GREATER NEW YORK HOSPITAL ASSOCIATION | THE NEW YORK ACADEMY OF MEDICINE Partnerships Between New York City Health Care Institutions and Community-Based Organizations A Qualitative Study on Processes, Outcomes, Facilitators, and Barriers to Effective Collaboration April 2018 Researchers: Kerry Griffin, MPA Carla Nelson, MBA Lindsey Realmuto, MPH Linda Weiss, PhD ii Table of Contents 2 Acknowledgements 4 Executive Summary 7 Introduction 9 Findings 9 Forming Partnerships 13 Maintaining HCO/CBO Partnerships: Logistics, Workflows, and Capabilities 15 Contracting and Financial Arrangements 18 Conclusions 20 Case Study One: JASA & Wyckoff Heights Medical Center Partnering for Care Transitions and Reduced Hospital Readmissions 24 Case Study Two: Little Sisters of the Assumption Family Health Service & OneCity Health Partnering for Improved Asthma Control in East Harlem 28 Case Study Three: Northern Manhattan Perinatal Partnership & NewYork-Presbyterian Hospital SKATE Program: A Community Health Worker Program for Children with Special Health Care Needs 31 Payer Perspective 32 Appendix A: Organizations Participating in Focus Groups and Interviews 33 Appendix B: Project Scope and Methods 35 Appendix C: Data Sources to Identify Community Needs and Potential Partners 37 Appendix D: Capacity-Building and Informational Resources for CBOs 1 Acknowledgements The New York Academy of Medicine (The Academy) and Director, New York State Department of Health, and Greater New York Hospital Association (GNYHA) wish to Patrick Germain, Executive Director of Policy, Planning, acknowledge the contributions of project advisory group and Strategic Data Use, New York City Department of participants who helped guide the research and ensured Health and Mental Hygiene. that the results were useful to stakeholders, including hospitals, performing provider systems (PPS), community- GNYHA and The Academy would like to thank focus based organizations (CBOs), and policymakers. group and interview participants who took the time to share valuable information about their partnerships Adrienne Abbate, Executive Director (Appendix A). The project team is also grateful to the Staten Island Partnership for Community Wellness CBOs that provided focus group venues. Marilyn Fraser, MD, Chief Executive Officer Finally, this project was generously funded by the Arthur Ashe Institute for Urban Health Altman Foundation. Its mission is to support programs and institutions that enrich the quality of life in New Marilyn Jacob, Senior Director York City, with a particular focus on initiatives that help 100 Schools Project individuals, families, and communities benefit from Jewish Board the services and opportunities that enable them to achieve their full potential. Sara Kaplan-Levenson, Executive Director Maimonides Health Home About The New York Academy of Medicine Sam Marks, Executive Director The Academy advances solutions that promote the Local Initiatives Support Corporation New York City health and wellbeing of people in cities worldwide. Established in 1847, The Academy continues to Edward Ubiera, Director of Policy address the health challenges facing New York City and Local Initiatives Support Corporation New York City the world’s rapidly growing urban populations. This is accomplished through the Institute for Urban Health, Amanda Parsons, MD, Vice President home of interdisciplinary research, evaluation, policy, Community & Population Health and program initiatives; the world-class historical Montefiore Health System medical library and its public programming in history, the humanities, and the arts; and a Fellows program, Celina Ramsey, Director a network of more than 2,000 experts elected by their Health Literacy, Diversity & Outreach peers from across the professions affecting health. Staten Island Performing Provider System Allison Sesso, Executive Director About Greater New York Hospital Association Human Services Council GNYHA represents more than 160 member hospitals and health systems across New York State, as well as in The project team also consulted with Peggy Chan, New Jersey, Connecticut, and Rhode Island. GNYHA Delivery System Reform Incentive Payment (DSRIP) supports its member hospitals in the areas of clinical 2 ACKNOWLEDGEMENTS – CONTINUED operations and quality improvement strategies, educational leadership in identifying and developing regulatory and legal compliance, effective financial new initiatives of interest to member hospitals, and operations and reimbursement, and cost-effective effectively implementing them. The role has been purchasing arrangements. GNYHA plays an active extended to support PPSs in their DSRIP program role in convening hospital administrative, clinical, and efforts. 3 Executive Summary While New York City-based health care organizations community needs. Many focus group participants (HCOs) and community-based organizations (CBOs) discussed specific service gaps, disconnects, and share the mutual goal of serving the needs of their unmet needs—identified through experience, public patients and clients, the extent to which they have datasets, or community needs assessments—that effectively partnered to address social needs that could be best addressed through partnerships impact health has varied. Now, partnerships between between HCOs and CBOs. these organizations are gaining increased attention and support in the context of health care reform and Generally, partnerships facilitated capacity building, staff addressing social determinants of health. This has professional development, networking opportunities, been catalyzed by the New York State Department and increased access to funding. They also resulted in of Health’s (DOH) Delivery System Reform Incentive improved access to services and wellbeing through the Payment (DSRIP) program and Medicaid Roadmap to use of home- and community-based services to improve Value-Based Payment (VBP), both of which require CBO care transitions, chronic disease self-management, and engagement as part of health care and population the provision of other social supports. health improvements. As these programs evolve, policymakers, HCOs, and CBOs are seeking additional Participants discussed challenges, offered insights, and information on how to best partner to support the made recommendations for successful partnerships needs of their patients, clients, and communities. This (see box, page 5). report details partnering experiences, challenges, and facilitators as discussed in focus groups and key stakeholder interviews with representatives from New Partnering under DSRIP York City HCOs and CBOs. The report also details DSRIP brings additional opportunities and complexities actionable information for HCOs and CBOs seeking to partnering. It has served as a prime motivator for to enter into or enhance existing partnerships. accelerated and expanded collaboration, and has provided new resources, including the interest of For this project, HCOs include hospitals and Performing DOH and the DSRIP Project Approval and Oversight Provider Systems (PPSs) implementing DSRIP, while Panel in partnerships that expedite linkages between CBOs are organizations that primarily provide social previously unacquainted partners. For organizations services. with existing relationships, investments using DSRIP funding have offered opportunities to strengthen ties, HCOs and CBOs recognize that partnerships are increase capacity, and expand services. key to improving health within their communities, as well as reducing avoidable health care utilization Still, HCOs and CBOs participating in DSRIP detailed and—ultimately—health care costs. HCOs and CBOs partnering complexities not previously encountered. discussed their reasons for seeking and establishing While CBOs expected the program to release vast partnerships with one another, including funder funds, PPSs were initially slow to share funds with and/or regulatory requirements and organizational CBOs—due partly to DSRIP program design. This responsibility (e.g., hospital community benefit strained some existing relationships and eroded trust. requirements, New York State Prevention Agenda Also, major health systems’ control of DSRIP funds goals, and organizational missions) for addressing exacerbated the perceived imbalance of resources, 4 Key Actions for Successful Partnerships Take sufficient time to build trust. Developing trust is contingent on many factors, including sufficient time to build a relationship, an understanding of the value that partners add, transparency in expectations on both sides, a commitment to doing the necessary work to achieve partnership goals, and clear, effective communication processes. Be strategic. Rather than contracting with several new partners at once, it is best to start with one partner and limit activities. CBOs in particular noted that starting small and building helped them better assess the financial and operational risks of partnering and develop effective processes over time. Establish project or partnership champions at both organizations. Organizational champions catalyzed new relationships and were described as essential to implementation success, given the effort required to develop and sustain partnership activities. Develop a formal process to ensure the alignment and feasibility of project goals. HCOs detailed how they used information sessions with groups of CBOs, written assessment tools, and site visits to assess the capabil- ities and expectations of potential partners. CBOs discussed the importance of finding the "right project" for their organization, meaning one that limited financial risk and aligned with their organization’s stated mission. Assess specific in-house skills and capacity such as information technology (IT) infrastructure, data capture, and reporting for health care-related measures. While HCOs are accustomed to data collection and reporting, they may not recognize the burdens such activities place on CBOs. Because HCOs use different reporting systems and processes, CBOs must likely implement multiple systems to contract with multiple HCOs. HCOs must be realistic about reporting requirements and CBOs’ abilities to operate multiple data- collection systems and report health-related data. Partnerships that support capacity building as an element of collaboration result in a higher probability of success. Maintain open lines of communication by identifying main points of contact for each organization, and systemize connections in preparation for potential organizational changes. Since individual staff can play key roles in the implementation of joint programming, relationships between CBOs and HCOs must survive inevitable organizational changes caused by staff turnover, among other things. This requires that information and systems be institutionalized. Address imbalances in size and power between large health systems and (generally smaller) CBOs. Imbalances commonly permeate partnerships between HCOs and CBOs. Proactive steps such as a commitment to transparency and joint decision-making can mitigate the potentially detrimental impacts of such imbalances. Honest feedback on contracting and funding requirements—though it can be complicated by power imbalances between HCOs and CBOs—is necessary to foster productive partnerships that result in realistic outcomes. CBOs should know their value, and HCOs should be prepared to acknowledge that value. During the contract- ing process, CBOs must be realistic and forthcoming about the costs of service delivery, administrative costs, and operating costs. When determining payment amounts, HCOs should consider the total cost of a CBO’s services, including the added value the CBO brings in terms of community knowledge, relationships, and trust. 5 EXECUTIVE SUMMARY – CONTINUED scale, and power between HCOs and CBOs. CBOs and CBOs see significant potential for partnerships in noted what they viewed as a lack of transparency in PPS the context of VBP and have noted that DSRIP and other processes, including outreach, partner selection, and partnering experiences provide useful knowledge, budgeting. They also noted that the funds available to skills, and capacity that could be leveraged to sustain date have not adequately compensated them for the future partnership activities. time their staff spent working on DSRIP requirements. Some CBOs opted out of DSRIP, believing costs would In focus groups and interviews, participants discussed be greater than benefits. Others are participating but the importance of payers, particularly Medicaid are wary of the financial risks. and Medicaid managed care organizations (MCOs), in sustaining programs developed through HCO/ Another challenge is that CBOs are held to the PPS’s CBO partnerships. More information is needed on performance measures overall, though they have little how to engage MCOs in payment models and VBP control over them. Also, CBOs can’t gauge progress arrangements that can support and sustain HCO/CBO because PPSs have not adequately shared outcomes partnerships, a topic outside this project’s scope. data for the individuals receiving CBO services. HCO/CBO partnerships face many challenges, including being impacted by the requirements Looking Ahead: Partnership Sustainability of funders, policymakers, or advisory bodies with and Potential for Growth insufficient appreciation of ground-level practices. Health care reforms and the increasing recognition of Despite such challenges, partnering between HCOs factors that affect health outside the clinical encounter and CBOs remains beneficial due to the potential have accelerated HCO/CBO partnerships, and likely of these relationships to improve health, reduce will continue to do so. DSRIP is currently in year three avoidable health care use, and better address key of five, with many lessons learned and meaningful factors outside hospital walls that impact the wellbeing partnerships with CBOs just reaching fruition. HCOs of communities. 