Phase II Funds Flow Metrics – Data Specification & Reporting

1. Phase II Funds Flow Metrics – Data Specification & Reporting Period Ending 9/30/2017 August 21, 2017

2. Attendance and Resources Attendance Link CLICK HERE to view the August 10th Phase II 9.30 Deliverables Webinar CLICK HERE to download the final presentation from the August 10th Phase II 9.30 Deliverables Webinar

3. Performance ActivityCategories Prerequisite » Must be completed by partners in order to be eligible for Phase II fundsflow » There are no dollars associated with thesemetrics » All prerequisites due per performance period must be completed in order to be eligible for funds flowduringcorresponding paymentperiod StandAlone » Metrics that are independent of any other performanceactivities » Partner will be paid dollar allocation of the activity if completed by due date (as long as prerequisites are completedforthe correspondingperiod)

4. Slide components

5. Additional Slides- Data Specifications

6. PLEASE NOTE… The IA reserves the right to conduct  more extensive reviews to ensure the information submitted by the PPS is accurate and verifiable so we ask our partners to keep a copy of all policies protocols and documents developed to support completion of the projects and contract deliverables. Provide supporting documentation as outlined in this document. Please submit all registry, patient engagement, and Performance Improvement Reporting Template data in excel format for future analytics, no PDFs please.

7. Data Specification & Reporting 7

9. Cohort Denominator Numerator

10. Report Formats • Performance Improvement Reporting Template (PIRT) • DOH patient engagement reporting template • Patient registries • Roster of patients • Use of LACE scoring tool for readmission risk assessment • Asthma root cause analyses

11. Performance Improvement Reporting Tool (PIRT)

12. Performance Improvement Reporting Template (PIRT)

13. DOH Patient Engagement template

14. Registry Related Cohorts & Payment Metrics • ED High Utilizer Registry - Activity ID: B11_003 • Cohort – Individuals with 3+ ED visits in the previous 6 months • CVD Registry – Multiple activities • Cohort - All individuals, 18 years and older, with Hypertension and other Cardiovascular Diseases • Asthma Registry – Multiple activities • Cohort - All individuals, ages 5 to 64 years, who are identified as having asthma, • BH Registry – Multiple cohorts & activities • Multiple cohorts – Depression, Schizophrenia, Bipolar conditions, SUD, ADHD • Uninsured Registry- Activity ID: P_021 • Cohort-

15. Reporting Population Cohorts 9/30/2017 deliverables Required – Organizational cohort and performance reports Preferred - Site-specific cohort and performance reports 12/31/2017 deliverables Required - Site-specific and, for select metrics, provider NPI-specific cohort and performance reports Site and/or Provider specific data will be a component of Phase-III funds flow structure

16. Phase II Funds Flow Metrics • 2.a.iii – Health Home At-Risk Intervention • 2.b.iii – ED Care Triage • 3.a.i – Primary Care & BH Integration – All Models • 3.b.i – Cardiovascular Disease project • 3.d.iii – Asthma Project • Behavioral Health Outcome Related Measures

17. Health Home At-Risk Intervention Project Kallanna Manjunath 17

18. Table of Contents B01_004: Quarterly Report of Care Management Plans P_022: Quarterly Report of Patients Referred to Health Home and BHNNY-Cares

20. DOH Patient Engagement template

24. ED Care Triage Metric Owner: Karla Powers, MBA 24

25. Table of Contents B11_002: Patient Navigators B11_003: ED Registry B11_004: Patient Engagement P_010: LACE Tool

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28. ED High Utilizer Registry – Data Elements • Last Name • First Name • DOB • Gender • Address • Patient Phone Number • CIN • Primary Insurance Plan • PCP Name • NPI of Primary Care Provider • Date(s) of Service • Reason for Visit • Primary Diagnosis • Secondary Diagnosis (List top five) • Primary Procedure • Pt.'s Social Barriers (i.e., housing, transportation, nutrition) • Follow-up Visit scheduled? (Y/N) • Follow-up Visit Date • Health Home Eligible • Health Home Care Management Agency (current health home patients) • HH Referral Date • Health Home Name 28

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30. DOH Patient Engagement template

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33. P_010: LACE Score Patient Roster

34. PC BH Integration Metric Owner: Karla Powers, MBA 34

35. Table of Contents BH Registry Template – Not a contract metric B02_006: Patient Engagement Model 1 B03_007: Patient Engagement Model 3 B09_007: Patient Engagement Model 2

36. BH Registry

37. BH Registry Elements • Demographics • List of Chronic Conditions (ICD-10 Codes) • Current Medications • Antidepressant Medications • Antipsychotic Medications • ADHD Medications • BH Screenings – PHQ & Other screenings • Date of most recent screening • Screening result: Positive/Negative/Numeric score • If positive, date of Follow-up care given • "Warm transfer" after positive screening • Vital Signs & Labs • Blood Pressure • Cholesterol (Lipid Panel) • HbA1C • Glucose • Date of Last Screening • Results • Community referrals/Outreach (Structured Format)

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39. DOH Patient Engagement template

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42. DOH Patient Engagement template

45. DOH Patient Engagement template

47. Cardiovascular Disease Project Metric Owner: Tara Foster, MS, RN 47

48. Table of Contents B10_006: CVD Registry B10_007: Patient Engagement, Self Management P_016: Statin Therapy

50. Registry Elements (use CVD Registry Reporting Template) Demographic Information (Name (First and Last), Date of Birth (DOB), CIN) PCP Name and NPI Date of Last Appointment with PCP Date of last hospitalization Date of last ED visit Current BP reading Home Blood Pressure Monitoring Tobacco Screening/Quitline Referral Current Medication List (including HTN meds)/Prescription date/refills Aspirin usage Self Management Plan Self-Management Goals Influenza Vaccine Referrals: Tobacco Cessation Programs/ CHW programs