REPORT TO THE BOARD OF DIRECTORS – December 2019

City

Dr. Nichola Davis, Senior Assistant VP for Chronic Diseases and Prevention and Eunice Casey, Senior Director for HIV Services participated in a New York City Council oversight hearing this month on New York City’s Efforts to Prevent and Address HIV and Hepatitis. Dr. Davis and Ms. Casey were available to answer questions pertaining to the gaps and barriers to care for HIV and Hepatitis (HCV) – namely pregnant women’s access to care for HCV; the treatment protocol for someone newly diagnosed with HIV and Hepatitis; getting the number of individuals infected with HIV down to zero; increasing access to PrEP and PEP; and our partnership with the NYC Department of Health to end both the HIV and HCV epidemics.

State

• Last month, the New York State Department of Health submitted an 1115 Waiver amendment application to the Centers for Medicare & Medicaid Services (CMS). Under the current 1115 Waiver, the Delivery System Reform Incentive Payment Program (DSRIP), which funds OneCity Health, ends on March 31, 2020. The State requested $8 billion over a four-year period consisting of two parts: a one-year DSRIP Waiver Extension to March 31, 2021, and a waiver renewal for three more years. Prior to the submission of the State application, NYC Health + Hospitals and OneCity Health both submitted comments in support of the State’s request.
• The Governor released the State’s updated financial plan which indicates the 2020-21 State fiscal year will start with a $6.1 billion deficit, due largely in part to the $4 billion Medicaid budget shortfall in its current fiscal year, which ends on March 31st, 2020. The Governor is developing a 2020 savings plan which may include a range of cuts, payment reductions and adjustments, and other cost containment and administrative measures. NYC Health + Hospitals continues to have discussions with the State on how best to address the deficit while protecting safety net providers in advance of the announcement of his January 2020 executive budget. Our advocacy will continue through the budget process.
• We are awaiting the outcome of Design Build Legislation. The State Legislature passed the NYC Design Build Act which would give City agencies and Health + Hospitals the authority to utilize design-build delivery for new construction projects. This method would save our system precious dollars and accelerate our projects. We received letters in support from elected officials who would benefit from one of our new primary care centers as well as from the Primary Care Development Corporations, and we participated in a press conference to highlight the need for Design Build authority. We are urging the Governor to sign this bill before the end of the year.

Federal

On Monday, Congressional leadership announced the framework of a deal to fund the Federal government in advance of the December 20^th expiration of the current Continuing Resolution. This complex package includes a 5-month delay of pending Medicaid DSH cuts. That means our advocacy to further delay or eliminate the cuts will continue into 2020.

NYC Care has enrolled more than 10,000 New Yorkers in the Bronx since its launch in August, two months ahead of projected schedule. To date, all new members were offered a primary care appointment within the first two weeks of enrolling. Through the program’s extended pharmacy hours, members have filled over 14,000 prescriptions, most commonly for prescriptions to treat diabetes and hypertension, conditions that require timely medication management and adherence. To maintain the enrollment momentum, NYC Health + Hospitals and MOIA will extend funding for six more months to the five Bronx community based organizations that have conducted culturally appropriate outreach to prospective NYC Care members: Bronx Works, Emerald Isle Immigration Center, Mekong NYC, Northwest Bronx Community and Clergy Coalition, and Sauti Yetu Center for African Women. And we are doing a second round of placements for our multilingual public awareness campaign including advertisements in public transportation, social media, neighborhood stores, ethnic and community media and LinkNYC terminals as well as street marketing outreach and special ethnic media partnerships. NYC Care will launch in Brooklyn and Staten Island in January 2020, and will be available citywide by the end of next year.

