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Welcome to the LCHP Newsletter!
Upcoming Dates to Remember:
- June 14th: 2017 Q2 Executive Governance Meeting (EGB)
- June 30th: 2017 Q2 Project Advisory Council Meeting (PAC)
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A Letter from the Executive Director
Dear Partners:
It is with mixed emotions that I am leaving my post as Executive Director of the Leatherstocking Health Collaborative Partners PPS effective May 12, 2017. I have accepted a newly created position of Senior Director of the Cancer and Blood Diseases Institute at Johns Hopkins All-Children's Hospital in St. Petersburg, Florida. It will be an equal honor to work with children with cancer as it has been to lead our DSRIP initiatives over the past two and a half years.
I want to thank you for joining us on this journey designed to provide comprehensive care and services to our region's most vulnerable population. I am supremely confident that you will continue to be successful in your endeavors, which I will be watching closely from afar.
Warmest regards,
Sue van der Sommen
Executive Director
Leatherstocking Collaborative Health Partners PPS
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LCHP Team Updates
Congratulations to LCHP's Project Manager and Workforce Lead, Wendy Kiuber, who recently became certified as a Content Expert by the NCQA!
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LCHP Welcomes New Team Members
Oliver Bourgeois has joined the LCHP DSRIP team as a Project Manager. He
oversees the
2bviii - Hosp Home Care
,
3gi - Palliative Care
,
3diii - Asthma
,
4bi - Tobacco Cessation
. Oliver graduated from The College of Saint Rose with a degree in Physical Science and Math. He most recently worked for Unalam, managing a multitude of glue laminated timber projects involving engineering, custom manufacturing and construction.
Halley Chiodo joined the LCHP DSRIP team in December as the Executive Assistant. She graduated from Ithaca College with a Bachelor's Degree in Art History with Concentrations in Architecture and Printmaking. She has been a Bassett employee for two years, working in Inpatient Medicine as a Unit Clerk.
Lucinda (Cindy) Levene has joined LCHP as Network Operations Manager for DSRIP. In her new role, Cindy is visiting the counties in LCHP's service area to bring together community-based organizations in partnership with DSRIP projects. Cindy is also supporting the work surrounding practitioner engagement, health literacy and rural transportation. Prior to her new role, Cindy served for five years as the Patient Representative in Quality and Risk Management at Bassett.
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Project Advisory Oversight Panel (PAOP) Mid-point Review: February 2017
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Leatherstocking PPS was among the 25 PPS' in the state to present to the Project Advisory Oversight Panel (PAOP) in Albany during the first week of February, 2017. The PAOP is comprised of appointees of the Centers for Medicare and Medicaid Services and NYS Department of Health charged with oversight of the success of the DSRIP program, with particular attention being paid to programmatic success at the midpoint of the program.
Leatherstocking's presentation focused on transformation efforts to date, including the early success of the ambulatory-based medication-assisted treatment program, developed through close collaboration with community-based organizations; the transformation of our primary care practices in achieving NCQA Patient-Centered Medical Home Level III recognition; the overall focus on disparities of care (transportation, LGBTQ); and the patient-activation and navigation projects. Additionally, Leatherstocking was able to share its funds flow model, which was praised by the state PAOP for its inclusiveness and transparency.
The work of the Leatherstocking PPS was well-received with no additional recommendations for improvement.
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In photo from Left to Right: Dr. James Anderson, Dr. Richard Brown, Senator James Seward, Dr. Andrew Kolodny, Dr. Brian White, Dr. Julie Dostal, and Dr. Steven Heneghan.
CNY
Heroin & Opioid Key Stakeholder Summit:
A Call to Action
March 16, 2017
Cooperstown, NY - Leatherstocking Collaborative Health Partners (LCHP), in collaboration with New York State Senator James Seward (R/C/I- Oneonta) and Bassett Healthcare Network, staged a Heroin and Opioid Summit for key stakeholders in the region, Thursday, March 16 at the Otesaga Resort Hotel. The event brought together individuals, organizations, agencies and others with the ability to influence positive change in regard to the public health impacts of the heroin and opioid crisis.
"The goal of the summit was to understand all of the efforts underway in the region to address the crisis and engage in a conversation about how best to move forward toward workable solutions," explains Julie Dostal, Ph.D., Executive Director, LEAF Council on Alcoholism and Addiction. "By understanding the efforts currently underway, we can also better identify gaps, agree on those we can influence and decide on next steps. In the end, I believe it is important that we identify and commit to compassionate and evidence-based ways to reduce the impacts of this crisis in our region."
Among those attending the March 16 summit were members of the law enforcement community, local and state government officials, county public
health representatives, members of the substance abuse treatment and recovery community, medical and mental health professionals, leaders and faculty from area colleges and others.