6 Introduction The Academy and GNYHA are pleased to release this stakeholder PPSs, most of which are led by hospitals joint report on partnerships between HCOs and CBOs interested in engaging and funding partnerships with in New York City. The report describes findings from CBOs as part of their strategy to reduce avoidable focus groups and interviews with New York City-based hospital use. DSRIP also requires that all participating HCOs and CBOs in which participants discussed primary care providers become certified as patient- partnering experiences and processes. For this project centered medical homes by the National Committee and report, HCOs include PPSs implementing DOH’s on Quality Assurance’s 2014 standards or the New York DSRIP program, hospitals, and health systems. CBOs State Advanced Primary Care model, both of which are broadly defined as organizations that primarily support collaboration with CBOs that provide non- provide social services, including meals, case management, health education, and mental health and counseling services. Additional information on project scope About DSRIP and methods is in Appendix B. New York’s DSRIP program is a five-year initiative funded by an $8 billion Medicaid waiver from the Centers for Medicare While HCOs and CBOs share a mutual & Medicaid Services (CMS). DOH was awarded the funding goal in serving the needs of their because it achieved significant savings through its mandatory patients and clients, the extent to which Medicaid managed care program and implementation they have effectively partnered has of Governor Andrew Cuomo’s Medicaid Redesign Team varied. Now, partnerships between these initiative to reduce Medicaid program costs and improve organizations are receiving increased outcomes. DSRIP aims to reduce avoidable Medicaid hospital attention in the context of health care admissions, readmissions, and emergency department (ED) reform, the shift to value-based payment visits by 25% by March 2020. The program began in April 2015. (VBP) for health care services, and more general concerns about addressing social DSRIP is being implemented across New York State by 25 PPSs, needs that impact health, such as housing most of which are led by a safety net hospital or health system. and food insecurity, educational needs, PPS partners include various health care stakeholders such as job and financial assistance, and other other hospitals, federally qualified health centers, large and social determinants.1,2 In New York State, small community-based practices, behavioral health providers, HCO/CBO partnerships have addressed long-term care organizations, home health agencies, and CBOs. various issues, and many have lengthy PPSs must implement between seven and 11 projects that histories. Still, health care institutions now build integrated delivery systems and improve chronic disease have greater interest and motivation to management and public health. PPSs are awarded incentive partner with CBOs to address conditions payments for achieving prescribed milestones and demonstrating outside hospital walls that impact health improvement on more than 40 outcomes measures. and health care utilization. This shift is partly due to DSRIP, which requires multi- 1 For more information on social determinants of health, visit www.healthypeople.gov. 2 GNYHA designed a curriculum on social determinants of health, available at https://www.gnyha.org/tool/training-primary-care-residents- on-the-social-determinants-of-health/. 7 INTRODUCTION – CONTINUED clinical services. PPS implementation plans submitted New York State, created a VBP commission that is to DOH in 2014 described various mechanisms for developing a roadmap for identifying models and meeting partnership requirements, including contracts contracting pathways for human services organizations and referral relationships with CBOs. Still, despite to contribute to health outcomes and participate in DSRIP program requirements and PPSs’ written VBP. HSC expects to publish its recommendations in intentions to engage with CBOs, DOH and the CBO spring 2018. community have expressed concerns that CBOs have not been meaningfully engaged or funded with DSRIP This report complements ongoing efforts to assess dollars. The DSRIP Project Approval and Oversight and support HCO/CBO partnerships by emphasizing Panel (PAOP) has also focused on meaningful CBO empirical data that describes partnerships at differing engagement as a central concern and has encouraged stages and with varying levels of success. The diversity PPSs to improve in this area. The PAOP is comprised of institutions and partnership focus also distinguishes of health care and community stakeholders and serves this report from other efforts. HCOs, CBOs, and other DOH and PPSs in an advisory and reviewer capacity. stakeholders can benefit from guidance elicited In reports to the PAOP, PPSs have publicly described from their peers as they undertake these activities in their challenges and progress on CBO engagement the context of changing policy mandates, payment and funding. reform, and the need to jointly address social needs to improve community and population health. Significant work is being done nationally to examine and support the development of HCO/CBO This report describes partnering experiences— partnerships. In a recent project, the Center for Health including challenges and facilitators to effective Care Strategies, the Nonprofit Finance Fund, and the partnerships, as reported by HCO and CBO Alliance for Strong Families and Communities analyzed representatives—and provides specific examples and lessons from existing cross-sector partnerships across tools to facilitate the development and sustainability the country and detailed success stories in a set of of partnerships that best support public health. The case studies. Key findings included the importance of report includes the following components, which complementary expertise and open communication, summarize research findings and provide actionable challenges of estimating resource needs and tracking information for developing partnerships. outcomes, and securing sustainable funding.3 Several New York projects have examined the current state • Key findings by major topic of HCO/CBO partnerships. The Citizens Budget • Key recommendations and actionable advice for Commission recently published a discussion paper organizations pursuing partnerships on the specific challenges of integrating CBOs into • Spotlights on HCO/CBO partnership elements PPS activities.4 Some challenges raised in that paper that reflect findings and recommendations are well aligned with research findings in this report. • Case studies that detail the experiences of HCO/ Additionally, the Human Services Council (HSC), CBO partners and other stakeholders which represents social service organizations across 3 E. Miller, T. Nath, and L. Line, “Working Together Toward Better Health Outcomes,” Center for Health Care Strategies, Inc. (July 2017). https://www.chcs.org/resource/working-together-toward-better-health-outcomes/. 4 “The Challenges of Enhancing Effective Engagement of Community-Based Organizations in Performing Provider Systems,” Citizens Budget Commission (November 13, 2017). 8 Findings Forming Partnerships The Benefits of Partnering Throughout this project, many specific partnership benefits were described. For CBOs, partnerships Key Findings: facilitated organizational capacity building, staff pro- • HCOs and CBOs agree that partnering has fessional development, and networking opportuni- many benefits and is key to improved health for ties, as well as increased access to funding. For HCOs, community members, reduced health care use, partnerships resulted in improved access to care and—ultimately—reduced health care costs. and quality of services for at-risk populations. These • Successful partnerships are built over time and services include community- or home-based care include attributes such as clear and transparent coordination and medication reconciliation following communications that foster and instill trust. hospital discharge, reducing environmental triggers in • It is difficult for HCOs and CBOs to identify new the homes of children with asthma, or home delivery partners, or even partnership opportunities, of meals. Both HCOs and CBOs benefited from because they lack familiarity with one another’s educational and training opportunities, including organizations and services, and in some cases, mental health and substance use training for school don’t have the appropriate contacts. personnel, health education for preschool parents, • Though DSRIP has accelerated partnership and cultural competency training for HCO staff. As formation, its scale, requirements, and over- focus group participants said: all funding have brought new challenges to the partnering process. We’ve been able to leverage a lot of training and professional development at a high level for our Key Recommendations: case management staff, for our senior center staff, • Whenever possible, build on long-term for a multitude of our staffing. (CBO) relationships and existing partnerships. • Identify community needs and potential Our families get better services . . . That’s what we partners using available data, including pub- really get out of it. We get a more comprehensive lic surveys and community needs assess- service for our kids . . . If we can bring those ments. See Appendix C for a list of potential services to homes or closer to the home, then that data sources. will increase—my thinking—their school activity, • Develop a formal review process to ensure school productivity, graduation, so on and so that potential partners have aligned goals forth. (CBO) and the capabilities to achieve them within the partnership. Site visits by both parties can I think we’ve been able to more appropriately provide helpful context and a sense of the place people in aftercare and aftercare housing5 potential partnership benefits and challenges. than ever before and maintain people in the • Obtain leadership buy-in and support, and community better over the past maybe four identify project or partnership champions at years than we ever did in our history before that. both organizations. (Hospital) 5 Housing and supportive services provided following hospital discharge for patients with complex social and health needs. 9 FINDINGS – FORMING PARTNERSHIPS – CONTINUED HCOs and CBOs discussed reasons for seeking and that capacity, and I thought this would be a good establishing partnerships with one another. Many area to provide support. (CBO) partnerships were motivated by funder and/or regulatory requirements, including DSRIP. For others, HCOs often identified particular community needs, the key motivator was organizational responsibility but had difficulty finding a CBO partner. In general, for addressing community needs (e.g., as related HCOs reportedly lacked basic information about to hospital community benefits, New York State CBOs in their local communities and their relevant Prevention Agenda goals, HCO or CBO organizational services. HCOs were sometimes impeded by lack of missions). Many focus group participants discussed correct contact information. While CBOs knew about specific service gaps, disconnects, and unmet needs— HCOs, they often did not know who the best contact identified through experience, public datasets, or person was, or how to contact them. community needs assessments—that could be best addressed through a partnership between HCOs and We have a spreadsheet, but a lot of the information CBOs. might be outdated, or we’re just finding that we call, and [the hospitals] don’t really know who to It really grew up just because of proximity and put us through to, and we don’t know who to ask referrals. These are the patients that were, for. (CBO) essentially, coming to us . . . from a particular agency. And the need to discharge back to [that Focus group participants discussed processes for agency] really required we work closely with them. assessing the needs, capabilities, and expectations of (Hospital) potential partners (and themselves). HCOs detailed information sessions with groups of CBOs, written I started using a lot more public data, but then assessment tools, and site visits—to determine current also doing some focus groups in our community capacity and reach, which sometimes differed from . . . So I knew in [this area] there were really high what CBOs described. CBOs, in contrast, discussed rates of preventable hospitalizations, and I was the importance of finding the "right project" for their trying to align this with where [we] had services, organization to limit financial risk and ensure alignment too . . . I also looked at the penalties for hospitals with their stated organizational mission. for readmissions. So, I knew who was hurting in Spotlight: Using Public Data to Develop a Partnership Proposition Jewish Association Serving the Aging (JASA), a CBO that delivers a wide array of services to older adults, de- veloped the capacity to address issues related to care transitions for high-risk patients recently discharged from the hospital. JASA ultimately aimed to create the service line and formally partner with hospitals whose patients could benefit from it. To determine hospital targets, the organization reviewed various public data sources, including readmissions data, CMS readmissions penalties, and a free data tool called Data2GO.NYC. JASA developed a business proposition based on relevant information and shared it with the chief executive officer at Wyckoff Heights Medical Center. Wyckoff ultimately contracted with JASA for their care transitions services, as described in more detail in Case Study One, page 20. 