Background on Amida Care’s Involvement in DSRIP Population Health Initiatives
On April 14, 2014, Governor Andrew Cuomo announced a groundbreaking waiver that allows New York State (NYS) to reinvest $8 billion in federal savings generated by the Medicaid Redesign Team reforms. The resulting Delivery System Reform Incentive Payment (DSRIP) Program promotes community-level collaborations and focuses on system reform, specifically with a goal to achieve a 25% reduction in avoidable hospital use by 2020. Since then, Amida Care has worked closely with NYS and with providers throughout New York to maximize the impact to the DSRIP program for its members and other Medicaid beneficiaries with complex chronic conditions.
Amida Care applied for and received a planning grant that supported efforts to develop recommendations for community-based projects aimed at meaningful transformation of the chronic illness sector (see full report below). Amida Care also conducted citywide and statewide advocacy to advance its priorities and recommendations, including focusing on statewide inclusion of HIV/AIDS projects and citywide inclusion of all five recommendations in DSRIP applications, and specifically acting as a community liaison between DSRIP and the State’s Ending the Epidemic (EtE) Task Force.
Following the planning process, Amida Care was funded by the NYS Department of Health AIDS Institute to facilitate a statewide learning collaborative to support NYC Performing Provider Systems (PPSs) to implement their selected HIV/AIDS projects, and to support HIV/AIDS-focused community-based organizations’ involvement in DSRIP population health projects, including those that intersect with ETE efforts.
DSRIP Domain 4 HIV/AIDS Projects Implementation Support
Under the DSRIP Program, Domain 4: Population-wide Projects represent priorities in the State’s Prevention Agenda that are intended to influence population-wide health. In NYC, seven of the PPSs selected projects under Domain 4.c.ii: Increase early access to, and retention in, HIV care. Through this work, and with support from the NYC Department of Health and Mental Hygiene (DOHMH), the PPSs formed the NYC DSRIP HIV/AIDS Coalition to share best practices and support implementation of selected HIV/AIDS projects. To achieve its goals, the Coalition operates six subcommittees that meet monthly to guide implementation of selected projects.
Amida Care, through a statewide collaborative, is working with the Coalition to identify areas for technical support. Examples include conducting advocacy for policy changes that advance DSRIP Project 4.c.ii. and ETE goals, and garnering support for innovative projects that promote DSRIP goals. Amida Care will work closely with the NYC DOHMH to minimize duplication of efforts, and will attend subcommittee meetings to ensure ongoing collaboration.
Domain 2: System Transformation of the DSRIP Program
Domain 2: System Transformation of the DSRIP Program aims to connect providers across the health care system to create a community-based system that reduces fragmentation in care. DSRIP Project 2.d.i. Utilizing Patient Activation to Expand Access to Community-Based Care for Special Populations is focused on increasing patient activation related to health care, paired with increased resources that can help the uninsured as well as non-utilizing and low-utilizing populations gain access to and utilize the benefits associated with DSRIP PPS projects. Through Project 2.d.i., organizations are funded to administer the Patient Activation Measure (PAM), a 10-question tool, at baseline and at regular intervals; and to provide health coaching and linkage to appropriate community-based preventive, health care, and supportive services.
Through a statewide collaborative, Amida Care is working with the Greater New York Hospital Association (GNYHA), the entity working with PPSs statewide to support DSRIP implementation, to identify areas of technical support, particularly related to increasing involvement of HIV/AIDS focused community-based organizations (CBOs) in PPSs’ projects outside of NYC. In February 2016, Amida Care conducted a survey with AIDS Institute-funded CBOs to assess their DSRIP/Project 2.d.i. participation and the target populations they serve. The survey results were shared at an all-PPS meeting, which showed that these organizations are well suited to help PPSs implement the PAM and engage patients in care through health coaching, as they are serving some of the highest-need and costliest users on Medicaid; however, only 38% were partnering with a PPS on Project 2.d.i. Following the presentation, the PPSs indicated that having hot-spot data on HIV and other risk factors for HIV would be useful in understanding the types of organizations to engage, along with a list of organizations in their regions; and that additional patient activation and engagement training for CBOs would be useful.
