Success of the DSRIP program requires CPWNY to develop and implement various PPS-wide policies and procedures, including:

Governance

  • Clinical quality standards and measurements
  • Standardized clinical care management processes
  • Ability to be held accountable for realizing clinical outcomes
  • Process for selecting members of the governing body
  • Decision making/voting process that will be implemented and adhered to by the governing team
  • How the PPS governing body will ensure a transparent governing process, such as methodology in which the governing body will transmit the outcomes of meetings
  • Policy and procedures documenting the formal development of governance processes
  • Role the PAC will serve within the PPS organization
  • Mechanisms for identifying and addressing compliance problems related to the PPS’ operations and performance
  • Processes that will be implemented to support the financial success of the PPS and the decision making of the PPS’ governance structure
  • Process in which the PPS will monitor performance
  • How the PPS will address lower performing members within the PPS network
  • Process for the sanctioning or removing a poor performing member of the PPS network who fails to sufficiently remedy their poor performance. Methodology proposed for member removal must be consistent and compliant with the standard terms and conditions of the waiver.

Workforce

  • Process by which the identified employees and job functions will be retrained and whether the retraining will be voluntary
  • Process and potential impact of this retraining approach, particularly in regards to any identified impact to current wages and benefits to existing employees
  • Process by which the identified employees and job functions will be redeployed
  • Process and potential impact of redeployment approach, particularly in regards to any identified impact to current wages and benefits to existing employees
  • Ramifications to existing employees who refuse their redeployment “assignment”

Data Sharing, Confidentiality, and Rapid Cycle Evaluation

  • Oversight of the interpretation and application of RCE results and which organizational unit will be accountable and their relationship to governing team

Cultural Competency/Health Literacy

  • Strategic plan and ongoing processes the PPS will implement to develop a culturally competent organization and a culturally responsive system of care
  • Policies and procedures which articulate requirements for care consistency and health literacy

2ai Create an Integrated Delivery System 

  • Contractual agreements with providers, Health Homes, and Managed Care Organizations
  • Protocols for care coordination

2.b.iii ED Triage for at-risk Patients

  • Defined process for triage of patients from patient navigators to non-emergency primary care and needed community support resources. Documented protocol, detailed steps and process flows within the emergency room
  • (Optional) Protocols and operations in place to transport non-acute patients to appropriate care site.

2.b.iv Care Transitions Model to Reduce 30-day Readmissions

  • Standardized protocols to manage overall population health and perform as an integrated clinical team
  • Coordination of care strategies focused on care transitions in place, including identification of responsible resources at each stage of the workflow
  • Protocols to identify Health Home eligible patients and link them to services as required under the ACA
  • Policies and procedures for early notification of planned discharges, include the ability of transition case manager to visit the patient in the hospital to develop transition of care services
  • Policies and procedures in place for including care transition plans in patient medical record and ensuring medical record is updated in interoperable EHR or updated in primary care provider record
  • Policies and procedures reflect the requirement that 30-day transition of care period is implemented and utilized

2.c.ii. Expand the use of Telemedicine in Underserved Areas

  • Standard service protocols, as well as consent and confidentiality standards meeting all federal and state requirements for: patient eligibility, appointment availability, medical record protocols, educational standards, continuing education credits

3ai. Integration of Behavioral Health and Primary Care Services

  • Collaborative, coordinated evidence-based care protocols that include medication management and care engagement process.
  • Policies and procedures to facilitate and document completion of screenings, positive screenings result in “warm transfer” to behavioral health provider

3.b.i Cardiovascular Health: Evidence-based Strategies for Disease Management 

  • Program to improve management of cardiovascular disease using evidence-based strategies
  • Standardized treatment protocols for hypertension and elevated cholesterol aligned with national guidelines
  • Care coordination policies and procedures, processes and workflows
  • Policies and procedures for follow up blood pressure checks without copay or advanced appointment
  • Protocols, polices, and procedures to ensure blood pressure measurements are taken correctly with the correct equipment
  • Protocols for follow up on patients who have repeat blood pressure readings in the medical record and no diagnosis of hypertension
  • Protocols for determining preferential drugs based on ease of medication adherence where there are no other significant non-differentiating factors
  • Policies on establishing patient driven self management goals documented in the clinical record
  • Policies and procedures for follow up with referrals to community based programs to document participation and behavioral and health status, warm transfer protocols
  • Protocols, policies and procedures, for home blood pressure monitoring with follow up support, protocols for home blood pressure monitoring, protocols for follow up support to patients with ongoing blood pressure monitoring including equipment evaluation and follow up if results are abnormal
  • Referral and follow up policies and procedures to facilitate referrals to NYS Smoker’s Quitline, including warm transfer protocols
  • Policies and procedures that reflect principles from the Million Lives Campaign

3.f.i Increase Support Programs for Maternal and Child Health

  • Policies and procedures for early identification of women who are or may be high risk, policies include a referral system

3.g.i Integration of Palliative care into the PCMH Model

  • Clinical guidelines agreed to by all partners including services and eligibility, including implementation, where appropriate, of DOH-5003 Medical Orders for Life Sustaining Treatment