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Christina Jenkins, MD
Chief Executive Officer, OneCity Health Services
Vice President, NYC Health + Hospitals
199 Water Street, New York, NY 10038

Sent via electronic mail to

December 19, 2016

To Whom It May Concern:

Thank you for the opportunity to comment on the DSRIP Independent Assessor Mid–Point Assessment Report for OneCity Health PPS (the "PPS"), prepared by the DSRIP Independent Assessor (the "IA") and dated November 2016.

OneCity Health is New York City´s largest Performing Provider System. It is sponsored by NYC Health + Hospitals, the nation´s largest municipal healthcare system and the City´s safety net integrated healthcare delivery system. OneCity Health comprises four operating hubs, located in Brooklyn, the Bronx, Queens, and Manhattan, a committee–based governance structure, and a central services organization providing operational management, called OneCity Health Services. To ensure appropriate care for all New York City residents – with a focus on preventive and primary care – the OneCity Health partnership includes hundreds of community–based healthcare providers, services, and organizations, as well as NYC Health + Hospitals´ large network of acute care hospitals, nursing homes, community clinics, home–care service, and MetroPlus, NYC Health + Hospitals´ health insurance plan.

OneCity Health is undertaking 11 DSRIP projects, including one focused on engaging uninsured and Medicaid beneficiaries, which is a particularly complex but essential undertaking. The PPS´s essential goal is to become an integrated delivery system of health and social service providers that closes critical gaps in the continuum of care, thereby reducing avoidable hospital use by 25 percent by the end of the DSRIP project.

From the Mid–Point Assessment Report, it is clear that the Independent Assessor recognizes the important role OneCity Health plays in DSRIP and, more importantly, in the wellness of over 1 million New Yorkers. We also appreciate the recognition of our efforts to work with other performing provider systems in New York City, particularly with the Maimonides–led system.

While the PPS appreciates its success to date, we also acknowledge that, as with any new endeavor, there are opportunities to improve, including by engaging our many partners further than we already have and by continuing to advance value–based strategies and approaches while ensuring we effectively address social determinants of health. We address these opportunities in the comments listed below, responding to specific statements found in the Mid–Point Assessment Report.

Page(s) IA Report statement Comment
6 The most relevant data point from the OneCity 360 survey is that the selected partners have a (generally) positive attitude about the PPS. However, some key community–based providers (Mental Health, Substance Abuse, and Clinics) have a negative perception towards the PPS´ Engagement, Communication, and Effectiveness. OneCity Health recognizes that mental health providers, substance abuse providers, and clinics are key community–based provider types that are critical to DSRIP efforts, including our activities to identify and connect all patients with appropriate care providers. Accordingly, OneCity Health continues to assess and improve our engagement of all provider types, especially including those listed above.

We would like to clarify that based on our understanding of the scoring methodology used for the 360 survey, our score of ´3´ among the mental health partner types represents agreement regarding the adequacy of support by OneCity Health. We therefore respectfully request that the IA reconsider its comment with regards to the mental health providers ´ perception.
9 Looking further at the PPS fund distributions to the PPS PMO, OneCity distributed $15,963,136.00 to the PPS PMO out of a total of $16,817,150.41 in funds distributed across the PPS network, accounting for 94.92% of all funds distributed through DY2, Q2. Comparatively, the statewide average for PPS PMO distributions equaled $5,966,502.64 or 42.85% of all funds distributed. Given the scope and size of our PPS network, OneCity Health´s spending on administrative activities, including investments in a robust project management office, reflect the necessary costs to establish and build a PPS and its supporting infrastructure. As encouraged by the New York State Department of Health, our PPS seeks to invest appropriately in organizational infrastructure to support the implementation of DSRIP projects to meet our goals and create a sustainable model for DSRIP following the end of the State´s groundbreaking demonstration project. We expect that many of these necessary expenses are one–time costs; over time the amount spent on the PMO should account for a significantly smaller proportion of the total funds the PPS expends and distributes.

OneCity Health has budgeted over 60% of PMO costs in DY2 for project implementation costs that include investments in strengthening the partner networks for DSRIP and beyond, including, but not limited to:
  • Assistance to our community primary care providers in achieving PCMH certification,
  • Design and implementation of cultural competency and health literacy programs, and
  • Centralized, PPS–sponsored care management software platform across the network.
  • A budgeted amount of $55 million in DY2 for direct payment to partners; we are currently developing a DY3 partner contracting methodology
9 In further assessing the engagement of CBOs by OneCity, the IA found that the PPS had distributed $159,402.52 or 0.95% of the funds distributed to its CBO partners through DY2, Q2. OneCity Health recognizes the importance of supporting our CBO partners so that they may fully engage with the PPS and successfully participate in projects. We also respect the requirement to remain within the limits of the remuneration set forth by the DSRIP Special Terms and Conditions. While an initial review of the forms provided suggest that the PPS has distributed $159,403 to CBOs,