This month we mark an important milestone in our health system’s transformation. We completed the successful launch of the H₂O/Epic electronic medical record system at NYC Health + Hospitals/Kings County and at nine associated Gotham Health community-based health centers. For the first time in the history of our health system, we can deliver care using a single unified medical record system (EMR) across our acute care hospitals, ambulatory care clinics and home health care. The new, advanced EMR will help our clinicians provide safe, efficient, quality care. The technology equips providers with alerts to prevent medical errors, avoid duplicative and unnecessary tests and keep patients’ preventive health screenings on schedule. It will also empower our patients with the adoption of MyChart, a secure online patient portal that puts their medical history at their fingertips. With MyChart, patients can request prescription refills, send messages to their care team and access appointment information. This represents the largest public health Epic implementation in the country that will unify over 50,000 users in more than 70 patient care sites.

Mayor Bill de Blasio last week announced that the City of New York reached a contract agreement with the New York State Nurses Association (NYSNA), which represents nearly 8,500 nurses across the NYC Health + Hospitals system. Nurses are at the heart of our mission to care for all without exception and I am pleased that the agreement includes standard wage increases, along with significant targeted compensation incentives to help us recruit and retain the best nurse professionals. The agreement also ensures our nurses have the support they need to continue to provide excellent care to all New Yorkers in the form of standard nurse-to-patient staffing ratios. These ratios were established by us, based on industry standards, but we committed to NYSNA to meet them in this contract. The new agreement improves compensation for hard to recruit and retain nursing positions, such as Nurse Practitioners, and nurses in certain targeted specialty areas like ICUs and Emergency Departments.

Too many people with debilitating chronic conditions that limit their mobility find it very challenging to leave the home and travel to visit their primary care physician. They are more likely to be disconnected to care, skip regular preventive care, and end up with additional health complications. Our first home-based primary care pilot program will break down barriers and help improve health outcomes for some of the City’s most vulnerable population. The pilot program will support a new team of visiting doctors and nurse practitioners who will make house calls to home-limited patients served by NYC Health + Hospitals/Kings County in Brooklyn. The program will offer primary care services in the home and use telehealth video visits to connect patients to specialty care, mental health services and help from social workers. The new home-based primary care pilot program is expected to serve 200 patients, and is funded in part by grants from the Altman Foundation, the New York Community Trust, and the Fan Fox and Leslie R. Samuels Foundation, Inc., as well as investments by NYC Health + Hospitals, totaling $900,000 over the next two years to cover the cost of new staff, transportation, equipment and supplies. Based on the results of the pilot, we expect to expand the at-home primary care service model to other communities served by NYC Health + Hospitals.

At NYC Health + Hospitals, we are committed to providing New Yorkers effective treatment for substance use disorder in a safe and compassionate environment that supports recovery. For this reason we are transitioning from 72 hour detox units to a more comprehensive model of care at seven of our hospitals. This new model replaces an outdated and ineffective inpatient Substance Use Disorder detox practice that has failed patients for many years. San Francisco, Los Angeles, and other municipalities across the nation have not used this type of care in decades because of the high rates of recidivism. The current model requires that patients have substances on board to be admitted, so it cannot help people who want to stay sober but have not recently used. Because the focus is on abstinence during the 72 hours, our patients are at high risk for a lethal overdose following release.

The new detox model both destigmatizes the process and ensures patients with complex medical needs are treated for all of their needs at once. Patients who need hospitalization because they are withdrawing will still be admitted to the hospital, but they will be admitted to the medicine service. This is much safer for them if there is a medical complication of withdrawal. There is no decrease in service or staffing. This new model is an important part of our health system transformation and will offer better, more clinically effective services that are in-line with best practices, improved patient outcomes, and reduce relapse.

This is a phased transition to ensure patient continuity of care and that new services are responsive to patient and community needs. We are making investments to ensure our hospitals also have new teams of addiction counselors, peers, physicians or nurse practitioners to engage patients with co-occurring substance use disorder, start them in treatment, including medications, and coordinate follow-up outpatient care at the hospital or in the community based on their needs. With more than half of our 131 detox beds empty every day, it was clear that we had to create a detox service that made sense for our patients – where recovery is possible. I am confident that they will truly benefit from this transition as they will receive the treatment they need in an environment that is most appropriate for them.

