Population Health

Improvement Program

Kick-Off Meeting

February 26, 2015

HealtheConnections

Cayuga Community Health Network

Seven Valleys Health Coalition

Madison County Rural Health Council

Central New York Health Home Network

Onondaga County Health Department

Oswego County Opportunities 1

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“Connecting You to Better Care”

In collaboration with our Central New York stakeholders and participants, HealtheConnections' trusted and valued

services support healthcare transformation and efficiency initiatives focused on achieving the triple aim of better care,

better population health and lower healthcare costs.

HealtheConnections provides unbiased, neutral health information exchange (HIE) services*, population health

improvement support services, data analytics, and electronic health record adoption and meaningful use advisement

services for the eleven counties of the Central New York region.

The name HealtheConnections represents our commitment to connect and engage Central New York healthcare

physicians, hospitals, public health, mental and behavior health, human services and other health care providing

entities, insurers, business and consumers to implement services and initiatives that support New York State’s health

information exchange and population health improvement agendas.

In the pursuit of this mission, the actions of leadership, staff and our business partners will be guided by the following

values:

Integrity & Trust, Excellence, Teamwork & Collaboration, Respect, Commitment, Accountability, Responsibility, &

Diversity

HealtheConnections takes a business oriented approach to our non profit work; emphasizing value, efficiency, results

and sustainability.

*HealtheConnections is a Qualified Entity of the State Health Information Network of New York (SHIN-NY)

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Introduction of the PHIP Team

HealtheConnections

Rob Hack

Rachel Kramer

Bruce Hathaway

Mary Carney

Megan Lee

John Snow, Inc.

Craig Stevens

Alec McKinney

Apter & O’Connor

Nancy Smith

County Agents

Cayuga: Cayuga County

Community Health Network

Cortland: Seven Valleys Health

Coalition

Madison: Madison County

Rural Health Council

Oneida: Central New York

Home Network

Onondaga: Onondaga County

Health Department

Oswego: Oswego County

Opportunities

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Meeting Goal

By the end of the meeting, participants will understand:

• Activities necessary to meet NYS contractual obligations

• Objectives and priorities

• Framework and recommended approaches

• PHIP resources that can be leveraged

• County priorities across 6-county region

• Expectations for stakeholder involvement

• Contract parameters and payments from HeC

• Activities to be accomplished within first 6 months

Build an engaged and informed Central New York Population Health Improvement Program (PHIP) team.

• PHIP Overview

• Central New York PHIP Framework and Approach

• Example of PHIP Approach

• Working Lunch – Discussion of County Priorities

• Stakeholder Mapping

• Next Steps and Closing

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Agenda

Better population

health

Better care

Fewer health

disparities

Lower health

care costs6

NYS DOH Population Health Improvement

Program (PHIP) will promote the Triple Aim

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Promote population healthReduce health care disparities

Best Practices

Innovative Strategies

Identifying

Sharing

Disseminating

Helping to implement

PHIP contractors will provide a neutral forum for:

PHIP contractors will engage stakeholders, including but not limited to:

Health, behavioral health, & disabilities

service providers

Rural health networks

Insurers, and other payers Consumer & patient advocacy organizations

Behavioral health advocacy organizations Disability rights organizations

Local public health officials, other elected

officials

Local human service agencies

Business community Unions

Schools Higher education institutions

Local housing authorities Local transportation authorities

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Stakeholder Engagement

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• Support and advance the Prevention Agenda by

serving as a resource and assisting in the

implementation of evidence based initiatives to

address priorities

• Support and participate in the development,

implementation, measurement and evaluation of

innovative health system strategies that support the

goals and objectives of the SHIP

• Serve as a resource to DSRIP Performing Provider

Systems (PPS)

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PHIP contractors will, within their regions:

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PHIP Regions

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PHIP Contractors by Region

Central New York PHIP Objectives

1. Convene stakeholders and demonstrate

transparency

2. Incorporate health disparities strategies

3. Data-driven priorities and decision making

4. Advance state and county goals

5. Promote consumer engagement and coordinate

regional activities

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HealtheConnections Roles & Responsibilities

• Ensure meaningful engagement of stakeholders

• Develop and implement governance structure

• Develop strategic plan and business plan

• Identify and disseminate best practices and innovative

strategies

• Identify and implement capacity-building trainings for region

• Support awareness and coordination of existing regional

initiatives

• Facilitate and support plans for regional health improvement

initiatives

• Develop website • Compile, analyze, interpret and present population health data

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County Agent Roles & Responsibilities

