. As a result of an updated PIT with engagement included at the entity and provider levels and the earlier suggested edit to change the risk score of this project from 4 to 3 this text should be modified.
The IA considers this project to be at risk but this project could meet intended goals with some performance improvements and overcoming challenges. To date, through DY2, Q2, the PPS has failed to report any figures associated with Patient Engagement in this project.
Midpoint Assessment Report Page 16 The Independent Assessor notes that the PPS has marked milestones related to Electronic Health Record operability as on hold. The IA recommends that the PPS develop a plan to address interoperability requirements. This pertains to 3ai Model 3 IMPACT since we are only participating in Model 1 and 2. Suggest language removal.
Midpoint Assessment Report Project 3.a.i The number of engaged providers such as the Practitioner –Primary care providers are incorrect as this was pulled directly from the PIT which is reporting 0. As a PPS, we are updating our PIT to be able to capture the relevant information as displayed in the table. Suggest Recommendation for CCN to be able to update to truly demonstrate the actual number of PCPs who are engaged in the project. The PPS will need to update the PIT and capture the required fields to be able to accurately report. We will be providing an updated PIT that has engagement at the practitioner level.

Ref Document Description Item Published Document Care Compass Network Comments
1 Organizational Recommendations Partner Engagement Recommendation 1 The IA recommends that the PPS develop a strategy to increase partner engagement throughout the PPS, particularly with Primary Care Providers and Non–Primary Care Providers. Care Compass Network suggests this recommendation be removed. With the five health systems present in our PPS, four of them have integrated primary care networks. When Care Compass Network contracts with a health system, we have done so at the entity level which is inclusive of the primary care and specialty care networks within the systems. To date this represents more than 1,000 primary and non–primary care providers across the four health systems. Care Compass Network has also contracted with ten individual primary care practices including efforts such as provision of PCMH consulting, PCMH reimbursement and incentives, and developing a pilot Medicaid VBP program with an existing Medicare ACO. As a result of this report and seeing how the IA seeks to leverage individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17 to more clearly indicate the partner engagement level within broader enterprises. However, due to the above we still believe the recommendation should be removed.
2 Organizational Recommendations Patient Engagement Recommendation 1 The IA requires the PPS to develop a plan to increase patient engagement across all projects. CCN agrees that the targets established for speed and scale across the projects have not unilaterally been achieved to date. This presents as a critical short term focus and priority for the PPS. Based on initial analysis and review with partners CCN has determined common root causes including workflow redesign, system functionality, and in some cases mechanisms of PPS funds flow. While performance trends have migrated towards PPS speed and scale goals the growth has not been at a pace on par with the established targets. As such, CCN has commenced coarse corrective measures to realign performance with these targets. A more formal PPS action plan, to be fully vetted by the PAC Executive Council and Board of Directors, will be submitted in accordance with the required DSRIP timetables at a later date.
3 Organizational Recommendations Community Based Organization Contracting Recommendation 1 The IA recommends that the PPS accelerate finalizing contracts with its partnering Community Based Organizations in order to fully implement projects. CCN suggests this recommendation be removed. In our MidPoint narratives and onsite meeting, CCN reported having signed 96 contracts with 54 CBOs for the work of implementing the projects. The value of these commitments is approximately $2.8 million through March 31, 2017. Due to restrictions in current reporting tools (MAPP/PIT), this information does not show as it only reports actual spend and not committed spend. In addition, many of the organizations CCN considers to be CBOs are not defined as such in MAPP/PIT, but are instead found other categories such as "All Other." CCN has maintained aggressive contracting efforts with CBOs and has direct contracts for the clinical work of the projects with them. Our approach has been recognized in various forms across New York State as best practice for CBO engagement. Recommendation should be removed.
4 Organizational Recommendations Cultural Competency & Health Literacy Recommendation 1 The IA recommends that the PPS develop an action plan to roll out its trainings to its workforce and partners Care Compass Network has passed all Cultural Competency & Health Literacy Milestones and steps through this point, including the most recent submission of Milestone 2 in the DY2, Q1 report which stated "Develop a training strategy focused on addressing the drivers of health disparities (beyond the availability of language–appropriate material)." As part of this strategy, CCN has developed multiple RFIs which have been submitted to PPS partners for program development which would be subsequently utilized for CC/HL training purposes. This process commenced in the late summer and concluded in October. CCN is currently in the process of identifying Cultural Competency & Health Literacy training for its partner organizations who may not have robust training programs in place. Additionally, the PPS seeks to identify modules specific to its priority groups identified in its overall Strategy. The PPS is on target to have completed these steps (e.g., training selected, developed, and roll–out) beginning in DY2, Q4. Since then, the committee has solicited input from the PAC Executive Council in making final determinations of training programs for CCN. These programs include modules and programs planned for both our clinical and community– based partner organizations in an effort to further our Training Strategy. Given the scope of efforts and progress on execution of training strategies, as evident by quarterly reports and key Milestone rating of Pass CCN, this recommendation should be removed.
