PPS Quarterly Report - New York State Department of Health

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 1 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) TABLE OF CONTENTS Index.........................................................................................................................................................................................................................................................................................6 Section 01 - Budget...............................................................................................................................................................................................................................................................7 Module 1.1.........................................................................................................................................................................................................................................................................7 Module 1.2.........................................................................................................................................................................................................................................................................9 Module 1.3.......................................................................................................................................................................................................................................................................11 Module 1.4.......................................................................................................................................................................................................................................................................13 Module 1.5.......................................................................................................................................................................................................................................................................17 Module 1.6.......................................................................................................................................................................................................................................................................19 Module 1.7.......................................................................................................................................................................................................................................................................20 Module 1.8.......................................................................................................................................................................................................................................................................22 Module 1.9.......................................................................................................................................................................................................................................................................24 Module 1.10.....................................................................................................................................................................................................................................................................26 Module 1.11.....................................................................................................................................................................................................................................................................30 Section 02 - Governance.....................................................................................................................................................................................................................................................31 Module 2.1.......................................................................................................................................................................................................................................................................31 Module 2.2.......................................................................................................................................................................................................................................................................41 Module 2.3.......................................................................................................................................................................................................................................................................42 Module 2.4.......................................................................................................................................................................................................................................................................42 Module 2.5.......................................................................................................................................................................................................................................................................43 Module 2.6.......................................................................................................................................................................................................................................................................44 Module 2.7.......................................................................................................................................................................................................................................................................46 Module 2.8.......................................................................................................................................................................................................................................................................47 Module 2.9.......................................................................................................................................................................................................................................................................47 Section 03 - Financial Stability.............................................................................................................................................................................................................................................48 Module 3.1.......................................................................................................................................................................................................................................................................48 Module 3.2.......................................................................................................................................................................................................................................................................55 Module 3.3.......................................................................................................................................................................................................................................................................56 Module 3.4.......................................................................................................................................................................................................................................................................56 Module 3.5.......................................................................................................................................................................................................................................................................58 Module 3.6.......................................................................................................................................................................................................................................................................60 Module 3.7.......................................................................................................................................................................................................................................................................61 Module 3.8.......................................................................................................................................................................................................................................................................61 Module 3.9.......................................................................................................................................................................................................................................................................62 Section 04 - Cultural Competency & Health Literacy...........................................................................................................................................................................................................63 Module 4.1.......................................................................................................................................................................................................................................................................63 Module 4.2.......................................................................................................................................................................................................................................................................68

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module 4.3.......................................................................................................................................................................................................................................................................69 Module 4.4.......................................................................................................................................................................................................................................................................70 Module 4.5.......................................................................................................................................................................................................................................................................71 Module 4.6.......................................................................................................................................................................................................................................................................72 Module 4.7.......................................................................................................................................................................................................................................................................73 Module 4.8.......................................................................................................................................................................................................................................................................73 Module 4.9.......................................................................................................................................................................................................................................................................74 Section 05 - IT Systems and Processes..............................................................................................................................................................................................................................75 Module 5.1.......................................................................................................................................................................................................................................................................75 Module 5.2.......................................................................................................................................................................................................................................................................82 Module 5.3.......................................................................................................................................................................................................................................................................83 Module 5.4.......................................................................................................................................................................................................................................................................83 Module 5.5.......................................................................................................................................................................................................................................................................85 Module 5.6.......................................................................................................................................................................................................................................................................88 Module 5.7.......................................................................................................................................................................................................................................................................90 Module 5.8.......................................................................................................................................................................................................................................................................90 Section 06 - Performance Reporting...................................................................................................................................................................................................................................91 Module 6.1.......................................................................................................................................................................................................................................................................91 Module 6.2.......................................................................................................................................................................................................................................................................94 Module 6.3.......................................................................................................................................................................................................................................................................95 Module 6.4.......................................................................................................................................................................................................................................................................96 Module 6.5.......................................................................................................................................................................................................................................................................97 Module 6.6.......................................................................................................................................................................................................................................................................98 Module 6.7.....................................................................................................................................................................................................................................................................100 Module 6.8.....................................................................................................................................................................................................................................................................100 Module 6.9.....................................................................................................................................................................................................................................................................100 Section 07 - Practitioner Engagement...............................................................................................................................................................................................................................101 Module 7.1.....................................................................................................................................................................................................................................................................101 Module 7.2.....................................................................................................................................................................................................................................................................105 Module 7.3.....................................................................................................................................................................................................................................................................106 Module 7.4.....................................................................................................................................................................................................................................................................106 Module 7.5.....................................................................................................................................................................................................................................................................107 Module 7.6.....................................................................................................................................................................................................................................................................108 Module 7.7.....................................................................................................................................................................................................................................................................109 Module 7.8.....................................................................................................................................................................................................................................................................109 Module 7.9.....................................................................................................................................................................................................................................................................109 Section 08 - Population Health Management....................................................................................................................................................................................................................110 Module 8.1.....................................................................................................................................................................................................................................................................110

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module 8.2.....................................................................................................................................................................................................................................................................117 Module 8.3.....................................................................................................................................................................................................................................................................118 Module 8.4.....................................................................................................................................................................................................................................................................118 Module 8.5.....................................................................................................................................................................................................................................................................120 Module 8.6.....................................................................................................................................................................................................................................................................121 Module 8.7.....................................................................................................................................................................................................................................................................122 Module 8.8.....................................................................................................................................................................................................................................................................122 Module 8.9.....................................................................................................................................................................................................................................................................122 Section 09 - Clinical Integration.........................................................................................................................................................................................................................................123 Module 9.1.....................................................................................................................................................................................................................................................................123 Module 9.2.....................................................................................................................................................................................................................................................................127 Module 9.3.....................................................................................................................................................................................................................................................................128 Module 9.4.....................................................................................................................................................................................................................................................................128 Module 9.5.....................................................................................................................................................................................................................................................................130 Module 9.6.....................................................................................................................................................................................................................................................................131 Module 9.7.....................................................................................................................................................................................................................................................................133 Module 9.8.....................................................................................................................................................................................................................................................................133 Module 9.9.....................................................................................................................................................................................................................................................................133 Section 10 - General Project Reporting.............................................................................................................................................................................................................................135 Module 10.1...................................................................................................................................................................................................................................................................135 Module 10.2...................................................................................................................................................................................................................................................................136 Module 10.3...................................................................................................................................................................................................................................................................137 Module 10.4...................................................................................................................................................................................................................................................................139 Module 10.5...................................................................................................................................................................................................................................................................141 Module 10.6...................................................................................................................................................................................................................................................................141 Module 10.7...................................................................................................................................................................................................................................................................143 Module 10.8...................................................................................................................................................................................................................................................................143 Section 11 - Workforce......................................................................................................................................................................................................................................................144 Module 11.1...................................................................................................................................................................................................................................................................144 Module 11.2...................................................................................................................................................................................................................................................................145 Module 11.3...................................................................................................................................................................................................................................................................151 Module 11.4...................................................................................................................................................................................................................................................................152 Module 11.5...................................................................................................................................................................................................................................................................152 Module 11.6...................................................................................................................................................................................................................................................................154 Module 11.7...................................................................................................................................................................................................................................................................155 Module 11.8...................................................................................................................................................................................................................................................................156 Module 11.9...................................................................................................................................................................................................................................................................156 Module 11.10.................................................................................................................................................................................................................................................................157

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module 11.11.................................................................................................................................................................................................................................................................158 Module 11.12.................................................................................................................................................................................................................................................................160 Projects..............................................................................................................................................................................................................................................................................161 Project 2.a.i....................................................................................................................................................................................................................................................................161 Module 2.a.i.1............................................................................................................................................................................................................................................................161 Module 2.a.i.2............................................................................................................................................................................................................................................................163 Module 2.a.i.3............................................................................................................................................................................................................................................................176 Module 2.a.i.4............................................................................................................................................................................................................................................................177 Project 2.b.iv..................................................................................................................................................................................................................................................................178 Module 2.b.iv.1..........................................................................................................................................................................................................................................................178 Module 2.b.iv.2..........................................................................................................................................................................................................................................................179 Module 2.b.iv.3..........................................................................................................................................................................................................................................................180 Module 2.b.iv.4..........................................................................................................................................................................................................................................................197 Module 2.b.iv.5..........................................................................................................................................................................................................................................................198 Project 2.b.viii.................................................................................................................................................................................................................................................................199 Module 2.b.viii.1.........................................................................................................................................................................................................................................................199 Module 2.b.viii.2.........................................................................................................................................................................................................................................................201 Module 2.b.viii.3.........................................................................................................................................................................................................................................................202 Module 2.b.viii.4.........................................................................................................................................................................................................................................................218 Module 2.b.viii.5.........................................................................................................................................................................................................................................................219 Project 2.c.i....................................................................................................................................................................................................................................................................220 Module 2.c.i.1............................................................................................................................................................................................................................................................220 Module 2.c.i.2............................................................................................................................................................................................................................................................222 Module 2.c.i.3............................................................................................................................................................................................................................................................223 Module 2.c.i.4............................................................................................................................................................................................................................................................231 Module 2.c.i.5............................................................................................................................................................................................................................................................233 Project 3.a.i....................................................................................................................................................................................................................................................................234 Module 3.a.i.1............................................................................................................................................................................................................................................................234 Module 3.a.i.2............................................................................................................................................................................................................................................................235 Module 3.a.i.3............................................................................................................................................................................................................................................................236 Module 3.a.i.4............................................................................................................................................................................................................................................................260 Module 3.a.i.5............................................................................................................................................................................................................................................................261 Project 3.a.iii...................................................................................................................................................................................................................................................................262 Module 3.a.iii.1..........................................................................................................................................................................................................................................................262 Module 3.a.iii.2..........................................................................................................................................................................................................................................................263 Module 3.a.iii.3..........................................................................................................................................................................................................................................................264 Module 3.a.iii.4..........................................................................................................................................................................................................................................................272 Module 3.a.iii.5..........................................................................................................................................................................................................................................................273

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 3.b.i....................................................................................................................................................................................................................................................................274 Module 3.b.i.1............................................................................................................................................................................................................................................................274 Module 3.b.i.2............................................................................................................................................................................................................................................................276 Module 3.b.i.3............................................................................................................................................................................................................................................................277 Module 3.b.i.4............................................................................................................................................................................................................................................................313 Module 3.b.i.5............................................................................................................................................................................................................................................................314 Project 3.c.i....................................................................................................................................................................................................................................................................315 Module 3.c.i.1............................................................................................................................................................................................................................................................315 Module 3.c.i.2............................................................................................................................................................................................................................................................316 Module 3.c.i.3............................................................................................................................................................................................................................................................317 Module 3.c.i.4............................................................................................................................................................................................................................................................331 Module 3.c.i.5............................................................................................................................................................................................................................................................332 Project 4.b.ii...................................................................................................................................................................................................................................................................333 Module 4.b.ii.1...........................................................................................................................................................................................................................................................333 Module 4.b.ii.2...........................................................................................................................................................................................................................................................334 Module 4.b.ii.3...........................................................................................................................................................................................................................................................343 Project 4.c.ii....................................................................................................................................................................................................................................................................344 Module 4.c.ii.1...........................................................................................................................................................................................................................................................344 Module 4.c.ii.2...........................................................................................................................................................................................................................................................345 Module 4.c.ii.3...........................................................................................................................................................................................................................................................350 Attestation..........................................................................................................................................................................................................................................................................351 Status Log.........................................................................................................................................................................................................................................................................352 Comments Log..................................................................................................................................................................................................................................................................353 Module Status....................................................................................................................................................................................................................................................................354 Sections Module Status.................................................................................................................................................................................................................................................354 Projects Module Status..................................................................................................................................................................................................................................................358 Review Status....................................................................................................................................................................................................................................................................360 Section Module / Milestone............................................................................................................................................................................................................................................360 Project Module / Milestone.............................................................................................................................................................................................................................................363 Providers Participating in Projects.....................................................................................................................................................................................................................................368

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Quarterly Report - Implementation Plan for Mount Sinai PPS, LLC Year and Quarter: DY3, Q1

Quarterly Report Status:

Adjudicated

Status By Section Description

Section

Status

Section 01

Budget

Completed

Section 02

Governance

Section 03

Financial Stability

Completed Completed

Section 04

Cultural Competency & Health Literacy

Completed

Section 05

IT Systems and Processes

Completed

Section 06

Performance Reporting

Completed

Section 07

Practitioner Engagement

Completed

Section 08

Population Health Management

Completed

Section 09

Clinical Integration

Completed

Section 10

General Project Reporting

Completed

Section 11

Workforce

Completed

Status By Project Project ID

Project Title

Status

2.a.i

Create Integrated Delivery Systems that are focused on Evidence-Based Medicine / Population Health Management

Completed

2.b.iv

Care transitions intervention model to reduce 30 day readmissions for chronic health conditions

Completed

2.b.viii

Hospital-Home Care Collaboration Solutions

Completed

2.c.i

Development of community-based health navigation services

Completed

3.a.i

Integration of primary care and behavioral health services

Completed

3.a.iii

Implementation of evidence-based medication adherence programs (MAP) in community based sites for behavioral health medication compliance

Completed

3.b.i

Evidence-based strategies for disease management in high risk/affected populations (adult only)

Completed

3.c.i

Evidence-based strategies for disease management in high risk/affected populations (adults only) Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings (Note: This project targets chronic diseases that are not included in domain 3, such as cancer Increase early access to, and retention in, HIV care

Completed

4.b.ii 4.c.ii

NYS Confidentiality – High

Completed Completed

Page 7 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 01 – Budget IPQR Module 1.1 - PPS Budget - Waiver Revenue (Baseline) - READ ONLY Instructions : READ ONLY - The Baseline Budget table was left for ease of reference during reporting.

Budget Items

DY1 ($)

DY2 ($)

DY3 ($)

DY4 ($)

DY5 ($)

Total ($)

Waiver Revenue

21,976,836

23,422,094

37,874,679

33,538,903

21,976,836

138,789,348

Cost of Project Implementation & Administration

13,190,540

5,856,910

9,468,903

8,382,877

5,492,588

42,391,818

Implementation

0

0

0

0

0

0

Administration

0

0

0

0

0

0

Revenue Loss

0

0

0

0

0

0

Internal PPS Provider Bonus Payments

0

0

0

0

0

0

Cost of non-covered services

0

0

0

0

0

0

8,793,693

17,570,731

28,406,711

25,148,629

16,477,766

96,397,530

Other Sustainability Fund

0

4,685,528

7,575,123

6,706,301

4,394,071

23,361,023

Contingency Fund

5,496,058

2,342,764

3,787,561

3,353,151

2,197,035

17,176,569

Performance-Based Payments

2,857,950

8,199,675

13,256,465

11,736,027

7,689,624

43,739,741

439,685

1,171,382

1,893,781

1,676,575

1,098,518

6,279,941

0

1,171,382

1,893,781

1,676,575

1,098,518

5,840,256

21,984,233

23,427,641

37,875,614

33,531,506

21,970,354

138,789,348

0

0

0

7,397

6,482

0

Safety Net and CBO Funds Bonus Funds Total Expenditures Undistributed Revenue

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : All budgeted dollars were done according to State guidance and rounded four digits from the decimal. For instance, DY1: 0.1584 DY2: 0.1688 DY3: 0.2729 DY4: 0.2416 and DY5: 0.1583. As a result, waiver revenue calculations may differ with total expenditures.

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File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

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Page 9 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 1.2 - PPS Budget - Waiver Revenue (Quarterly) Instructions : Please include updates on waiver revenue budget items for this quarterly reporting period. Reported actual spending will be compared to baseline projections and deviations will be evaluated. Any explanations regarding deviations from baseline projections must be included within the textbox, not as narrative within uploaded documentation.

Benchmarks Waiver Revenue DY3

Total Waiver Revenue

37,874,679

138,789,348

Undistributed Revenue YTD 31,974,644

Undistributed Revenue Total 100,015,148

DY3 Q1 Quarterly Amount - Update

Cumulative Spending to Date (DY1 - DY5)

Cost of Project Implementation & Administration

3,100,035

28,852,050

6,368,868

Implementation

1,860,021

Administration

1,240,014

Budget Items

Remaining Balance in Current DY

Percent Remaining in Current DY

Cumulative Remaining Balance

67.26%

Percent Remaining of Cumulative Balance

13,539,768

Revenue Loss

0

0

0

0

Internal PPS Provider Bonus Payments

0

0

0

0

Cost of non-covered services

0

0

0

0

Other

2,800,000

9,922,150

25,606,711

Sustainability Fund

2,800,000

Contingency Fund

0

Performance-Based Payments

0

Non-Safety Net and CBO Funds

0

Bonus Funds

0

Total Expenditures

5,900,035

90.14%

86,475,380

31.94%

89.71%

38,774,200

Current File Uploads User ID

File Type

File Name

No Records Found

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA.

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

Page 10 of 932 Run Date : 09/29/2017

Page 11 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 1.3 - PPS Flow of Funds - Waiver Revenue (Baseline) - READ ONLY Instructions : READ ONLY - The Baseline Funds Flow table was left for ease of reference during reporting.

Funds Flow Items

DY1 ($)

DY2 ($)

DY3 ($)

DY4 ($)

DY5 ($)

Total ($)

21,976,836

23,422,094

37,874,679

33,538,903

21,976,836

138,789,348

Practitioner - Primary Care Provider (PCP)

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Practitioner - Non-Primary Care Provider (PCP)

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Hospital

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Clinic

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Case Management / Health Home

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Mental Health

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Substance Abuse

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Nursing Home

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Pharmacy

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Hospice

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

Waiver Revenue

Community Based Organizations All Other

1,007,314

1,073,465

1,735,928

1,537,158

1,007,314

6,361,179

10,897,299

11,612,946

18,779,587

16,629,248

10,897,299

68,816,379

Uncategorized

0 0

0

0

0

0

0

Total Funds Distributed

PPS PMO

21,977,753

23,421,061

37,874,795

33,537,986

21,977,753

138,789,348

Undistributed Revenue

0

1,033

0

917

0

0

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : Placeholder figures have been included as required by the implementation template; however the criteria for evaluating funds flow are in development based on provider roles and responsibilities in PPS-wide projects which is a work in progress. MS PPS is not comfortable with submitting formal projections at this time and committing to future payment allocations per type as we will be continuously refining provider incentives to ensure appropriate transition of DSRIP projects into sustainable outcomes. We would also note that according to the implementation plan, we are not required to finalize this work until DY1 Q3, and the list of project participants is now due to DOH in October 2015, which is a huge

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File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) determinant of funds flow.

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

Page 12 of 932 Run Date : 09/29/2017

Page 13 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.4 - PPS Flow of Funds - Waiver Revenue (Quarterly) Instructions : Please include updates on waiver revenue flow of funds for this quarterly reporting period by importing the PIT file and filling out the PPS PMO line manually. Reported actual fund distribution will be compared to baseline projections and deviations will be evaluated. Any explanations regarding deviations from baseline projections must be included within the textbox, not as narrative within uploaded documentation.