• Convene local stakeholders to inform PHIP activities and

share best practices

• Collect, analyze and utilize county-specific data

• Support and advance county activities addressing Prevention

Agenda priorities

• Serve on Operating Committee and Leadership Advisory

Committee

• Support and participate in regional health improvement

initiatives

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John Snow, Inc. Roles & Responsibilities

• Provide recommendations regarding:• PHIP governance structure

• PHIP strategic plan

• Best practices for community engagement and addressing health disparities

• Assist with county inventories

• Provide trainings to build capacity in community engagement

• Compile population health data with focus on health disparities

• Support the development of a public use data dashboard and portal

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• Develop performance management plan • Incorporate evaluation outcomes and measures reflective

of strategic plan

• Prepare report on best practices for regional health improvement initiatives

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Apter & O’Connor Roles & Responsibilities

• Hire HealtheConnections staff

• Establish contracts with County Agents, John Snow, Apter &

O’Connor

• Identify governance structure

• Put in place Leadership Advisory and Operating Committees

• Identify stakeholders and partners at county and regional level

• Identify county level prevention agenda priorities and existing

initiatives

• Review and compile regional data

• Review and compile best practices

• Complete business plan and strategic plan

• Launch PHIP website

First Six Months of PHIP

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• Convene local stakeholders to inform PHIP activities and share best practices, with a focus on improving health and health equity

• Collect, analyze and utilize county-specific data

• Support and advance county activities addressing

Prevention Agenda priorities

Wo

rk W

ith

in t

he

Co

un

ty

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Working Together Across the Region

• Serve as a nexus for data management and analytics

• Establish regional PHIP objectives that support Prevention Agenda priorities

• Participate in CNY regional population health improvement strategies

• Promote local participation in the PHIP Leadership Advisory Council (LAC) and other operating committees

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Working Together Across the Region

Wo

rk W

ithin

th

e C

ou

nty

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PHIP Vertical

and Horizontal

Alignment

Madison

Oswego

Cortland

Oneida

Cayuga

HeC

Onondaga 24

Working As A

Team

LEVERAGE and

CONNECT

PREP PLAN ACT SHARE

P1: Identify

County and

Hospital Priorities

P2: Identify

Stakeholders

P3: Examine Data

P4: Explore

Evidence-Based

Approaches

P5: Identify

Existing

Interventions

P6: Identify Gaps

and Opportunities

P7a: Implement

County-Level

Work and

Evaluation

(Vertical)

P7b: Implement

Regional Work

and Evaluation

(Horizontal)

P8: Report Back

P9: Illustrate

Impact

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Introduction

to Lincoln

County

Prevent Chronic Diseases

• Reduce obesity

• Increase access to high-quality chronic disease preventive care and management

Promote Healthy Women, Infants, and Children

• Reduce premature births

• Increase the rate of babies who are breast fed

Lincoln County ExamplePhase 1: Identify county and hospital priorities

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Lincoln County ExamplePhase 2: Identify stakeholders

Lincoln County Health Department National Alliance for the Mentally Ill (NAMI)

Excellus BlueCross BlueShield, Lincoln Valley Lincoln Valley Midwifery Services

Big Lincoln Hospital YMCA of Lincoln Valley

Four Trees Walk-In Community Clinic Lincoln Transit Authority

Lincoln City School District University of Lincoln Student Health Center

United Builders of Lincoln County, No. 56 American Cancer Society

Lincoln City Landscape Architecture Firm Little Lincoln Hospital

Maryam Mallory, Mayor of Lincoln City Big Brother Big Sisters

Planned Parenthood Associates for Cardiac & Vascular Surgery

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Lincoln County ExamplePhase 3: Examine data

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LincolnNYS

PA 2017

Percentage of infants exclusively

breastfed in the hospital (33)

From Vital Statistics data, February 2014

Lincoln County ExamplePhase 3: Examine data

Infants

breastfed

Average number

of live birthsPercentage

Black Non-Hispanics 33 101 32.6%

White Non-Hispanics 324 667 48.6%

Medicaid patients 140 401 34.9%

Non-Medicaid patients 254 487 52.2%

Total 389 888 43.8%

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From Vital Statistics data, February 2014

Prevent Chronic Diseases

• Reduce obesity

• Increase access to high-quality chronic disease preventive care and management

Promote Healthy Women, Infants, and Children

• Reduce premature births

• Increase the rate of babies who are breast fed

Lincoln County ExampleRevisitation of Phase 1: Identify county and hospital priorities

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Lincoln County ExampleRevisitation of Phase 2: Identify your stakeholders