OneCity Health has in fact invested over $16 million in PCMH technical assistance, cultural competency and health literacy programs, and care management software, and other activities, much of which is directed to support CBOs ´ contribution to achievement of DSRIP goals. These and other investments in CBOs ´ success and viability are not captured within the current funds flow reporting mechanism, and represent the investment made to support our entire network, including CBO partners.
9 OneCity Health is working with CulturaLink to assist in implementing its CCHL strategy. Additionally, the PPS will conduct focus groups, and use key informant interviews to help advance training and educate staff The PPS indicated its workforce training is to be completed by December 31, 2016. The PPS would like to clarify that the initial proposed work plan and timeline with Cultural link included a targeted goal of completing all site self–assessments, key informant interviews, and focus groups by December 31, 2016. The PPS did not plan to complete the training that would be in formed by these assessments, interviews, and focus groups by the end of Calendar Year 2016.
11 Further, in assessing the PPS funds distributions to all partner categories relative to that across the state, OneCity Health has distributed a smaller portion of its earned funds through DY2, Q2 than all but one other PPS. In DSRIP Year 2, OneCity Health allocated $55 million for direct payments to partners covering 11 DSRIP projects. The PPS has obligated $36 million, set forth in contracts with various partners, to ensure the success of eight clinical projects (those relating to the Integrated Delivery System, ED Care Triage, Care Transitions, Primary Care Behavioral Health Integration, and Palliative, Cardiovascular, HIV, and Asthma Care), and has contracted with our partners a value of approximately $20 million on other implementation efforts, including (but not limited to):
  • $10.4M for Health Home At – Risk,
  • $5M for Asthma project implementation, and
  • $1. 9M for Care Transitions.
Perceived delays in funds flow to partners is due largely to the PPS´s system to ensure proper partner implementation, invoicing, and payment. In carrying out fiduciary responsibility, the OneCity Health team performs diligence required to validate performance prior to fund distribution, which may delay immediate payment and cause a reporting lag. As DSRIP continues to advance, funds will flow based on the success of our partners in implementing DSRIP projects, as the PPS has committed to in its contracts.



The data presented in the partner engagement tables in the following pages includes the partner engagement across all defined partner types for all projects where the PPS is lagging in partner engagement.

Of further concern is the limited engagement of PCPs across all of the projects highlighted in the tables above.

Figure 17: Overall Project Assessment

Figure 18: 2.a.i Project Risk Score
OneCity Health recognizes the importance of full partner engagement throughout the PPS and the duration of the DSRIP project. Because of the reporting mechanisms provided to the PPS, true partner engagement is understated. Due to both (1) the PPS partners´ employment structure, wherein many partner types are employed by the larger NYC Health + Hospitals system and by large health care delivery practices, and (2) that the PPS must report to the State its investments at a system/organizational level and not at a more granular individual NPI level, the PPS´s engagement and disbursement of funds to all partner types, including primary care providers, is distorted. Particularly, partner engagement appears in the reports used in this Assessment Report much lower than is actually the case. As one example of many, primary care providers and mental health partners affiliated with a larger system would be significantly underreported, especially given the size of our largest partners (NYC Health + Hospitals and SUNY Downstate).


Figure 7: Project 3.d.ii (Expansion of asthma home–based self–management program) Patient Engagement

Project 3.d.ii was also highlighted for the PPS failure to meet Patient Engagement targets consistently through the PPS Quarterly Reports, which provides an additional level of concern when combined with the PPS´ failure to meet Patient Engagement targets for this.

Figure 17: 3.d.ii Project Assessment
According to updated guidance from DOH, for a patient to be deemed engaged in Project 3.d.ii (Asthma Home Based Self–Management), that patient must undergo an in–person home assessment. Because this qualification is a much more stringent one than the original guidance, OneCity Health is unlikely achieve patient engagement ("speed and scale") estimates or commitments during the course of the DSRIP program. It is expected based on prior programs and national studies that approximately 20%–30% of patients offered asthma prevention–related services from a community health worker will accept these services and allow a home visit. The PPS and its Executive Committee view the achievement of outcomes improvements via adherence to clinical best practices and the implementation of new relationships between community and in–clinic care teams to be of primary importance, and the PPS continues to work diligently and is making its best faith effort to perform as many appropriate home–based asthma assessments as possible.

While the IA did not identify any specific risks associated with project 2.a.i. beyond Partner Engagement, the IA notes that the organizational challenges identified, most notably the need for the NYC Health + Hospitals to fully support the OneCity Health PPS´ DSRIP efforts combined with the limited Partner Engagement across all projects raises the risk associated with the PPS´ ability to successfully implement this project.