Benchmarks Waiver Revenue DY3

Total Waiver Revenue

37,874,679.00

Undistributed Revenue YTD

138,789,348.00

Funds Flow Items

Practitioner - Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP) Hospital

Undistributed Revenue Total

37,874,679.00

Percentage of Safety Net Funds - DY3 Q1 Quarterly Amount Update

DY3 Q1 Quarterly Amount Update

117,634,906.39

Percent Spent By Project Safety Net Funds Flowed YTD

Safety Net Funds Percentage YTD

Total Amount Disbursed to Date (DY1DY5)

DY Adjusted Difference

Projects Selected By PPS

2.a.i

2.b.iv

2.b.vi ii

2.c.i

3.a.i

3.a.iii

3.b.i

3.c.i

4.b.ii

Cumulative Difference

4.c.ii

0

0.00%

0

0.00%

68,133.82

0

0

0

0

0

0

0

0

0

0

1,735,928

6,293,045.18

0

0.00%

0

0.00%

713.45

0

0

0

0

0

0

0

0

0

0

1,735,928

6,360,465.55

0

0.00%

0

0.00%

839,363.44

0

0

0

0

0

0

0

0

0

0

1,735,928

5,521,815.56

Clinic

0

0.00%

0

0.00%

1,594,503.53

0

0

0

0

0

0

0

0

0

0

1,735,928

4,766,675.47

Case Management / Health Home

0

0.00%

0

0.00%

369,171.12

0

0

0

0

0

0

0

0

0

0

1,735,928

5,992,007.88

Mental Health

0

0.00%

0

0.00%

950,703.67

0

0

0

0

0

0

0

0

0

0

1,735,928

5,410,475.33

Substance Abuse

0

0.00%

0

0.00%

232,322.04

0

0

0

0

0

0

0

0

0

0

1,735,928

6,128,856.96

Nursing Home

0

0.00%

0

0.00%

46,907.77

0

0

0

0

0

0

0

0

0

0

1,735,928

6,314,271.23

Pharmacy

0

0.00%

0

0.00%

206,904.96

0

0

0

0

0

0

0

0

0

0

1,735,928

6,154,274.04

Hospice

0

0.00%

0

0.00%

209,007.03

0

0

0

0

0

0

0

0

0

0

1,735,928

6,152,171.97

Community Based Organizations

0

0.00%

0

0.00%

207,459.51

0

0

0

0

0

0

0

0

0

0

1,735,928

6,153,719.49

All Other

0

0.00%

0

0.00%

1,954,132.91

0

0

0

0

0

0

0

0

0

0

18,779,587

66,862,246.09

Uncategorized

0

0.00%

0

0.00%

338,266.36

0

0

0

0

0

0

0

0

0

0

0

0

Additional Providers

0

0.00%

0

0.00%

99,275

PPS PMO

0

0.00%

0

0.00%

14,037,577

0

0

Total

0

0.00%

0

0.00%

21,154,441.61

NYS Confidentiality – High

Page 14 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA.

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) * Safety Net Providers in Green Waiver Quarterly Update Amount By Provider Provider Name

Provider Category

Practitioner - Primary Care Provider (PCP) Practitioner - Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP) Hospital

DY3Q1 0 0 0 0 0

Hospital

0

Clinic

0

Clinic

0

Case Management / Health Home

0

Case Management / Health Home Mental Health Mental Health Substance Abuse Substance Abuse Nursing Home Nursing Home Pharmacy Pharmacy Hospice Hospice Community Based Organizations Community Based Organizations All Other All Other Uncategorized Uncategorized

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NYS Confidentiality – High

Page 15 of 932 Run Date : 09/29/2017

Page 16 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) * Safety Net Providers in Green

Provider Name

* Safety Net Providers in Green Waiver Quarterly Update Amount By Provider IA Provider Provider Category Approval/Rejection Indicator Additional Providers

DY3Q1

Provider Name 0

Liveonny

Additional Providers

Approved

0

Sage (Services And Advocacy For Glbt Elders)

Additional Providers

Approved

0

Woodcrest Nursing Home Inc.

Additional Providers

Approved

0

Bridging Access To Care

Additional Providers

Approved

0

Additional Providers

Approved

0

Additional Providers

Approved

0

Additional Providers

Approved

0

Comprehensive Medical Care

Additional Providers

Approved

0

Choices Women'S Medical Center

Additional Providers

Approved

0

Centers Health Care

Additional Providers

Approved

0

Cure Urgent Care

Additional Providers

Approved

0

Daughters Of Jacob Nursing Home Company

Additional Providers

Approved

0

Federation Of Organizations

Additional Providers

Approved

0

Fountain House, Inc.

Additional Providers

Approved

0

Hope Center

Additional Providers

Approved

0

Personal Touch Home Health Services (Chha)

Additional Providers

Approved

0

Senior Care Ems

Additional Providers

Approved

0

Venture House

Additional Providers

Approved

0

Concern For Independent Living

Additional Providers

Approved

0

Nami-Nyc Metro

Additional Providers

Approved

0

Centers For Care

Additional Providers

Approved

0

Brooklyn Community Services

Additional Providers

Approved

0

Allmedical Ipa

Additional Providers

Approved

0

Suny University Eye Center

Additional Providers

Approved

0

Tri Center Inc.

Additional Providers

Approved

0

Brooklyn Gardens Nursing & Rehabilitation Center Bushwick Center For Rehabilitation And Healthcare Counseling Service Of Edny, Inc. (Csedny)

Beach Garden Rehab & Nursing Center Brooklyn Center For Psychotherapy, Inc. East Harlem Council For Human Services, Inc. Boriken Neighborhood Health Center

NYS Confidentiality – High

Waiver Quarterly Update Amount By Provider IA Provider Provider Category Approval/Rejection Indicator

DY3Q1

Additional Providers

Approved

0

Additional Providers

Approved

0

Additional Providers

Approved

0

Page 17 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.5 - Prescribed Milestones Instructions : Please provide updates to baseline target dates and work breakdown tasks with target dates for required milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

Status

Milestone #1

Complete funds flow budget and distribution plan and communicate with network

Completed

Task

Step 1. Finalize funds flow and distribution plan. Includes feedback from PPS providers who participate in various multi-disciplinary workgroups and committees.

Completed

Task

Step 2. Governance approval of funds flow, criteria for distribution of funds from each budget category and distribution plan

Funds Flow Budget and Distribution Plan, signed off by your Finance Committee, including details of your approach to funds flow on a whole-PPS and project-by-project basis; evidence of involvement of provider network in developing funds flow methodology. Finance workgroup is responsible for assembling the final funds flow after receiving resource requirements from PPS work groups. The executive leadership group has been developing a number of options for funding distribution methodologies to PPS partners. It has been established that the funds will be distributed through performance-based contracts and will be strictly based on partner performance in completing defined milestones and meeting metrics. The finance workgroup is currently in process of narrowing down funding distribution options and data sources for identifying provider award per provider. The next step in the process is for the finance workgroup to review the available options and provide recommendations.

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

07/15/2015

09/30/2015

07/15/2015

09/30/2015

09/30/2015

DY1 Q2

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Finance Committee and Board of Managers Approval. On Hold On Hold as it requires completion of previous step Funds Flow and Distribution Communication Packet.

Task

Step 3. Communication of approved Funds Flow and Distribution Plan to PPS providers

Description

DSRIP Reporting Year and Quarter

On Hold

On Hold as it requires completion of previous step

NYS Confidentiality – High

AV

YES

Page 18 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Complete funds flow budget and distribution plan and communicate with network

Milestone Review Status Milestone # Milestone #1

Review Status

IA Formal Comments

Pass & Complete

NYS Confidentiality – High

Upload Date

Page 19 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.6 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

Page 20 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.7 - PPS Budget - Non-Waiver Revenue (Baseline) Instructions : This table contains five budget categories for non-waiver revenue baseline budget reporting . Please add rows to this table as necessary in order to identify sub-categories.

Budget Items

DY1 ($)

DY2 ($)

DY3 ($)

DY4 ($)

DY5 ($)

Total ($)

Non-Waiver Revenue

42,335,113

42,335,113

42,335,113

42,335,113

42,335,112

211,675,564

Cost of Project Implementation & Administration

10,583,778

10,583,778

10,583,778

10,583,778

10,583,778

52,918,890

Administration

4,233,511

4,233,511

4,233,511

4,233,511

4,233,511

21,167,555

Implementation

6,350,267

6,350,267

6,350,267

6,350,267

6,350,267

31,751,335

Revenue Loss

0

0

0

0

0

0

Internal PPS Provider Bonus Payments

0

0

0

0

0

0

Cost of non-covered services

0

0

0

0

0

0

31,751,336

31,751,336

31,751,336

31,751,336

31,751,336

158,756,680

8,467,023

8,467,023

8,467,023

8,467,023

8,467,023

42,335,115

Other Sustainability Fund Contingency Fund

4,233,511

4,233,511

4,233,511

4,233,511

4,233,511

21,167,555

Performance-Based Payments

14,817,290

14,817,290

14,817,290

14,817,290

14,817,290

74,086,450

Non-Safety Net and CBOFunds

2,116,756

2,116,756

2,116,756

2,116,756

2,116,756

10,583,780

Bonus Funds

2,116,756

2,116,756

2,116,756

2,116,756

2,116,756

10,583,780

42,335,114

42,335,114

42,335,114

42,335,114

42,335,114

211,675,570

0

0

0

0

0

0

Total Expenditures Undistributed Revenue

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : MSPPS used the same initial funds flow categories and methodology for budgeting both waiver and non-waiver revenue across the 5 years.

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

Page 21 of 932 Run Date : 09/29/2017

Page 22 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.8 - PPS Budget - Non-Waiver Revenue (Quarterly) Instructions : Please include updates on non-waiver revenue budget items for this quarterly reporting period. Reported actual spending will be compared to baseline projections and deviations will be evaluated. Any explanations regarding deviations from baseline projections must be included within the textbox, not as narrative within uploaded documentation.

Benchmarks Non-Waiver Revenue DY3

Total Non-Waiver Revenue

42,335,113

211,675,564

Budget Items

Undistributed Non-Waiver Revenue YTD

Undistributed Non-Waiver Revenue Total

31,377,905

165,333,350

DY3 Q1 Quarterly Amount - Update

Cost of Project Implementation & Administration

5,757,208

Administration

2,302,883

Implementation

3,454,325

Revenue Loss Internal PPS Provider Bonus Payments Cost of non-covered services

Cumulative Spending to Date (DY1 - DY5)

Remaining Balance in Current DY

Percent Remaining in Current DY

Percent Remaining of Cumulative Balance

27,915,362

4,826,570

0

0

0

0

0

0

0

0

0

0

0

0

Other

5,200,000

18,426,852

26,551,336

Sustainability Fund

5,200,000

Contingency Fund

0

Performance-Based Payments

0

Non-Safety Net and CBOFunds

0

Bonus Funds

0

Total Expenditures

10,957,208

46,342,214

NYS Confidentiality – High

45.60%

Cumulative Remaining Balance

83.62%

25,003,528

140,329,828

47.25%

88.39%

Page 23 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text :

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 24 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.9 - PPS Flow of Funds - Non-Waiver Revenue (Baseline) Instructions : In the table below, please detail your PPS's projected flow of non-waiver funds by provider type.

Funds Flow Items Non-Waiver Revenue Practitioner - Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP)

DY1 ($)

DY2 ($)

DY3 ($)

DY4 ($)

DY5 ($)

Total ($)

42,335,113

42,335,113

42,335,113

42,335,113

42,335,112

211,675,564

0

0

0

0

0

0

408

408

408

408

408

2,040

Hospital

2,646,665

2,646,665

2,646,665

2,646,665

2,646,665

13,233,325

Clinic

3,881,616

3,881,616

3,881,616

3,881,616

3,881,616

19,408,080

Case Management / Health Home

555,829

555,829

555,829

555,829

555,829

2,779,145

2,915,794

2,915,794

2,915,794

2,915,794

2,915,794

14,578,970

570,599

570,599

570,599

570,599

570,599

2,852,995

97,707

97,707

97,707

97,707

97,707

488,535

Pharmacy

444,080

444,080

444,080

444,080

444,080

2,220,400

Hospice

455,130

455,130

455,130

455,130

455,130

2,275,650

Community Based Organizations

525,218

525,218

525,218

525,218

525,218

2,626,090

4,580,448

4,580,448

4,580,448

4,580,448

4,580,448

22,902,240

260,551

260,551

260,551

260,551

260,551

1,302,755

10,583,778

10,583,778

10,583,778

10,583,778

10,583,778

52,918,890

Total Funds Distributed

27,517,823

27,517,823

27,517,823

27,517,823

27,517,823

137,589,115

Undistributed Non-Waiver Revenue

14,817,290

14,817,290

14,817,290

14,817,290

14,817,289

74,086,449

Mental Health Substance Abuse Nursing Home

All Other Uncategorized PPS PMO

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : Different from the projected flow of funds by provider type for waiver revenue provided in DY1 Q1, MSPPS has more information on its network and the contracting strategy for our providers. As such, we can provide a more accurate projection for flow of funds by provider type for non-waiver revenue. Of note - as MSPPS has opted to flow funds to the top-level/parent organization, there are no substantial funds projected to flow to

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) individual PCPs and Non-PCPs.

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

Page 25 of 932 Run Date : 09/29/2017

Page 26 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.10 - PPS Flow of Funds - Non-Waiver Revenue (Quarterly) Instructions : Please include updates on flow of funds for this quarterly reporting period by importing the PIT file and filling out the PPS PMO line manually. Reported actual fund distribution will be compared to baseline projections and deviations will be evaluated. Any explanations regarding deviations from baseline projections must be included within the textbox, not as narrative within uploaded documentation.

Benchmarks Non-Waiver Revenue DY3 42,335,113.00

Total Non-Waiver Revenue 211,675,564.00

Funds Flow Items

Undistributed Non-Waiver Revenue YTD

Undistributed Non-Waiver Revenue Total

42,335,113.00

183,399,213.79

Percentage of Safety Net Funds DY3 Q1 Quarterly Amount Update

DY3 Q1 Quarterly Amount Update

Safety Net Funds Flowed YTD

Safety Net Funds Percentage YTD

Total Amount Disbursed to Date (DY1-DY5)

DY Adjusted Difference

Cumulative Difference

Practitioner - Primary Care Provider (PCP)

0

0.00%

0

0.00%

126,534.23

0

0

Practitioner - Non-Primary Care Provider (PCP)

0

0.00%

0

0.00%

1,324.98

408

715.02

Hospital

0

0.00%

0

0.00%

1,558,817.81

2,646,665

11,674,507.19

Clinic

0

0.00%

0

0.00%

2,961,220.83

3,881,616

16,446,859.17

Case Management / Health Home

0

0.00%

0

0.00%

685,603.51

555,829

2,093,541.49

Mental Health

0

0.00%

0

0.00%

1,765,592.52

2,915,794

12,813,377.48

Substance Abuse

0

0.00%

0

0.00%

431,455.21

570,599

2,421,539.79

Nursing Home

0

0.00%

0

0.00%

87,114.42

97,707

401,420.58

Pharmacy

0

0.00%

0

0.00%

384,252.08

444,080

1,836,147.92

Hospice

0

0.00%

0

0.00%

388,155.91

455,130

1,887,494.09

Community Based Organizations

0

0.00%

0

0.00%

385,281.95

525,218

2,240,808.05

All Other

0

0.00%

0

0.00%

3,629,103.98

4,580,448

19,273,136.02

Uncategorized

0

0.00%

0

0.00%

628,208.95

260,551

674,546.05

Additional Providers

0

0.00%

0

0.00%

169,482.83

NYS Confidentiality – High

Page 27 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Funds Flow Items

Percentage of Safety Net Funds DY3 Q1 Quarterly Amount Update

DY3 Q1 Quarterly Amount Update

PPS PMO

0

Total

0

0.00%

Safety Net Funds Flowed YTD

Safety Net Funds Percentage YTD

0 0

0.00%

Total Amount Disbursed to Date (DY1-DY5) 15,074,201

DY Adjusted Difference

10,583,778

Cumulative Difference

37,844,689

28,276,350.21

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text :

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) * Safety Net Providers in Green Non-Waiver Quarterly Update Amount By Provider Provider Name

Provider Category

Practitioner - Primary Care Provider (PCP) Practitioner - Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP) Practitioner - Non-Primary Care Provider (PCP) Hospital

DY3Q1 0 0 0 0 0

Hospital

0

Clinic

0

Clinic

0

Case Management / Health Home

0

Case Management / Health Home Mental Health Mental Health Substance Abuse Substance Abuse Nursing Home Nursing Home Pharmacy Pharmacy Hospice Hospice Community Based Organizations Community Based Organizations All Other All Other Uncategorized Uncategorized

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NYS Confidentiality – High

Page 28 of 932 Run Date : 09/29/2017

Page 29 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) * Safety Net Providers in Green

Provider Name

* Safety Net Providers in Green Non-Waiver Quarterly Update Amount By Provider IA Provider Provider Category Approval/Rejection Indicator Additional Providers

Bridging Access To Care

DY3Q1

Provider Name 0

Non-Waiver Quarterly Update Amount By Provider IA Provider Provider Category Approval/Rejection Indicator

DY3Q1

Sage (Services And Advocacy For Glbt Elders)

Additional Providers

Approved

0

Suny University Eye Center

Additional Providers

Approved

0

Additional Providers

Approved

0

Additional Providers

Approved

0

Tri Center Inc.

Additional Providers

Approved

0

Additional Providers

Approved

0

Woodcrest Nursing Home Inc.

Additional Providers

Approved

0

Additional Providers

Approved

0

Comprehensive Medical Care

Additional Providers

Approved

0

Choices Women'S Medical Center

Additional Providers

Approved

0

Centers Health Care

Additional Providers

Approved

0

Cure Urgent Care

Additional Providers

Approved

0

Daughters Of Jacob Nursing Home Company

Additional Providers

Approved

0

Federation Of Organizations

Additional Providers

Approved

0

Fountain House, Inc.

Additional Providers

Approved

0

Hope Center

Additional Providers

Approved

0

Personal Touch Home Health Services (Chha)

Additional Providers

Approved

0

Senior Care Ems

Additional Providers

Approved

0

Venture House

Additional Providers

Approved

0

Concern For Independent Living

Additional Providers

Approved

0

Nami-Nyc Metro

Additional Providers

Approved

0

Centers For Care

Additional Providers

Approved

0

Allmedical Ipa

Additional Providers

Approved

0

Additional Providers

Approved

0

Additional Providers

Approved

0

Brooklyn Community Services

Additional Providers

Approved

0

East Harlem Council For Human Services, Inc. Boriken Neighborhood Health Center

Additional Providers

Approved

0

Liveonny

Additional Providers

Approved

0

Brooklyn Gardens Nursing & Rehabilitation Center Bushwick Center For Rehabilitation And Healthcare Counseling Service Of Edny, Inc. (Csedny)

Beach Garden Rehab & Nursing Center Brooklyn Center For Psychotherapy, Inc.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 1.11 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 30 of 932 Run Date : 09/29/2017

Page 31 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 02 – Governance IPQR Module 2.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation. Note some milestones include minimum expected completion dates.

Milestone/Task Name

Status

Description

Completed

This milestone must be completed by 9/30/2015. Governance and committee structure, signed off by PPS Board.

Milestone #1

Finalize governance structure and subcommittee structure Task

Step 1. Identify the size and number of standing committees

Completed

Task

Step 1. Identify the size and number of standing committees

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Original Start Date

Original End Date

Start Date

04/01/2015

06/30/2015

04/01/2015

Completed

Step 2. Confirm composition and membership of various committees

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 3. Installation of committee co-chairs, and members of the five standing committees (Finance, Clinical, IT, Leadership, Workforce)

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 4. Establish a MSPPS LLC

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 5. LLC formally adopts existing Leadership committee as its board

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 6. LLC adopts existing committee structure including Finance, Workforce, Clinical, Compliance and IT

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Step 7. Complete by-laws/operating agreement of LLC

Completed

Step 7. Complete by-laws/operating agreement of LLC

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Task

Completed

Step 8. Establish Compliance Committee and install members

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Step 2. Confirm composition and membership of various committees. Task

Step 3. Installation of committee co-chairs, and members of the five standing committees (Finance, Clinical, IT, Leadership, Workforce) Task

Step 4. Establish a MSPPS LLC Task

Step 5. LLC formally adopts existing Leadership committee as its board Task

Step 6. LLC adopts existing committee structure including Finance, Workforce, Clinical, Compliance and IT Task

NYS Confidentiality – High

AV

YES

Page 32 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

Step 8. Establish Compliance Committee and install members Task

Step 9. Installment of Compliance Officer and Compliance Lead

Completed

Step 9. Installment of Compliance Officer and Compliance Lead

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

This milestone must be completed by 12/31/2015. Clinical Quality Committee charter and committee structure chart

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 1. Appoint leadership for clinical committee

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 2. Recruit partners for Project Working Group membership for 10 MSPPS project-level sub-committees

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 3. Develop regular meeting schedules for Committee and Sub-commitees

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

Completed

Step 4. Draft and adopt project working group under clinical committee direction

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 5. Establish guidelines and protocols and clinical excellence for implementation

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 6. Collaborate with MSO to select and develop metrics for tracking performance

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 7. Establish a Program Management Office for operational support and project management

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 8. Develop PMO structure, operational policies across partners with installation of all members

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 9. Establish PMO relationship with Management

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Milestone #2

Establish a clinical governance structure, including clinical quality committees for each DSRIP project Task

Step 1. Appoint leadership for clinical committee Task

Step 2. Recruit partners for Project Working Group membership for 10 MSPPS project-level sub-committees Task

Step 3. Develop regular meeting schedules for Committee and Sub-commitees Task

Step 4. Draft and adopt project working group under clinical committee direction Task

Step 5. Establish guidelines and protocols and clinical excellence for implementation Task

Step 6. Collaborate with MSO to select and develop metrics for tracking performance Task

Step 7. Establish a Program Management Office for operational support and project management Task

Step 8. Develop PMO structure, operational policies across partners with installation of all members Task

NYS Confidentiality – High

YES

Page 33 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Step 9. Establish PMO relationship with Management Services Organization (MSO) to provide operational support and management support with clinical integration and population health management

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

Services Organization (MSO) to provide operational support and management support with clinical integration and population health management

Milestone #3

Finalize bylaws and policies or Committee Guidelines where applicable

Description

Original Start Date

Completed

This milestone must be completed by 9/30/2015. Upload of bylaws and policies document or committee guidelines.