10 FINDINGS – FORMING PARTNERSHIPS – CONTINUED I was working with this partner in Brooklyn, and we partnership goals; and clear and effective processes had all these meetings, and it was so wonderful . for communication, including a point person at . . but when we went into the community . . . the each organization. Organizational champions were community that was once there was gone, and it described as essential, given likely barriers. was gentrified Brooklyn. And so the people . . . being described were no longer there. And so it Every community partnership that we pursue and wasn’t relevant to our service area and our service we engage with, we come in with a strategic plan goals . . . So we now have a set of questions when that really lines up to our roadmap for success we do a visit, so there’s some back and forth before for our hospital . . . And we find ways to engage we engage in a formal agreement. (Hospital) partners in looking at the value that they add, not only to us but to the communities . . . So I think it’s just figuring out the right project. We’re understanding and defining what the value added risking a lot by being in some of these relationships for both of us upfront has been a really wonderful and contracts where we’re not actually funded to experience and something that people could hold do the work, and there’s a lot of like, “We may on to and say, “I’m invested in this partnership, get the money at the end of the year. We may because I can see the changes in outcomes.” not.” We can only have so many of those. So we (Hospital) chose the ones where we know we have strong partnerships, and we trust that hopefully we can For us, it’s leadership driven. The leaders of the get there. (CBO) hospital value community-based organizations. I think that’s what allows the partnership to function Focus group participants discussed how the trust the way it does, because it definitely isn’t driven needed for partnership development was commonly by funding. It’s driven by the leaders saying, “We absent. CBOs, in particular, noted that HCOs lacked need to do more for our constituents. How do we appreciation for their capacity, work, and their potential do that?” (CBO) role as liaisons to community members. Establishing Partnerships in the Context of DSRIP The hospitals have to learn what we have to offer . DSRIP has been a prime motivator for accelerated and . . they have to be willing to give up a little of that expanded collaboration. DOH’s and DSRIP PAOP’s control to be a real partner with the community, particular interest in engaging CBOs in PPS activities not walled off from the community. For them to has expedited familiarity and linkages between do that, they really have to partner with CBOs who previously unacquainted partners. For organizations are out there . . . there’s a lot of mistrust in the with existing relationships, DSRIP offered an community of hospitals, either from your cultural opportunity to strengthen ties, increase capacity, and background or experience. So, we are a valuable expand services. resource for them, and we have a reputation in the communities that is positive and can help bridge At our hospital, we started doing this before that gap. (CBO) DSRIP. I think that time to cultivate and build is imperative. It translates to loyalty. It translates to The development of trust was contingent on several long-lasting relationships, and so when something factors, including sufficient time for relationship like DSRIP comes, we already had a core group building; an understanding of the value added that we can turn to and say, “Hey, we have this in partnering; transparency in expectations; a opportunity. Join us.” (Hospital) commitment to the necessary work to achieve 11 FINDINGS – FORMING PARTNERSHIPS – CONTINUED The hospitals didn’t know what was going on in I tell you what I do think complicates things: I think the community. Everything stopped at the hospital that the PAOP’s pressure for the PPSs to contract door when they discharged somebody. So, I think with Tier 1s6 complicates things because we feel that’s one of the values of DSRIP now. They’re a ton of pressure—we’re trying to figure out how starting to realize what’s out there. (CBO) to do this, how to implement these projects, and then, this immense pressure to bring these While PPSs generally perceive the value CBOs bring to organizations in one at a time, and it’s not fast their communities, they expressed concerns about the enough, it’s not enough money ever, but how do pressure to develop and formalize partnerships quickly, you do it in a meaningful way? (PPS) and to provide funding at levels they consider unrealistic. Both HCOs and CBOs described partnering complex- Spotlight: Aligning System-Wide ities not previously encoun- tered, including the challenges Efforts to Achieve DSRIP Goals and of partnering within the context Engage CBO Partners of a PPS, a large entity that may be disconnected from specific hospitals and neighborhoods. NYU Langone Brooklyn and its PPS are moving to leverage and align HCOs and CBOs also noted their system-wide efforts to increase the likelihood of meeting DSRIP that although they had part- goals and support sustainability beyond DSRIP. The hospital and PPS nered for many years with little leveraged diabetes self-management education resources from the to no funding, the vast funds New York City Department of Health and Mental Hygiene (DOHMH) and anticipated to be available plan to fund two of their longstanding CBO partners with DSRIP funding through DSRIP—but initially to educate the community, which bolstered their DSRIP diabetes project slow to reach CBOs in substan- activities. They have also engaged their CBO partners to provide cultural tial amounts—strained some competency guidance in asthma education brochures that are co- existing relationships and erod- branded and distributed throughout the community. The hospital noted ed trust. that one benefit of working with CBOs is that community members are “clients, they’re our patients, and we need to understand from their The thing that I didn’t think perspective . . . to help guide a lot of the work that we’re doing.” about prior to this partnership is that the PPS itself is distinct from the hospitals. And that—I [CBOs] still have this expectation and this feeling just remember walking into one of the initial like, “DSRIP’s got lots of money.” . . . So, there’s this meetings and seeing that tension, which I felt was perception that DSRIP is the answer to everything. inner tension within the organization, and realized It’s the cash cow—let’s just say it—and it comes that the PPS is a layer that’s separate from all these from everywhere, even within this organization. It’s hospitals. (CBO) like, “We want to do this project. Well, let’s just have DSRIP fund it.” (PPS) But since DSRIP . . . in general, all the CBOs that we work with, it’s changed the dynamic a little bit. 6 DOH defines a Tier 1 CBO as a CBO that is non-profit, non-Medicaid billing, community-based social and human service organizations (such as housing, social services, religious organizations, and food banks). 12 FINDINGS – FORMING PARTNERSHIPS – CONTINUED Because now, through these years, nobody had Trust and clear communication processes remained money, so we struggled. Everybody did things as themes in focus group descriptions of successful you could. Now there’s this pot of money that is partnerships. HCOs and CBOs both emphasized that out there, and it’s just the feeling that now it’s like, partnerships are commonly sustained by “champions” well, what’s that effort worth? And everything has a and personal relationships, and are negatively dollar sign. So, to me at least, some of it has—the impacted by staff turnover. relationship’s a little bit tainted, okay? They were great before. . . But now, it’s kind of like with the When a hospital social worker or discharge thought that how many millions of dollars is the planner or one of the nurses refers to us, [and] hospital getting? (Hospital) the results are good, they keep referring. And it is based on that personal relationship. But if that person leaves, or they retire, it’s broken and there’s Maintaining HCO/CBO Partnerships: no system to keep it going. (CBO) Logistics, Workflows, and Capabilities There’s a high rate of turnover in community-based organizations, and you’ll have this momentum Key Findings: with a team of people or a few people and then • CBO responsiveness is impacted by lean you learn all of a sudden next week, they’re not budget and staffing constraints. there. And you’ve spent weeks building this, or • Collecting, managing, and reporting data months, or four years, and this person just kind can be challenging for CBOs, particularly of disappears . . . And they’re the keeper of so if requirements focus on health outcomes, much, and there’s no one to replace that person which CBOs may be unaccustomed to immediately. (Hospital) reporting. • PPSs have provided resources to support and Participants also described the importance of build CBO capacity. knowledge and appreciation related to partner capacity, particularly regarding CBOs. CBOs reported Key Actions for Successful Partnerships: operating on very lean budgets. Hiring new staff before • Maintain open lines of communication by contracts are in place and adequately funded creates identifying main contact people at both levels of risk sometimes considered unacceptable. organizations. When current staff are already working at capacity, it is • Put systems in place in the HCO and CBO to difficult to shift their responsibilities. mitigate challenges related to staff turnover, and ensure that multiple staff members are Inadequate IT and data systems within CBOs also impact aware of ongoing partnership initiatives partnership functioning, particularly when reporting and are trained in processes developed to requirements are new (e.g., health outcomes), extensive, maintain partnership activities. and/or inconsistent with reporting requirements from • Facilitate CBO access to patients at the HCO other partners or funders. Many CBOs cannot easily site to ensure seamless handoffs between generate the operational data that may be required in a organizations. partnership with an HCO. • Honest feedback on contracting and funding requirements is necessary for productive IT and data are traditionally hard for social service partnerships with realistic outcomes. organizations, and so to be totally blunt about this . . . we actually track everything in Excel, which is 13 FINDINGS – MAINTAINING HCO/CBO PARTNERSHIPS – CONTINUED hideous for us. It is hugely difficult for the amount introduce these computer systems that are not of data we’re collecting . . . it’s a big burden. (CBO) user friendly, and it takes a full-time staff [person] just to understand the system, or there is not We would like to know the date and time of every adequate training, or things like that. So, we pediatric asthma patient that’s come in over the haven’t really been able to meet their demands. last six months from [this zip code]. And for us, We had a bit of incentive money that was given to that’s several keystrokes. For them, if they’re not us, and yet when trying to meet those contractual on an electronic filing system, that is a massive obligations, it’s just been extremely challenging. activity. [A] routine question . . . could potentially They haven’t set up the system in an organized be a multi-week effort. But I want that right now, manner that helps community providers give them and they still have an organization to run that does what they need. (CBO) a range of other things. (Hospital) [This hospital] has a portal . . . that they opened While HCOs recognized CBO limitations, they also up to all the partners . . . So all of our staff and noted that reporting constraints presented challenges, the whole agency has been trained on it and has particularly in the context of DSRIP and potentially for an access code to be able to use [the system] . . . VBP. The amount of support PPSs provided CBOs to So now you have this web-based referral system, facilitate reporting varied significantly. which has been very useful. We’re really happy. It has so many great features to it. (CBO) We want to also help with these types of skillsets: workflows, technology . . . [T]hey genuinely Appendix D includes a list of resources for local CBOs really care about the community and furthering to help them build their capacities and skills to partner the community they represent. So, the logistics with HCOs. then become what we can help them with, and we have a lot of resources here, so we put together this really huge training Spotlight: Learning Collaborative program here that we’re rolling to Support Community Health out right now, and I keep saying . . . from a training and development Worker Asthma Interventions standpoint, what other resources OneCity Health, the NYC Health + Hospitals PPS, developed a can we offer to some of these learning collaborative for CBOs engaged in its asthma project. community-based organizations Comprised of community health worker (CHW) organizations, to help move the needle? Some of the collaborative reviewed elements of the PPS’s asthma project them really are not sophisticated. implementation toolkit, which described project expectations They need some help in these and gave CHWs opportunities to roleplay various scenarios, areas. They