5 Organizational Recommendations Cultural Competency & Health Literacy Recommendation 2 The IA recommends that the PPS develop metrics to assess its most effective strategies to engage Medicaid members and the uninsured. Care Compass Network has leveraged direct feedback from Medicaid members to assess the efficacy of programs designed or implemented. A panel comprised of Medicaid Members and the uninsured provide feedback directly to CCN on a 4–6 week basis on a host of topics. These topics vary based on upcoming or recently released programs, including Cultural Competency & Health Literacy, Transportation, and Access to Primary Care being several completed in 2016. Other topics include patient engagement, communication preferences, etc. While these do not consist of "metrics", there are reports generated from each of these surveys to summarize findings and inform PPS strategies and has proven extremely beneficial to program development thus far. Recommendation should be removed.
6 Organizational Recommendations Financial Sustainability & VBP Recommendation 1 The IA recommends that the PPS create an action to address the assessment of its network partners for VBP readiness. CCN suggests this recommendation be removed, provided that this has already occurred. As noted by the IA on page 10 of the report, the IA indicated that "There was no indication of the extent to which it (CCN) has surveyed and assessed the readiness of their partner networks to implement VBP." This statement is invalid. In the Financial Narrative provided as part of the MidPoint review by the PPS, the PPS overviewed in detail the performance of a detailed baseline assessment of revenue linked to value–based payment and MCO strategy. Information provided included specific dates, number of surveys sent out, the response rate, the results, as well as the overarching PPS decision made by the CCN Board that CCN act as a facilitator and coordinator/convener for the PPS partners and that it would not be contracting with MCOs on behalf of its partners. The corresponding steps in our implementation plan were also marked as passed in MAPP prior to the DOH´s removal of the overall milestone. Recommendation should be removed.
7 Organizational Recommendations Financial Sustainability & VBP Recommendation 2 The IA recommends that the PPS establish a plan to further educate and support their partners move toward VBP arrangements. CCN suggests this recommendation be removed, provided that this effort is already underway. As noted by the IA on page 10 of the report, the IA indicated that "There was no indication of the extent to which it (CCN) has surveyed and assessed the readiness of their partner networks to implement VBP." This statement was invalid and incorrectly prompted the generation of this comment. In the Financial Narrative, it was indicated that CCN will continue its plan of further educating and supporting their partners in the short–term through education given by the MCOs through Payor Forums like the one held with United Health Care in August of 2016. In addition, the PPS will be further developing its plan to educate and support partners with the completion of Financial Sustainability Milestone #6, recently released at the All–PPS meeting. Recommendation should be removed.
8 Project Recommendations 2ai Recommendation 1 The IA recommends the PPS develop a strategy to increase partner engagement to support the successful implementation of this projects and in meeting the PPS´ DSIRP goals. Due to the restrictions in the reporting mechanisms (MAPP/PIT), CCN recommends this recommendation be removed, as engagement has been reported at the entity level. As commented above with regard to engagement with health systems containing over 1,000 primary and non–primary care providers, our health systems also have home care organizations, hospice organizations, skilled nursing facilities, and other organization types under their umbrella. As some of those sub–organizations are non–safety net organizations, it was preferable for CCN to engage and contract with the safety net organization to keep within the 95/5 requirements of DSRIP funds flow. As a result of this report and seeing how the IA seeks to leverage individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17 to more clearly indicate the partner engagement level within broader enterprises. Recommendation should be removed.