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 1. Draft and adopt charter for each Committee

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 2. Develop draft for governing charter

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 3. Adopt Charter standards and objectives

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 4. Adopt MSPPS bylaws

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 5. Draft and adopt dispute resolution policies and procedures

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 6. Draft and adopt partnership agreements and data sharing

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 7. Develop service contracts and agreements for the PPS, as needed

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 8. Establish approval process for contracts and agreements for the PPS

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 9. Establish approval process of DSRIP reporting to the state and CMS

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 10. Develop and adopt Compliance policies and procedures

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

This milestone must be completed by 12/31/2015.

07/20/2015

12/31/2015

07/20/2015

12/31/2015

12/31/2015

DY1 Q3

YES

Task

Step 1. Draft and adopt charter for each Committee Task

Step 2. Develop draft for governing charter Task

Step 3. Adopt Charter standards and objectives Task

Step 4. Adopt MSPPS bylaws Task

Step 5. Draft and adopt dispute resolution policies and procedures Task

Step 6. Draft and adopt partnership agreements and data sharing Task

Step 7. Develop service contracts and agreements for the PPS, as needed Task

Step 8. Establish approval process for contracts and agreements for the PPS Task

Step 9. Establish approval process of DSRIP reporting to the state and CMS Task

Step 10. Develop and adopt Compliance policies and procedures Milestone #4

Establish governance structure reporting and

NYS Confidentiality – High

YES

Page 34 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Governance and committee structure document, including description of two-way reporting processes and governance monitoring processes.

monitoring processes Task

Step 1: Develop a process for tracking progress of governance structure and monitoring process.

Completed

Step 1: Develop a process for tracking progress of governance structure and monitoring process.

07/20/2015

12/31/2015

07/20/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 2. Leadership committee receives reports from IT, Clinical, Workforce, Finance and Compliance at each meeting and reports up on deliverables and risks needing mitigation

07/20/2015

12/31/2015

07/20/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 2. Leadership committee receives reports from IT, Clinical, Workforce, Finance and Compliance at each meeting and reports up on deliverables and risks needing mitigation Task

Step 3. MS PPS PMO along with DSRIP Management Team (DMT) with direction from Clinical Committee and Clinical Executive Committee provides operational oversight and monitoring of quality care, then reporting to appropriate committees

Completed

Step 3. MS PPS PMO along with DSRIP Management Team (DMT) provides operational oversight and monitoring of quality care, then reporting to appropriate committees

07/20/2015

12/31/2015

07/20/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 4. Identify key program metrics to assess workstream progress in financial management, clinical management, workforce management and IT management

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 5. Develop and adopt compliance monitoring process and ensure mitigation of any risks flagged.

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 6. Develop tools for collection and reporting data from all participating providers

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 7. Deploy protocols and tools to all participating providers through MS PMO

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 8: Train all stakeholders involved including MS PPS PMO and DMT on mointoring and tracking of processes.

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 4. DMT and PMO identify key program metrics to assess work stream progress in financial management, clinical management, workforce management and IT management Task

Step 5. Develop and adopt compliance monitoring process and ensure mitigation of any risks flagged. Task

Step 6. Develop tools for collection and reporting data from all participating providers Task

Step 7. Deploy protocols and tools to all participating providers through MS PMO Task

Step 8: Train all stakeholders involved including

NYS Confidentiality – High

AV

Page 35 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

MS PPS PMO, DMT and clinical on monitoring and tracking of processes. Task

Step 9: All committees and stakeholders will complete reporting tool and submit to MS PPS PMO for review and to DMT for approval for presentation to governing committees.

Completed

Step 9: All committees and stakeholders will complete reporting tool and submit to MS PPS PMO for review and to DMT for approval for presentation to governing committees.

08/01/2015

12/31/2015

08/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Community engagement plan, including plans for two-way communication with stakeholders.

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Milestone #5

Finalize community engagement plan, including communications with the public and non-provider organizations (e.g. schools, churches, homeless services, housing providers, law enforcement) Task

Step 1. Identify community resources and organizations participating in activities impacting population health

Completed

Task

Step 2. Recruit participants from PPS who can support community engagementfocusing on CBOs, MH, OASAS and BH

Completed

Task

Step 3. Create a clear strategic community engagement plan

Completed

Task

Step 4. Community Engagement Plan developed with input and representation of continuum of

Completed

The PPS has identified over 73 partners that are also community-based organizations and represent the full spectrum of clinical and social services that are critical in supporting the Medicaid beneficiary population. As noted above, Mount Sinai has recruited a robust membership for its cross-cutting Stakeholder Engagement Workgroup. 73 community-based organizations were invited to participate with 27 responding interest to join the committee. The first workgroup meeting will take place in August/September 2015 The Mount Sinai PPS, in conjunction with the Stakeholder Engagement Workgroup, is establishing a community engagement plan that will include, among other elements, the expectations for partner participation as DSRIP implementation continues, an internal plan for ongoing communications and regular opportunities for engagement with the PPS, clear roles and responsibilities for stakeholders and for the PPS, and a set of goals and milestones that will be achieved through the engagement process. It is our commitment that the PPS cannot be successful in achieving delivery system transformation without the robust participation and buy-in of our partners and stakeholders. The Stakeholder Engagement Workgroup will meet monthly to collaborate and work on key pieces of the community

NYS Confidentiality – High

NO

Page 36 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

care and geographic representation of stakeholders comprising the PPS Task

Step 5. Leadership committee to approve community engagement plan

On Hold

Task

Step 6. Distribute communications and events to community organizations (i.e. CBOs, MH, BH, OASAS, etc…)

Completed

Task

Step 7. Recruit community resources, with ongoing outreach and participation

Completed

Description engagement plan to ensure comprehensive representation and robust participation. Once developed, the community engagement plan will be presented to the Stakeholder Engagement Workgroup for review and approval and then forwarded on as a resolution for approval by the Mount Sinai PPS Board of Managers. Communication materials are regularly distributed via PPS Newsletters, PPS Update email communications and monthly Town Hall meetings. These communications will continue and will be augmented as additional implementation milestones approach. In addition to the Stakeholder Engagement Workgroup, the PPS will benefit from advice and feedback from the Project Advisory Committee (PAC) through quarterly meetings and regular email communications.

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Original Start Date

Original End Date

Start Date

04/01/2015

03/31/2020

07/01/2015

AV

Milestone #6

Finalize partnership agreements or contracts with CBOs

Completed

Signed CBO partnership agreements or contracts.

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

Partnership agreements finalized (June 2015)

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

04/01/2015

06/30/2015

04/01/2015

06/30/2015

06/30/2015

DY1 Q1

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Task

Step 1. Draft partnership and vendor agreements with CBOs Task

Step 2. Finalize partnership and vendor agreements with CBOs for review

Completed

Task

Step 3. Identify appropriate committees for CBO representation, including finance

Completed

Task

Step 4. Contract are distributed, signed and implemented

Completed

Partnership agreement with CBOs finalized; confirmation emails distributed (June 2015); additional contracting arrangements to be determined. Cross-functional Stakeholder Engagement Workgroup being established and first meeting to take place in August/September. Committee will be comprised of CBO partners and representation from Finance Committee and Workforce Committee to ensure cross functional efforts are incorporated. PPS "Partner Profiles" are under development and will be distributed to all PPS partners for confirmation of signed agreements and to confirm interest in individual DSRIP project participation and to identify additional IT and contracting needs. Provider relations team will engage all PPS partners individually to identify and meet IT and other

NYS Confidentiality – High

NO

Page 37 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Original Start Date

Original End Date

Start Date

04/01/2015

12/31/2016

04/01/2015

AV

implementation needs for successful DSRIP implementation. Milestone #7

Finalize agency coordination plan aimed at engaging appropriate public sector agencies at state and local levels (e.g. local departments of health and mental hygiene, Social Services, Corrections, etc.)

Completed

Task

Step 1. Identify appropriate public sector agencies to engage in service area

Completed

Task

Step 2. Engage selected agencies by recruitment in coordination with municipal authorities

Completed

Agency Coordination Plan.

The Mount Sinai PPS will work with its Stakeholder Engagement Workgroup to identify the appropriate agencies for engagement with our PPS And begin development of an agency coordination plan in the fall of 2015. Implement a monthly subgroup meeting of representatives from the PPS, the Stakeholder Engagement Work group and public sector agencies to ensure robust communication and adequate policy interactions.

NO

Task

Step 3: Collaborate with agencies at state and local level in development of coordination plan

Completed

Work with public sector agencies at state and local levels in design of the plan

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Under development and will be presented for Stakeholder Engagement Workgroup review in August/September

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Workforce communication & engagement plan, including plans for two-way communication with all levels of the workforce, signed off by PPS workforce governance body (e.g. workforce transformation committee).

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 1. Outline objectives, principles, and milestones that must be communicated with the MSPPS workforce.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

Task

Step 4. Develop action plan for coordinating agency activities for discussion, review and adoption with Municipal authorities and agencies

Milestone #8

Finalize workforce communication and engagement plan Task

Step 1. Outline objectives, principles, and milestones that must be communicated with the MSPPS workforce. Task

Step 2. Assessment of workforce needs by partner and evaluate value and interest level, level of commitment

Completed

Step 2. Assessment of workforce needs by partner and evaluate value and interest level, level of commitment

NYS Confidentiality – High

NO

Page 38 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Completed

Step 3. Perform Audience and Vehicle Analyses: Define the communication needs and required key messages by audience group, as well as the available communication channels that can be utilized for stakeholder engagement

Task

Step 3. Perform Audience and Vehicle Analyses: Define the communication needs and required key messages by audience group, as well as the available communication channels that can be utilized for stakeholder engagement Task

Step 4. Create workforce communication and engagement strategy which accomplishes goals identified in Sept 1.

On Hold

Task

Step 5. Approval of communication engagement strategy by MSPPS governance.

Milestone #9

Inclusion of CBOs in PPS Implementation.

06/30/2016

06/30/2016

DY2 Q1

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

10/01/2015

06/30/2016

04/01/2015

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

Step 6. Finalize/Implement workforce communication and engagement strategy.

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Explain your plans for contracting with CBOs and their continuing role as your PPS develops over time; detail how many CBOs you will be contracting with and by when; explain how they will be included in project delivery and in the development of your PPS network.

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 1: Using the partner network list, identify CBOs to contract within projects and in the PPS.

09/01/2015

03/31/2016

09/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 2: Working with CBOs, assess regularly continuing role in projects.

09/01/2015

03/31/2016

09/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 3: Collaborate with stakeholders such as CBOs, Finance Committee and Clinical committee in detailing and finalizing contracts related to CBO role in project delivery and PPS engagement.

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Task

Step 2: Working with CBOs, assess regularly continuing role in projects and PPS.

10/01/2015

Start Date

Step 5. Approval of communication engagement strategy by MSPPS governance.

Task

Step 1: Using the partner network list, identify CBOs to contract within projects.

DSRIP Reporting Year and Quarter

Original End Date

On Hold

Task

Step 6. Finalize/Implement workforce communication and engagement strategy.

Step 4. Create workforce communication and engagement strategy which accomplishes goals identified in Sept 1.

End Date

Quarter End Date

Original Start Date

Task

Step 3: Collaborate with stakeholders such as CBOs, Finance Committee and Clinical committee in detailing and finalizing contracts related to CBO role in project and PPS engagement. Task

Step 4: CBOs are involved in PPS implementation.

Completed

Step 4: CBOs are involved in PPS implementation.

NYS Confidentiality – High

AV

NO

Page 39 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IA Instructions / Quarterly Update Milestone Name

IA Instructions

Finalize governance structure and sub-committee structure Finalize bylaws and policies or Committee Guidelines where applicable

Quarterly Update Description

If there have been changes, please describe those changes and upload any supporting documentation as necessary. If there have been changes, please describe those changes and upload any supporting documentation as necessary.

Please state if there have been any changes during this reporting quarter. Please state yes or no in the corresponding narrative box. Please state if there have been any changes during this reporting quarter. Please state yes or no in the corresponding narrative box.

Prescribed Milestones Current File Uploads Milestone Name Finalize governance structure and sub-committee structure

Establish a clinical governance structure, including clinical quality committees for each DSRIP project

Establish governance structure reporting and monitoring processes

User ID

File Type

dlumbao

Other

dlumbao

Other

dlumbao

Other

dlumbao

Other

dlumbao

Other

File Name

Description

34_DY3Q1_GOV_MDL21_PRES1_OTH_Governa nce_Meeting_Schedule_Template_DY2_Q4__M1_Ongoing_reporting_16044.xlsx 34_DY3Q1_GOV_MDL21_PRES2_OTH_Clinical_ Quality_Committee_Meeting_Schedule__DY3_Q1_16048.xlsx 34_DY3Q1_GOV_MDL21_PRES2_OTH_DY3Q1_ Workforce_Committee_Member_Changes_16046.x lsx 34_DY3Q1_GOV_MDL21_PRES2_OTH_DY3_Q1 _Compliance_Committee_Member_Changes_1604 5.xlsx 34_DY3Q1_GOV_MDL21_PRES4_OTH_Quarterly _Cttee_Reporting_Monitoring__Gov_M4_DY3Q1_Ongoing_16047.xlsx

Governance Meeting Schedule Template DY2 Q4 - M1 Ongoing reporting

07/17/2017 04:08 PM

Yes, ongoing reporting.

07/17/2017 04:21 PM

DY3Q1 Workforce Committee Member Changes

07/17/2017 04:14 PM

DY3 Q1 Compliance Committee Member Changes

07/17/2017 04:13 PM

Quarterly Cttee Reporting Monitoring - Gov M4 DY3Q1_Ongoing

07/17/2017 04:15 PM

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Finalize governance structure and sub-committee structure Establish a clinical governance structure, including clinical quality committees for each DSRIP project Finalize bylaws and policies or Committee Guidelines where applicable Establish governance structure reporting and monitoring processes

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Finalize community engagement plan, including communications with the public and non-provider organizations (e.g. schools, churches, homeless services, housing providers, law enforcement) Finalize partnership agreements or contracts with CBOs Finalize agency coordination plan aimed at engaging appropriate public sector agencies at state and local levels (e.g. local departments of health and mental hygiene, Social Services, Corrections, etc.) Finalize workforce communication and engagement plan Inclusion of CBOs in PPS Implementation.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Complete

Milestone #5

Pass & Complete

Milestone #6

Pass & Complete

Milestone #7

Pass & Complete

Milestone #8

Pass & Complete

Milestone #9

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 40 of 932 Run Date : 09/29/2017

Page 41 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name Milestone

Mid-Point Assessment

Status

Description

Completed

Mid-Point Assessment

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

06/01/2016

07/31/2016

06/01/2016

07/31/2016

09/30/2016

DSRIP Reporting Year and Quarter DY2 Q2

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 42 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in implementing your governance structure and processes and achieving the milestones described above, as well as potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Current risks to achieving the above milestones include: financial fragility of many participating providers; the culture of competition rather than cooperation that exists among similar agencies and providers; the ability of the PPS to attain project goals within the proposed budget; the ability of partners to provide up front capital and investments to implement projects; potentially low distribution of DSRIP dollars at the individual provider level; and the lack of understanding DSRIP and impact of payment reform among provider participants. Other risks include ability to develop and share data in a meaningful way to support care coordination, the availability of HIE services by SHIN-NY, availability of capital dollars (including impact of the CRFP awards), and the ability of partners to participate in the planning process (many smaller partners have cited their lack of resources and ability to participate in multiple committees and work groups). The impact of these risk may result in provider partners dropping out of the PPS, not enough capital to launch projects at the partner level that may result in the need to find additional partners, and delaying the PPS's ability to meet DSRIP goals.

IPQR Module 2.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) Major dependencies include the ability to complete participating partner contracting, establishing the working relationships between the PPS and provider partners, ability of partners to launch projects and engage in project work groups, availability of HIE services by SHIN-NY to ensure data sharing infrastructure can be established, and the ability/authority of the PPS to implement monitoring and compliance programs and partner's response to those efforts. We anticipate the need for significant partner education and outreach, particularly at the individual community provider level. The primary interdependency is the participating provider contract that will link providers to the PPS and establish the working relationship between the PPS and its provider network. Integral to that network is an IT platform that is available to all PPS participants and establishes a framework for data exchange and management as well as reporting. The Workforce plan will be a key component of transformation for many providers as they move away from traditional facility based activities into community based activities. The PPS will need to have a plan and program in place to retrain a sufficient number of providers to work in community based settings providing case management and care coordination. Additionally, a robust PMO will be necessary to manage the data and report on the activities of each of the projects and the PPS as a whole.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for the development of your governance structure and processes and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Lead Applicant Entity

Arthur Gianelli, Mount Sinai PPS LLC

PPS Governance and organization

Jill Huck/MS PPS LLC PMO Director

Physician Organizations and large practices Key Advisors, Counselors, attorneys and consultants Audit and Compliance Committee

Finance Committee under co-chairs: Don Scanlon, Mount Sinai PPS LLC and Mark Pancirer, Amsterdam Nursing Home IT Committee under co-chairs: Kumar Chatani, Mount Sinai PPS LLC and Barbara Hood, Ryan Center Clinical Committee under co-chairs: Theresa Soriano, Edwidge Thomas -Mount Sinai PPS LLC and Matthew Weissman, Community Healthcare Network NYC Workforce Committee under co-chairs: Jane Maksoud, Mount Sinai PPS LLC Health System and All Med IPA Mount Sinai Attorneys, Harbage Consulting, PS PPS LLC PMO staff and COPE Mount Sinai and Partners Compliance members

Edwidge Thomas

Clinical Director of the MS PPS PMO

Financial Management and oversight IT Development, information sharing and Implementation Clinical Quality Workforce Development

Key deliverables / responsibilities By law and policy development, funding and staffing resources Establish LLC, PMO contract, provider participation agreements/contracts, compliance program Financial structure, and management of PPS, treasury and accounting, financial oversight of PPS participating providers IT platform, interconnectivity with PPS partners, data base management, performance reporting management Finalize metrics and milestones for each project, monitor quality of projects, review and approve all quality reports Develop workforce strategy Board and Committee members Drafts governance documents, provider agreements, policies and procedures, etc. Oversee compliance to NYSDOH reulations and policies Oversees clinical quality, monitoring and reporting of all DSRIP Projects.