don’t have tons of including safety-related and clinical issues. Additional informa- resources. (PPS) tion, including the perspective of OneCity Health’s CBO part- ner, Little Sisters of the Assumption Family Health Service, is in So, we have all of this work that Case Study Two, page 24. we need to do, provide all these metrics to these [PPSs], and they 14 FINDINGS – CONTRACTING AND FINANCIAL ARRANGEMENTS – CONTINUED Contracting and Financial Arrangements responsibilities generally require contracts, though with significant variability in the terms, ranging from simple to highly complex, the latter with a broad array Key Findings7: of legal conditions that proved burdensome for CBOs • Many HCO/CBO partnerships have operated during the contract review period. Many CBOs do successfully without a contract or disburse- not have legal departments, or even lawyers on staff, ment of funds, though the scope and ex- and reported struggling with lengthy contracts that pectations generally were relatively limited. included complex language that seemed “boilerplate” Others, including grant-funded programs, and irrelevant to the specific project. have paid CBOs based on process measures such as units of service or number of staff It’s a very diverse group. You have the big fancy dedicated to a project. [CBOs] who sometimes have in-house counsel, • Payments to CBOs based on unit of service and then you have the smaller ones that don’t have do not regularly account for costs incurred for any, and they’re all up against these big hospital administration and the meeting of reporting legal departments, and it’s a very difficult process, requirements. even if you want to change something or make it • Large differences in organizational size real and relevant to the grant. (Hospital) and scope have an impact on trust and the delineation of clear expectations. I think CBOs traditionally think of a partnership as • When partnering with large entities such a pleasant negotiation [between] the person with as PPSs, CBOs have limited leverage to the money and the person with the product, and negotiate contract terms and pricing. it’s not. It really is a negotiation, and you have to be firm. I’m not doing this work for you unless you Key Actions: give me money up front. And, a lot of people put • During the contracting process, CBOs should themselves in a position where you get involved with be realistic and forthcoming about the cost something, and then you don’t have the resources, of service delivery and other expenses. and the hospital has the resources. (CBO) • When determining payment, HCOs must consider the total cost of CBO services, as I meet with [our partner CBOs] every other month well as differentiating factors such as the . . . And we are experiencing some challenges with CBO’s added value in community knowledge, the smaller organizations, but working with them relationships, and trust. hands-on has become my main focus of the DSRIP work . . . [T]hey get monthly tracker tools, and it’s an Excel file, and then they submit that to us every Several participants described successful partnering month . . . and every tracker tool looks different for efforts that operated without contracts. Referral the [xx] projects. (PPS) relationships and community health promotions (e.g., screening and other educational programs Economics of Partnering under DSRIP for community groups) are among the kinds of DSRIP contracts were commonly described as efforts typically implemented without a contract or particularly problematic. In most cases, CBOs exchange of funds. Projects with greater scope and reported having little to no leverage, or opportunity 7 While similar questions were asked of HCOs and CBOs, challenges related to contracting and financial arrangements were more clearly evident to, and commonly reported by, CBOs. Thus, the CBO perspective is more strongly represented in this section. 15 FINDINGS – CONTRACTING AND FINANCIAL ARRANGEMENTS – CONTINUED Spotlight: Best Practice in Contract Negotiation NewYork-Presbyterian Hospital (NYP) and the Northern Manhattan Perinatal Partnership (NMPP) have col- laborated for several years on programs that provide self-management support to children and families in the surrounding community. Per the contract, NYP supports salaries and other expenses for CHWs em- ployed by NMPP. This partly results from NMPP leadership’s directness about staffing costs of desired programs, and NYP leadership recognizing the importance of the CHWs’ community-based work for their patients. More information on the partnership between NYP and NMPP is in Case Study Three, page 28. to provide input or negotiate terms. Although some like, “This is not for me,” whereas they have a lot of PPSs provided a comment period, CBOs felt that value and work that could really help the PPS and it their recommended changes were not adequately would be great for them to partner with them, but addressed. PPSs agreed that CBOs had limited they just can’t deal with these contracts.” (CBO) power to negotiate contract terms, and attributed this to the complexity of the program and the The major health system control of DSRIP funds has pace at which contracting needed to happen. PPSs exacerbated imbalances in resources, scale, and described developing master contracts for use across power between HCOs and CBOs. CBOs noted a lack their networks, with addenda for specific projects. of transparency in PPS processes, including outreach, According to both PPSs and CBOs, CBOs understood selection of partners, and budgeting. CBOs recognize the advantages of involvement in delivery system and that they have little control over the contracting payment reform, so were eager to enter into DSRIP process. They feel that funds available to them to- contracts. Some CBOs opted out of DSRIP, believing date do not adequately cover staff time for the the costs would be greater than revenues. Others are range of DSRIP requirements, including planning and participating but are wary of the financial risk. governance activities, service delivery, and reporting. I think within the DSRIP world, though, folks will . . . It’s a very hospital-centric thing. They’ve got all sometimes overpromise and under-deliver because the money, and power, and the decision-making they don’t want to be left out . . . But no one wants capability. (CBO) to say they won’t be able to do that for fear that they will miss out on the funding. So I think that So, the money we’ve received from PPSs does sometimes that happens, that folks are concerned not cover the amount of time that our workers that they will be left out of the equation if they don’t have put in thus far. We think that it will, down the say yes, or actually sign a [contract]. I’ve had CBOs line with this contract, but we do need to have a sign a Schedule B and not be able to participate. greater volume of patients. But not too many, you I’m like, “Why did you sign that?” They’re like, know? In order to hit that sweet spot. So we’re still “Well, you know, we were worried.” (PPS) figuring that out. (CBO) “I spend God knows how many hours going A few PPSs have begun to incorporate VBP concepts through this contract having many conversations into their contracting, holding CBOs responsible for with each of the PPSs trying to understand what specific outcomes. While many CBOs felt that it was we’re actually committing to. Small CBOs don’t important to understand costs and outcomes, and have the time for that. They’ll just see it and be that better data would help them eventually get to 16 FINDINGS – CONTRACTING AND FINANCIAL ARRANGEMENTS – CONTINUED more appropriate contract conditions, CBOs do not and maintain these relationships going forward. yet have the data on costs and outcomes that could (CBO) support the business case for a VBP contract. Also, given their relative size and lean budgets, CBOs are HCOs and CBOs perceived significant potential for not equipped to take on financial risk, particularly for partnership sustainability in the context of VBP, and outcomes over which they have little control. These noted that DSRIP and other partnering efforts are constraints are exacerbated by a lack of reciprocity providing useful information for the transformation to in data access: CBOs submit data to PPSs but do not VBP. They hope that knowledge, skills, and capacity receive information back about the outcomes that are increasing and that VBP will offer the means for New York State uses to determine incentive payments continued funding for partnership activities. for PPSs. I think, too, the issue towards value-based rather We have no idea and zero control (over whether) than volume opens the door, really, for organizations the PPS meets their large goals at the end of the like ours—so trying to get in line with as much as we year. We’re risking. We’re paying for this person. can, whether it’s using data or trying to find some of We’re hoping, at the end of the year, we’re getting the pain points of our clinical partners with being reimbursed something based on the number of fined for readmissions, or they need to help with visits we’re doing, but it’s really hard. (CBO) chronic care management to reach certain goals. Trying to identify what those are, and using the best We can’t do this for free. I think there’s some data we can, but also trying to just explain, to give trepidation that some people have about actually us a shot to work together to deliver value. So that saying that. “Oh, I didn’t know what I got into”… shift has opened a window for us. (CBO) but we’ve got to correct it when we move forward. It’s either we drop out or we change the Where we really do see the sustainability, I think, is reimbursement. (CBO) in the activities that we’re trying to build now, and that is around—because you can put a value on Looking Ahead: Partnership Sustainability and this—buying performance . . . So if we have these Potential for Growth value-based contracts, and these are the patients As noted, health care reforms and the increasing that we need to close gaps on, or that we need recognition of non-clinical factors that affect health to engage because they’re not engaged, these have accelerated HCO/CBO partnerships, and likely are the organizations that we want to build the will continue to. DSRIP is currently in year three of expertise, and we want to gain that expertise. . . I five, with many lessons learned, meaningful CBO think that’s a lot of where the sustainability is going partnerships just reaching fruition, and others just to come from, and we want to continue a lot of beginning. these relationships in the value-based world. (PPS) One of the interesting things is now that the CBOs also hope to leverage the knowledge and skills rubber is hitting [the] road in the third [year] of gained through DSRIP for potential negotiations with DSRIP, and going forward, is that the hospitals at MCOs, which are considered another potential source the beginning and the [PPSs]—they thought they of consistent funding for work CBOs now do. See the could control it, that they could do everything Payer Perspective on page 31 for how Healthfirst, within the bricks and mortars and maybe hire a a New York City-based MCO, is partnering and couple of people. Now, they’re realizing that, contracting with CBOs. to be successful, they really have to establish 17 FINDINGS – CONCLUSIONS – CONTINUED Conclusions Many HCOs and CBOs have already engaged Increased partnering between health care institutions in practices that facilitate strong partnerships, and CBOs has the potential to better address factors including partner assessments and open dialogues outside hospital walls that affect health and health for contracting. Learning and capacity-building care use. HCO/CBO partnerships include many opportunities for CBOs can be valuable, particularly challenges that become more pronounced as HCOs when focused on areas that can benefit the CBO are increasingly represented by entities like PPSs, within the partnership, while aligning with the CBO’s the scale of which could reduce flexibility and the overall goals and mission. PPSs have begun to support potential for negotiation with CBOs as equal partners. CBOs with “innovation funds.” Some PPSs have made The challenges of partnering may also be impacted grants available to CBO partners that allow them to by the requirements of funders and/or regulators— draw down funding not tied specifically to a DSRIP including speed, scale, and somewhat extensive project or metric. This has given CBOs flexibility to documentation—with insufficient appreciation of design projects or programs that demonstrate or ground-level practices and capabilities. build capabilities that decrease avoidable hospital utilization, a major DSRIP goal. According to CBOs and HCOs participating in this project, given these challenges, it is important that Significant challenges in HCO/CBO partnerships potential partners build from existing relationships, transcend what the organizations themselves can where knowledge and trust already exist. If not do. The financial value of CBO services within the possible, the parties need to assess capacity, fit, and context of health and health care savings has not compatibility. Transparency is important for both been carefully calculated and can be difficult to HCOs and CBOs, and can mitigate the challenges ascertain. Despite efforts within DSRIP to address associated with the imbalance of power in organization social needs, it has proven difficult to systematically size, scope, and financial capacity. Information link a social intervention with improvement on a about costs and outcomes should be available to all health care measure. While some