Nassau Queens PPS
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Nassau Queens PPS Community Needs Assessment December 2014 Introduction The Nassau Queens Performing Provider System (NQP) is proud to present to the residents, government agencies, healthcare providers, community based organizations of Nassau County and the Borough of Queens a comprehensive examination of the healthcare issues faced by the most vulnerable populations that live in the community – Medicaid, Medicare-Medicaid Dual Eligible and the Uninsured. The Affordable Care Act of 2010 recognizes that healthcare insurance is necessary for all residents of the United States of America by expanding Medicaid eligibility and establishing standards for coverage. In addition, and maybe most notably, is the ability of the uninsured to obtain coverage on the Health Insurance Exchange. The Empire State, has a long history of providing for its most at-risk populations through a more robust package of benefits and programs. In 2014, these benefits and programs, with the intention to improve the health of these populations, have been partially successful in that the health status indicators of NYS Medicaid beneficiaries ranks higher nationally. Unfortunately, the current delivery system is fragmented and the value (i.e., quality and access) is uneven. Through the work of the Medicaid Redesign Taskforce, the NYS Delivery System Redesign Incentive Queens County, NY Nassau County, NY Payment (DSRIP) program has been created. The stated goals of DSRIP are: Medicaid Enrollees Queens County, NY Medicaid Enrollees Nassau County, NY DSRIP's purpose is to fundamentally restructure the health care delivery system by reinvesting in the Legend Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years. Up to Quintile 5 $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results Quintile 4 in system transformation, clinical management and population health. Quintile 3 Quintile 2 The Nassau Queens Performing Provider System is applying to New York State Department of Health (DOH) Quintile 1 and the Department of Health and Human Services Centers for Medicare and Medicaid (CMS) to become the agent of healthcare delivery system transformation for Nassau and Queens residents who are Medicaid or Dual Eligible or uninsured (M-DE-U). Through collaboration with every PPS partner of the care continuum, social service agencies, insurers and local government agencies, NQP will lead to a more efficient and effective delivery system. The journey begins with understanding the healthcare status and clinical needs of the M-DE-U, and the December 2014 healthcare and social service resources available to meet those needs. Together the gaps in the delivery system can be identified. Working with the NQP Project Advisory Committee (PAC) and other community stakeholders a strategy, plan and priorities for healthcare system transformation can be developed. The DSRIP program will then be used to actualize that plan. NYS DOH guidance to Performing Provider Systems (PPS) provided the framework for the Community Needs Assessment (CNA). The guidance can be found by going to: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/community_needs_assessment.htm. North Shore LIJ Health System Office of Strategic Planning, and Office of Community and Public Health collaborated to collect and analyze the secondary data made available by the NYS DOH and other sources. The sources of data are footnoted in the figures, tables and maps in the CNA. Primary data collection of Medicaid member surveys was led by the NSLIJ Office of Community and Public Health and analyzed by the North Shore 1 LIJ Krasnoff Quality Management Institute (http://www.thekqmi.org/); provider stakeholder forums (focus groups) were administered and analyzed by Health Management Associates (http://www.healthmanagement.com/) and Visiting Nurse Service of New York Research (http://www.vnsny.org/vnsny-research/). Special thanks to Gwen O’Shea, President and CEO of the Health & Welfare Council of Long Island for hosting meetings of the CNA Steering Committee with the safety net providers to seek their participation in the CNA survey process and stakeholder forums (http://www.hwcli.com/). 2 Executive Summary The CNA is a key component of the DSRIP application because it informs the PPS’s choice of projects and serves as an accounting of the capacity of the PPS and other providers in the area to successfully implement the PPS’s chosen projects. The Following is a summary of key CNA findings: Nassau County and Queens County have diverse populations. Nassau has approximately 1,339,532 residents of which 223,494 (16.7%) are unique Medicaid enrollees. Of these Medicaid enrollees, 38% are Hispanic; 26% are white; 20% are black; and 9% are Asian/Pacific Islanders. The Hispanic population comprises the largest group of Medicaid enrollees in Nassau County, specifically females between the ages of 0-17 and 18-44. Eastern Queens has 445,274 unique Medicaid enrollees with Asian/Pacific Islanders comprising the largest group of individuals (33%), followed by blacks (25%), Hispanics (18%), and whites (11%). The Asian/Pacific Islander population makes up the largest group of Medicaid enrollees in Eastern Queens, specifically males and females between the ages of 18-44. There are 49,511 uninsured in Nassau County, and 102,702 uninsured in Eastern Queens, including the Rockaways. Cardiovascular Disease, mental health, and diabetes are the conditions most associated with avoidable inpatient and ED utilization. Nearly 71% of Nassau and 75% of Queens ED T&Rs are avoidable. This is largely driven by 1) ill-defined diagnoses (e.g., cough, headache), and 2) respiratory illness (e.g., viral infections). Almost one-third of PQIs (adult ambulatory sensitive admissions) are due to acute conditions, such as urinary tract infections or dehydration. When considered together, psychiatric disorders and substance abuse are the top drivers of 30 day readmissions. Fifty percent of Medicaid recipients visited the ED in the last year. Reasons for ED usage that are potentially preventable included: emergency room is the closest provider, doctor’s office closed, most care is in the emergency room and no other place to go. The extraordinary diversity in the PPS brings about unique challenges for providers and residents alike, such as language and cultural competency issues, trust issues (particularly among the uninsured), and misalignment between the demographic characteristics of providers and those of the patients they serve. Some providers are more affected by this than others, particularly those that do not have the resources to train staff in cultural competency and offer wide-ranging translation services; this is particularly true in Queens. The PPS leads and their healthcare partners provide wide-ranging services across the continuum of care in the region, from primary care to rehabilitation services. North Shore-LIJ alone is the largest clinically integrated healthcare network in New York State. NuHealth is the region’s safety net hospital, and Catholic Health Services of Long Island serves hundreds of thousands Long Islanders each year and operates St. Francis Hospital, New York’s only specially designated cardiac center. 3 There are no consistent funding streams for non-traditional care providers (such as peer navigators and health coaches) as well as a variety of providers who help patients with what are often called social determinants of health (such as access to healthy food and transportation). Some providers provide such services but pay for them through foundation grants, which is not the best strategy for sustainability. Nassau County and Queens have a rich array of other healthcare providers, such as FQHCs, primary care providers, specialty medical providers, dental providers, skilled nursing facilities, and home care agencies, among others. Depending on the type of provider, the number of providers per 100,000 population in the region sometimes exceeds the state average and is sometimes below the state average. There is also a rich array of community based resources for both Nassau and Queens, although Queens tends to lag behind Nassau in both the availability of healthcare and community based resources. Unfortunately these resources are not always located where the need is greatest and/or are stretched thin due to high demand. Medicaid patients often have to wait months for an appointment with a primary care provider, giving patients no choice but to visit the ED for care, and there are many wait lists for services provided by community-based organizations. Other reasons for potentially preventable ED visits include: ED is the closest provider; the patient has no other place to go; or the doctor’s office was not open. Despite the breadth of services available in the region, there is significant lack of communication between providers and little, if any, integration or coordination of care. These issues become most pronounced when transitioning a patient from one setting to another and seem to be most problematic when the patient has mental health and/or substance abuse problems. Lack of timely communication was the top problem mentioned in virtually every stakeholder forum and may be the most difficult problem to solve. Some participants in stakeholder forums insisted that “warm hand- offs” (telephone or in-person communication, depending on the situation) are still necessary, despite the greater use of EMRs. Readmissions in the region