NYS Confidentiality – High

Page 43 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Module 2.6 - IPQR Module 2.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS with regard to your governance structure and processes.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Mount Sinai Hospital Group; Art Gianelli; Arthur Klein; Brad Beckstrom; Caryn Scwab; Don Scanlon; Ed Lucy; Frank Cino; Gary Burke; Jane Maksoud; Kelly Cassano; Sabina Lim; Theresa Soriano; Berthe Erisnor

Lead Applicant, Leadership contributor

Funding, leadership, personnel, committee chairs

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

External Stakeholders Affinity Health Plan; Ajhezza Gonzalez 1199 SEIU; Saily Cabral Amerigroup; David Ackman The Brooklyn Hospital Center; Joan Clark-Carney ArchCare; Scott La Rue VNSNY; Hany Abdelaal William Ryan Center Brian Mcindoe CBC and SUS/Palladia

NYS Confidentiality – High

Page 44 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Key stakeholders Donna Colonna NYSNA James Ferris Metropolitan Jewish Health System Jay Gormley Amsterdam House Jim Davis Settlement Health (CBO) Mali Trilla CityMd Richard Park Aids Service Center (Substance abuse) Sharen Duke AllMed IPA Rizwan Hameed Phoenix House (Behavioral Health) Peter Scaminaci Settlement Health Mali Trilla AIDs Service Center Sharen Duke Institute Family Health; Neil Calman Healthfirst; Tom Meixner NYC Mayor's Office; Sarah Samis

Role in relation to this organizational workstream

Key deliverables / responsibilities

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Leadership, participant

Leadership, committee members

Community Based Organization, Leadership Participant

Involved in CBO engagement and leadership committee

Leadership Participant,

Involved in leadership committee

Leadership Participant,

Involved in leadership committee

Leadership Participant,

Involved in leadership committee

Leadership Participant,

Involved in leadership committee

NYS Confidentiality – High

Page 45 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support this particular workstream and your ability to achieve the milestones described above. The shared IT infrastructure is key to the development of an integrated delivery system, the foundation of the PPS transformation. Development of the IT infrastructure and the process of linking providers to that system will be a major indicator of the success of the PPS in creating an integrated delivery system. A crucial functionality of the overall IT strategy will be identifying risks. To do that, the PPS will use dashboards to monitor multiple dimensions of program performance and the ability to gauge progress against milestones for the appropriate allocation of financial and operational resources. As such, the MS PPS IT infrastructure will allow for PPS-wide data sharing across all provider types through a combination of integration via the RHIO, a user portal for providers, or directly into the MS PPS HIE. The infrastructure to enable data sharing will allow the Board and committees the ability to query key performance indicators for the PPS, by partner type, project and key metrics, both defined by DSRIP and those defined as critical to performance management by each committee. The performance management capability will enable committee members to define key indicators, thresholds (goal charts) and frequency of data collection to monitor partner performance and stability. With relation to DSRIP performance, the MS PPS Rapid Cycle Evaluation (RCE) process will be driven by the data collected and informed by input from the committees and project leads, to ensure timely process improvement initiatives can be put into place to address areas of risk. While performance reporting will be largely informed by claims data, real time or near real-time data will be accessed and utilized for RCE activities and utilization management. This will enable timely feedback loops and course corrections so that improvements aren't limited to quarterly data feeds or otherwise historical data. CBOs will also be able to engage and connect into the MS PPS IT platforms to share information and report on their performance. MS PPS will implement a data normalization service to consume non-standard data produced by existing CBO systems. CBOs will be able to connect into the care coordination and referrals management platforms between them and partnering organizations, as well as access to other IT services through the MS PPS user portal. Additionally, the IT workstream overlaps with the work of the Governance workstream. Successful execution of IT policy and process tasks will inform the development of a comprehensive governance framework for the PPS that includes robust data governance components such as data access, data security, and other IT-related policy elements. Finally, the successful realization of these deliverables will require the shared IT infrastructure to support specific governance milestones such as posting of minutes and agendas on provider and public portals, and soliciting feedback from stakeholders on PPS activities and decisions. These tools will allow the PPS to provide information and technical assistance across its network and service area, thus meeting governance-specific deliverables. In addition, a robust and shared IT infrastructure will minimized the risk for DSRIP under-performance and provide the PPS governing body with data and informatics required to support effective, strategic decision-making.

NYS Confidentiality – High

Page 46 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 2.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. The governance workstream will be successful when the PPS governance structure is fully stood up with timely achievement and establishment of the governance structures. Leadership Committee is operating as the governing board of the PPS and has transitioned to be the Board Of Managers (BoM) in which they will function to approve budgets, distribute funds, contract for services with the PMO, oversee and monitor quality and compliance and foster outreach to providers and beneficiaries. The Leadership committee has transitioned to become the Board of Managers of the MS PPS LLC where the nomination and voting in of the BoM, development and adoption of the bylaws, policies and procedures for all the committees and sub committees along with the development and completion of partner agreements will assist in the operation of the MS PPS. Success will also be determined by the execution of the performance management systems including the data collection, analyses and reporting to support the decision making by the BoM. Having performance management systems ready to collect data and determine the status of each partner in the network will be important for monitoring and reporting of the deliverables set by the PPS.

IPQR Module 2.9 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 47 of 932 Run Date : 09/29/2017

Page 48 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 03 – Financial Stability IPQR Module 3.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation. Note some milestones include minimum expected completion dates.

Milestone/Task Name

Status

Milestone #1

Finalize PPS finance structure, including reporting structure

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Finance committee has been formed and includes representation for different provider types across PPS's geographic region. Finance committee members are represent hospitals, primary care practices, community health centers, long-term care centers, home health agencies

06/01/2015

09/30/2015

06/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Finance work group has been established to include representation from the partner organizations engaged in DSRIP efforts, Mt. Sinai Health System and the Project Management Office. Supported by a consulting team, below are the names of the finance workgroup members to date: Joe Gurracnio, Pat Semenza, Mark Pancirer, Brian McIndoe, Glenn Tolchin, Mike Bruno, Brendan Loughlin, Rachel Amalfitano, Frank Cino, Darrick Fuller, Peter R. Epps, Steve Maggio, Nina Bastian

06/01/2015

07/01/2015

06/01/2015

07/01/2015

09/30/2015

DY1 Q2

Completed

Mt. Sinai Health System has elected two individuals to lead the accounting structure for DSRIP including budgeting and other functions.

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

The MS PPS team has identified staffing needs and costs in relation to carrying out the finance functions for DSRIP. The PMO office staff has also been identified as contributors to the centralized DSRIP efforts.

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 4. Determine the finance function staffing and support services including accounting, financial reporting, budgeting, accounts payable,

End Date

DSRIP Reporting Year and Quarter

06/01/2015

Task

Step 3. Finalize accounting GL structure for recognizing revenues and expenses and for completing DSRIP budgets.

Start Date

Quarter End Date

This milestone must be completed by 12/31/2015. PPS finance structure chart / document, signed off by PPS Board.

Task

Step 2. Establish Finance Work group to review and assimilate funds flow and other financing policies, procedures and issues.

Original End Date

Completed

Task

Step 1. Establish process for nominating and electing finance committee members, to ensure representation from different provider types so that different views and perspectives are considered.

Description

Original Start Date

NYS Confidentiality – High

AV

YES

Page 49 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

Completed

A model of funds flow has been developed that looks at performance payment to partners. The current work being conducted revolves around finalizing project participation per partner, partner list with appropriate service types. The model will be going through finance committee approval process once the input data are finalized. Meanwhile the committee will be approving the principles and thought process behind the funds flow mechanism.

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 6. Develop guiding principles for funds allocation to establish budget categories.

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

AV

and cash management.

Task

Step 5. Establish Funds Flow process that includes a mechanism for review and approval of payments to providers per the funds flow plan by the governance committees.

Task

Step 6. Develop guiding principles for funds allocation to establish budget categories.

Milestone #2

Perform network financial health current state assessment and develop financial sustainability strategy to address key issues.

Completed

Task

Step 1. Develop criteria for assessing financial health of PPS partners.

Completed

Task

Step 2. Develop a process for quarterly submission of financial data/ratios by PPS providers that will require PPS providers to

Completed

This milestone must be completed by 3/31/2016. Network financial health current state assessment (to be performed at least annually). The PPS must: - identify those providers in their network that are financially fragile, including those that have qualified as IAAF providers; -- define their approach for monitoring those financially fragile providers, which must include an analysis of provider performance on the following financial indicators: days cash on hand, debt ratio, operating margin and current ratio; -- include any additional financial indicators that they deem necessary for monitoring the financial sustainability of their network providers The finance work group has developed a draft process and guidelines for the next steps in assessing the financial health of PPS partners. A tentative timeline of all current PPS assessments has been designed to determine the best time frame during which the assessments will be disseminated out to the PPS and Financial Health Assessment is likely to be distributed during DY1 Q2 to allow enough time for completion. A drat process has been drafted by the finance team to allow for quarterly submision of financial ratio data including definitions of ratios, examples and identifying technical support resources for questions and concerns by partners.

NYS Confidentiality – High

YES

Page 50 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Task

End Date

DSRIP Reporting Year and Quarter

Step 3. Re-establish financial baseline with updated roster of MSPPS partners

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 4. Initiate quarterly financial monitoring and analysis of MSPSS partners

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 5. Develop Corrective Action Plan for providers that are deemed fragile.

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 6. Finance Committee to develop a process for PPS members to request the use of contingency funds.

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

This milestone must be completed by 12/31/2015. Finalized Compliance Plan (for PPS Lead).

05/01/2015

12/31/2015

05/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 1. Complete review of NY Social Services Law 363-d, determine scope and requirements of compliance program and plan based upon the DSRIP related requirements that are within the scope of responsibilities of the PPS Lead.

05/01/2015

08/01/2015

05/01/2015

08/01/2015

09/30/2015

DY1 Q2

Completed

Step 2. Develop written policies and procedures that define and implement the code of conduct and other required elements of the PPS Lead compliance plan that are within the scope of responsibilities of the PPS Lead.

06/01/2015

08/01/2015

06/01/2015

08/01/2015

09/30/2015

DY1 Q2

Completed

Step 3. Obtain confirmation from PPS network providers that they have implemented a compliance plan consistent with the NY State Social Services Law 363-d.

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 4. Develop requirements to be included in the PPS

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 5. Develop Corrective Action Plan for providers that are deemed fragile.

Start Date

Quarter End Date

Completed

Task

Step 4. Initiate quarterly financial monitoring and analysis of MS PPS partners

Original End Date

AV

The Internal PMO team has been identified for carrying out data collection and analysis process and the finance workgroup will assess data accuracy.

submit and attest to data accuracy and financial condition. Step 3. Reestablish financial baseline with updated roster of MS PPS partners

Description

Original Start Date

Task

Step 6. Finance Committee to develop a process for PPS members to request the use of contingency funds. Milestone #3

Finalize Compliance Plan consistent with New York State Social Services Law 363-d Task

Step 1. Complete review of NY Social Services Law 363-d, determine scope and requirements of compliance program and plan based upon the DSRIP related requirements that are within the scope of responsibilities of the PPS Lead. Task

Step 2. Develop written policies and procedures that define and implement the code of conduct and other required elements of the PPS Lead compliance plan that are within the scope of responsibilities of the PPS Lead. Task

Step 3. Obtain confirmation from PPS network providers that they have implemented a compliance plan consistent with the NY State Social Services Law 363-d. Task

NYS Confidentiality – High

YES

Page 51 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Step 4. Develop requirements to be included in the PPS Provider Operating Agreement that the network providers will maintain a current compliance plan to meet NY State requirements for a provider.

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

Provider Operating Agreement that the network providers will maintain a current compliance plan to meet NY State requirements for a provider.

Task

Step 5. Obtain Executive Body approval of the Compliance Plan (for the PPS Lead) and Implement

Completed

Step 5. Obtain Executive Body approval of the Compliance Plan (for the PPS Lead) and Implement

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Administer VBP activity survey to network

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

On Hold

Step 1. Develop value-based contracting principles and objectives.

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Step 2. Obtain from the providers and stakeholders the following input: Identify services linked to value-based and FFS payments from providers, revenue from value-based contracts, current understanding of value-based care delivery

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Step 3. Conduct initial meetings with select MCOs to evaluate current and future options in line with requirements for valuebased contracting with providers.

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

In collaboration with select MCOs develop materials to educate partnership on various types of value-based payments and State's goals with MCO contracts

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Milestone #4

Develop a Value Based Payments Needs Assessment ("VNA") Task

Step 1. Develop value-based contracting principles and objectives. Task

Step 2. Obtain from the providers and stakeholders the following input: Identify services linked to value-based and FFS payments from providers, revenue from valuebased contracts, current understanding of valuebased care delivery Task

Step 3. Conduct initial meetings with select MCOs to evaluate current and future options in line with requirements for value-based contracting with providers. Task

Step 4. Identify provider performance metrics to incentivize appropriate behaviors to achieve quality, patient satisfaction and financial goals. Task

Step 5. Develop metrics for evaluating success under a risk-based contracts. Task

Step 6. Develop a contract matrix for cataloging

On Hold

On Hold

Hold information sessions with stakeholders, providers and MCOs to share results of partner assessment regarding current understanding and status of value-based arrangements in the PPS Information request from partners and MCOs via electronic submission and key informant interviews to evaluate plans

NYS Confidentiality – High

YES

Page 52 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

all DSRIP contracts.

Task

Step 7. Complete baseline assessment report and develop value-based purchasing strategies.

On Hold

Task

Step 8. Develop and conduct an education session with providers and other stakeholders on VBP.

On Hold

Description and potential strategies toward value-based arrangements Using results from information requests, educational session and interviews with stakeholders develop a baseline assessment report to include current value-based revenue for the PPS, likely changes in the revenue from both MCO and provider perspective and future potential arrangements that will drive the shift toward value-based payment mechanisms Socialize baseline assessment report with partnership and key MCOs in the PPS providers for review and feedback Obtain approval of Board of Managers on the final baseline assessment of revenue linked to value-based payments, preferences for development

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Original Start Date

Original End Date

Start Date

04/01/2015

03/31/2020

04/01/2015

AV

Milestone #5

Develop an implementation plan geared towards addressing the needs identified within your VNA

Completed

Submit VBP support implementation plan

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

Identify services linked to value-based payments and FFS services for feedback by MCOs and providers

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

Identify appropriate metrics required to evaluate success under risk-based contracts using baseline assessment results

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

Conduct a series of meetings with MCOs to finalize valuebased metrics and pringiples for value-based contracts with PPS Providers

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

Step 4. Socialize MCO meeting results with PPS for comments and feedback

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

Step 5. Develop a final plan for achieving 90% value-based payments to include goals for future meeting with MCOs stakeholder engagement schedule and communication plan, MCO contracting arrangements for the providers in the PPS network

04/01/2015

03/31/2020

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Task

Step 1. Update services linked to value-based payments and FFS services and collaborate with providers in the network to determine the best approach to contracting with MCOs. Task

Step 2. Finalize metrics for evaluating success under a risk-based contract. Task

Step 3. Discuss PPS value-based payment plan with MCOs within the framework of NY DOH Value-Based Payment Roadmap Task

Step 4. Socialize MCO meeting results with PPS for comments and feedback Task

Step 5. Develop a final plan for achieving 90% value-based payments to include goals for future meeting with MCOs stakeholder engagement schedule and communication plan, MCO contracting arrangements for the providers in the PPS network

NYS Confidentiality – High

YES

Page 53 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Milestone #7

VBP Milestones TBD Milestone #8

VBP Milestones TBD

End Date

DSRIP Reporting Year and Quarter

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

YES

Original End Date

Start Date

04/01/2015

03/31/2020

AV

Completed

Initial Milestone Completion: Submit VBP education/training schedule Ongoing Reporting: Submit documentation to support implementation of scheduled trainings, including training materials and attendance sheets through quarterly reports

In Progress

TBD

04/01/2017

03/31/2020

03/31/2020

DY5 Q4

YES

In Progress

TBD

04/01/2017

03/31/2020

03/31/2020

DY5 Q4

YES

Milestone #6

Develop partner engagement schedule for partners for VBP education and training

Description

Quarter End Date

Original Start Date

IA Instructions / Quarterly Update Milestone Name

IA Instructions

Finalize PPS finance structure, including reporting structure

Quarterly Update Description

If there have been changes, please describe those changes and upload any supporting documentation as necessary.

Please state if there have been any changes during this reporting quarter. Please state yes or no in the corresponding narrative box.

Prescribed Milestones Current File Uploads Milestone Name Develop an implementation plan geared towards addressing the needs identified within your VNA

Develop partner engagement schedule for partners for VBP education and training

User ID

File Type

dlumbao

Other

dlumbao

Implementation Plan & Periodic Updates

dlumbao

Other

dlumbao

Other

File Name

Description

34_DY3Q1_FS_MDL31_PRES5_OTH_Milestone_ #5_170913_17075.pdf 34_DY3Q1_FS_MDL31_PRES5_IMP_Milestone_# 5_16190.pdf 34_DY3Q1_FS_MDL31_PRES6_OTH_Milestone_ #6_170913_17076.pdf 34_DY3Q1_FS_MDL31_PRES6_OTH_Milestone_ #6_16191.pdf

Financial Sustainability Milestone #5 Documentation

09/14/2017 12:36 PM

Implementation plan

07/20/2017 04:21 PM

Financial Sustainability Milestone #6 Documentation

09/14/2017 12:38 PM

Submit VBP education/training schedule

07/20/2017 04:24 PM

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Finalize PPS finance structure, including reporting structure Perform network financial health current state assessment and

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

develop financial sustainability strategy to address key issues. Finalize Compliance Plan consistent with New York State Social Services Law 363-d Develop a Value Based Payments Needs Assessment ("VNA") For DY3Q1 Remediation- please see this upload as a response to IA comments on Financial Stability Milestone 5 "The IA does not consider this milestone complete. The PPS must include specific support activities for both providers and community based organizations as it relates to VBP needs." Develop an implementation plan geared towards addressing the needs identified within your VNA

Develop partner engagement schedule for partners for VBP education and training

For Milestone#5 Completion_Develop an implementation plan geared towards addressing the needs identified within your VNA. For DY3Q1 Remediation- please see this upload as a response to IA comments on Financial Stability Milestone 6 "The IA has reviewed the documentation by the PPS and has determined that it has not met the minimum requirements for milestone #6. The PPS did not submit a schedule that was topic specific based on the VNA with respect to VBP. The PPS must submit a plan with topic specific sessions related to the VNA." For Milestone #6 completion- Develop partner engagement schedule for partners for VBP education and training

VBP Milestones TBD VBP Milestones TBD

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Complete

Milestone #5

Pass & Complete

Milestone #6

Pass & Complete

Milestone #7

Pass & Ongoing

Milestone #8

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 56 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 3.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in implementing these cross-cutting organizational strategies, including potential impacts on specific projects and, crucially, any risks that will undermine your ability to achieve outcome measure targets. "There may be challenges and risks in 5 key areas: 1) Risk/challenge: Being able to reliably receive quarterly results from providers to monitor financial health. There will be a large volume of materials coming in to review and MSPPS will need to create a standardized submission and review process. a. Mitigation: Process must include conversations with, and obtain buy-in from, providers to understand why financials may be trending one way or another. There may be unique seasonality at a provider or changes to financial statements may be due to something other than DSRIP. Consider contract terms that permit penalties or sanctions for non-performing providers. 2) Risk/challenge: If a provider is experiencing revenue loss due to DSRIP project implementation, there exists a challenge to evaluate loss due to DSRIP quantified vs. loss due to other reasons and the level of due diligence necessary by MSPPS in evaluating requests for funding to cover revenue loss. a. Mitigation: Develop a mechanism in evaluating budget vs. actual spending on DSRIP related work as part of assessing overall financial health of PPS partners. 3) Risk/Challenge: There is a need to establish confident estimates of future awards when making financial decisions such as adding PMO staff and setting annual budgets. a. Mitigation: Work closely with MSPPS IT and Business Intelligence capabilities to continually assess progress against goals for estimating potential awards and progress. 4) Risk/Challenge: Ability to contract with MCOs and get 90% of payments under value-based payment methodologies. a. Mitigation: Work in close collaboration with the State in incentivizing MCOs to negotiate and work with MSPPS. 5) Risk/Challenge: Performance is hard to define or isn't available initially so payments are based on missing or inaccurate data. In addition, accurate data is required for project attribution for initial valuation of provider commitments. a. Mitigation: Evaluation mechanism to ensure speed and scale commitments are realistic and achievable) and accurate performance data with provider attribution so that performance can be measured efficiently and fairly.

IPQR Module 3.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) "IT Systems: As part of developing data reporting mechanism to manage the provider data base and performance and process reporting, the finance team would need to ensure the appropriate measures are captured as part of the reporting process and appropriate analytics are built in

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) over time to allow for real-time dashboard reporting. Workforce: As part of the workforce strategy budget, the finance workstream would need to consider the impact on the PPS and potential mitigation strategies (i.e. tapping into reserve funds to ensure this workstream is successful). Governance: Finance Committee is part of the formal governance structure. A number of elements requiring integration are CBO contracting and evolving governance model. Cultural Competency and Health Literacy: As part of the training or change management programs that the PPS sets out to achieve, integration around cost of those services and monitoring of them brings an essential collaborative opportunity between the two workstreams. Performance Reporting: Financial health reporting protocols will need to be standard across the PPS in order for the lead organization to be able to make accurate assessment of the overall PPS health. The development of strategies to establish the appropriate reporting structure will be approved by the Finance Committee before being finalized. Population Health Management: As part of performing provider contracts, outcome measures will drive the majority of the incentive payments earned in the last years of DSRIP. The strategy for population health management and roadmap development must align with the performance contracting process and principles. Practitioner Engagement: as part of performing provider contracts, provider engagement early in the contracting process and throughout DSRIP period is key to ensure the contractual obligations are met."