Senator Seward noted, "The heroin crisis has reached every segment of our population and is destroying individuals, families, and communities. As a member of the Senate's Joint Task Force on Heroin and Opioid Addiction, I have helped enact a number of new laws to increase access to treatment and support those in recovery. We have made progress but we have not beaten this public health epidemic. Bringing together community stakeholders that are on the front lines will help identify our needs and our strategy moving forward as we work to save lives."
President and CEO of Bassett Healthcare Network, Vance M. Brown, MD, said, "Our network is extremely fortunate to have a highly committed group of practitioners and other health care professionals leading a multi-faceted approach to helping address this issue among our patient population. The initiatives underway cut across the primary care, behavioral health, inpatient and emergency room settings. However, this is a problem that stretches beyond the walls of our facilities and this summit recognizes the need to have as many stakeholders as possible involved in developing a plan to build on our collective progress to date."
The summit brought stakeholders up to date on the following initiatives:
* Colgate Upstate Institute-Bassett Research Institute GIS mapping relative to the opioid epidemic
* Improved substance abuse identification and treatment, and the integration of behavioral health into the Bassett Healthcare Network primary care setting
* Bassett Healthcare Network's safe prescribing efforts and naloxone availability
* American Medical Association resolutions regarding the removal of pain as the 5th vital sign
* Safe medication return
* Community responses: Sober housing, police-assisted addiction recovery
The summit's keynote speaker was Dr. Andrew Kolodny, a senior scientist at the Heller School for Social Policy and Management at Brandeis University, and Executive Director and co-founder of Physicians for Responsible Opioid Prescribing (PROP).
Links to the video presentation are listed below:
Q and A Session:
Slides for each of the presentations for the event can be found
here.
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All-Partner Meeting Update
LCHP's latest All-Partner Meeting was held on March 22, 2017 at the Otesaga Hotel in Cooperstown. In a timely address, keynote speaker William Streck, MD shared insights about the new American Healthcare Act (AHCA) which was scheduled to be voted on the following day.
(Read more) Other topics included PPS performance improvement strategies, partner engagement in 2017, an area transportation update and a regional workforce update.
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Who We Are and Our History:
Our goal is to provide the very best care for patients and families dealing with a serious, progressive illness. We are the only hospice provider in the 3,100 square-mile region of Delaware, Otsego and Schoharie Counties. Our interdisciplinary team takes a holistic approach by providing comfort and care to manage physical, emotional and/or spiritual pain and symptoms. We
make life easier
for everyone involved. We were established 30 years ago by a group of local volunteers who called themselves the L.O.V.E. Committee (Lots of Volunteer
Effort). Their purpose was to provide comfort to the terminally ill.
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Average
Daily Census (patients on any given day):112
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Average
Length of Stay: 96.9 days
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Median Length of Stay: 21 days
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Patients/Families Served: 622
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Number of Days of Hospice Care: 41,239 days total
In 30 years, Catskill Area Hospice and Palliative Care (CAHPC) has grown and diversified. In addition to Hospice, we provide palliative care enabling patients and their families to receive comfort care earlier in the disease process. Under the leadership of our new President and CEO, Dan Ayers, we now employ 90 individuals, including physicians, nurses and hospice aides with advanced training in pain and symptom control. This interdisciplinary team is supported by social workers, spiritual care counselors and bereavement counselors. Additionally, massage therapy, physical therapy and dietitian services are provided. With the commitment of 250 volunteers, CAHPC provides programs such as Veterans' Appreciation, "Tuck In," "Story Keeper," and Vigil Volunteers along with a wide array of support including pet therapy, companionship, respite and errands. Bereavement services are available for 13 months, including the nationally-recognized child and teen bereavement camp, "Camp Forget-Me-Not."
Other Facts:
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End-Stage COPD is the #1 Reason for readmission to the hospital in the last 6 months of life,
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Catskill Area Hospice and Palliative Care successfully served 185 end-stage COPD patients in 2013 for a total of 12,701 days,
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Catskill Area Hospice and Palliative Care successfully kept these 185 COPD patients out of the hospital,
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41 COPD patients were referred during their "terminal" admission to the hospital,
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We served them for a total of 145 days in the hospital, which cost Medicare $90,00,
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According to Mt. Sinai study, if those 41 patients were referred to hospice two weeks sooner, it would have saved Medicare $246,000.
Hospice Patient Diagnosis Breakdown-2013
Location of Hospice Services Payor Mix
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Workforce Update
Workforce Achievement Value worth $3.1M:
The total Workforce Achievement Value (AV) for LCHP is valued at $3.1M. The Workforce AV is tied to all 11 clinical projects and is dependent upon completion of the prescribed workforce milestones and required semi-annual data reporting.
Five Prescribed Milestones have been successfully submitted to DOH:
- Define the Target Workforce State (09/30/16),
- Detailed Gap Analysis (09/30/16),
- Transition Road Map (09/30/16),
- Compensation & Benefits Analysis* (06/30/16),
- Training Strategy (09/30/16).