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Tabernacle Church of God in Christ Women’s Educational Opportunity Center

Obstetrics & Gynecology Care Network Dr. Kenneth Raymond & Rajeena Tiwari, NP

Lincoln County Health Department National Alliance for the Mentally Ill (NAMI)

Excellus BlueCross BlueShield, Lincoln Valley Lincoln Valley Midwifery Services

Big Lincoln Hospital YMCA of Lincoln Valley

Four Trees Walk-In Community Clinic Lincoln Transit Authority

Lincoln City School District University of Lincoln Student Health Center

United Builders of Lincoln County, No. 56 American Cancer Society

Lincoln City Landscape Architecture Firm Little Lincoln Hospital

Maryam Mallory, Mayor of Lincoln City Big Brother Big Sisters

Planned Parenthood Associates for Cardiac & Vascular Surgery

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Lincoln County ExamplePhase 4: Explore evidence-based approaches

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Lincoln County ExamplePhase 4: Explore evidence-based approaches

From the Lincoln County CHIP, 2013:

• Implement well-tested social marketing campaigns to change attitudes, social

norms and behaviors related to breastfeeding initiation, exclusivity and/or duration

• Train physicians, nurses, and other health care providers on the importance of

breastfeeding and lactation support, and reduce distribution of infant formula

• Ensure that businesses/organizations create an environment to support

breastfeeding, pumping and provide lactation support

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Lincoln County ExamplePhase 5: Identify existing, current, local interventions

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Lincoln County ExamplePhase 5: Identify existing, current, local interventions

Organization(s) Interventions

Lincoln City School District Improved workplace breastfeeding & pumping

policies; Converted designated areas.

Big Lincoln Hospital Training for new hires in clinical roles;

discouraging distribution of free formula at birth

Little Lincoln Hospital Pinpointed their low-wage shift workers as at-risk

population; Planning to improve policies

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Lincoln County ExamplePhase 6: Identify gaps and opportunities

DataCurrent

Interventions

Evidence Base

Stake-holders

CHA, CHIP, and

CSPs

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Lincoln County ExamplePhase 5: Identify existing, current, local interventions

Organization(s) Interventions

Lincoln City School District Improved workplace breastfeeding & pumping

policies; Converted designated areas.

Big Lincoln Hospital Training for new hires in clinical roles

Little Lincoln Hospital Pinpointed their low-wage shift workers as at-

risk population; Planning to improve policies

• Supply Little Lincoln Hospital with evidence based tools

• Participate in ongoing dialogue and engagement

• Convene Lincoln City School District administrators and

Little Lincoln Hospital project manager

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Lincoln County ExamplePhase 7a: Implement county-level work and evaluation

ACT

• Engage Leadership Advisory Committee

• LAC engages 3 neighboring County Agents

• County Agents assist in formation of large work group

• Big Lincoln Hospital leverages their expertise &

resources to bring the region’s providers on board

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Lincoln County ExamplePhase 7b: Implement regional-level work and evaluation

ACT

• Agencies contribute to a large-scale TV and radio media

campaign to highlight the importance of breastfeeding.

• Regional Agents bring in medical anthropology fellows

from the University of Lincoln to consult on the content

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Lincoln County ExamplePhase 7b: Implement regional-level work and evaluation

ACT

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SHARELincoln County ExamplePhase 8: Report back

Communicate with County & Regional Agents

Com

mun

icate

with

Sta

keh

old

ers

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Lincoln County ExamplePhase 9: Illustrate impact

SHARE

• Showed preliminary data from local hospitals

• Reported improvements to NYSDOH as part of

Prevention Agenda communications

• Presented approach & progress at NYSPHA conference

• Featured in media interviews and articles as part of

Central New York’s “Kids Health Week”

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Subcontracts

Master services agreement with HealtheConnections

Exhibit will include statement of work (aligned with MOU)

Budgets and Payment

$70,000 annually for two years

12 monthly payments ($5,833)

Monthly invoice submitted by 10th of following month

Reimbursement contingent upon receipt of HeC vouchers

Reporting

Will align with HealtheConections’ reporting to NYSDOH

Monthly report to submit with invoice

Reporting format, content and schedule TBD

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Subcontracts, Budgeting, and Reporting

• Provide feedback on meeting via Survey Monkey

• Meeting minutes

• Governance structure discussion – Friday, March 6th

• Nominations for Leadership Advisory Committee

• County assessment/inventory

• Monthly meetings of Operating Committee

• Weekly check-in with PHIP staff assigned to each county

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Next Steps

Thank you!

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