NYS Confidentiality – High

Page 57 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Finance Committee

Don Scanlon, Chair, Co-Chair Mark Pancirer, Co-Chair

Approve policies and procedures; maintain oversight of management of DSRIP funds; monitor financial performance of MSPPS and all partners; review capital and operating budgets

NYS Confidentiality – High

Page 58 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Role

Name of person / organization (if known at this stage)

Finance Workgroup

PPS Members

Compliance Committee

Frank Cino, Chair; PPS Members

Accounting and Treasury Management Services

Mike Bruno, SVP Finance, Mount Sinai

Consultants

COPE Health Solutions

Key deliverables / responsibilities

Develop guiding principles, define financial performance metrics, accounting processes; define reporting standards and requirements; and develop ongoing partner assessment processes Draft a compliance program and monitor performance Setup accounting services, GL chart of accounts, and treasury management services for the PPS Drive Finance Committee deliverables through proven DSRIP experience and project management support

NYS Confidentiality – High

Page 59 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Art Gianelli PMO Finance Leads

St. Lukes Roosevelt, President Obtain input regarding resource requirements, DSRIP operating plans, and work force requirements Obtain input regarding funds flow, financial sustainability requirements and MCO / risk based contracting strategy.

Executive leader of Mount Sinai PPS Feedback and request for resources Feedback on allocation and request for resources

External Stakeholders Skilled Nursing/Housing/Rehabilitation

Rachel Amalfitano, CFO, Village Care

Skilled Nursing/Nursing Home

Mark Pancirer, CFO, Amsterdam House

Home Care

Glenn Tolchin, CFO, VNSNY

Hospital

Joseph Guarracino, CFO, Brooklyn Hospital Center

FQHC

Jose Virella, CFO, Ryan Center Health Network

Participate in appropriate committees and provide generalized PPS feedback through townhall forum Participate in appropriate committees and provide generalized PPS feedback through townhall forum Participate in appropriate committees and provide generalized PPS feedback through townhall forum Participate in appropriate committees and provide generalized PPS feedback through townhall forum Participate in appropriate committees and provide generalized PPS feedback through townhall forum

NYS Confidentiality – High

Page 60 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support this particular workstream. At its core, IT services will provide the clinical integration and pop health backbone for the PPS, enabling enhanced care coordination, utilization management and provider integration. This infrastructure design will inherently enable management of PPS and DSRIP project performance across the entire PPS and multiple partners. The partners will be able to collect and submit financial reports directly to the PPS Finance team using an electronic platform. These reports and data will enable PPS leadership and appropriate committees the ability to understand how DSRIP projects are impacting overall utilization, associated Medicaid payments and overhead costs; allowing for the identification of appropriate business and utilization management strategies to minimize any unintended consequences. While it is expected that some providers will experience decreased volume, the intent is to achieve this in an incremental and controlled manner, which will allow providers to adapt over time during DSRIP, adjust to new volumes and financial incentives, and re-align operating models. MS PPS is also working to establish a customer-relations management tool in order to track all reporting functions of the PPS and all contracts. This will include the reporting of financial metrics on a quarterly basis. The data will be self-reported through easy-to use portal system. The PPS data warehouse containing information from RHIO, providers and payers will serve an essential purpose in evaluating value-based payment options as the PPS matures. The design of centralized IT services' ultimate goal is to enable more cost-effective health care delivery and minimize duplication and waste through reduced variability in clinical processes and decision-making, ongoing process improvement, reduced avoidable acute care utilization and other high-cost services and expenses. This more cost-effective delivery model will decrease total per patient spending, increase tangible value to patients, providers and payers and ultimately enable the network to engage in shared savings and/or value-based payment models. These new payment models will better incentivize health care transformation and maintenance of cost-effective care delivery across the continuum of care. Decreased per patient costs will in turn generate sufficient operating revenue for partners to further invest in infrastructure development and population health initiatives.

IPQR Module 3.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. Once implementation plan is complete, the plan and progress against its milestones will be reviewed by Finance Committee every 3 months. Success will be measured by tracking results of each commitment in the plan.

NYS Confidentiality – High

Page 61 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) The success of Financial Sustainability Plan will be achieved through a number of key elements: • Creating the funds flow principles, processes, and budgets for distribution of DSRIP funds to support implementation of the Financial Sustainability Plan. • Evolving Governance structure and participation of key stakeholders and providers in the PPS service area. • Focused integration of IT information and systems in order to enable accurate and timely information flow across PPS providers necessary for proactive performance monitoring. This information flow will include value-based payment measures. • Regular review of the implementation plan milestones and progress towards meeting the requirements with a report out to the committee on identified areas of risk and potential mitigation strategies to address them. • Strong PMO structure to facilitate effective implementation of the DSRIP projects.

IPQR Module 3.9 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 62 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 04 – Cultural Competency & Health Literacy IPQR Module 4.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation. Note some milestones include minimum expected completion dates.

Milestone/Task Name

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

Completed

This milestone must be completed by 12/31/2015. Cultural competency / health literacy strategy signed off by PPS Board. The strategy should: -- Identify priority groups experiencing health disparities (based on your CNA and other analyses); -- Identify key factors to improve access to quality primary, behavioral health, and preventive health care -- Define plans for two-way communication with the population and community groups through specific community forums -- Identify assessments and tools to assist patients with selfmanagement of conditions (considering cultural, linguistic and literacy factors); and -- Identify community-based interventions to reduce health disparities and improve outcomes.

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 1: Identify PPS partners with Cultural Competence / Health Literacy expertise and establish work-group.

06/01/2015

09/30/2015

06/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 2: Building on the CNA, conduct a gap analysis of cultural competency at the partner and PPS level to: 1) identify populations and practices with greatest health disparities and/or poor patient experience, 2) identify key factors and barriers to improve access to primary, behavioral health and preventive care, and 3) define role/capabilities of

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Milestone #1

Finalize cultural competency / health literacy strategy.

Original Start Date

Task

Step 1: Identify PPS partners with Cultural Competence / Health Literacy expertise and establish work-group. Task

Step 2: Building on the CNA, conduct a gap analysis of cultural competency at the partner and PPS level to: 1) identify populations and practices with greatest health disparities and/or poor patient experience, 2) identify key factors and barriers to improve access to primary,

NYS Confidentiality – High

AV

YES

Page 64 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

06/01/2015

09/30/2015

09/30/2015

DY1 Q2

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

Step 6: Develop metrics to evaluate and monitor ongoing impact of CC/HL initiatives.

06/01/2015

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

This milestone must be completed by 6/30/2016. Cultural competency training strategy, signed off by PPS Board. The strategy should include: -- Training plans for clinicians, focused on available evidencebased research addressing health disparities for particular groups identified in your cultural competency strategy

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Original Start Date

Original End Date

Start Date

Completed

Step 3: Inventory best practices, existing resources for training staff and delivering CC/HL - sensitive services. Using this information, establish PPS-wide definition of CC/HL, and standards for culturally and linguistically appropriate services and care.

06/01/2015

09/30/2015

Completed

Step 4: CC/HL work-group develops and collaborates with the Workforce Committee to present CC/HL Strategy to appropriate committees for approval, including plans for patient-related education and materials (including verbal scripts, print, media, online) with Clinical and Patient Advisory Board. Meet with partners and community groups to get buyin and support. Collaborate with IT and Finance Committees to outline and finalize financial and IT needs necessary to implement training strategy.

06/01/2015

Completed

Step 5: Develop communications and engagement approach designed to get partner and patient buy-in.

Completed

Completed

Status

behavioral health and preventive care, and 3) define role/capabilities of CBOs in our network to provide supportive services. This analysis will be used to identify key targets and goals for the PPS.

Description

AV

CBOs in our network to provide supportive services. This analysis will be used to identify key targets and goals for the PPS.

Task

Step 3: Inventory best practices, existing resources for training staff and delivering CC/HL - sensitive services. Using this information, establish PPS-wide definition of CC/HL, and standards for culturally and linguistically appropriate services and care. Task

Step 4: CC/HL work-group develops and collaborates with the Workforce Committee to present CC/HL Strategy to appropriate committees for approval, including plans for patient-related education and materials (including verbal scripts, print, media, online) with Clinical and Patient Advisory Board. Meet with partners and community groups to get buy-in and support. Collaborate with IT and Finance Committees to outline and finalize financial and IT needs necessary to implement training strategy. Task

Step 5: Develop communications and engagement approach designed to get partner and patient buy-in. Task

Step 6: Develop metrics to evaluate and monitor ongoing impact of CC/HL initiatives. Milestone #2

Develop a training strategy focused on addressing the drivers of health disparities (beyond the availability of language-appropriate material).

NYS Confidentiality – High

YES

Page 65 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

-- Training plans for other segments of your workforce (and others as appropriate) regarding specific population needs and effective patient engagement approaches Task

Step 1: The CC/HL work-group and PMO will create an inventory among network partners in PPS to identify existing training practices.

Completed

Step 1: The CC/HL work-group and PMO will create an inventory among network partners in PPS to identify existing training practices.

06/01/2015

03/31/2016

06/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 1.a: Prioritize and finalize training needs and programs with Workforce Committee and other stakeholders.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 2: Develop and test a uniform training and education platform that blends e-learning, self-assessment, and inperson review. This platform will educate both clinicians and non-clinicians on health literacy and cultural competency. The format and delivery of trainings will be consistent for clinicians and non-clinicians, however; content will vary for clinicians and non-clinicians to ensure relevance.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 2.a: Identify CC "champions" within each partner and establish corresponding points of contact with CBOs.

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Step 3: Collaborate with IT Committee to create web-enabled training.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 4: Develop tracking mechanism and evaluation mechanism to receive feedback from staff on trainings and possible steps to improve. This may include conducting focus groups with supervisors in open forums.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 5: PPS governance will prioritize training and roll out for the following three priority areas, using CNA and PPS-led meetings above [see Milestone 1],with the goal of maximizing

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Task

Step 1.a: Prioritize and finalize training needs and programs with Workforce Committee and other stakeholders. Task

Step 2: Develop and test a uniform training and education platform that blends e-learning, selfassessment, and in-person review. This platform will educate both clinicians and non-clinicians on health literacy and cultural competency. The format and delivery of trainings will be consistent for clinicians and non-clinicians, however; content will vary for clinicians and non-clinicians to ensure relevance. Task

Step 2.a: Identify CC "champions" within each partner and establish corresponding points of contact with CBOs. Task

Step 3: Collaborate with IT Committee to create web-enabled training. Task

Step 4: Develop tracking mechanism and evaluation mechanism to receive feedback from staff on trainings and possible steps to improve. This may include conducting focus groups with supervisors in open forums. Task

Step 5: PPS governance will prioritize training and roll out for the following three priority areas,

NYS Confidentiality – High

AV

Page 66 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

using CNA and PPS-led meetings above [see Milestone 1],with the goal of maximizing the potential number of patients benefitted by the enhanced training: 1. Primary care sites and providers with identified patients having high specific cultural needs and low health literacy levels. 2. Sites/providers with the largest workforce numbers requiring CC/HL training. 3. Sites/providers/practitioners that have the largest number of patients serviced by the PPS projects.

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

the potential number of patients benefitted by the enhanced training: 1. Primary care sites and providers with identified patients having high specific cultural needs and low health literacy levels. 2. Sites/providers with the largest workforce numbers requiring CC/HL training. 3. Sites/providers/practitioners that have the largest number of patients serviced by the PPS projects.

IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Finalize cultural competency / health literacy strategy. Develop a training strategy focused on addressing the drivers of health disparities (beyond the availability of languageappropriate material).

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 67 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 4.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 69 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 4.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in implementing your cultural competency / health literacy strategy and addressing the specific health disparities you are targeting (based on your CNA), and achieving the milestones described above - including potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Risk 1: Timeliness of retraining and redeploying the workforce. Mitigation: assess needs of individual providers and provide support to assist provider in meeting project timeline. Determine ability of provider and where in the roll out process they would be. Risk 2: Do organizations have adequate coverage to pull employees into additional training? Mitigation: work closely with union, identify funding for providers, and develop a broad base workforce via Workforce Committee strategies. Risk 3: Employee engagement. Mitigation: assess providers internal activity of employee engagement. Develop resources and programs for PPS providers to assist them with their programs. Risk 4: Needs of the community exceed the ability of the current workforce. Mitigation: Identify recruitment strategy for each project. Determine ability of providers to redeploy staff to different communities based on CC and HL. Risk 5: There is a strong co-dependency between the Clinical and Workforce Committees. The work task that the Clinical Committee creates must dictate the work structure the Workforce Committee supports in order for implementation to be successful. It is a potential risk, that with such a large undertaking, the work may become siloed within functional groups. Mitigation: the MSPPS will coordinate cross-functional work-groups to ensure collaboration. This will also serve to make estimates more realistic, as workforce will not examine each clinical project in isolation, but rather as part of a larger system change. Risk 6: The future state analysis of the workforce is similarly dependent on the outcomes of the Clinical Committee work. Mitigation: Workforce and Clinical leadership will work together to ensure necessary information is provided to the committees in order to achieve milestones. Risk 7: The MSPPS anticipates significant competition for talent in certain roles with other PPSs as the DSRIP initiative moves forward. Mitigation: The MSPPS plans on collaborating with other PPSs as well as key stakeholders and educational institutions to reduce potential difficulties. Risk 8: The MSPPS clinical work will need to scale faster than the training initiatives can support. Once training needs have been identified, curriculum may need to be developed, and the training itself may take time to be done effectively. Mitigation: The MSPPS will work with training providers to ensure we can scale appropriately, as well as collaborate internally to address clinical needs with the resources available. Risk 9: Each partner and employees at each partner will join the PPS at differing levels of education, experience, and baseline knowledge. Mitigation: The training strategy will take into account these different levels in designing training initiatives and timeline. Risk 10: Preliminary discussions with some of our community-based providers suggest that there may be regulatory issues that impact staffing, roles, and capacity of their work forces. Mitigation: The PPS will work with its partners and NYS to identify and implement solutions to such issues. Risk 11: The MSPPS may also face a risk of exposing confidential information as a result of sharing data across the various partners. Mitigation: There will be strict controls put in place as part of the assessment steps of implementation plan so as to minimize this risk.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 4.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) Successful planning and implementation of a cultural competency and health literacy strategy and a meaningful training program rests on several closely tied work streams with the PPS leadership, members and other technical committees. Clinical and Workforce committees, in collaboration with stakeholder unions and community advisers must assess existing curricula and develop one standardized training curriculum for multiple disciplines and workforce levels endorsed by the PPS provider organizations. Excellent provider and partner engagement to educate them about the strong linkage between poor cultural competency/health literacy and health outcomes, and the effectiveness of "universal precautions" (Step 1a – milestone 1) will be necessary to achieve buy-in for the importance of training of workforce and modification of current verbal and written communication. Adequate funds must be allocated to the development of these curricular programs and to the creation of different modes of training and evaluation depending on level or workforce and roles. This necessitates working with the IT committee to plan feasible curricular activities and develop a common training platform or alternate strategy that can be tracked within the individual organizations and by PPS leadership.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 4.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Clinical Committee Co-Chair

Theresa Soriano, Mount Sinai Health System

Provide input to shape policies and procedures.

Clinical Committee Co-Chair

Matt Weissman, Community Healthcare Network

Provide input to shape policies and procedures.

Clinical Director

Edwidge Thomas, Mount Sinai PPS

Provide input to shape policies and procedures.

IT Committee Co-Chair

Kumar Chatani, Mount Sinai Health System

Provide input to shape policies and procedures.

IT Committee Co-Chair

Barbara Hood, Ryan Center

Workforce Committee Co-Chair

Jane Maksoud, Mount Sinai Health System

Provide input to shape policies and procedures. Approve policies and procedures; lead and maintain oversight of committee activities and projects.

Workforce Committee Co-Chair Cultural Competence / Health Literacy Workgroup Co-Chair

Linda Reid, VNSNY

Workforce and Clinical Committees

PPS Members

Workforce Project Team

Workforce Committee representative members, including partner and union representation

Workforce Project Management

Daniel Liss, Mount Sinai Health System; MSPPS PMO Members

Consultants Cultural Competence / Health Literacy Workgroup Co-Chair

Undetermined

Approve policies and procedures; lead and maintain oversight of committee activities and projects.

Emma Sollars, Mount Sinai Health System

Assess and define the current and future states of the workforce; conduct a gap and benefits/compensation analysis; create a transition roadmap and training strategy. Complete implementation plan steps; make recommendations to the committee for review and approval. Drive completion of Implementation Plan deliverables; manage community and stakeholder engagement. Help prepare workforce and training analyses and materials. Approve policies and procedures; lead and maintain oversight of committee activities and projects.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 4.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Mount Sinai Health System

Lead Applicant

Clinical, Finance, and IT Committees

Key partners in developing workforce goals

Mount Sinai Department of Social Work Services

Cultural Competence and Health Literacy Workgroup Co-Chair Emma Sollars, Program Coordinator, Training and Education

Leadership; operation of centralized functions. Collaborate with Workforce Committee to determine needs, funding, and reporting mechanisms. Leadership.

External Stakeholders

Other MSPPS Partners

Workforce Committee Co-chair Partner / Cultural Competence and Health Literacy Workgroup Co-Chair - Linda Reid, Director, Workforce Planning & Diversity Partners in PPS

Labor Management Project (1199)

Partners in PPS - Michael Shay, Labor Management Consultant

NYSNA - TBD as needs are determined.

Partners in PPS

Community Healthcare Network (CHN)

NYCDOHMH

Partners in PPS - Emily Briglia, Health Literacy Program Manager Partners in PPS - Jamillah Hoy-Rosas,Director of Health Coaching and Clinical Partnerships Local Collaborator - - TBD as needs are determined.

NY Legal Assistance Group

Partners in PPS - Beth Breslin, Policy Associate

Other, non-MSPPS, organizations and PPSs

External Stakeholder - TBD as needs are determined.

Managed Care Organizations and other Payers

Partners in PPS and external stakeholders - TBD as needs are determined.

VNSNY

City Health Works

Leadership. Participate in Workforce Committee. Participate in Workforce Committee; will play prominent role in the coordination of training and other workforce efforts. Participate in Workforce Committee Provide input and expertise in strategy including training. Provide input and expertise in strategy including training and patient education. Provide input and expertise in strategy including training. Provide input and expertise in strategy including patients rights and training. Potentially collaborate with Workforce Committee and MSPPS on joint activities. Provide input and expertise in strategy including training.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 4.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support the development and implementation of your cultural competency / health literacy strategy and the achievement of the milestones described above. The development of a shared IT infrastructure will support the implementation of the MS PPS cultural competency/health literacy strategy by providing a means for the distribution of consistent, culturally competent materials and training for patients and providers, and by establishing Health Information Exchange (HIE) between the health system and culturally competent Community Based Organizations (CBOs). A central component of the MS PPS strategic plan, as it relates to cultural competency, is the provision of a myriad of training activities, including foundational instruction on the relationship between culture, stigma and health for the frontline and patient-interacting workforce. This training will be implemented via a core function of the MS PPS IT infrastructure- the Learning Management System (LMS). LMS will allow the PPS to deliver and track cultural competence training across all participating PPS providers and monitor both deficits and improvements, over time. Simultaneously, the PPS will use elements of its shared IT infrastructure to develop and deliver culturally appropriate information and education to its patient population, taking into account patient health literacy. The IT tool which supports this charge is the Patient Portal, which includes virtual support to assist in completing referrals for clinical and non-clinical services, after-hours care (triage)/warm-line and general PPS-level customer services. Finally, the IT infrastructure will include flat file/CBO data conversion implementation that will allow culturally competent CBOs participating in the PPS to exchange data and track outcomes, particularly around the provision of services impacting the social determinants of health.

IPQR Module 4.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. Staff Training: 1. Percentage of staff members that complete training modules within identified time period. 2. Percentage of staff members that score within target % range (to be identified) on post training competency evaluation. 3. Percentage of staff that receive meets or exceeds expectations on performance appraisals in these topic areas. Patient Population: 1. Percentage of identified patients that have improved compliance (identify target %) with attending medical appointments (primary care, specialty). 2. Percentage of identified patients that have improved adherence with medication regimen (identify target %). 3. Percentage of identified patients that have reduced unnecessary medical utilization (emergency department visits and hospitalizations).