While the decision to leverage the organizational capacity to support the DSRIP efforts does not concern the IA, it is important to the overall success of the PPS that the NYC Health + Hospitals organization fully support the efforts of the PPS in meeting its DSRIP goals. Additionally, the IA notes the cross collaboration with other PPS, including the alignment with Maimonides PPS in project selection.
OneCity Health recognizes that developing and supporting a truly clinically integrated delivery system is essential to the success of the DSRIP program and for each partner in the PPS. For the PPS´s lead alone, NYC Health + Hospitals takes seriously the opportunity to support this effort, undergoing unprecedented changes in leadership and organizational structure to advance the imperative to integrate its system. OneCity Health supports these changes by working closely and effectively with NYC Health + Hospital´s service line, hospital and clinic leaders.

It is also important to note that the relationship between the PPS and NYC Health + Hospitals is reciprocal; the PPS has been successful due to the full organizational support from NYC Health + Hospitals. For example, NYC Health + Hospitals leadership has been engaged in the PPS´s progress and activities, and has provided in kind guidance given NYC Health + Hospitals´ evidence–based expertise in serving the Medicaid and uninsured populations as New York City´s largest safety net system.
30 The IA has some concerns regarding OneCity Health´s project implementation however. For example, OneCity Health has done very little Partner Engagement throughout their network as illustrated in the Partner Engagement details presented in this assessment. This limited reporting of Partner Engagement, however, does not correlate with OneCity Health ´s achievement of Patient Engagement in most of its projects through DY2, Q2. This may be the result of a reporting issue, but it represents a discrepancy that the IA urges OneCity Health PPS to address in future reporting. OneCity Health continues to use multiple channels of communications to engage our partner network. Efforts include monthly webinars, newsletters, hub team outreach activities, support desk assistance for partner inquiries, and governance committees.

OneCity Health concurs with the IA´s statement that the discrepancy between partner engagement and patient engagement is related to a reporting issue that the PPS is working to correct for DY2 03. As was stated in our previous comments (referring to pages 15, 24, 26, and 28 in the IA report), the design of the tool the PPS relies on, called the PIT, forces OneCity Health to understate the PPS´s broader and effective engagement efforts.

The perceived discrepancy between partner engagement and achievement of patient engagement metrics is due in part to a strategic decision made by leadership at the time of application to take a conservative approach to achieving patient engagement targets and rather focus efforts around improving outcomes for patients.

Partner Engagement Recommendation 1: The IA recommends that the PPS develop an action plan to increase partner engagement across all projects being implemented by the PPS.
2.a.i Recommendation 1: The IA recommends that the PPS develop a plan to increase partner engagement to ensure the PPS is able to successfully meet project implementation milestones, performance metrics, and DSRIP goals.
OneCity Health will continue to use multiple channels of communications (e.g., email newsletters, in–person meetings, and website announcements) and a variety of opportunities to engage our partner network. Additionally, the PPS looks forward to working collaboratively with the State to improve its reporting design to allow the PPS to reflect its partner engagement achievements.
30 Funds Flow Recommendation 1: The IA recommends that the PPS accelerate a contracting strategy to distribute funds to their partners to promote more engagement. OneCity Health´s approach to contracting involves a multi–pronged approach for partner engagement and funds distribution. As stated above, OneCity Health committed $55 million in partner payments in DY2, contingent on those partners´ performance and commitment to meet DSRIP goals. In developing a DY3 framework, we will engage partners for their input on contracts through, a sustained flow of information, expansion of training opportunities, and provision of technical assistance for community primary care and non–Medicaid billing social services providers.
31 3.d.ii Recommendation 1: The IA recommends the PPS continue to pursue workforce solutions through its identified workforce partners to foster workforce pipeline for necessary workers with appropriate skill sets OneCity Health appreciates the opportunity to update the State on its workforce–related project implementation activities within the Asthma project, which have increased significantly since the submission of the DY2 Q1 report. OneCity Health has contracted with CBOs that provide Community Health Worker (CHW) services and matched CHWs at all 17 participating NYC Health + Hospitals facilities and two community partner sites. The PPS expects all participating partners to have onsite CHWs, as appropriate, by April 2 017. Staff training activities have concurrently intensified since the DY2 Q1 report. 69 individuals received CHW training modules and over 80 people from clinical teams were trained in the CHW referrals process via the information technology platform, GSI. Training modules are developed within GSI, and support key components of the various DSRIP projects. Through GSI, OneCity Health is able to track key process measures such as number of patients enrolled in CHW services and number of patients who have received home visits. Performance reports are in development to track other data in GSI, such as the inclusion of Asthma Action Plans with referrals from primary care to CHW agencies. Additionally, December marked the first month in which the Provider Asthma Care Education (PACE) trainings launched. These five–hour trainings cover evidence–based asthma management guidelines and are planned to reach all pediatricians throughout the network.

OneCity Health PPS appreciates the partnerships we have fostered, not only with our DSRIP partners, but also with the New York State Department of Health and other State agencies, New York City public agencies, the DSRIP Project Approval and Oversight Panel, and others who share in the DSRIP vision and mission to support the lives of millions of uninsured and Medicaid–covered New Yorkers. We look forward to working with the State in further advancing the DSRIP goal to restructure health care delivery in New York.


Christine Jenkins, MD
Chief Executive Officer, OneCity Health Services