DSRIP Community Profiles
Following the all-PPS meeting, Amida Care developed a DSRIP Community Profile for each PPS implementing Project 2.d.i. Each profile includes an Executive Summary that presents summary data aggregated across all counties within the PPS service area, followed by individual county profiles. Data on the HIV/AIDS epidemic is included, along with data on risk factors for HIV transmission, keeping in mind what might be useful to the PPSs as they make decisions regarding DSRIP implementation (i.e., hospitalization costs related to behavioral health disorders). A PDF of each DSRIP Profile is included below.
Maximizing NYS DSRIP and ETE Resources to Activate and Engage Individuals in Care
Amida Care is working to develop regional capacity-building opportunities to support the participation of CBOs that serve people with chronic conditions such as HIV and behavioral health disorders in the DSRIP patient activation initiative. Tentative locations include NYC, Westchester, Buffalo, Binghamton, Syracuse, and Albany. More information on the capacity-building opportunities is forthcoming.
Amida Care’s Work on Viral Load Suppression (VLS)
Amida Care’s coordinated care management model includes proactive outreach and surrounds the individual with a community of committed providers—social workers, health navigators, behavioral health specialists and a designated medical home—to ensure the most effective care for populations with the greatest needs (people living with chronic issues like HIV, severe mental illness, and substance use disorders; dual eligible; long-term care recipients; and unstably housed/homeless). Through this model, Amida Care has demonstrated that intensive case management normalizes CD4 counts in HIV- infected patients receiving these services and has observed a 74% reduction in hospital admissions/re‐admissions and a 63% reduction in ER/ED visits.
In addition to its care management model, Amida Care is actively involved in viral load suppression (VLS) work citywide, including participating in the Undetectables VLS Consortium, led by the NYC DOHMH and Housing Works, and the DSRIP NYC HIV Coalition’s Models of Care for VLS workgroup. Amida Care has also developed a position statement to implement a VLS Financial Incentive Pilot Project, which would use incentives to reward HIV-positive individuals in achieving and maintaining VLS, in combination with a range of treatment adherence strategies. The position statement has been shared with city and state officials and was submitted as a potential implementation strategy for ETE initiatives.
Advancing Peer Workforce Development Initiatives
Amida Care has a strong commitment to utilizing peers to support its members. Amida Care launched its stipend peer work program in 2006 and has continued to expand peer employment at Amida Care and other community-based agencies through several grant-funded initiatives over the last 10 years. Starting in August 2014 with Housing Works and in August 2015 with ASCNYC, Amida Care entered into two pilot partnership programs for vocational training services for Amida Care members—the Workforce Initiative Network (WIN). Upon completion of the six- to seven-week vocational training cycle, Amida Care members are expected to graduate with basic job readiness skills that can enable them to gain employment in part-time peer positions at HIV community-based organizations. To date, 21 Amida Care members have graduated the program, and 14 were placed at jobs at Amida Care, ASCNYC, Housing Works, and GMHC. The graduates who were hired at Amida Care as Health Navigators and Community Health Outreach Workers report that they are still engaged in care and have achieved viral load suppression or have significantly reduced viral load levels and are soon to be suppressed, due to continued medication adherence.
Advocacy and Technical Assistance
In 2015, the NYS AIDS Institute initiated a statewide HIV Peer Certification Program, which includes training and practical work experience components, to meet the requirements for future Medicaid reimbursement. To support the implementation of HIV peers in the workforce, Amida Care developed a concept paper for an HIV Peer Workforce Innovator Project, which includes three core activities: 1) job placement, 2) provider support, and 3) data and evaluation. Amida Care has conducted advocacy with numerous entities, including the NYC City Council, ETE initiatives, and private foundations to garner support for the project.
Amida Care developed a brief survey to better understand caseloads, peer salaries, and supervision structures among peer programs across the city. The data is now being used to develop a sustainability model to present to the DSRIP HIV Coalition. With Coalition buy-in, Amida Care can advance a policy agenda with the State that advocates for an appropriate rate reimbursement (based on the model).