organizations have parties, so decisions are informed and negotiations demonstrated links between, for example, stable are fair and realistic. Partners must also recognize housing and decreased health care costs, it can be one another’s limitations. For HCOs, this means difficult to do this across the spectrum of social needs recognizing the capacity needs and data collection (and CBOs that address them) that complex patients constraints of CBOs. For CBOs, it means recognizing may require. Technical assistance or joint design the complexities of large health care institutions and around identifying appropriate measures would be the regulatory aspects of their operations. In general, beneficial to ensure that data can be appropriately partners should be forthcoming about challenges, collected and/or exchanged among partners. capabilities, and needs as part of a regular dialogue, ensuring that these discussions remain at the forefront New York City-based CBOs have actively worked so that issues can be addressed. Finally, CBO cash flow to better understand how to calculate their value, limitations and lack of funding for general operations current capabilities, and needs to prepare for HCO must be underscored. Many CBOs operate primarily partnerships, particularly within the context of VBP. on grant funding and government contracts that often DOH’s CBO Planning Grant provided awards to Tier do not cover total operating costs. Performance- 1 CBOs with budgets of less than $5 million, which based contracts that do not include upfront payments allowed the opportunity to identify capacity-building are a difficult fit, and may hinder partnership and needs and support a higher probability of success performance progress. working with HCOs. The Arthur Ashe Institute of Urban Health was awarded this grant for New York City, and is 18 FINDINGS – CONCLUSIONS – CONTINUED convening Tier 1 CBOs across the region to determine While this project made an effort to engage CBOs their needs. and HCOs of varying size, location, and mission within New York City—and with various partnering DOH is supporting CBO engagement in VBP through experiences—other perspectives may not have been various avenues. The current version of the State’s captured, including those of organizations unable to VBP Roadmap, which guides VBP contracting for partner to date. In addition, the sample was limited Medicaid managed care, requires VBP contracts at a to New York City-based CBOs and HCOs. The extent certain level to include a Tier 1 CBO. DOH has also to which their experiences are representative of other suggested social determinants of health interventions locations is unknown. Finally, the policy context and that could be included in VBP contracts, along with partnership activities continue to evolve, though the the types of CBOs that could be engaged. In addition, lessons and recommendations reported are expected DOH’s new Bureau of Social Determinants of Health to remain. was developed, in part, to support improved CBO engagement as part of addressing social needs. 19 Case Study One JASA & Wyckoff Heights Medical Center Partnering for Care Transitions and Reduced Hospital Readmissions The Partners target zip codes, and have no serious mental illness or JASA serves approximately 40,000 older adults in the substance use disorder. JASA receives approximately Bronx, Brooklyn, Manhattan, and Queens, and offers 40 referrals per month. services including case management and counseling, health navigation, home care, legal assistance, adult The care transitions teams are comprised of care protective services, home-delivered meals, mental transitions specialists, discharge specialists, and health services, and low-income housing. In addition, peer health coaches. The care transitions specialists JASA’s 22 senior centers offer a variety of social, coordinate post-discharge services, including access cultural, and wellness programs. JASA services are to community-based self-management and other funded by multiple sources, including Medicaid, social services. The discharge specialists ensure private insurance, City contracts, and philanthropy. patients understand discharge instructions; medication regimens, as provided on discharge; and other details Wyckoff Heights Medical Center is a 350-bed teaching on managing their conditions. The discharge specialists hospital in Bushwick, Brooklyn. It serves diverse are typically international medical graduates who have populations in Brooklyn and Queens, including a not yet identified a residency or practice position large number of immigrants and patients with limited in the US. While the team members do not provide English proficiency. clinical services, their medical education background allows them to recognize potential concerns, which they raise to either the inpatient care transitions Project Design & Development team or the patient’s primary care provider. The peer JASA and Wyckoff partner on a home-based care health coaches are older adults from the targeted transitions program for older adults. The goal is to community who are culturally similar to the clients. reduce hospital readmissions that occur within 30 days Because project staff meet clients in the hospital, they of being discharged. Funded by Wyckoff, the program are screened, registered, and trained as volunteers is offered to patients free of charge, independent through Wyckoff’s human resources department. of insurance status. The care transitions project was initially developed by JASA based on existing After the Wyckoff team obtains the patient’s evidence-based models and previously implemented verbal consent for a JASA visit, a JASA care team care transitions programs. JASA approached Wyckoff member meets the client in the hospital, providing about the project, noting that it could help Wyckoff opportunities for a “warm handoff” and the initial reduce its high 30-day readmission rates. Wyckoff staff identification of post-discharge needs. Such access to do not do home visits, so the care transitions program the client while in the hospital is somewhat atypical, fills an important gap for at-risk, medically complex with some facilities prohibiting it. JASA staff feel that patients. The project’s care transitions services are such early access demonstrates Wyckoff’s commitment available to individuals hospitalized at Wyckoff who to a productive partnership. It also strengthens the speak English or Spanish, are over age 60, live in the program by facilitating patient engagement post- 20 CASE STUDY ONE – CONTINUED discharge and promotes effective collaboration and system. Most of the tracking is in Excel, but efforts trust between the staff of both organizations, who are will be made this year to utilize an electronic medical in regular, in-person contact with one another. record (EMR) to share information. JASA project staff visit clients in their homes within 48 hours of discharge to complete a follow-up Challenges assessment. During the visit, staff check whether the While the partnering process has proceeded smoothly client understands his or her medical condition and its and the basic model is consistent with other programs management, lives in a safe and clean environment, implemented by JASA, the context and objectives and has food and any needed durable medical have produced new challenges. For example, as a equipment. In addition, project staff provide linkages hospital discharge program, the clients are more to resources (e.g., Meals on Wheels), help with medically complex than those previously served. medications, and planning for follow-up physician Rather than focusing purely on social services, JASA visits. The peer health coaches serve as community staff must understand medical needs and complicated health navigators and provide longer-term, targeted medication regimens—and be able to communicate support, consistent with need. A licensed counselor issues to hospital staff. To do this effectively, early on, also visits patients who have difficulty leaving their JASA incorporated international medical graduates homes. Although the project is focused on reduced into the project’s staffing. 30-day hospital readmissions, services are provided after the 30-day window, if needed. The client’s home environment may pose chal- lenges that are hard to identify without making an JASA and Wyckoff staff communicate openly in-person visit, and these challenges frequently and frequently about individuals in the program. involve medication. A patient may have a shoebox The partners have a standing biweekly call, but of medications under the bed and not know which communicate between scheduled meetings to discuss medications are current. So, being able to provide issues and concerns that arise. support and education to the patient and effec- tively communicate these challenges back to the hospital can be an important contribution. (JASA) Contracting and Logistics While JASA developed the specific contract conditions, Further, a portion of the patients referred for—and including the scope of work and budget, Wyckoff needing—home-based services are so ill that re- developed the final contract, which is expense-based hospitalization is likely, even with supportive services. and does not require JASA to assume risk. According to JASA records, approximately 10% of program clients are readmitted. Although the goal of the program is reduced re- hospitalizations, there are no specific targets or Many patients referred to JASA are ill and have detailed reporting requirements. The number of staff multiple comorbidities, some have end-stage and patients is small enough that verbal and e-mail disease, but all benefit from a JASA home visit. updates are the norm. JASA tracks referrals to, and Although the goal is to decrease readmissions, engagement in, the program, care transitions services some patients may need to return to the hospital provided, service referrals, and readmissions for its within the 30-day period. Our joint concern is not own records and voluntarily gives the information to the number of patients that are readmitted, but that Wyckoff. Tracking services is difficult for JASA due to the referred patients receive the care and support staffing constraints and a cumbersome information needed after the initial discharge. (Wyckoff) 21 CASE STUDY ONE – CONTINUED For JASA, challenges in the current program are mini- Leadership commitment is essential to project mal, but would be more evident if the model was sig- success. (JASA) nificantly expanded. As noted, a small number of staff are responsible for contracting and implementation. Payment represents a future challenge if the program Personal relationships between them have facilitated were to expand, given JASA’s financial constraints. trust, responsiveness, and an acceptance of flexibility Organizational leadership at JASA is receptive to that might be absent in a larger program. transitioning to a fee-for-service, then a VBP, contract, feeling that such arrangements will help them to better track costs and revenue—thereby facilitating higher Benefits levels of reimbursement than previous contracts, Since the start of the care transitions program, 30- which were insufficient to cover expenses. Leadership day readmissions at Wyckoff have sharply declined. also felt that a transition to VBP would encourage a The project has not only assisted enrolled patients, focus on client outcomes rather than units of service. but also has helped Wyckoff identify systemic issues associated with high readmission rates. For You can say that’s a good thing that we’re not example, JASA project staff identified several post- taking on any risk, per se, but it’s something that discharge medication errors. Recognizing a pattern, we actually would like to think about differently, Wyckoff developed a quality improvement project for a number of reasons. So, it would mean really on medication prescribing at discharge; subsequent doing things differently within the services side, changes in practice have resulted in a significant which is really thinking about what is the cost per reduction in errors. Language issues have also been patient and offering a service package that way, linked to readmissions, and bilingual JASA project versus how it is today. (JASA) staff have provided translation services and helped Spanish-speaking patients understand their discharge We have 50 years of experience with contracts that instructions. frequently don’t cover the costs of our services— they don’t meet the needs, really, of services . . . I think [the transition is] a way for us to not Lessons Learned and Future Directions only recover costs, but to work toward being JASA and Wyckoff staff describe the care transitions compensated for the value of the services we partnership as an unqualified success, and underscored deliver—making sure our services are sustainable. the importance of leadership support. (JASA) The success of the collaboration between JASA Ultimately, JASA leadership is confident that the care and Wyckoff hospital can be attributed, in part, to transitions program will reduce health care costs and the commitment of the individual team members, be a valuable service for hospitals. Documentation as well as the support of leadership at both of outcomes and service costs will be necessary to organizations. This program is a vital asset and, if ensure fair and appropriate contract conditions— possible, should be replicated at other hospitals. and a financially viable program. Tracking is diffcult, (Wyckoff) however, given the lack of experience and dedicated personnel focused on reporting. Wyckoff, I believe, has a leader who sees the hospital as an important organization