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 4.9 - IA Monitoring Instructions :

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 05 – IT Systems and Processes IPQR Module 5.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

Milestone #1

Perform current state assessment of IT capabilities across network, identifying any critical gaps, including readiness for data sharing and the implementation of interoperable IT platform(s).

Completed

Detailed IT current state assessment. Relevant QEs (RHIOs/HIEs) should be involved in performing this assessment.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Current state assessment planning has begun. We are currently working with other workstreams to coordinate the assessment process and finalize the list of PPS partners

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 2. Develop current state assessment plan to determine the current landscape for PPS lead entity to support project and reporting requirements.

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Step 3. Conduct data collection (survey of partners) for assessment utilizing tools such as email, phone, and in person assessments.

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Step 4. Validation of survey responses from partners

Completed

Step 4. Validation of survey responses from partners

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Completed

Step 5. Leverage the assessment data collected to conduct

01/01/2016

09/30/2016

01/01/2016

09/30/2016

09/30/2016

DY2 Q2

Task

Step 1. Develop current state assessment plan to determine the current landscape of EHR deployments, state of implemented interoperability between these systems, and levels of functional data sharing in the MS PPS provider network, including a list of PPS participant organizations to be queried Task

Step 2. Develop current state assessment plan to determine the current landscape for PPS lead entity to support project and reporting requirements. Task

Step 3. Conduct data collection (survey of partners) for assessment utilizing tools such as email, phone, and in person assessments. Task

NYS Confidentiality – High

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Step 5. Leverage the assessment data collected to conduct an IT gap analysis pertaining to Mount Sinai PPS partner organizations

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

an IT gap analysis pertaining to Mount Sinai PPS partner organizations

Task

Step 6. Leverage the assessment data collected to conduct an IT gap analysis on internal PPS IT infrastructure

Completed

Step 6. Leverage the assessment data collected to conduct an IT gap analysis on internal PPS IT infrastructure

01/01/2016

09/30/2016

01/01/2016

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 7. Review and approval of initial findings and gap analyses by PPS leadership

01/01/2016

09/30/2016

01/01/2016

09/30/2016

09/30/2016

DY2 Q2

Completed

IT change management strategy, signed off by PPS Board. The strategy should include: -- Your approach to governance of the change process; -- A communication plan to manage communication and involvement of all stakeholders, including users; -- An education and training plan; -- An impact / risk assessment for the entire IT change process; and -- Defined workflows for authorizing and implementing IT changes

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 1. Develop IT governance strategy and framework for centralized PPS

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 2. Develop the IT governance strategy and framework for PPS partners

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 3. Develop IT Change Management Strategy including approach to governance, communication, education and training, IT change management reporting by providers, risk management, and workflows

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 4. Review and approval by PPS leadership

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Roadmap document, including current state assessment and workplan to achieve effective clinical data sharing and interoperable systems where required. The roadmap should include:

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Task

Step 7. Review and approval of initial findings and gap analyses by PPS leadership

Milestone #2

Develop an IT Change Management Strategy.

Task

Step 1. Develop IT governance strategy and framework for centralized PPS Task

Step 2. Develop the IT governance strategy and framework for PPS partners

NO

Task

Step 3. Develop IT Change Management Strategy including approach to governance, communication, education and training, IT change management reporting by providers, risk management, and workflows Task

Step 4. Review and approval by PPS leadership Milestone #3

Develop roadmap to achieving clinical data sharing and interoperable systems across PPS network

NYS Confidentiality – High

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

-- A governance framework with overarching rules of the road for interoperability and clinical data sharing; -- A training plan to support the successful implementation of new platforms and processes; and -- Technical standards and implementation guidance for sharing and using a common clinical data set -- Detailed plans for establishing data exchange agreements between all providers within the PPS, including care management records (completed subcontractor DEAAs with all Medicaid providers within the PPS; contracts with all relevant CBOs including a BAA documenting the level of PHI to be shared and the purpose of this sharing). Task

Step 1. Develop framework for data sharing and interoperability roadmap, including resources responsible for key components

Completed

The data sharing strategy is currently in development and in the process of refinement and approval with the IT Committee

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Draft timelines and project plans are in development for all IT centralized services for the PPS.

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 3. Develop draft governance and policy framework for data sharing and shared IT infrastructure, including data exchange agreements

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 4. Solicit stakeholder input on plan for IT standards and infrastructure, including from local RHIOs, and revise as needed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Completed

Step 5. Solicit stakeholder input on draft governance and policy framework, including data exchange agreements, and revise as needed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

On Hold

Step 6. Map IT standards and infrastructure plan to finalized IT Current State Assessment

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

Step 7. Review and approval by PPS leadership of roadmap, including governance and policy framework, plan for IT standards and infrastructure, and guidance to participants

04/01/2016

12/31/2016

04/01/2016

12/31/2016

12/31/2016

DY2 Q3

Task

Step 2. Develop draft plan for IT standards and infrastructure, including training Task

Step 3. Develop draft governance and policy framework for data sharing and shared IT infrastructure, including data exchange agreements Task

Step 4. Solicit stakeholder input on plan for IT standards and infrastructure, including from local RHIOs, and revise as needed Task

Step 5. Solicit stakeholder input on draft governance and policy framework, including data exchange agreements, and revise as needed Task

Step 6. Map IT standards and infrastructure plan to finalized IT Current State Assessment Task

Step 7. Review and approval by PPS leadership of roadmap, including governance and policy

NYS Confidentiality – High

AV

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

07/01/2015

09/30/2017

09/30/2017

DY3 Q2

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

07/01/2015

09/30/2017

07/01/2015

09/30/2017

09/30/2017

DY3 Q2

In Progress

Step 3. Refine draft plan based on stakeholder input and findings in IT Current State Assessment, including assessment of engagement methodologies that will be most effective in facilitating stakeholder outreach

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

In Progress

Step 4. Develop plan for patient engagement

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

In Progress

Step 5. Review and approval by PPS leadership, including review of cultural competency guidelines developed by the Cultural Competency and Health Literacy workstream

04/01/2016

09/30/2017

04/01/2016

09/30/2017

09/30/2017

DY3 Q2

Completed

Data security and confidentiality plan, signed off by PPS Board, including: -- Analysis of information security risks and design of controls to mitigate risks -- Plans for ongoing security testing and controls to be rolled out throughout network.

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

On Hold

We are currently working on developing the information security strategy required for the PPS.

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Step 2. Incorporate data security guiding principles into draft governance and policy framework and draft IT standards and

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Original Start Date

Original End Date

Start Date

In Progress

PPS plan for engaging attributed members in Qualifying Entities, signed off by PPS Board. The plan should include your approach to outreach into culturally and linguistically isolated communities.

07/01/2015

09/30/2017

Completed

Step 1. Perform environmental scan as part of assessments of partners to understand if they have access to the HIE/RHIO and status of MU attestation

07/01/2015

In Progress

Step 2. Develop draft engagement plan for providers in partnership with the QEs

Status

Description

AV

framework, plan for IT standards and infrastructure, and guidance to participants Milestone #4

Develop a specific plan for engaging attributed members in Qualifying Entities

NO

Task

Step 1. Perform environmental scan as part of assessments of partners to understand if they have access to the HIE/RHIO and status of MU attestation Task

Step 2. Develop draft engagement plan for providers in partnership with the QEs Task

Step 3. Refine draft plan based on stakeholder input and findings in IT Current State Assessment, including assessment of engagement methodologies that will be most effective in facilitating stakeholder outreach Task

Step 4. Develop plan for patient engagement Task

Step 5. Review and approval by PPS leadership, including review of cultural competency guidelines developed by the Cultural Competency and Health Literacy workstream

Milestone #5

Develop a data security and confidentiality plan.

Task

Step 1. Define data security and confidentiality guiding principles Task

Step 2. Incorporate data security guiding

NYS Confidentiality – High

NO

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

principles into draft governance and policy framework and draft IT standards and infrastructure plan

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

infrastructure plan

Task

Step 3. Conduct analysis of information security risks of the technical and policy components fo the IT Data Sharing and Interoperability Roadmap

On Hold

Step 3. Conduct analysis of information security risks of the technical and policy components fo the IT Data Sharing and Interoperability Roadmap

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Step 4. Develop plan for risk mitigation and ongoing security testing and controls

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Step 5. Review and approval of data security and confidentiality plan by PPS leadership and assignment of responsibility for maintaining adherence across the PPS network

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

Step 6. Create and submit security workbooks for System Security Plan Overview, Access Controls (AC), Configuration Management (CM), Identification and Authorization (IA), System and Communications Protection (SC).

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 7. Create and submit security workbooks for Awareness and Training (AT), Audit and Accountability (AU), Incident Response (IR), Physical and Environmental Protection (PE), Personnel Security (PS)

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 8. Create and submit security workbooks for Security Assessment and Authorization (CA), Risk Assessment (RA), System and Information Integrity (SI), Media Protection (MP)

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 9. Create and submit security workbooks for Planning (PL), Program Management (PM), System and Services Acquisition (SA), Contingency Planning (CP), Maintenance (MA)

01/01/2016

06/30/2016

01/01/2016

06/30/2016

06/30/2016

DY2 Q1

Task

Step 4. Develop plan for risk mitigation and ongoing security testing and controls Task

Step 5. Review and approval of data security and confidentiality plan by PPS leadership and assignment of responsibility for maintaining adherence across the PPS network Task

Step 6. Create and submit security workbooks for System Security Plan Overview, Access Controls (AC), Configuration Management (CM), Identification and Authorization (IA), System and Communications Protection (SC). Task

Step 7. Create and submit security workbooks for Awareness and Training (AT), Audit and Accountability (AU), Incident Response (IR), Physical and Environmental Protection (PE), Personnel Security (PS) Task

Step 8. Create and submit security workbooks for Security Assessment and Authorization (CA), Risk Assessment (RA), System and Information Integrity (SI), Media Protection (MP) Task

Step 9. Create and submit security workbooks for Planning (PL), Program Management (PM), System and Services Acquisition (SA), Contingency Planning (CP), Maintenance (MA)

NYS Confidentiality – High

AV

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name Develop a data security and confidentiality plan.

User ID tomfitz

File Type

File Name

Description

34_DY3Q1_IT_MDL51_PRES5_TEMPL_HIPAA_T raining_Template_MountSinaiPPS_DY3_Q1_1609 0.xlsx

Templates

Update: HIPAA compliance training schedule for DY3 Q1

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Perform current state assessment of IT capabilities across network, identifying any critical gaps, including readiness for data sharing and the implementation of interoperable IT platform(s). Develop an IT Change Management Strategy. Develop roadmap to achieving clinical data sharing and interoperable systems across PPS network Develop a specific plan for engaging attributed members in Qualifying Entities Develop a data security and confidentiality plan.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Complete

Milestone #3

Pass & Ongoing

Milestone #4

Pass & Ongoing

IA Formal Comments

The IA does not consider this milestone complete. The PPS must extend its due date until it can submit documentation to meet the requirement to implement guidelines for the use of common data sets for each of the projects chosen by the PPS in order to substantiate completion of this milestone.

NYS Confidentiality – High

Upload Date 07/19/2017 11:22 AM

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone # Milestone #5

Review Status

IA Formal Comments

Pass & Complete

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 5.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 83 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 5.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in creating and implementing your IT governance structure, your plans for data sharing across your network, your approach to data security and confidentiality, and the achievement of the milestones described above, including the potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Risk 1: PPS partners not fully comprehending the IT requirements Mitigation Strategy: Engage in comprehensive community-based partner education through workshops, web-based learning tools and 1:1 interaction at partner sites; development of education materials by provider type to clearly state expectations and requirements. Risk 2: Partners inability to achieve meaningful adoption of IT capabilities to connect to centralized IT services and engage in data sharing Mitigation Strategy: PPS has planned for provision of technical assistance with relation to EHR adoption and PCMH certification. PPS will establish incremental IT adoption milestones and site visits to ensure progress towards defined requirements and performance objectives. Financial incentives will be put into place to encourage IT adoption by partners with DSRIP dollars. Risk 3: Breadth of EHRs and electronic platforms currently in use may pose significant barrier and/or cost for development of interfaces by vendors for HIE connectivity Mitigation Strategy: PPS IT committee will conduct a deeper assessment to better understand vendors within PPS, work to negotiate interfaces for top volume platforms first; as well as work with partners without IT platforms to adopt software from a select set of vendors. Risk 4: Consent process may inhibit ability to access and share pertinent patient data Mitigation Strategy: Continue to coordinate with GNYHA, other PPSs, RHIOs and stakeholders to drive policy change and consent education for patients through providers to continually improve level of consent and mitigate policy barriers. Risk 5: As with any collaborative, stakeholders may not reach consensus on strategic, business or governance decisions in a timely manner Mitigation Strategy: Implementation plan will carefully map out deliverable/decision points and risks of indecision will be raised immediately to PPS leadership for arbitration; PPS will leverage State guidance on key business and technical decisions where appropriate. Risk 6: RHIO and SHIN NY implementation and upgrade timelines may be delayed or may experience unforeseen barriers, which may cause any intended functionality to be implemented by the PPS that depends on these core infrastructure components to be delayed. Mitigation Strategy: MS PPS will work closely with RHIO partners and with NYSDOH to continuously gauge performance benchmarks as set by SHIN NY for RHIO system upgrades, and by NYSDOH for core functionality components of the MAPP. The PPS will be specifically including a RHIO gap analysis as part of the current state IT assessment in DY1 to help mitigate this risk. Additionally, MS PPS and RHIO will have overlap with Boards of both organizations to promote alignment. Risk 7: Funding challenge to attain resources to help realize IT strategy and investments Mitigation Strategy: MS PPS has already submitted a capital request to help fund the IT needs for the PPS. Partners have also been encouraged to apply for a capital request, which many have done. Additionally, the PPS is providing information for alternative funding sources, such as PCIP, for partners to connect with. Risk 8: Assure data security is upheld across all partners Mitigation Strategy: MS PPS will develop data security protocols and policies that will be vetted through compliance to ensure patient data remains protected while data sharing is promoted to help us achieve DSRIP milestones.

IPQR Module 5.4 - Major Dependencies on Organizational Workstreams

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) The IT Systems and Processes developed by the MS PPS are are highly interdependent with other organizational workstreams: Workforce: The proposed IT infrastructure will support workforce transformation through the inclusion of a Learning Management System that will allow the PPS to deploy and track workforce training and understanding of PPS-developed project-driven protocols. Governance and Financial Sustainability: The proposed IT infrastructure will support PPS governance and financial sustainability by providing the governing board with timely access to clinical, financial and provider-related information, that they might make informed and accurate decisions. Cultural Competence and Health Literacy: The proposed IT infrastructure will support cultural competence and health literacy by providing a means for the distribution of consistent, culturally competent materials and training for patients and providers, and by establishing Health Information Exchange (HIE) between the health system and culturally competent Community Based Organizations (CBOs). Performance Reporting: The proposed IT infrastructure will put in place the IT systems necessary to gather, store and analyze information across all PPS providers to facilitate efficient and valid performance reporting. Practitioner Engagement: The proposed IT infrastructure will support practitioner engagement through implementation of the MS PPS User Portal, offering wide-spread access to the MS PPS data warehouse, including analytic functionality, dashboards, care management tools, Learning Management System modules and DSRIP performance reporting support. Population Health Management: The proposed IT infrastructure will support population health management through the deployment of a centralized data warehouse and associated analytic platforms that will include critical functions, such as clinical decision support, population health metrics, predictive analytics, reporting and registries for care management, and utilization management Clinical Integration: The proposed IT infrastructure will support clinical integration through the wide-spread achievement of data exchange and interoperability. Financial Sustainability: Capability to monitor and track PPS partner performance metrics will depend on the financial sustainability of the PPS overall, in order to provide the needed centralized infrastructure for performance reporting. Funds Flow: The availability of DSRIP funds to support the centralized infrastructure that will be necessary in order to support all DSRIP projects and the ability to achieve metrics and milestones.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 5.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Provision of centralized IT services to fulfill 2.a.i and other project core IT requirements

Kumar Chatani, CIO, Mount Sinai Health System and IT Committee: Greg Fortin, Isabella Nursing Home; Richard Pineda, Amsterdam Nursing Home; Warria Esmond, Settlement Health; Kate Nixon, Visiting Nurse Service of New York; Mitze Amoroso, ArchCare; Miguel Mendez, Housing Works; Daniel Lowy, Argus Community, Inc.; Bill Moran, The Brooklyn Hospital Center; Richard Clarkson, Callen-Lorde Community Health Center; Ricardo Santiago, Village Center for Care d/b/a VillageCare; Vivek Sawhney, YAI; Kathy Cresswell, Institute of Family Health; Patricia Marthone, 1199 SEIU UHWE; Michael Buckner, Bailey House; Barbara Hood, William F. Ryan Community Health Network; Crystal Jordan, Harlem United; Deborah Witham, VIP Community Services; Edwin Young, MD, Mount Sinai; Kash Patel, Sr. Director of Innovation & Analytics, Mount Sinai

Design, plan and implementation of IT infrastructure to achieve: bidirectional data sharing, HIE connectivity, alerts, messaging, care coordination, PCMH level III and adoption of MU II eligible EHRs

Inform clinical requirements and data needs for UM, performance management and RCE

Theresa Soriano, MD, MPH, Mount Sinai, Matthew Weissman, MD, MBA, FAAP, Community Health Network, and CMO Edwidge Thomas, Clinical Director of DSRIP PMO, Mount Sinai

Coordinate with IT committee to ensure clinical data needs for reporting, RCE, UM and quality management are understood and included within IT strategy and proposed solutions; including RHIO data capture. Inform workflow needs and how data integration will impact care delivery and coordination.

Ensure alignment of strategy with long-term vision, business priorities and DSRIP objectives

Jill Huck, Director and Edwidge Thomas, Clinical Director of Mount Sinai DSRIP PMO and the MS PPS Board of Managers : Art Gianelli*, MS Health System; Arthur Klein, MS Health System; Brad Beckstrom, MS Health System; Brian Mcindoe, William Ryan Center; Caryn Scwab, MS Health System;

Strategic oversight and alignment across workstreams, PPS and DSRIP projects Arbitrate priorities for strategic success and resource allocations (in coordination with recommendations and guidance of CFO and Finance committee)

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Don Scanlon, MS Health System; Donna Colonna, CBC and SUS/Palladia; Ed Lucy, MS Health System; Frank Cino, MS Health System; Gary Burke, MS Health System; Hany Abdelaal, VNS of New York; James Ferris, NYSNA; Jane Maksoud, MS Health System; Jay Gormley, Metropolitan Jewish Health System; Jim Davis, Amsterdam House ; Joan Clark-Carney, Brooklyn Hospital Center; Kelly Cassano, MS Health System; Kumar Chatani, MS; Mali Trilla*, Settlement Health; Neil Calman, IFH; Peter Scaminaci, Phoenix House New York; Richard Park, City MD; Rizwan Hameed, All Medical IPA; Roy Cohen, MS; Sabina Lim, MS Health System; Saily Cabral, SEIU 1199; Scott La Rue, Arch Care; Sharen Duke, AIDS Service Center; Theresa Soriano, MS Provision of IT and data governance for PPS partners, RHIOs and coordination with State entities and MCOs for data exchange, analytics, reporting, etc.

CIO Kumar Chatani, CIO, Mount Sinai Health System and IT Committee (see names above)

Provide feedback on overall IT strategy in its ability to meet DSRIP and PPS requirements for data sharing and project requirement.

