September 13, 2018 NYP Queens PPS PAC Meeting - PowerPoint Presentation

September 13, 2018 NYP Queens PPS PAC Meeting

Agenda Welcome PPS Updates MY3 Current PerformanceMAPP Reporting (DY4 Q2) Clinical Project Updates Clinical Projects Quality CommitteesJust Breathe – Asthma Pilot Poster MAX Project Update Charter Progress UpdateQuestions NYP/Q PPS PAC Meeting

NYP Queens PPS PAC Meeting NYPQ PPS PAC Meeting PPS Updates

NYPQ PPS PAC Meeting PPS Updates Scorecard/Dashboard Available Measurement Year 4 Month 6 of 12 (1/2017 - 12/2017) Results

DY4, Q2 Reporting On September 30,2018 our DSRIP PMO will coordinate and process the PPS DY4 Q2 MAPP report. The report will consist of P4R deliverables in our HIV project that specify the following: HIV Milestone 6. Empower people living with HIV/AIDS to help themselves and others around issues related to prevention and care.Documentation and results of collaborative initiatives with partners Bright Point Health and ACQC on peer-led interventions and service expansion will be submitted. All HIV and Primary Care Behavioral Health P4R project deliverables are scheduled to be completed by DY4, Q3. NYPQ PPS PAC MeetingPPS Updates

NYP Queens PPS PAC Meeting NYPQ PPS PAC Meeting PMO Clinical Project Updates

Current Clinical Projects Patient Navigation Program Focused on improving performance across adults and pediatric measures through patient engagement and outreach services. Objective to achieve 5 star rating across prioritized measures. Smoking Cessation ProjectImplement protocols to assess and manage patients with a tobacco use disorderImplement a patient referral programPartner with the ALA to Launch an 8 week Freedom from Smoking group at 182nd clinic. Group session to be facilitated by DSRIP facilitators SNF Quarterly Committee PMO to support MLTC 101 – Managed LTC- Value Based Planning & Education. The PMO to facilitate sessions to educate Skilled Nursing partners how to calculate readmission rates. Collaboratively the PMO and the SNF committee developed a Blood Transfusion Protocol aimed at improving patient discharges. NYP/Q PPS PAC Meeting

PPS Quality Committees Adult Ambulatory The current action items for this committee includes the following: Analyze No Show rates from our clinics Replication of Pediatrics Ambulatory scheduling pilotCommittee to focus on data going forward Integrate Smoking Cessation Initiatives into committeePediatric Ambulatory Theresa Lang piloted an Annual scheduling project to increase scheduled appointments for the clinic . From the start date of March 2018 to September 2018 there is a 17% increase of scheduled appointments.Theresa Lang has published flyers containing timeline information for pediatrics to receive immunization and annual appointments to be dispersed in the clinic and local WIC office .Pediatric Hospital NYP Queens Pediatric Asthma Center, Theresa Lang, American Lung Association – Asthma Coalition of Queens and St. Mary’s Home Care are collaborating to launch an asthma medication adherence pilot to incorporate care coordination and smart inhalers into patients daily usage. The “Just Breathe” pilot will begin late-September and the NYP Queen Pediatric Asthma Center is currently recruiting patients to participate. The Theresa Lang Clinic will receive provider education in-service by the American Lung Association - Asthma Coalition of Queens and St Mary's Home Care in mid-September NYP Queens Pediatric Asthma Center and Total Care Rx are partnering on an additional pilot program to increase communication and pharmacy care management for pediatric asthmatic patients. The pilot will focus to improving medication adherence and will allow for additional services to patients such as medication delivery, pharmacy care management, and direct provider communication regarding medication needs or complications. The pilot began in August 2018 and will be monitored to identify quality and process improvements for the pediatric asthma population at the NYP Queens Pediatric Asthma Center. Hospital Based In August 2018 we launched the kick-off for our MAX Goals of Care Project. The focus of the project is on improving Goals of Care (GOC) discussions and documentation throughout the Hospital. Our DSRIP NP is currently in the process of educating our PAs and Hospitalist providers. A Supporting CAPC Marketing campaign is also being promoted through out the hospital. NYP/Q PPS PAC Meeting

“ Just Breathe” Asthma PilotPartners: New York-Presbyterian Queens Pediatrics Asthma CenterAmbulatory Care Partner - Primary Care and Specialty CareNew York-Presbyterian Queens-Theresa Lang Children’s Ambulatory CenterPediatric Ambulatory ClinicThe Asthma Coalition of Queens County Community Based Organization – Provider Education and Patient Outreach St. Mary’s Home Care Home Assessment Agency – Home Assessments & Patient Education Overview : Increase medication adherence and lower hospital utilization for pediatric asthma patients utilizing care management strategies and technology . Pilot Goals Improve pediatric asthma medication based quality indicators Reduce hospital utilization Improve access to Community Based services NYP/Q PPS PAC Meeting

Just Breathe Asthma Pilot Flyer NYP/Q PPS PAC Meeting

Goals Of Care Project Charter PROBLEM At NYPQ, a chart review of readmitted patients by our Palliative NP revealed a notable lack of documented Goals of Care (GOC) discussions and advanced directives in the form of a MOLST. This was true regardless of being readmitted from home or SNF, and found to be a major contributor to their readmission. Many of these patients had critical/chronic illness at end-of-life placing them at high risk for readmission. Given that the demand for Palliative Care’s services exceeds available resources, generalist (non-palliative care) providers need to be educated in general palliative care and engage patients and their families in goals of care discussions. GOALS Provide education to generalist providers in the Department of Medicine regarding the importance of GOC discussionsProvide family education on GOCEducate generalists on how to conduct and document GOC conversations Increased generalist utilization of a structured GOC note and MOLST form to better document goals of care for transitions in care Escalation, as appropriate, for difficult end- of- life cases (Palliative consults, Ethic Committee referrals ) SCOPE (IN BOUNDS ) Critically/Chronically ill patients, including but not limited to a list specific diagnoses Patients on the Medicine Service SCOPE (OUT OF BOUNDS) Patients who are not critically/chronically ill Patients already enrolled in hospice Patients not on the Medicine Service CUSTOMER ’ S VOICE: The end users will be the Providers (MDs and PAs) who will be responsible for completing this documentation. TEAM MEMBERS Executive sponsors: Owners: Robert Crupi, MD & RoxanaElena Lazarescu, MD Team Members: Hoda Abdelaziz, NP, Marlon Hay, Coleen Dunkley, Cynthia Pan, MD and Calvin Hwang, MD NYP/Q PPS PAC Meeting

MAX Project – Progress Update NYP/Q PPS PAC Meeting

NYP/Q PPS PAC Meeting Questions

Contact Information Marlon Hay mah9214@nyp.org (718) 670-2103NYP/Q PPS PAC Meeting