in the We have a far way to go, but I’m really excited about community, serving needs beyond acute care, and it because when you talk about metrics, I think we that’s helpful for building this type of partnership. can achieve metrics at a very low cost. I don’t want 22 CASE STUDY ONE – CONTINUED to get off-subject, but we go into patients’ homes metrics actually will matter, and we’ll be very well- and they can’t read their discharge orders or how positioned for value-based payment, if we can to take their medicine. We have to do a home visit, kind of figure out how to shape and design the of course, but it’s very low cost to do that versus programs accordingly. (JASA) a readmission. I have great confidence that these 23 Case Study Two Little Sisters of the Assumption Family Health Service & OneCity Health Partnering for Improved Asthma Control in East Harlem The Partners provide asthma education, conduct assessments for Little Sisters of the Assumption Family Health Service home-based triggers, and make referrals for integrated (LSAFHS) is a neighborhood-based human services pest management (IPM) services, which are provided organization that has served East Harlem for more through contracts with DOHMH. than 50 years with home visits, support groups, classes, and other services. In 1997, LSAFHS established its Once we knew what issues were in the home, we Environmental Health Services program to better didn’t want to be a partner or PPS that just said, address high rates of asthma among East Harlem “Oh, great, we’re identifying the issues,” but we children. Staffed and led by CHWs, the Environmental weren’t doing anything about them. So, we added Health Services program has focused on mitigating the IPM services, and we’re the only PPS that the negative effects of unhealthy living conditions has done that. Because without addressing that through hands-on remediation, caregiver education environment, we’re not really impacting anything and skill building, and advocacy to promote systemic else. (OneCity Health) changes from housing management. At the project’s start, OneCity Health issued a Project OneCity Health is a PPS formed by NYC Health + Participation Opportunity (PPO) to identify appropriate Hospitals, New York City’s public hospital system. partnering CBOs. Those interested were asked to It operates in Brooklyn, the Bronx, Queens, and complete a brief questionnaire and participate in Manhattan in partnerships with hundreds of follow-up conversations to describe their catchment organizations, including Health + Hospitals acute care area, CHW experience and capacity, and motivation hospitals, community clinics, CBOs, and others. for partnering. LSAFHS responded to the PPO with: Seeing the statistics for the neighborhood, we Project Design & Development know that there are children who are very severe OneCity Health and LSAFHS partner on a DSRIP project and uncontrolled that we weren’t getting to—we to reduce hospitalizations and ED visits for children weren’t able to identify and get those referrals. with persistent, uncontrolled asthma. OneCity Health So, we felt like being part of this would improve began its CHW asthma program in 2016, building access to the patients who really need it. (LSAFHS) from CHW programs that were operational at two NYC Health + Hospitals sites. The initiative partners CBOs selected for the project were gathered into a clinical sites with local CBOs. The clinical sites identify learning collaborative, and education and training patients appropriate for the program and refer them was provided to facilitate standardization across to CHWs employed by the CBOs. As per the child’s sites regarding program delivery and workflow, asthma action plan, CHWs visit families at home, patient assessment, use of asthma action plans, and 24 CASE STUDY TWO – CONTINUED communication protocols. Tools were also created home visits, outreach, and engagement). To focus to provide a range of templates and an electronic more on quality and outcomes in the second phase, platform with intervention prompts and platforms for OneCity Health changed the payment methodology data entry and submission. to be more consistent with a VBP approach. A signing bonus equal to 10% of the contract limit is provided While OneCity Health considered standardization at the start for upfront costs. Subsequent payments essential, it presents challenges for LSAFHS, which are based on the attainment of particular process and uses an Environmental Health Program with a more outcome thresholds. According to OneCity Health, comprehensive model. LSAFHS CHWs do home the change caused concern among the CBOs: remediation and work closely with parents and other caregivers, so they have the knowledge and skills to So when we changed that methodology, they were address asthma triggers in the future. Providing a more very concerned. They weren’t shy about letting us limited set of services to families referred through the know. But we had lots of conversations with them, OneCity Health program would be problematic, so and we said to them, “This is VBP and being in a LSAFHS will offer the broader set of services where performance-based environment means that you deemed necessary—and LSAFHS will absorb the costs will have some risk, some financial risk, that you of the extra services. have to absorb. You’re not going to get all of your money upfront. And so this is the beginning of We will try to follow the model—have that fidelity— understanding how to manage what is expected but if we feel like it’s not enough, we’re going to of you contractually without clearly knowing all of take the next step and help the family. (LSAFHS) the dollars that will be available to you.” (OneCity Health) Contracting From LSAFHS’s perspective, learning to work in a VBP OneCity Health has a centralized process and a standard context is essential and a benefit of the project. contract for all CBOs working on the asthma project. From their perspective, use of a standard contract We feel like we have to be in this to understand ensured transparency “that all partners are being how [VBP] works, and so in that way, I think that held to the same standards and being paid the same that has also been beneficial . . . it has been sort way.” They note that the centralized process allows the of gradual learning and getting towards that. And clinical partners (i.e., hospitals and community health so, I still probably should take a few webinars on centers) to focus on project implementation. value-based payment, and hopefully I’ll have the time to do that soon. But you know, I think we’ll— Contract deliverables and indicators were developed by the end—we should be able to learn how to and vetted through multiple parties, including the play this game. (LSAFHS) OneCity Health Executive Committee, which has multiple CBO members. The partnering CBOs were given the opportunity to meet with OneCity Health to Challenges discuss concerns. The contract for the project specifies Several challenges arose with implementation, in part that CBOs must comply with OneCity Health’s efforts due to the number of organizations and stakeholders, to provide supervision and ensure quality assurance. and minimal experience working together previously. In addition, OneCity Health’s monitoring and oversight In the early phase of the project, payment was for systems were still under development at the start of the unit of service (e.g., case conference attendance, project, leading to hurdles and delays for the CBOs, as 25 CASE STUDY TWO – CONTINUED well as interruptions in payment and service delivery. staff had responsibilities early on, but invoicing to cover For example, the clinical sites required the CHWs to salaries could not begin until services were delivered. have toxicology tests and submit a “chain of custody” Throughout, adequate funding for staff time required form with the test results. Neither CHWs nor their that agreed-upon metrics be met. However, LSAFHS providers were familiar with the form (or that it would felt that expectations—to the extent they were clear— be required), necessitating repeat tests that resulted were reasonable. in delays (onboarding took five months for one CHW), missed work, and out-of-pocket costs. Outside the The reporting requirements have also been startup challenges, OneCity Health emphasized the problematic, given pre-existing data management importance of careful monitoring: systems for families enrolled in LSAFHS’s Environmental Health Services program, but who are outside the I think in the beginning, they were surprised . . . OneCity Health initiative. To avoid the burden of But I think our concern was, again: [one], it’s highly double entry, LSAFHS now has client records in two clinical, and two, the population is pediatric. So we different data entry and management systems. While had to be very sure that they really understood the the hope is to integrate results when reports are run, expectations, they were meeting the requirements such functionality does not yet exist. The problem of in order to go out and be in a patient’s—a multiple data systems is not unique to this project. minor’s— home, and engage with that minor and their guardian or parent. So we took it very, very seriously . . . We don’t want parents or guardians Benefits or anyone on the clinical team to feel like we are OneCity Health and LSAFHS described the sending unqualified staff in. (OneCity Health) partnership’s benefits as increased knowledge and trust, better care, and better health outcomes through From OneCity Health’s perspective, CBOs were not improved coordination between the community and accustomed to the level of oversight considered clinical services. necessary for the project to succeed. I think it kind of opens the eyes of the clinical [The CBOs] didn’t realize that we actually would team as well, because in the office, it’s all about put parameters around what we expected and the medication adherence, it’s not really about quality that we expected from them. So that was environment. And opening these channels has surprising. I think many of them come from a grant really been an eye-opener for the clinical team, background where they’re just told, “You have a as well. So we’re still following patients that have grant agreement,” and you’re pretty much left been participating in this program, seeing their to figure out how you’re going to deliver on that ED trends, whether they go back or not, so it is grant. They never expected that we would give ongoing, but I think it has made a difference so far. the materials, the training, and then the [quality (OneCity Health) assurance] and support that we provided. So, there are lots of meetings that we convene with And we feel like we have a lot to offer . . . a contract them around looking at their performance, the is another stream, but I think it also helps us to quality of their documentation, the quality of their perform better, because we’re closer to the rest of engagement. (OneCity Health) the health care team, and we case conference with physicians, and the nurses, and the social workers. The financial arrangements also presented And then we also are getting the infrastructure to challenges—particularly at the project’s start. CBO actually communicate with them securely. Prior to 26 CASE STUDY TWO – CONTINUED this project, that just didn’t happen in a regular way. That said, LSAFHS and OneCity Health see significant Some of the providers who would refer to us would benefits in the collaboration and intend to sustain it in ask for feedback, and we’d give it to them. But the coming years. others would just send their patients to us, and they wouldn’t ask—or we sometimes tried to reach out to We want these partnerships to sustain. Whether or doctors and, you know, and not hear back. (LSAFHS) not OneCity Health needs to be the coordinator is a question and whether or not there’s a role or need for that beyond DSRIP, that’s something Lessons Learned and Future Directions that I think we’re still trying to figure out. But Some of the lessons learned are typical: for example, outside of that, in general, this is a partnership ensure that goals and objectives are clear and shared that should continue for clinical sites, because it by both partners. The specifics of implementation are provides a valued service that they can’t provide more informative: understanding the required levels for themselves. It allows them to have eyes into of commitment and support, infrastructure needs, and the community and into a patient’s home. And clarity on reporting requirements and processes. Given that’s the only way that they can fully understand the resource constraints CBOs typically face, sufficient how to tailor their interventions to really address financial support during the planning phase may have that patient’s needs. (OneCity Health) facilitated early recognition of potential problems— and solutions. 