This month we announced a unique and innovative model of care for patients in City jails whose clinical conditions do not require hospitalization but need frequent monitoring and access to specialty and subspecialty care. The new Outposted Therapeutic Housing Units will be managed by the NYC Health + Hospitals Correctional Health Services (CHS) and offer a more normalized environment to help healing and recovery, and better position patients for discharge. Our plan is to open the therapeutic units at two sites, at NYC Health + Hospitals/Bellevue in Manhattan and the other at NYC Health + Hospitals/Woodhull in Brooklyn with a total of 250 beds for incarcerated individuals with complex medical, mental health, or substance use needs. This is an innovative solution to address a gap in the patient care continuum.

Currently, when incarcerated individuals have complex medical problems, they must be transported to hospitals for specialty care like chemotherapy or surgery. That process can be disruptive and lengthy, and it contributes to patients refusing the care they need and deserve. Unlike the traditional “forensic” hospital units where incarcerated individuals are admitted when they are in a medical or mental health crisis and get stabilized enough to be discharged, this new clinical model will offer longer-term services. The new therapeutic beds will allow for safer and better access to hospital-based specialists and more interactive and supportive treatment to stabilize patients for successful reentry to the community.

CHS health care professionals will determine which incarcerated individuals should be admitted based on their clinical needs, and our partners in the NYC Department of Correction will provide the security necessary for individuals under custody. With the new therapeutic beds, individuals in custody who need daily radiation treatment, weekly follow up after surgery, or must regularly see several specialists because of their multiple chronic conditions will no longer face obstacles to the lifesaving care they need. I am extremely proud that NYC Health + Hospitals, as both innovator and advocate, will be pioneering this approach for more dignified and humane care.

This past Tuesday the Mayor announced a 6- Point Action Plan to end long-term street homelessness over the next five years. The plan will increase housing, mental health and medical services for unsheltered individuals, and enhance outreach resources to deliver more urgent and rapid responses to unsheltered individuals in need.

NYC Health + Hospitals, in coordination with multiple City agencies, are bringing all relevant experience and expertise to the table, to ensure unsheltered New Yorkers with the most serious mental health challenges are closely connected to care, referred to care coordination, and/or engaged by mobile treatment teams, which provide psychosocial and psychiatric assessment, medication management, care coordination, peer support, and housing placement assistance to people where they are. Additionally, teams offer specialized treatment interventions for trauma and substance use, taking a harm reduction approach.

We participate in interagency coordination meetings to ensure a patient’s smooth transition between homeless outreach, removal to the hospital for emergency services, and discharge back to the community. Further, there will be hospital coordination with the Department of Homeless Services to improve discharge planning for patients returning to shelter. The NYC Health + Hospital Central Office will coordinate with city agency partners, outreach teams, and hospitals to ensure ongoing communication.

NYC Health + Hospitals reached several end-of-year milestones in our efforts to promote more proactive, preventive care. Blood pressure control among our patients reached 77.0% and 66.5% of our patients with diabetes had their blood sugar (hemoglobin A1c levels) under control. Both measures are the highest they have been since the health system started tracking these several years ago. This translates into hundreds of averted strokes, heart attacks, and amputations. We were also able to sustain quality outcomes for two other measures: depression improvement for patients in collaborative care was 58.0% and HIV viral load suppression for actively engaged patients was 85%. Community Care, our health system’s care coordination and home-based care division, embarked upon a transformation focused on high-risk patients. About 47% of such patients were connected with at least one Community Care service over the course of one-year. Our focus on social determinants of health is also yielding tangible results. More than 30,000 patients were screened for social needs. Almost 4,000 patients received legal services through LegalHealth. We helped 3,000 patients enroll in the Supplemental Nutrition Assistance Program (SNAP, also known as food stamps). And more than 1,000 patients received tax assistance such as enrollment in the Earned Income Tax Credit. Finally, over 200,000 referrals have now flowed through our eConsult system since its inception, improving access to specialty care.

