2018 was a whirlwind year for the Nassau Queens Performing Provider System. With much happening related to health policy at the Federal and State level, NQP continued to push onwards to deliver DSRIP’s fourth year objectives.

At the forefront, NQP invested tremendous efforts towards increasing access, improving quality of care, and improving wellness of the populations in both Nassau and Eastern Queens.

Successes

We wanted to reflect and highlight some of our noteworthy achievements as 2018 draws to a close.

  • Successfully earned 95% of available funding for Demonstrations Year 1 through Demonstration Year 3 (2015-2017)
  • Recognized by the American Heart Association as the only PPS participating in the Target Blood Pressure (BP) Program in New York State
  • In Measurements Year 2 and Year 3 (July 1, 2015 to June 30, 2017), NQP met 56% of its clinical performance metrics. These measurements included medication management and adherence, C&G CAHPS, care coordination, access, CV monitoring and Schizophrenia, Diabetes Monitoring and Schizophrenia and Potentially Preventable Emergency Department Visits for persons with Behavioral Health Diagnosis
  • Across the network, providers engaged in innovative programs with various Community Based Organizations that targeted the social determinants of health. These efforts included new relationships as well as innovative models intended to address nonmedical factors that influence health. Exciting programs in place include:
    • Food is Health (Food is Health WSJ article)
    • Community Health Worker education program and graduates (CHW)
    • Community Based Organization Innovation Fund
      • NQP contracted with 8 Behavioral Health Providers to hire additional staff (Peer specialists, CHWs, RNs and Navigators) to work with high utilizers. Furthermore, utilizing services such as Uber to get patients to appointments, and delivering medications to patients home resulted from this partnership
      • NQP contracted with 20 Community Based Organizations to educate the community on local health care resources. Of the 20, 7 are working with Community Health Workers and Navigators to enhance the care coordination of the populations we serve.
  • Increased investment and expansion of behavioral health services across the Nassau and Eastern Queens County to enhance BH services and lower BH related emergency room visits. This resulted with:
    • 34 newly integrated behavioral health sites
    • Creation of a Creedmoor Psychiatric Center Local Emergency Assistance and Diversion (LEAD) team, made up of peers from the Transitional Services for New York (TSINY) to intervene when an individual is in crisis (see Crain’s article)
  • Enhancement in technology with increased use of digital health, Regional Health Information Organizations (RHIO), telehealth, data analytics and business intelligence
    • Seven Skilled Nursing Facilities are now implementing telehealth to reduce Potentially Avoidable Readmissions, and Preventable Emergency Department Visits
    • Use of social determinants of health targeted digital health platforms to enhance care in real-time, allowing for seamless transfer of patients to organizations that meet their non-medical needs
  • Capacity building community based providers to enhance their service lines and business propositions to contract with payors in a value based environment. This includes VBP trainings and education that were tailored to providers (Primary Care, Behavioral Health and Community Based Organizations) to support them in their conversations with large health care providers and systems

The above successes are only a small portion of the efforts NQP and its many collaborators has put forth in making positive changes to our health care system. With all the work that is being done, and continues to be done, we are proud of the level of impact we are making for the people who need our services in the Nassau County and Eastern Queens communities.

Challenges

While NQP has enjoyed many successes, as we’ve described above, NQP and many of our fellow PPS’s all struggle with some ongoing challenges.

  • The availability of timely, actionable data for use by providers remains elusive. Providers’ capability to utilize data for their own electronic health records, Healthix and health plans needs significant further development.
  • Ongoing funding beyond DSRIP, scheduled to be completed in 2020, for innovative community-based services needs to be finalized. The value of services addressing social determinants of health care needs to be documented to demonstrate value worthy of investment by government, health systems and health plans.
  • Innovative technology solutions have begun to show promise in care coordination activities. Ongoing financial support for such IT initiatives, particularly for CBO’s systems, needs to be identified.
  • The relations between academic institutions and health care delivery systems to train the workforce of the future needs to continue to grow collaboratively to adapt to changes in demand for important new and burgeoning roles to take care of our communities well into the future.

While the challenges may be many and complicated, our industry has recently taken smarter and swifter steps to adapt to changes that are necessary to maintain the health of our communities. DSRIP has shown that positive changes can be made with the will and the resources to make it happen. We are optimistic that, with the right resources and incentives, these challenges will be met. Ultimately, we need to adjust our thinking to work with the “whole” person, their health and how and where they live, to safeguard healthy populations—in that way, our goal of reducing costs and improving quality of care will become a reality.