27 Case Study Three Northern Manhattan Perinatal Partnership & NewYork-Presbyterian PPS SKATE Program: A Community Health Worker-Led Program for Children with Special Health Care Needs The Partners We actually worked probably about four to five The Northern Manhattan Perinatal Partnership (NMPP) months in that planning process identifying, “Well, provides health and social services to children and what are the things we’d like our CHWs to work on parents, with a primary focus on Harlem and other with these families, in particular?” which was a new northern Manhattan communities. Founded to population. “What are the issues that those families combat infant mortality in northern Manhattan, most face? What are the resources that they need to NMPP programming is focused on case management be linked to . . .” Things like connecting them to and social support services for pregnant women and SSI, things like early intervention, the community families with young children. of preschool education . . . And we really worked with NMPP in building that curriculum, not only NewYork-Presbyterian’s (NYP) PPS is a network to train our staff, but then to actually deliver that of approximately 90 providers and community intervention to the families. (NYP) collaborators anchored by NewYork-Presbyterian Hospital. At NYP, the Special Kids Achieving Their The CHWs conduct home visits that include Everything (SKATE) CHW program is based in the assessments of clients’ needs and goals, which they Ambulatory Care Network of the Weill Cornell Medical share with the practice medical team during regularly Center and the Columbia University Medical Center. scheduled interdisciplinary meetings. CHWs identify social determinants of health and provide support— including navigation, education, and social service Project Design & Development referrals—to promote improved health and wellbeing. The SKATE program supports children with special health care needs who are considered medically . . . understanding their medication and how to use complex or socially unstable. SKATE is a DSRIP-funded it, understanding the diagnosis and what it is that initiative that sits within NYP’s Center for Community their child has. Sometimes it’s like making sure they Health Navigation (CCHN) and works to improve care have all the medical equipment that they need in and outcomes for high-risk and high-cost children the home. It can be educational-based goals. A with special health care needs. The initiative is led by lot of the patients will need homeschooling or CCHN and based on its more than a decade of CHW other [things], like PT, speech therapy, [or] all of programming experience. Two CHWs—selected, those, so making sure that they’re getting those credentialed, and supervised jointly by NYP and connections and getting those referrals done. It NMPP—are on NMPP’s staff and serve patients and can be making sure that their insurance is not cut family members of NYP’s Cornell pediatric ambulatory off, so they don’t miss appointments or can’t see practice. the doctors. (NMPP) 28 CASE STUDY THREE – CONTINUED While CHWs do not have access to NYP’s EMR and in there. Like, anything the CHW would [use] . . . the scheduling system, they document in the hospital’s phone, the tablet, all of the resources. So, we want care management system. The CHWs are treated as this to be capacity building. We don’t want it to be equal and embedded members of the care teams, drawing resources from the community. We want to moving freely in the hospital and regularly participating put the resources into the community and basically in care management meetings. As mentioned, NMPP expand the portfolio and the resources that the and NYP share supervision, supporting the CHWs in CBOs have. (NYP) both the medical and community contexts. NMPP is responsible for ensuring quality services are For NMPP, the SKATE CHW program is unique in that provided to the identified community members and it serves children up to age 21 in all five boroughs. In agreed-upon performance requirements are included addition, the program has strict criteria for enrollment, in the contract. While payments are not withheld for limiting possibilities for cross-referrals, which is a missing performance targets, there is an expectation that common practice in other NMPP programs. NMPP regular in-person interaction and close collaboration will describes it as “an experiment” consistent with its resolve issues that arise. If requirements are not met, the interest in expansion. team works together to support the CHW and develop a plan for improvement. Regular communication between NYP and NMPP ensures that both parties are Contracting and Logistics engaged and better able to incorporate continued Contracting was described as unproblematic, improvements into the program. benefiting from NYP’s decade of experience partnering to implement CHW programs and program champions It’s not like we’re just, “Here’s money for a CHW. identified by the institution. NYP vets potential See you.” And it’s not, “Give us the person, and partners, but requires only stable infrastructure to we’ll see you.” It doesn’t work that way. So, we’ve support the CHWs, the ability to invoice, and a point really set it up that the managers on our end are person for the collaboration. The contract covers meeting monthly with people at the CBO level so direct service costs and the associated administrative that there’s information being exchanged, rather expenses. than, “Oh, we cut you the check for 12 months, and by the way, here’s the report.” (NYP) They were always willing to see our side of it and really make those numbers work for us. That’s not what we had within the other PPS. It never even got to the Benefits point where we could have this discussion, where NYP and NMPP staff describe the CHW partnership as they can hear why it doesn’t work for us. It was just a success with notable positive outcomes. like, “This is what we have. Take it or leave it.” (NMPP) It was a great balance, and again, that goes back to We don’t want this to come as an expense to the sort of the crux of how the model was developed. CBO in any way, and we want to make sure that we’re We bring the medical piece from the medical not only paying for the community health worker center expertise. They bring the real community but all of the resources that would be needed to and social piece. (NYP) support that community health worker. So, the subcontract . . . pays for the CHW’s salary, pays for We get really positive feedback from the resident fringe, pays a stipend for our local supervisor; there doctors and the doctors who are making the are indirect, operational sort of overhead funds put referrals—and just the value that they see in having 29 CASE STUDY THREE – CONTINUED the CHWs at those team meetings, and giving Lessons Learned and Future Directions them a really good vision of what’s going on. And, Although the SKATE program is new and was just having them step back from themselves and developed within the context of DSRIP, it builds seeing the patients and the families in a different on—and is facilitated by—years of experience and way, and just having access to somebody to help familiarity between stakeholders. that patient deal with all of the other stuff. (NMPP) If we just came together for this project, and then Benefits go beyond the SKATE program’s direct services we disbanded when the grant was over, it wouldn’t and the families impacted. NYP/Cornell pediatricians work. We’re really building upon years and years have learned about other NMPP services and make of relationships. So, like we said, before we started referrals for families outside the SKATE CHW program. working with [the NMPP staff person] on this NMPP staff also have had opportunities to learn more project, we already knew her, we’d already worked about health care issues and medical services. together, there’s already an inherent trust there. So, I think that (the) longevity of that relationship I’ve gone to meet with all of the team at NYP/ and just building upon this foundation helps us Cornell. They wanted to know what we do here, with each new project. (NYP) and, “How do we advertise what you guys do?” . . . “How do we make referrals to you guys outside While time and familiarity are important, the duration of the SKATE program if we identify families of the relationship may be attributable to other that can use your services?” It’s just been many factors, including appreciation of the relative resource opportunities that we’ve been able to increase our base and contribution of the two institutions, and visibility with them and also just strengthen our a partnership broader than the scope of services relationship in a real way that we feel like they’re required for a specific project. true partners. (NMPP) 30 Payer Perspective How Healthfirst Partners with CBOs In focus groups and interviews, participants discussed most health care resources, Healthfirst must consider the importance of payers, particularly Medicaid and projects that can be scaled to reach the broader MCOs, in sustaining programs developed through membership. HCO/CBO partnerships to address social needs. Healthfirst is an MCO serving 1.2 million members While Healthfirst does not conduct a formal in New York City and on Long Island. It provided assessment to identify and select CBO partners, information on the organization’s history with CBOs it focuses on programs that fill particular gaps or and how they promote social services that impact address priority areas. Generally, Healthfirst works health. with CBOs with a long history, an appropriate mission, and a good reputation within the community. CBOs Healthfirst aims to build strong relationships with must have specific expertise that meets a need among organizations that address health and social needs, Healthfirst members, and they must pass Healthfirst’s including CBOs, faith-based organizations, public privacy and compliance standards. This process helps health agencies, and other types of organizations that ensure program integrity and that Medicaid dollars serve Healthfirst members. Partnerships throughout are appropriately spent. As an MCO, Healthfirst risks New York City engage communities and facilitate being denied payment by DOH if its use of funds is outreach to members that the health system otherwise considered inappropriate. Healthfirst needs special cannot engage via typical channels. Many partnerships permission from DOH to use funds for services outside stem from its Healthy Village Initiative (HVI), through the benefit scope. which Healthfirst sponsors health programming and performs community-based activities—a number of Healthfirst has a few contracts with CBOs, which are which are grant funded—in partnership with local paid a “case rate” for a set of services provided to health care providers. HVI is also a testing ground for Healthfirst members. Healthfirst discussed various pilot projects to engage the community. challenges in partnering and contracting with CBOs. Many CBOs lack the infrastructure to bill payers Healthfirst has been methodically testing models to for services, and others lack infrastructure to scale determine payment for CBO services, and has begun projects. As a payer, Healthfirst is typically unable to contracting with CBOs that employ CHWs and/or provide funding for capacity building. Healthfirst also peers who can engage patients in care. Healthfirst has discussed the challenges of measures and connecting found that these services fill important gaps between CBO activities to health care outcomes. Because of clinical care and community. Finding projects that meet these challenges, Healthfirst designs incentives for the scale required for a payer has been a particular CBO partners around process measures related to challenge. While the organization sees general value finding Healthfirst members, connecting them to care, in assisting so called “high utilizers” who require the and navigating them to needed services. 31 Appendix A Focus Group Participating Organizations Health Care Organizations Community-Based Organizations Bronx Partners for Healthy Communities Arab-American Family Support Center Bronx-Lebanon Hospital Center Archcare Community Care of Brooklyn Brooklyn Community Services Hospital for Special Surgery (2) Bedford Stuyvesant Restoration Corporation Interfaith Medical Center BronxWorks Montefiore Health System (2) Carter Burden Network Montefiore/BX Accountable Healthcare Network CityMeals on Wheels Mount Sinai Health Home Directions for Our Youth Nassau Queens PPS The Fortune Society NewYork-Presbyterian (2)* Fountain House NewYork-Presbyterian–Weill Cornell Medical Center God’s Love We Deliver NewYork-Presbyterian Health Home Jewish Association Serving the Aging (JASA)* NYC Health + Hospitals (2) Jewish Community Center Staten Island NYC Health + Hospitals/Bellevue Jewish Board NYC Health + Hospitals/Jacobi Little Sisters of the Assumption Family Health Service* NYC Health + Hospitals/Lincoln Make the Road New York* NYU Langone–Brooklyn* Northern Manhattan Perinatal Partnership* NYU Langone–Brooklyn PPS (2)* Person Centered Care Services OneCity Health* Regional Aid for Interim Needs (2) (RAIN) Staten Island PPS SCO Family of Services Wyckoff Heights Medical Center† SeedCo Zucker Hillside Hospital LGBTQ Rights Center City Harvest START Treatment and Recovery Centers Staten Island Partnership for Community Wellness (2) Transportation Alternatives Transitional Services for New York, Inc. VISIONS * Participated in interview. † Participated in interview, but not in a focus group. 