IT Committee (see names above)

Provide consistent, impartial and balanced leadership for PPS IT strategy and infrastructure needs

Kumar Chatani, CIO, Mount Sinai Health System and IT Committee (see names above)

Data governance model and data use agreement(s) by provider type Minimum Data Set requirements by provider type HIPAA and IS compliance policies, training and infrastructure Data and user access management & audits Vendor selection and management Feedback on IT strategy from partner organizations to ensure that the strategy takes all partner, DSRIP, and PPS needs into consideration to ensure that requirements and milestones can be met in a timely manner. Partners will also provide feedback throughout the implementation phase to ensure all issues and challenges are addressed to minimize risks/impact. IT leadership on behalf of MS PPS partners to ensure IT strategy, investments and services/ infrastructure meet the needs of the PPS, address critical gaps and enable ongoing rapid cycle evaluation and performance management

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Role

Operational leadership and Performance management oversight

Name of person / organization (if known at this stage)

MS PPS, LLC: Board of Directors; CIO (TBD)

Key deliverables / responsibilities Development of performance management and reporting tools Development of dashboards as needed by PPS leadership, committees and providers IT implementation plan management; daily oversight of project teams and vendors Lead development of technical assistance and resources with vendors, project teams, etc.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 5.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Barbara Hood, CIO, William F. Ryan Community Health Network & Kumar Chatani, CIO, Mount Sinai Health System

Responsible for representation of PPS partner interests/needs

MS PPS Committees and workgroups

PPS partner representation and project managers/ leads

Ongoing coordination and strategy alignment across PPS to ensure data sharing and care coordination for significant proportion of PPS members; Responsible for development of implementation plan with in put from committee members Coordination with IT committee and representation of PPS partners to inform IT needs for projects and network performance; ensure IT strategy reflects and address the collective partner needs and will enable improve care delivery to address CNA

External Stakeholders MS PPS IT Committee members: Greg Fortin, Isabella Nursing Home; Richard Pineda, Amsterdam Nursing Home; Warria Esmond, Settlement Health; Kate Nixon, VNS of New York; Mitze Amoroso, ArchCare; Miguel Mendez, Housing Works; Daniel Lowy, Argus Community, Inc.; Bill Moran, The Brooklyn Hospital Center; Richard Clarkson, Callen-Lorde Community Health Center; Ricardo Santiago, Village Center for Care d/b/a VillageCare; Vivek Sawhney, YAI; Kathy Cresswell, Institute of Family Health; et al.

Represent various partner types for 2ai and PPS to ensure diversity of partner needs, roles and capabilities are represented in planning, governance and implementation

Representation of PPS provider types

Local RHIOs Leadership: Tom Check and Jason Thaw of Healthix; additionally, Interboro RHIO and Bronx RHIO.

RHIO leadership within region

PPS Parnters: (In first wave) Greg Fortin, Isabella

Performing partners and coordinating providers

Responsible for coordination with MS PPS IT leadership for deployment of IT strategy; delivery of HIE connectivity, and select functionality (e.g. DIRECT messaging); ensuring cross-RHIO/PPS connectivity via SHIN-NY; provision of consent management and integration with statewide MPI and data sharing initiatives Responsible for informing IT needs of PPS, being responsive to

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Key stakeholders Nursing Home; Warria Esmond, Settlement Health; Mitze Amoroso, ArchCare;Bill Moran, The Brooklyn Hospital Center; Kathy Cresswell, Institute of Family Health; Barbara Hood, William F. Ryan Community Health Network

Role in relation to this organizational workstream

Key deliverables / responsibilities assessment and planning requests, investing in basic IT infrastructure per DSRIP project and IT strategy requirements; adopting standards and protocols defined by PPS leadership; ongoing engagement in reporting and process improvement activities

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 5.7 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. The IT work stream leadership will develop a comprehensive implementation plan, supplemented by GANTT chart outlining quarterly milestones based on performance requirements (DSRIP) and implementation milestones for the PPS IT strategy. The implementation plan will provide a measurable guide for progress that will be regularly shared with Leadership and collaborating committees to ensure provision of deliverables, services and functionality in line with PPS scale and speed, and overall PPS IT requirements. The IT team will also work to identify a set of internal metrics that will define success beyond meeting the milestones required by the state to ensure high quality of service that meets the PPSs DSRIP needs. In addition to IT implementation progress tracking and management, the committee will engage in PPS partner feedback requests through surveys and discussion forums to ensure solutions and services continually meet partner needs, expectations and deliver value.

IPQR Module 5.8 - IA Monitoring Instructions :

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 06 – Performance Reporting IPQR Module 6.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

01/01/2017

09/30/2017

09/30/2017

DY3 Q2

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 4. Define dashboard technologies that will be used by staff and participants to monitor outcomes and guide targeted quality improvement interventions, taking into account functionality elements provided by NYSDOH via the MAPP.

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 5. Establish framework for facilitating rapid cycle improvement informed by continuous outcomes monitoring.

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

Original Start Date

Original End Date

Start Date

In Progress

Performance reporting and communications strategy, signed off by PPS Board. This should include: -- The identification of individuals responsible for clinical and financial outcomes of specific patient pathways; -- Your plans for the creation and use of clinical quality & performance dashboards -- Your approach to Rapid Cycle Evaluation

01/01/2017

09/30/2017

Completed

We are currently finalizing the interim reporting strategy for DY1 reporting needs.

04/01/2015

Completed

Step 3. Define metrics to track and report on processes and outcomes in collaboration with local stakeholders and NYSDOH, including any PPS metrics beyond NYSDOH requirements.

Status

Milestone #1

Establish reporting structure for PPS-wide performance reporting and communication.

Description

Task

Step 2. Develop Interim reporting solutions to begin reporting on requirements and milestones, including those in Speed and Scale, identified for DY1. Task

Step 3. Define metrics to track and report on processes and outcomes in collaboration with local stakeholders and NYSDOH, including any PPS metrics beyond NYSDOH requirements. Task

Step 4. Define dashboard technologies that will be used by staff and participants to monitor outcomes and guide targeted quality improvement interventions, taking into account functionality elements provided by NYSDOH via the MAPP. Task

Step 5. Establish framework for facilitating rapid cycle improvement informed by continuous

NYS Confidentiality – High

AV

NO

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Milestone/Task Name

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

09/30/2017

09/01/2015

03/31/2018

03/31/2018

DY3 Q4

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Performance reporting committee will request review by various stakeholders to comment on draft plan.

10/01/2015

06/30/2017

10/01/2015

12/31/2017

12/31/2017

DY3 Q3

In Progress

Step 3. Finalize training program for execution.

01/01/2016

06/30/2017

01/01/2016

12/31/2017

12/31/2017

DY3 Q3

In Progress

Step 4. Review and approval by MS PPS leadership.

01/01/2016

06/30/2017

01/01/2016

12/31/2017

12/31/2017

DY3 Q3

In Progress

Need to solicit partners for training of performance reporting and clinical quality.

01/01/2016

09/30/2017

01/01/2016

09/30/2017

09/30/2017

DY3 Q2

Original Start Date

Original End Date

Start Date

Completed

Step 1.: Establish a committee with project manager lead and Director of Provider Relations from the PMO, including Clinical committee leads and IT committee leads to design PPS wide performance monitoring and communication.

04/01/2015

09/30/2015

In Progress

Finalized performance reporting training program.

09/01/2015

In Progress

Performance Reporting committee will work with provider relations team and Stakeholder engagement Crossfunctional working group to design overall PPS plan.

In Progress

Status

Description

AV

outcomes monitoring. Task

Step 6. Establish a committee with project manager lead and Director of Provider Relations from the PMO, including Clinical committee leads and IT committee leads to design PPS wide performance monitoring and communication. Milestone #2

Develop training program for organizations and individuals throughout the network, focused on clinical quality and performance reporting. Task

Step 1. Develop PPS-wide training program for clinical quality and performance reporting. Task

Step 2. Establish draft training program for review by multidisciplinary team of partners. Task

Step 3. Finalize training program for execution.

NO

Task

Step 4. Review and approval by MS PPS leadership. Task

Step 5: Deliver training program to PPS partners.

IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

No Records Found

NYS Confidentiality – High

Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Establish reporting structure for PPS-wide performance reporting and communication. Develop training program for organizations and individuals throughout the network, focused on clinical quality and performance reporting.

Pushed out dates six months to accommodate training schedule.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 6.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 95 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 6.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in implementing performance reporting structures and processes and effective performance management within your network, including potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Risk 1: There is currently lack of definition on the performance monitoring and reporting infrastructure that will be provided by NYSDOH via the MAPP relative to what will be provided by PPSs themselves. Mitigation Strategy: Close collaboration and transparency with NYSDOH, including participation in DSRIP CIO forum. Risk 2: Defining performance metrics in multi-stakeholder environments often takes significant time and effort. Mitigation: Develop initial set of measures with input from NYSDOH and experts in the field, with stakeholder input throughout the process. Risk 3: Some MS PPS members may not want their performance outcomes to be evaluated or compared with their competitors' performance. Mitigation: Develop a communications strategy to address these concerns. Risk 4: Risks resulting from the integration of a broad network of providers into a new network with contracting dollars linked to performance, including some competing provider organizations and others with no experience in collaborative care models. Mitigation: Implement transparent governance and oversight of performance monitoring and outcomes-based payment processes. Define processes and expectations well in advance of implementing collaborative care practices and the underlying IT infrastructure. Risk 5: Risk that technology vendors will not deliver services enabling the detailed performance and financial monitoring demanded by the PPS. Mitigation: Engage in a thorough and standardized procurement process for IT vendors, beginning with detailed definition of requirements. Include detailed requirements in procurement documents, and provide training to proposal evaluation committees so that they fully understand requirement details to optimize their decision-making process. Apply vendor contracting and management best practices. Risk 6: Workforce(s) inexperienced in performance management and reporting systems. Mitigation: staff to required level at the PPS, including education and training staff; provide "high-touch" education and training to PPS participants; develop accessible resources and toolkits; elicit participant concerns early and often, listen to them in a sincere manner, and address them with respect without deviating from the overall goals of the program. Risk 7: Operating in multiple markets within NYC exposes the PPS to several performance monitoring and reporting risks. Mitigation: Because our attributed patient population will cut across market segments, our analytic tools will enable tracking of outcomes and performance among specific cohorts that the PPS and PPS members can define according to multiple such as geography, health condition, provider affiliation, RHIO affiliation, etc. While we will pursue broad outcome improvement initiatives across the PPS, we will utilize more granular segmentation of patients for interventions appropriate to specific market segments and populations. Risk 8: partners who are participating in multiple PPSs Mitigation: The PPS will collaborate with multiple PPSs to develop reporting measures, roll-out plan, and implementation to reduce risk of duplication and conflicting reporting processes Risk 9: Partners may experience constraints on resources and conflicting reporting requirements from participation in multiple programs Mitigation: The PPS will develop reporting structure in alignment with existing program requirements where ever possible. For instance, the PPS will develop reporting tools for MU in alignment with MU requirements to reduce duplication of reports. Additionally, the PPS will consolidate reports where ever possible to reduce resource constraints and work with other reporting distribution channels to align communications on those measures.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 6.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) Performance reporting will require close coordination with other committees and leadership to ensure all key metrics and indicators are effectively tracked, captured, reported and maintained in a central data repository. Each respective committee, e.g. workforce, finance, IT, etc. will define key indicators, thresholds for performance (e.g. max and min) for performance monitoring. Monitoring and reporting will support PPS governance, rapid cycle evaluation and partner funds flow distribution in alignment with performance-based contract requirements and expectations. Careful coordination will be required with project leads and committees to determine these indicators are the best, most efficient means for standardized, consistent data collection and reporting. Additionally, the PPS will have to carefully communicate with other committees and partners to ensure performance reporting plan, requirements, and training are consistent and efficient. Successful PPS reporting will require the development of a CRM tool that will enable easy tracking of partner performance and deployment of PPS governance and provider dashboards. In addition, the Performance reporting will coordinate with NYSDOH to ensure alignment and fulfillment of reporting requirements.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 6.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Oversight and accountability for delivery of performance reporting capability.

MS PPS Leadership; CIO; IT Committee

Responsible for informing development of performance tools, monitoring performance of partners and PPS, informing process improvement and corrective action.

Leadership, Finance Committee, IT Committee, Clinical Committee

Responsible for determining appropriate actions to ensure PPS performance based on available information.

Governing Board

Key deliverables / responsibilities Performance reporting infrastructure (design, planning and implementation). Coordination with NYDOH, PPS partners and other sources for data collection. Development of dashboards to enable performance management and rapid cycle evaluation. Management and oversight of performance reporting and data collection staff and project leads, including engagement of committees and governance leads to inform process. Inform identification of key indicators and operational, clinical, financial, quality and other performance metrics. Responsible for informing development of dashboards, performance thresholds, reviewing data/reports and making recommendations to Governing Board on necessary actions. Responsible for reviewing dashboards and performance recommendations from leadership and committees and making decisions for PPS to ensure necessary process improvements, corrective actions, etc.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 6.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders PPS Partners

Submit data and review dashboards.

PMO

Project Management office for the Mount Sinai PPS.

IT Committee

Design and build of performance reporting infrastructure.

Clinical Committee

Governance of performance reporting and partner engagement.

MSHP

Collaborate with IT committee on performance reporting.

Based on reports and data, adapt DSRIP performance, strategies and initiatives to achieve metrics/milestones and/or bridge gaps to goal measures; provide timely reporting and submission of data in specified manner/format. Tracks and reports performance and data throughout the PPS and to the state. Executes projects from implementation plan to ensure the success of DSRIP. Design and build infrastructure for performance reporting including the capacity to capture and store critical data, connectivity with partners and any necessary analytics support Develop and implement governance structure for reporting, monitoring projects from implementation plan to ensure the success of DSRIP. Will support IT in developing performance reporting platforms and dashboards.

External Stakeholders

NYSDOH

Provision of statewide/PPS dashboards and performance data

Patients, Advocates and Caregivers (consumers)

Member Satisfaction and loyalty

Provide data, including claims data, consolidated reports and webbased dashboards for PPSs for performance management; provide templates for DSRIP performance reporting; provide common operational definitions for metrics and milestones and reporting requirements; provide guidance on performance improvement opportunities and evidence-based guidance and PPS benchmark data. Provide direct and indirect feedback to FLPPS. Direct feedback through patient satisfaction surveys, HCAHPS, CAHPS, etc. as well as indirect feedback through utilization patterns - preferred providers will have higher demand. Planning process will include engagement of consumer input in design of services, user engagement/activation tools and marketing, outreach and education.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Key stakeholders MCOs

Role in relation to this organizational workstream Provision of claims data, benchmark data and support in development of population health analytic tools

Key deliverables / responsibilities Coordinate with PPS in provision of claims data and benchmark data to support performance management; potential for contract negotiation based on improved total cost management.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 6.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support your approach to performance reporting. The MS PPS data infrastructure will enable performance monitoring and reporting in several ways: (1) Interoperability between systems including RHIO infrastructure will create a robust pool of data for analysis and reporting; (2) the MS PPS data analytics platform will enable performance tracking from the provider to the PPS level, and tracking of outcomes for specific population cohorts; (3) care management teams will proactively engage prioritized patient cohorts; and (4) reporting tools and dashboards informed by DSRIP metrics will produce reports for internal stakeholders, NYSDOH, and external stakeholders.

IPQR Module 6.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. Success will be defined by developing a set of measures that will consider the progress in planning, design and deployment of the performance reporting processes, tools and centralized dashboard with user access. Performance reporting will likely begin as a more manual process, with increasing automation, queries, user features and data points over time. The IT Committee, in coordination with other Committees such as Clinical, PMO, Provider Relations Team and PPS leadership will define the requirements and milestones for performance reporting capabilities and timeline, in line with State provided reporting tools, data and timelines. In addition, the PMO will track the number of engaged partners in the training program for performance monitoring and clinical quality by partners. It will be critical to have a high success rate of partner participation by those who adhere to the training protocol and report improvement in their practice. The PPS will continue to develop a robust system to track the set of metrics during Rapid Cycle evaluation with our partners.

IPQR Module 6.9 - IA Monitoring Instructions :

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 07 – Practitioner Engagement IPQR Module 7.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

In Progress

Practitioner communication and engagement plan. This should include: -- Your plans for creating PPS-wide professional groups / communities and their role in the PPS structure -- The development of standard performance reports to professional groups --The identification of profession / peer-group representatives for relevant governing bodies, including (but not limited to) Clinical Quality Committee

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

Draft provider engagement list of best practices.

09/01/2015

06/30/2016

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Stakeholder engagement meeting minutes.

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Draft provider/stakeholder engagement print and media educational materials; meeting minutes

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

Draft provider/stakeholder engagement print and media educational materials; meeting minutes

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Milestone #1

Develop Practitioners communication and engagement plan.

Original Start Date

Task

Step 1. Identify models of provider engagement that work best within multiple settings, and how engagement may need to vary geographically or by project participation. Task

Step 2. Assess with our partners their challenges in engaging with practitioners. Task

Step 3. Develop effective messages for practitioners, such as describing discrete financial gains from achieving patient care objectives as described by PPS and ensure leadership adherence to foster provider trust. Task

Step 4. Develop a draft physician communication and engagement plan which: 1) Reflects identified provider engagement models and best

NYS Confidentiality – High

AV

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

06/30/2016

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Original Start Date

Original End Date

Start Date

09/01/2015

06/30/2016

09/01/2015

AV

practices; 2) Leverages early adopters and leaders as potential PPS "champions"; 3) Reflects physician feedback to the PPS regarding information needs and preferred methods of communication and engagement; 4) Establishes channels for two-way information flow between the PPS/PMO and physicians; 5) Facilitates peer-to-peer learning for participating providers; 6) Engages the clinical committee and project committees, as appropriate. Stakeholder engagement meeting minutes and attendance lists

Task

Step 5. Assess availability of key practitioner stakeholders to hold positions of leadership within the PPS.

Completed

Task

Step 6. Identify early adopters within the provider network.

Completed

Task

Step 7. Identify potential conflicts in values and beliefs between providers in the PPS and with PPS leadership.

Completed

Stakeholder engagement meeting minutes and attendance lists

Stakeholder engagement meeting minutes and attendance lists

Task

Step 8. Finalize provider communication and engagement plan which reflects stakeholder input.

In Progress

Board-approved provider communication and engagement plan

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

In Progress

Practitioner training / education plan.

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

Stakeholder Engagment Committee meeting minutes detailing discussion of communication tools

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

PPS traning/education plan

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Milestone #2

Develop training / education plan targeting practioners and other professional groups, designed to educate them about the DSRIP program and your PPS-specific quality improvement agenda. Task

Step 1. Assess communication tools to be used by practitioners within the PPS. Task

Step 2. Design training/education plan for

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NO

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Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

practitioners that includes materials and strategies for targeting: 1) large practitioner organizations in each of the Domains; 2) smaller practitioner organizations, particularly those needing additional support around IT; and 3) different provider types and practice levels. Task

Step 3: Develop plan to define metrics to track and measure success of trainings for each group above (Step 2)

Completed

PPS training/education plan with metrics for success of each group

11/30/2015

09/30/2016

11/30/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

Summary report of practitioner feedback

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

PPS practitioner education/training toolkit

12/01/2015

09/30/2016

12/01/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

Board-approved practitioner retention policies

12/01/2015

06/30/2017

12/01/2015

12/31/2017

12/31/2017

DY3 Q3

Task

Step 4. Solicit practitioner feedback to improve and refine training, educational plans, materials, and metrics to track. Task

Step 5. Develop toolkit materials to educate practitioners about the DSRIP program and PPS projects, as well as outreach and education plan to reach practitioners. Materials will be targeted at types of practitioners and by DSRIP project topics. For example, educational materials on evidence-based goals for at home patient care will be distributed to non-physician dominated groups to ensure home agencies are aligned with goals of patient care. Task

Step 6. Develop formal provider retention policies that are standardized with discrete goals, and which can be supported by the training programs.

IA Instructions / Quarterly Update Milestone Name

IA Instructions

No Records Found

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Quarterly Update Description

AV

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

Upload Date

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Develop Practitioners communication and engagement plan.

Milestone due date has been extended to allow for recent PPS clinical implementation activities to occur. These ongoing activities will influence and provide input to the plan.

Develop training / education plan targeting practioners and other professional groups, designed to educate them about the DSRIP program and your PPS-specific quality improvement agenda.

Milestone due date has been extended to allow for recent PPS clinical implementation activities to occur. These ongoing activities will influence and provide input to the plan.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 7.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 7.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the current level of engagement of your physician community in the DSRIP program and describe the key challenges or risks that you foresee in implementing your plans for physician engagement and achieving the milestones described above. Describe any potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Major risks include the availability of funding to carry out the major changes associated with DSRIP and the Mt. Sinai PPS. Each provider needs an assessment as to the information technology, workforce, and data reporting capabilities to ensure smaller providers are not left behind in achieving goals. This assessment should start using key early adopters, who can serve as role models and champions for the PPS, but will need expansion. The ease of use of the IT selected software package will have a large impact on the ability to aggregate data and share findings with individual groups of providers. Each domain's educational goals and performance improvement benchmarks will require identifying the large stakeholders for the initial round of education. Survey utilization can confirm the education progress and alignment of goals.