Ongoing Workforce Reporting in the HWapps platform is required for quarters ending 3/31 and 9/30 throughout DSRIP:
*Associated with the Workforce Achievement Value
*Workforce AV driving milestones and required reporting make up $3.1 million of the $12.6 slated for organizational projects.
*There is no partial AV for workforce reporting. We must successfully report all 3 to receive 1 AV.
The Workforce Steering Committee, in conjunction with Health Workforce New York as LCHP's workforce consultants, has been developing the strategic plan to inform the detailed work plan. The drilldown of data by job titles, facility type and geographic areas follows:
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New Partners:
Please join us in welcoming our newest partners: Oneida Healthcare and The Neighborhood Center.
Oneida Healthcare has a 160-bed extended care facility which provides an array of services that include physical, occupational, speech, recreational and massage. They are incorporating INTERACT tools to assist in the early recognition of issues leading to unnecessary hospitalizations.
Our PPS is also collaborating with the
Mobile Crisis Assessment Team at The Neighborhood Center in suicide prevention as a part of integrating behavioral health and primary care.
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Click on the logo to visit their website.
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Click on logo to visit their website.
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Embedded Health Navigators in the ED & Hospitals - A DSRIP Project to Help Patients Enroll in Insurance Plans
Navigating the health care system is complex enough for healthy members of the
community, so consider the impact of navigating the health care system when patients are receiving care in the emergency department and also worried about how they are going to pay for the care.
"When someone is ill and not feeling well, the last thing the person should have to think about is how they are going to pay for the bill. This is where I can help," says Kim Steenburg, community health navigator for Bassett Medical Center's emergency department.
As an embedded community health navigator in the ED, Steenburg helps patients and their families sign up for insurance plans, renew lapsed insurance coverage and receive other important resources. Medicaid Health Home, "patient engagement" and "patient navigation" are the DSRIP* projects that this work falls under. Of the 27 staff members who work in community health navigation, 17 of them are navigators.
Steenburg has been a community health navigator since May 2016, although she has worked for Bassett for 10 years. "This is where my heart is, to help others."
Kim Kelley, an ED community health navigator at Little Falls Hospital, explains, "It's like one-stop-shopping; people can get their medical care and their insurance coverage all in one visit." The ED navigators also work to assist hospital inpatients who are underinsured or uninsured.
Navigators are not clinicians; they are professionals and resource experts who are embedded in specific departments to assist patients. All health navigators are trained and certified by the NY State of Health. They have knowledge of insurance plans and the resources to get people signed up. Helping people get regular health care and other services also may mean fewer future trips to the emergency room or less time spent in the hospital. Navigators work closely with Patient Access Services and patient registration staff who are also trained and state-certified and doing similar/complementary work with patients throughout Bassett Healthcare Network.
Community Health Navigators who are embedded in the emergency room:
-enroll patients in an insurance plan or renew lapsed Medicaid coverage in real time while they are in the ED,
-assist patients and members of their immediate family obtain a primary care provider,
-assist patients with accessing services and resources for food (such as SNAP, Supplemental Nutrition Assistance Program), HEAP (Home Energy Assistance Program), housing and transportation to health appointments.
Recently, a child was in the ED with flu-like symptoms. The sick child's mother was the only one in the family who was covered under insurance; the rest of the family had no coverage. "I received notification from the ED that the child had no insurance and so I went right over with my laptop and with the mom's help, got the child and also two other family members enrolled in a plan before they left the hospital," says Steenburg. "We help the patient in the moment and the patients are usually very happy that they can get health coverage."
Sometimes a person may come into the ED with complications related to diabetes. If patients have no primary care provider nor diabetic medication, they often end up in an emergency room. "While the patient is still in the ED, I can make the arrangements to get the patient set up with a primary care provider and then the patient can get regular follow-up, obtain necessary prescriptions and, hopefully, stay healthier," says Steenburg.
Kelley adds, "We have made it convenient for those patients that show no active insurance or no insurance at all, to get health insurance while they are here to be seen. It's good for our patients and it's good for Bassett."
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Reprinted with permission from Bassettworks
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Link to Additional Resource
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Disparities Of Care Conference- March 2017
On Thursday through Sunday, March 30-April 2, Kara Travis, Sue van der Sommen, Dr. Sarah Mader, Dr. Ed Bischof and Dr. James Dalton represented Bassett and DSRIP at the annual meeting of the Alliance of Independent Academic Medical Centers (AIAMC). The themes of the meeting were resilience and well-being in health care, as well as disparities in health care. Along with 18 other institutions in the AIAMC (which includes about 80 institutions around the country), the group presented the work that Bassett's Disparities Workgroup and DSRIP have been doing. Click the following link to view the poster they presented.
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Don't forget, we have moved into our new location at 6181 NYS Rt 7, Colliersville, NY 13747!
607-322-5150
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| Leatherstocking Collaborative Health Partners | 607-322-5150 (Main)
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| leatherstockingpartners.org
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