32 Appendix B Methods Project Scope and Definitions intended to elicit information on common issues This project focused on HCO/CBO partnerships in New and concerns. In contrast, the interviews focused on York City. The HCO category included hospitals, health specific partnerships and were used to develop this systems, DSRIP PPSs, and hospital-led Medicaid Health report’s case studies. Homes. Federally qualified health centers (FQHCs), key providers in many communities, were not included Written guides were used for the focus groups and because the project focused on larger health care interviews, and included questions on partnership institutions where partnering challenges are perceived history; goals; the contributions of each partner; to be the most significant. The CBO category included funding sources; contractual arrangements; and nonprofit organizations that primarily provide services barriers, facilitators, and lessons learned. Focus groups related to social determinants of health, including but and interviews were audio recorded and professionally not limited to housing supports, food, education, and transcribed. Focus group transcripts were coded to social support. Many, but not all, are neighborhood- facilitate careful analysis. Focus group findings are based. reported without specific attribution to protect the confidentiality of participants. Case studies, in contrast, The term “partnership” was defined broadly for this identified the partners to provide needed context. project and includes the following: • Referral relationships Focus Group Sample • Contractual relationships Eleven focus groups were conducted, six with CBOs • Formal DSRIP engagement via a contract (with or (30 participants) and five with HCOs (26 participants). without the flow of funds) Organizations from all five boroughs were represented. • Joint work (funded or unfunded) to meet a specific population’s needs HCO participants were from 14 hospitals, eight PPSs, and four hospital-led Health Homes. The hospital participants represented departments that included Data Collection administration, ambulatory care, psychiatry, social Data for this project were collected via a series work, community health, and grants administration. of focus groups and key stakeholder interviews. Most PPS participants were responsible for community Participants were recruited through existing Academy engagement. Because the sample of hospital- and GNYHA contacts, including umbrella and led Health Homes was small, and because the networking organizations that could do outreach to organizations have a unique set of challenges and their members. Eligibility was limited to individuals requirements, data collected from that focus group from CBOs and HCOs with firsthand experience in was excluded from this report. a specific HCO/CBO partnership, either current or in the recent past. Although interviews and focus Participating CBOs were of variable size (see figure groups covered similar topics, the focus groups were on page 34). A majority reported serving low-income 33 APPENDIX B – CONTINUED populations, children and adolescents, older adults, and/ one PPS about its general partnership experiences, or those with behavioral health needs. Fifty-five percent one CBO about its VBP and sustainability strategy, of the participating CBOs bill Medicaid for eligible and one MCO about its organizational perspective on services. Nearly half of the CBO representatives reported CBOs and VBP. that they provided advocacy, case management, care coordination, and/or health education services as Partnerships Described part of their partnerships with HCOs. Sixty percent of In focus groups and interviews, partnerships focused CBO representatives described their role as program on a wide variety of activities designed to keep management. people well. Most partnerships focused on improving quality of care for patients or providing additional community supports between Size of Participating CBOs health care visits. Several focused on care coordination, care transitions, or case in Focus Groups management, including support focused on prevention or management of specific illnesses through education, assistance with medication, and/or health coaching. Other partnerships focused on populations with 17% 24% specific needs, such as older adults, LGBTQI, and individuals with disabilities. Partnerships focused on immigrant populations provided with language services and/or supports related to cultural competency. Finally, a 28% 17% number of partnerships addressed social determinants of health such as food security, 14% housing quality and safety, and access to public benefits. Many partnerships focused on a specific n Less than 50 n 101–250     n Over 500 geographic community. In addition, several n 51–100 n 251–500 focused on particular populations, as described above, or on high utilizers of costly health care services, such as frequent users Interview Sample of inpatient and emergency department services, or Nine key stakeholder interviews were conducted. those with certain conditions such as asthma. Staffing Interviewees were selected based on information varied according to project scope and included gathered in the focus groups. The intention was community health workers, social workers, and to identify interviewees that could describe well- counselors. developed partnerships that were diverse in scope and configuration. The project team interviewed HCO and Partnership activities ranged from high-level CBO representatives from one PPS/CBO partnership, transactional activities, such as completing surveys, one hospital/CBO partnership, and one partnership to full service integration and collaboration, such as between a CBO and a hospital that also leads a PPS. embedding CHWs in the hospital care team or having The project team also conducted an interview with them do home visits. 34 Appendix C Data Sources Using Data to Identify Community Needs The United States Office of Disease Prevention and Many publicly available data sources provide Health Promotion and Office of Minority Health community-based information on disease prevalence, support a publicly available tool called DATA2020, health care outcomes, health disparities, and CBOs. which can query health disparities information for The below data sources may be useful. measurable, population-based objectives. The tool is part of Healthy People 2020, a Federal public health initiative to improve the health of all Americans. National DATA2020 and instructions on using it are at https:// Behavioral Risk Factor Surveillance System (BRFSS) www.healthypeople.gov/2020/data-search/health- data (http://www.cdc.gov/brfss/) are used to describe disparities-data. the population of New York State, New York City, and counties/boroughs in terms of health status (e.g., percentage of the population uninsured, percentage New York State with diabetes or obese). The BRFSS is a telephone Health Data NY collects data on myriad chronic survey and the de-identified, individual-level data are diseases and can be accessed at https://health.data. publicly available for download from the Centers for ny.gov. The Community Health & Chronic Disease Disease Control and Prevention. section of the site links to more than 150 reports, documents, and datasets that can identify ongoing County Health Rankings and Roadmaps, at http:// and potential initiatives to improve health and impact www.countyhealthrankings.org, includes snapshots health disparities. Local health departments also often and comparisons of county-level health measures. Full offer data to the public to inform policy and evaluate datasets are also available for analysis. public health programs. The datasets can also be used by residents to identify community health gaps and The Center for Medicare & Medicaid Services has a opportunities for improvement. Mapping Medicare Disparities (MMD) Tool with health outcome measures for disease prevalence, costs, and New York State Community Health Indicator Reports hospitalization for 18 specific chronic conditions, (CHIRS) include data on more than 300 health indicators. emergency department utilization, readmissions rates, Accessible at https://www.health.ny.gov/statistics/ mortality, and preventable hospitalizations. The tool chac/indicators/, the reports are organized by 15 health allows the visualization of health outcome measures at topics and include data tables, graphs, and maps. a national, state, or county level. Outcome measures are available by age, race and ethnicity, and gender, The New York State Prevention Agenda 2013-2018 and comparisons between geographic locations and Tracking Indicators provide data for counties for a racial and ethnic groups can be explored. The MMD variety of health outcomes, including rates of preterm Tool is available at https://data.cms.gov/mapping- birth, unintended pregnancy, maternal mortality, new medicare-disparities. HIV cases, new STI cases, immunization rates, obesity, and smoking. The indicators can be found at https:// 35 APPENDIX C – CONTINUED health.data.ny.gov/Health/Prevention-Agenda-2013- include 2-1-1, NY Connects, and other locally managed 2017-Tracking-Indicators-Co/47s5-ehya. databases. IMAGE: NYC, an Interactive Map of Aging, located New York City at http://www.imagenycmap.org, was created by DATA2GO.NYC is a free online mapping and data tool The New York Academy of Medicine in partnership created by the nonprofit Measure of America of the with the Center for Urban Research at The Graduate Social Science Research Council, with funding from Center/CUNY, with support from the Fan Fox & Leslie the Leona M. and Harry B. Helmsley Charitable Trust. R. Samuels Foundation. IMAGE: NYC is an open- It brings together Federal, State, and City data on a source map of New York City’s current and projected broad range of issues critical to the wellbeing of all population aged 65 and older, with overlays of age- New Yorkers. friendly resources, services, and amenities. EpiQuery: NYC Interactive Health Data provides City New York City Community Health Profiles, available health data, including surveys, surveillance data, and at https://www1.nyc.gov/site/doh/data/data-pub- vital records (births and deaths). Datasets that may be of lications/profiles.page, contain information on the interest through EpiQuery include the Community Health health of New York City’s 59 community districts, in- Survey, HIV/AIDS Surveillance Data, Infant Mortality Data, cluding broader measures of health such as housing and NYC Census Data. EpiQuery modules are available quality, air pollution, and food environment. Profiles at https://a816-healthpsi.nyc.gov/epiquery/. are also available at the county level. GNYHA’s Health Information Tool for Empowerment NYC Open Data, available at https://opendata. (HITE), at http://www.hitesite.org, is a public website cityofnewyork.us/, is a user-friendly repository of that lists health and social service providers in New all publicly available datasets managed by New York City’s five boroughs, as well as Nassau and Suffolk York City. Datasets can be organized by category counties. HITE lists approximately 6,000 resources for (e.g., environment, health), agency (e.g., DOHMH, low-income, uninsured, and underinsured individuals. Department of City Planning), or type of data (e.g., Outside New York City, available resource directories charts, maps). 36 Appendix D Capacity-Building and Informational Resources for CBOs Aging and Disability Business Institute Health, CTHE is funded by DOH’s CBO planning grant. https://www.aginganddisabilitybusinessinstitute.org/ It has developed goals and strategies to improve CBO The website, sponsored by the Aging and Disability capacity and concretize a sustainable infrastructure Business Institute (Business Institute), provides tools and process to demonstrate CBO value, experience, and resources to help CBOs successfully adapt to and impact to inform DSRIP activities and ensure the changing health care environment, enhance CBO engagement in a health care delivery system. organizational capacity, and capitalize on emerging CTHE also plans to develop capacity-building tools opportunities to diversify funding. The Business for the CBO community, including a platform for inter- Institute focuses on building skills and knowledge organizational communication. across business disciplines while looking ahead to the future of aging and disability services. The initiative’s overarching vision is to improve the health and DOH Resources for CBOs wellbeing of America’s older adults and people with https://www.health.ny.gov/health_care/medicaid/ disabilities through improved and increased access to redesign/dsrip/vbp_library/ quality services and evidence-based programs. DOH has compiled information to facilitate CBO involvement in VBP arrangements. Webinars, contracting documents, and information on CBOs Capacity Building & Oversight Trainings across New York State are included in the DSRIP VBP https://www1.nyc.gov/site/mocs/nonprofits/cbo- Resource Library in the Social Determinants of Health training.page and Community-Based Organizations section. The New York City Mayor’s Office of Contract Services conducts free trainings for nonprofits to strengthen board governance and financial management, legal Linkage Lab Initiative compliance, and contract management. Board http://www.thescanfoundation.org/linkage-lab- members, officers, and staff members of nonprofit initiative organizations with current contracts or grants with This webpage, developed by the SCAN Foundation, New York City may participate free of charge. contains materials from the organization’s Linkage Lab initiative, which was developed to prepare California’s CBOs to partner effectively with health care entities. Communities Together for Health Equity The SCAN Foundation has published resources to (CTHE) help CBOs identify and develop specific capabilities. https://www.arthurasheinstitute.org/aaiuh-dsrip Tools include case studies, webinars, and a list of the A New York City coalition of CBOs across the city’s five contracts that participating CBOs entered into. boroughs led by the Arthur Ashe Institute of Urban 37 © Copyright 2018 Greater New York Hospital Association and The New York Academy of Medicine All rights reserved. This publication or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of Greater New York Hospital Association or The New York Academy of Medicine. The views presented in this publication are those of the authors and not necessarily those of The New York Academy of Medicine, or its trustees, officers or staff.