Clinical pharmacists at NYC Health + Hospitals work closely with primary care teams with a focus on diabetes care management. Starting next Spring, we are expanding their role to also help patients manage hypertension. There are more than 98,000 New Yorkers diagnosed with hypertension who receive care in our hospitals and community-based health centers. Clinical pharmacists will assist patients with uncontrolled hypertension or complicated hypertension medication regimens to manage their medications between primary care visits with their doctor. They are certified to adjust, stop or start any medications related to the disease they are treating. The expansion of our clinical pharmacists’ role demonstrates how NYC Health + Hospitals is making efficient care more accessible to patients. Managing chronic diseases can be challenging for some, creating reoccurring doctor visits and creating some backlog in scheduling. Utilizing all appropriate health providers is crucial in streamlining care and ensuring patients are seen appropriately.

MetroPlus Health Plan announced a new partnership with InquisitHealth to provide peer-to-peer mentoring to members with poorly-controlled diabetes. The new pilot program pairs MetroPlus members who have diabetes with trained peer mentors who are successfully managing their diabetes. The program utilizes a technology-enabled workforce of “peer mentors” to address the social and behavioral factors that may impact a patient’s health. The mentor/mentee relationship enables members to work closely with others who serve as trusted advisors and coaches to guide members towards better health. Reflecting the health plan’s ongoing commitment to using proven interventions to work, this initiative is designed to efficiently and cost-effectively improve participating members’ overall health and wellness. The peer-to-peer initiative is part of a larger effort by MetroPlus to promote self-management of diabetic symptoms before serious complications occur. This mentoring program utilizes a key component of the comprehensive, primary care-centered diabetes management program recently launched by NYC Health + Hospitals in July to improve care for tens of thousands of New Yorkers.

Our new teleretinal screening approach changes the way patients with diabetes are evaluated for retinopathy. Time is of the essence when identifying retinal changes – before irreversible damage is done to someone’s vision. We plan to install teleretinal screening machines in primary care clinics at all 11 acute care facilities, select Gotham Health sites, and Correctional Health by the end of 2020. Since August, the adult primary care clinics where we have already installed this equipment — NYC Health + Hospitals/Coney Island, Elmhurst, Lincoln, Queens, and Woodhull — have already screened more than 1,880 patients with diabetes for signs of diabetic retinopathy — a disease of the retina, that if left untreated, can result in loss of vision. It is the leading cause of blindness in United States among adults ages 20 to 74. It may not cause symptoms immediately, that’s why early detection is so important. Approximately 30 percent of patients screened at our facilities were referred to ophthalmology for further testing to confirm diagnosis of diabetic retinopathy. Before we equipped our primary care clinics with the teleretinal screening equipment, patients would have to schedule a separate appointment with their ophthalmologist to get tested. All patients with diabetes, regardless of duration or control, are at risk for significant retinopathy and vision loss. By providing easy access to teleretinal screening services at our primary care sites, we can provide patients important preventive care in a more convenient way.

NYC Health + Hospitals/Elmhurst hosted a kickoff ceremony for the future construction of its Emergency Department (ED) expansion. The $43 million capital expansion project will include the renovation and redesign of the existing 28,900 square feet of space, along with the addition of a second story with an additional 19,400 square feet. The expansion will feature 33 new patient rooms in the adult ED space, which includes rooms dedicated to bariatric, special pathogens, and critical care isolation. The new ED will feature 25 patient bays, 19 surge bed capable locations and an expanded 10 bed critical care/trauma space, up from seven. The new second floor will accommodate the hospital’s Adult and Child Emergency Psychiatry and Partial Hospitalization programs. The space will incorporate a state-of the-art Stroke Center, featuring an advanced medical imaging unit that will allow the hospital to expedite life-saving care for stroke patients. Funding for the project was provided by the New York City Council, the Queens Borough President, NYC Health + Hospitals, and New York State’s DSRIP program. The expansion is scheduled to begin in late Spring of 2020 and be completed in the Spring of 2023. As one of the busiest EDs in the City, the renovations, expansion, and new state-of-the-art technology that’s coming to NYC Health + Hospitals/Elmhurst is critical in continuing to care for New Yorkers, especially in the event of a life-threatening event.