9 Project Recommendations 2biv Recommendation 1 The IA recommends the PPS develop a strategy to increase partner and community engagement. Due to the restrictions in the reporting mechanisms (MAPP/PIT), CCN recommends this recommendation be removed, as engagement has been reported at the entity level. As commented above with regard to engagement with health systems containing over 1,000 primary and non–primary care providers, our health systems also have home care organizations, hospice organizations, skilled nursing facilities, and other organization types under their umbrella. As some of those sub–organizations are non–safety net organizations, it was preferable for CCN to engage and contract with the safety net organization to keep within the 95/5 requirements of DSRIP funds flow. As a result of this report and seeing how the IA seeks to leverage individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17 to more clearly indicate the partner engagement level within broader enterprises. CCN will also seek ways to elevate developing relationships within the PPS, including instances already under whereby Health Systems subcontract with CBOs for project related efforts (e.g., such as Tier 2 reporting). Recommendation should be removed.
10 Project Recommendations 2biv Recommendation 2 The IA recommends the PPS develop a plan to increase outreach and education materials to partners. Provided the information illustrated throughout this document, CCN has engaged a larger number of providers and partners than was discerned from the MAPP/PIT tool. This was achieved through utilization of existing trainings and outreach efforts with 2biv partners conducted throughout 2016. CCN recommends this recommendation be removed.
11 Project Recommendations 2di Recommendation 1 The IA recommends the PPS develop a strategy to assist partners in better identifying the targeted population for this project. Care Compass Network has developed a screening tool to assist partners in identifying the target population, which has been imbedded with the PAM training program since late 2015. The PPS partners have identified target populations for outreach as reflected in individual contracts which have exceeded, through 3/31/17, the PPS speed and scale requirements for DY2,Q4. Consistent with other recommendations within this report, organizational focus is now targeting facilitation of reporting and workflow redesign to ensure partners are positioned to achieve these commitments with the Medicaid members. Recommendation appears duplicative with Patient Engagement Recommendation 1 in the Organizational section and should be removed.
12 Project Recommendations 2di Recommendation 2 The IA recommends the PPS develop plan to increase outreach and education materials to partners with respect to patient activation measures. Provided the information illustrated throughout this document, CCN has engaged a larger number of providers and partners than was discerned from the MAPP/PIT tool. This was achieved through utilization of existing trainings and outreach efforts with 2di partners conducted throughout 2016. CCN recommends this recommendation be removed.
13 Project Recommendations 2di Recommendation 3 The IA recommends the PPS create a plan to address the shortage of primary care physicians engaged in this project in order to meet their project implementation speed commitments. Due to the restrictions in the reporting mechanisms (MAPP/PIT), CCN recommends this recommendation be removed, as engagement has been reported at the entity level. As commented above with regard to engagement with health systems containing over 1,000 primary and non–primary care providers, our health systems also have home care organizations, hospice organizations, skilled nursing facilities, and other organization types under their umbrella. As some of those sub–organizations are non–safety net organizations, it was preferable for CCN to engage and contract with the safety net organization to keep within the 95/5 requirements of DSRIP funds flow. As a result of this report, as seeing how the IA leverages individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17. However, due to the above we still believe the recommendation should be removed.
14 Project Recommendations 3ai Recommendation 1 The IA recommends the PPS create a plan to address the shortage of primary care physicians engaged in this project in order to meet their project implementation speed commitments. Due to the restrictions in the reporting mechanisms (MAPP/PIT), CCN recommends this recommendation be removed, as engagement has been reported at the entity level. As commented above with regard to engagement with health systems containing over 1,000 primary and non–primary care providers, our health systems also have home care organizations, hospice organizations, skilled nursing facilities, and other organization types under their umbrella. As some of those sub–organizations are non–safety net organizations, it was preferable for CCN to engage and contract with the safety net organization to keep within the 95/5 requirements of DSRIP funds flow. As a result of this report, as seeing how the IA leverages individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17. However, due to the above we still believe the recommendation should be removed.
15 Project Recommendations 3ai Recommendation 2 The IA recommends the PPS develop a plan to address the workforce challenges with licensed behavioral health specialists and care coordinators. CCN agrees that this is a critical workforce need and as such has identified each within the overarching Domain 1 Workforce program as recently reported in the DY2, Q2 report. In particular, the Workforce Gap Analysis identified Care Coordination and Behavioral Health positions as two of the top three needs of the PPS. The Workforce Target State also identifies these with high priority and includes actions to meet these needs. While workforce needs have elements of consistency and variability across the state, the CCN has already developed a plan to address these challenges and will continue to report progress against these plans as required as part of on–going quarterly reporting. Provided these plans have already been developed we recommend this recommendation be removed.
16 Project Recommendations 3bi Recommendation 1 The IA requires the PPS develop a comprehensive action plan to address the implementation of this project in consultation with the Project Advisory Council (PAC) that must be reviewed and approved by the Board of Directors. This Action Plan must detail how the PPS will monitor and intervene when project milestones, partner engagement, or patient engagement for this project fall behind schedule. Based on published methodologies this recommendation has been provided based on the elevated risk rating given to the project. In consideration of the information provided as part of 3bi Recommendation 2, regarding an updated PIT table which more clearly supports engagement at the entity and provider levels, we recommend this project be evaluated at a risk level of three. With the rating of a three, this recommendation would be modified consistent with feedback provided to other PPSs as follows "The IA recommends that the PPS create a plan to engage the proper patient and partner types while focusing on the purpose of the project and the successful implementation of the same. "
17 Project Recommendations 3bi Recommendation 2 The PPS should develop a strategy to educate their partners on the value of DSRIP in order to increase their engagement. Due to the restrictions in the reporting mechanisms (MAPP/PIT), CCN recommends this recommendation be removed, as engagement has been reported at the entity level. As commented above with regard to engagement with health systems, 3bi contracting represents over 400 primary and non–primary care providers. Of note, our health systems also include home care organizations, hospice organizations, skilled nursing facilities, and other organization types under their umbrella. As some of those sub–organizations are non–safety net organizations, it was preferable for CCN to engage and contract with the safety net organization to keep within the 95/5 requirements of DSRIP funds flow. As a result of this report, as seeing how the IA leverages individual tables within the PIT, CCN will modify its reporting approach effective the next reporting cycle on 1/31/17. However, due to the above we believe the recommendation should be removed.
18 Project Recommendations 3bi Recommendation 3 To address the issue of partner reluctance to participate in this project due to perceived lack of reimbursement, the PPS should develop creative strategies, either in the form of services, consultation, or work with a vendor to assist the PPS in this outreach. We agree with the recommendation and note that this would be a critical element of the new proposed 3bi Recommendation 1 "The IA recommends that the PPS create a plan to engage the proper patient and partner types while focusing on the purpose of the project and the successful implementation of the same." As such, we recommend this be consolidated with 3bi Recommendation 1.
19 Project Recommendations 3bi Recommendation 4 In order to address the issue of identifying targeted panels of patients eligible to be included in this project, the IA recommends that the PPS convene a group of stakeholders to develop a strategy to develop common solutions. Care Compass Network has not previously identified this as a project challenge. The PPS partners have identified target panels as reflected in individual contracts which have exceeded, through 3/31/17, the PPS speed and scale requirements for DY2,Q4. Consistent with other recommendations within this report, organizational focus is now targeting facilitation of reporting and workflow redesign to ensure partners are positioned to achieve these commitments with the Medicaid members. Recommendation should be removed.
20 Project Recommendations 3gi Recommendation 1 The IA requires the PPS develop a comprehensive action plan to address the implementation of this project in consultation with the Project Advisory Council (PAC) that must be reviewed and approved by the Board of Directors. This Action Plan must detail how the PPS will monitor and intervene when project milestones, partner engagement, or patient engagement for this project fall behind schedule. Based on published methodologies this recommendation has been provided based on the elevated risk rating given to the project. In consideration of the information provided as part of 3gi Recommendation 3, regarding an updated PIT table which more clearly supports engagement at the entity and provider levels, we recommend this project be evaluated at a risk level of three. With the rating of a three, this recommendation would be modified consistent with feedback provided to other PPSs as follows: "The IA recommends the PPS create an action plan to increase the presence of palliative team members in primary care practices in order to increase referrals, which will future improve patient engagement shortcomings. "
22 Project Recommendations 3gi Recommendation 3 To address the issue of partner reluctance to participate in this project due to perceived lack of reimbursement, the PPS should develop creative strategies, either in the form of services, consultation, or work with a vendor to assist the PPS in this outreach. The primary cause for partner reluctance was expressed concern over changes in project scope throughout early 2016. We have seen a departure from this positioning into the later half of 2016. CCN has had success in remediating this reluctance, yielding more partner engagement figures than required by targets set within the partner engagement tool. This was not clearly represented due to formatting of CCN reporting of partner engagement in MAPP/PIT and will be corrected in the 1/31/17 report. Recommend removal of this recommendation.