IPQR Module 7.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) IT, Clinical Integration, and Workforce will be critical for practitioner engagement. Many practitioners will need significant support from the PPS in implementing standardized IT systems to allow for communication and data flow across the PPS, as well as workforce development and deployment to support the DSRIP transformation initiatives as well as data collection. The better the PPS can clearly communicate to practitioners about all relevant aspects of PPS implementation, the more effectively practitioners can be engaged in the process.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 7.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Director of PMO

Jill Huck, MS

General oversight & management

Head of Network Development

Arthur Klein, MS

Strategic oversight and input

Network Development & Strategy

Ben Kornitzer, MS

Strategic oversight and input, provider engagement

Network Development & Strategy

Brent Stackhouse

Strategic oversight and input, provider engagement

IPA Management

Ed Lucy

Strategic oversight and input, IPA engagement

Head of Population Health & MSO Development

Niyum Gandhi

Strategic oversight and input, population health and MSO support

MSO Operations

Theresa Dolan

MSO operations & support

Clinical Committee Co-chair

Theresa Soriano

Clinical operations oversight and strategy

Clinical Committee Co-chair Behavioral Health Expert, Leadership Committee

Matt Weissman, Community Healthcare Network

Clinical operations oversight and strategy

Sabina Lim

Behavioral health specific strategy

PMO Medical Director

Edwidge Thomas

Clinical operations oversight and strategy

Community Affiars Director

Brad Beckstrom

Community Affairs

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IPQR Module 7.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Target of engagement activities Oversight of all training strategies, including practitioner education / training described above

Attend training sessions; report to relevant Practitioner Champions

Internal Stakeholders Network Practitioners Workforce Committee Members Clinical Committee Members

Governance committee on which practitioner Champions sit

IT Committee Members

Oversight of IT/data sharing strategies

MSO Leadership

Provide supportive services

Input into practitioner education / training plan Monitor levels of practitioner engagement; forum for decision making about any changes to the practitioner engagement plan Oversight and protocals related to HIE & data sharing to support population health Supportive services as needed based on site specific needs

External Stakeholders PPS partner organizations Settlement Health - Warria Esmond, CMO Community Healthcare Network - Matthew Weissman, CMO William F. Ryan Center - Jonathan Swartz, CMO Brooklyn Hospital Center - Joshua Rosenberg

Provide expertise and guidance with their successful engagement training program

Input into practitioner education / training plan

Payers

Provide expertise and guidance with their successful engagement training program

Input into practitioner education / training plan

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 7.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support this particular workstream. The proposed deployment of a shared IT infrastructure will support PPS Practitioner Engagement, particularly through implementation of the MS PPS User Portal. This tool is a web-based portal that will allow access to the MS PPS data warehouse, including analytic functionality, dashboards, care management tools, Learning Management System modules and DSRIP performance reporting support. The goal of the portal is to improve communication between providers and patients and allow for timely access to health information to support chronic disease selfmanagement and population health management while minimally impacting existing provider workflows by ideally provisioning a single point of access. In addition, the MS PPS proposed IT infrastructure will deliver efficiency, interoperability and high value solutions to participating providers, facilitating practitioner engagement through provision of tools that support better time management and overall provider satisfaction.

IPQR Module 7.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. Practitioners will be given multiple opportunities to contribute to the leadership structure of the PPS. The continuation of town halls combined with smaller meetings at provider locations will ensure practitioner concerns are taken seriously by PPS leadership and that communication can flow both to and from practitioners. Formal roles should be created to ensure providers have an opportunity to grow within the PPS as their contributions increase. The PPS will create dashboards enabling comparison between both similar geographic locations and sized organizations in the PPS. Quality control surveys will help assess the quality of education, define success of education and training plan, and inform any changes needed in how the PPS is interacting with practitioners.

IPQR Module 7.9 - IA Monitoring Instructions :

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 08 – Population Health Management IPQR Module 8.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

In Progress

Population health roadmap, signed off by PPS Board, including: -- The IT infrastructure required to support a population health management approach -- Your overarching plans for achieving PCMH 2014 Level 3 certification in relevant provider organizations --Defined priority target populations and define plans for addressing their health disparities.

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

PMO table of organization and meetings

09/01/2015

09/30/2015

09/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

Results of data analysis of patient population

09/01/2015

06/30/2016

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Results of prioritization and process on milestones and health outcomes

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Milestone #1

Develop population health management roadmap.

Original Start Date

Task

Step 1. PMO will be established to support and report progress on the development of clinical programming, network provider and patient engagement, financial and risk management, and IT infrastructure to support an IDS. Task

Step 2. PMO, with MSHP support, will use data from CNA, attribution list, available payer claims, and internal PPS data to identify PPS patient population, characterizing subgroups of need by region, practice, preventable utilization, and/or service needs. Task

Step 3. From results of data analyses in Step 2, the Clinical Committee and PMO will determine highest-priority diagnoses, practice sites, and geographic areas in PPS to prioritize selection and timing of applicable projects for

NYS Confidentiality – High

AV

NO

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Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

implementation, provide feedback to projects on progress of milestones and strategies with positive impact on health outcomes. Task

Step 4: Define priority target populations by using community needs assessment and available data to develop disease specific profiles that identifies co-morbidities and social determinants of health.

Completed

.

10/30/2015

09/30/2016

10/30/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

.

10/30/2015

06/30/2017

10/30/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

.

10/30/2015

09/30/2016

10/30/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

.

10/30/2015

06/30/2017

10/30/2015

12/31/2017

12/31/2017

DY3 Q3

In Progress

.

10/30/2015

06/30/2017

10/30/2015

12/31/2017

12/31/2017

DY3 Q3

In Progress

.

10/30/2015

06/30/2017

10/30/2015

12/31/2017

12/31/2017

DY3 Q3

In Progress

Preliminary report of IT infrastructure and platform, includes plan for phased adoption; Resource assessment that includes existing resources and identified gaps; Quarterly report of progress towards adoption of common IT platform

09/01/2015

06/30/2017

09/01/2015

12/31/2017

12/31/2017

DY3 Q3

On Hold

Board approved PCMH practice assessment plan for PPS; Quarterly report on progress towards PCMH level 3

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Step 5: Working with clinical committee and project work groups, define plans for addressing target population health disparities. Task

Step 6. Acquire, aggregate and leverage data for analysis in support of population health management of identified target populations. Task

Step 7: Engage stakeholders including patients, partners/providers and CBOs to create a collaborative partnership to develop population health road map. Task

Step 8: Present to leadership for approval of population health road map. Task

Step 9: Work with IT to identify the necessary IT infrastructure to support a population health approach. Task

Step 10: IT Committee, with MSHP support, will leverage state and existing PPS partner resources to plan phased adoption of a common IT platform for secure clinical data and care plan sharing within and between PPSs (Milestone 6). Task

Step 11: PMO, with MSHP support and

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Finalize PPS-wide bed reduction plan.

DSRIP Reporting Year and Quarter

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

12/31/2015

06/01/2015

12/31/2015

12/31/2015

DY1 Q3

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Original End Date

Start Date

On Hold

PPS Bed Reduction plan, signed off by PPS Board. This should set out your plan for bed reductions across your network, including behavioral health units/facilities, in line with planned reductions in avoidable admissions and the shift of activity from inpatient to outpatient settings.

04/01/2015

03/31/2020

Completed

1. Identify workgroup members, meeting schedule, concrete goals with more refined timelines of completion of goals

06/01/2015

On Hold

1. Complete report of all described data elements for each site for entire PPS 2. High level summary report of data collection and reporting requirements across the PPS 3. Preliminary report of data analysis

04/01/2015

Status

experienced PPS partners will develop plan for assessing practices and begin providing technical assistance for 2014 PCMH Level 3 certification (Milestone 5). This includes identifying PCMH Level 3 requirements by provider type and developing a strategy on how the PPS works with those providers to meet these requirements.

Milestone #2

End Date

Quarter End Date

Original Start Date

Description

certification

Task

Step 1. Establish Bed Complement and Utilization Workgroup. This workgroup will consist of partners/stakeholders who are impacted by bed reduction . The group will be responsible for creating a model and methodology for determining the number of beds that can be reduced. Additionally, this group will oversee monitoring and reporting on reductions in avoidable hospital use, as well as modeling the impact of all DSRIP projects on bed utilization. Task

Step 2. Assessment Phase: 1. Inventory number of beds by type, location and occupancy rate to develop both site-based and overall PPS bed count and occupancy rates by bed type 2. Obtain patient days and LOS data by MSDRGs for baseline bed occupancy type by diagnosis, to determine both site-based and overall PPS occupancy rates by MSDRG 3. Determine the baseline/starting point for where all partners who are affected.

AV

NYS Confidentiality – High

NO

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Milestone/Task Name

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

Completed

1. Complete report of all described data elements for each site for entire PPS 2. High level summary report of data collection and reporting requirements across the PPS 3. Preliminary report of data analysis

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

On Hold

Draft written model and methodology

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Report of workforce impact

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

Preliminary report of IT infrastructure and platform

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

4. Determine data collection and reporting requirements necessary across the PPS to be able to analyze and review on defined frequency bed utilization data 5. Review Community Needs Assessment and other community health related data for any geographic variability in health conditions that may impact bed utilization Task

Step 3. Preliminary Data Analysis Phase 1. Analyze data from assessment phase and identify any additional data needs and/or planning steps to consider in formulating bed plan Task

Step 4. Forecasting Phase: Develop a model and methodology to forecast impacts of all DSRIP projects on avoidable hospital use and utilization based on targeted reduction of avoidable hospitalizations by DSRIP years. Model/Methodology may include contributing variables such as: 1. DRGs most impacted by DSRIP projects; 2. Bed types most likely affected by DSRIP projects; 3. Conditions driving potentially preventable hospitalizations and re-admissions; 4. Specific community health needs/conditions that may affect bed complement and bed utilization both related to and independent of DSRIP projects 5. Contingency planning for unexpected mass health crises Task

Step 5. Workforce Impact: Assess employees impacted by bed reduction with workforce and type of training that will need to occur Task

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 6. Data Collection and Analysis IT PlatformPhase 1: Identify IT tools, data collection, and data reporting framework to obtain regular and accurate service utilization data across the PPS Task

Step 7. Vetting of Draft Model and Methodolologies: Share model and methodologies with partners via PPS Governance Structure regarding approach to bed reduction for feedback, revision, to further inform forecasting

On Hold

Governance Structure Minutes

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Draft forecasts with data elements as described

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Draft written Bed Capacity Change Plan

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Final summary re: IT platform

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Final written plan

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Step 8. Establish high-level forecasts of the following (this forecast capacity model will be updated on a regular basis throughout the 5 years) a. Reduced avoidable hospital use over time by bed type (and diagnoses if possible) b. Changes in inpatient capacity, by bed type c. Resulting changes in required community / outpatient capacity Task

Step 9. Draft Bed Capacity Change Plan: 1. Providers impacted by forecast capacity change to determine their own 'first draft' capacity change plan, to be consolidate into a PPS-wde capacity change plan. 2. Bed Complement and Utilization Workgroup to develop first draft capacity change plans and vet through PPS Governance Structure. Task

Step 10. Data Collection and Analysis IT Platform--Phase 2: Finalize IT tools and infrastructure necessary for seamless updates and reporting of forecasts Task

Step 11. Final Bed Capacity Plan: Finalize and publish final capacity change / bed reduction

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

plan, establish and schedule of annual updates on capacity changes across the network Task

Step 4: Forecasting Phase: Develop a model and methodology to forecast impacts of all DSRIP projects on avoidable hospital use and utilization based on targeted reduction of avoidable hospitalizations by DSRIP years. Model/Methodology may include contributing variables such as: 1. Conditions most impacted by DSRIP projects; 2. Bed types most likely affected by DSRIP projects; 3. Conditions driving potentially preventable hospitalizations and re-admissions; 4. Specific community health needs/conditions that may affect bed complement and bed utilization both related to and independent of DSRIP projects

On Hold

Draft written model and methodology

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

High level summary report of data collection and reporting requirements across the PPS.

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

Task

Step 2: Assessment Phase:. Determine the baseline and starting point for all partners affected. Determine the data collection and reporting requirements necessary across the PPS to be able to analyze and review on defined utilization data. Review Community Needs Assessment and other community health data for anything that may impact bed utilization

IA Instructions / Quarterly Update Milestone Name

IA Instructions

No Records Found

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Quarterly Update Description

AV

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

Upload Date

No Records Found

Prescribed Milestones Narrative Text Milestone Name Develop population health management roadmap.

Narrative Text Milestone due date has been extended to allow for recent PPS clinical implementation activities to occur. These ongoing activities will influence and provide input to the roadmap.

Finalize PPS-wide bed reduction plan.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

Page 117 of 932

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 8.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 8.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in implementing these cross-cutting organizational strategies, including potential impacts on specific projects and, crucially, any risks that will undermine your ability to achieve outcome measure targets. Risk 1: Inadequate patient and community engagement. Mitigation: MSPPS will hold introductory and recurring community-based forums starting early in DY1 to educate and gather feedback from stakeholders about local DSRIP project implementation and the goal of an IDS. The PPS PMO will create a patient advisory board which will meet regularly to inform PPS governance of reactions and response to project and IDS implementation. Risk 2: Inadequate PPS Provider engagement may result in continued disjointed care. Mitigation: Our PPS will create regional "hubs" to tailor and implement PPS projects relevant to specific communities' and populations' clinical and social service needs, engaging local providers and service organizations to provide core project services. We are implementing a PPS Stakeholder Engagement Committee to proactively gather feedback on operational planning and future decisions across PPS domains. Workforce and Clinical technical committees are collaborating on a centralized training program for all provider types to deliver culturally sensitive and competent service that promote health literacy and address social determinants of health specific to our projects' target populations. Through MSHP, we will provide support for performance tracking and management, IT implementation, PCMH certification, and care management training or staff recruitment so partners with less infrastructure can achieve required DSRIP goals while also meeting other internal priorities. Risk 3: Challenges in workforce recruitment, training, and collaboration with labor groups to adequately meet demand. Mitigation: We will leverage and establish relationships with labor groups (e.g. SEIU, NYSNA) and training/advocacy organizations (e.g. PHI) to communicate DSRIP project plans, identify training needs and develop re/training programs that optimize workforce knowledge and skills in the successful delivery of DSRIP program services. We will work with recruitment agencies, health worker training programs and professional schools of social work, nursing, behavioral and health sciences to educate trainees about career opportunities in an integrated delivery system, and hold regular recruitment events. Risk 4: Inability to secure adequate resources to support population health infrastructure for all partners. Mitigation: We will leverage existing IT, clinical and care management resources, including PPS partners and Mount Sinai's population health infrastructure, MSHP, to provide the IDS's foundation. The IT, Clinical and Finance committees are meeting to ensure responsible decisionmaking regarding (1) adequate flow of funds to carry out initiatives at every site; (2) selection of the appropriate applications for a common IT platform that can accommodate existing HIE, EMRs and other application; (3) planning for ultimate financial sustainability of individual projects; and (4) engaging with MCOs to gradually but aggressively shift contracts from fee for service to fully risk-based as groups within the PPS are able.

IPQR Module 8.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.)

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) The success of the clinical projects relies on the ability to establish a shared IT platform to communicate and share clinical and care management data across PPS providers, and between PPSs. Likewise, engagement, training, performance feedback and incentivization of workforce to operate as a clinically integrated system will be integral to the effective implementation of clinical projects. Ongoing, timely analysis of patient-level data will facilitate identification of subgroups that require intervention, in order to achieve the goal of optimizing population health management and reducing disparities. Transparent and adequate financial models that support the IDS as well as the PPS projects, and successful development of relationships that result in risk-based contracts with payers, will determine long-term sustainability of the IDS and its providers.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 8.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational work stream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

PMO Director

Jill Huck

Administrative oversight of PPS

PMO Medical Director

Edwidge Thomas

Clinical oversight of PPS projects

PMO Associate Directors

Nina Bastian

Leadership Committee

PPS members

Clinical Committee

PPS members

Finance Committee

PPS members

Workforce Committee

PPS members

IT Committee Mount Sinai Health Partners (Population Health Managed Services Organization)

PPS members

Assist PMO Director in oversight of PPS activities Provide guidance and feedback on population health management system implementation Develop, implement and modify PPS clinical projects Oversee and manage PPS financial operations; guiding processes towards value-based payer contracts and provider compensation models Lead PPS workforce assessment and needs for each project; design and implementation of training programs for PPS; collaborate on value-based compensation and benefits model Lead PPS IT systems assessment, design and implementation Provide data, IT, clinical integration, care management, and contracting support for PPS and/or partners

N/A

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 8.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Mount Sinai Health System

Lead applicant

Mount Sinai Health Partners (Population Health MSO)

Support role as above

Lead all PPS partners in clinical integration efforts to adequately deliver population-based health services Provide data, IT, clinical integration, care management, and contracting support for PPS and/or partners

External Stakeholders PPS partners

Service providers

FQHC partners

Service providers

Hospital partners

Service providers

LTC/SNF partners

Service providers

CHHA partners

Service providers

Other PPSs

Serving overlapping populations/geograpies

NYCDOHMH

Local collaborator

Managed Care Organizations

Long-term sustainability of PPSs as provider entities

Collaborate within PPS to implement clinical projects and redesign organizations to deliver care as an IDS Collaborate within PPS to implement clinical projects and redesign organizations to deliver care as an IDS Collaborate within PPS to implement clinical projects and redesign organizations to deliver care as an IDS Collaborate within PPS to implement clinical projects and redesign organizations to deliver care as an IDS Collaborate within PPS to implement clinical projects and redesign organizations to deliver care as an IDS Collaborate with each other in learning sessions; align clinical projects and/or infrastructural processes Convene HIV providers in common clinical project (4.c.ii) Work with PPSs to engage in value-based contracts which incorporate both clinical and non-clinical services

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 8.7 - IT Expectations Instructions : Please describe the current Population Health Management IT capabilities in place throughout your PPS network and what your plans are at this stage for leveraging these capabilities and/or developing new IT infrastructure. There are a number of population health management solutions implemented by The Mount Sinai Health System (MSHS) that will be leveraged for the MS PPS, under DSRIP, including a robust care management program for individuals living with HIV, an advanced multidisciplinary adolescent health program and a home-based primary and palliative care program, all of which rely on an existing IT infrastructure. MS PPS will leverage and grow these capabilities through the deployment of a centralized data warehouse and associated analytic platforms that will include critical functions, such as clinical decision support, population health metrics, predictive analytics, reporting and registries for care management, and utilization management. Together with the HIE for all providers and programs, these tools will be used to measure population health status and to prioritize the deployment of high value interventions to improve outcomes.

IPQR Module 8.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. The PMO will be responsible for overseeing and tracking progress of the various Committees' responsibilities and deliverables towards development of a Population Health Management infrastructure. The PMO will track and report process and clinical outcomes on a monthly basis for high-priority projects, and meet at least monthly to update and receive updates from Clinical, IT, Finance, Workforce and Leadership Committees to ensure specific goals are being met within the proper timeline.

IPQR Module 8.9 - IA Monitoring Instructions :

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 09 – Clinical Integration IPQR Module 9.1 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation.

Milestone/Task Name

DSRIP Reporting Year and Quarter

06/01/2015

12/31/2016

12/31/2016

DY2 Q3

06/30/2016

06/01/2015

06/30/2016

06/30/2016

DY2 Q1

06/01/2015

06/30/2016

06/01/2015

06/30/2016

06/30/2016

DY2 Q1

06/01/2015

06/30/2016

06/01/2015

06/30/2016

06/30/2016

DY2 Q1

Original End Date

Start Date

Completed

Clinical integration 'needs assessment' document, signed off by the Clinical Quality Committee, including: -- Mapping the providers in the network and their requirements for clinical integration (including clinical providers, care management and other providers impacting on social determinants of health) -- Identifying key data points for shared access and the key interfaces that will have an impact on clinical integration -- Identify other potential mechanisms to be used for driving clinical integration

06/01/2015

12/31/2016

Completed

Draft written work plan detailing action items for development of clinical integration needs assessment

06/01/2015

Completed

Documentation of process metrics and process of tracking success

Completed

Documentation of review, meeting review minutes

Status

Milestone #1

Perform a clinical integration 'needs assessment'.

End Date

Quarter End Date

Original Start Date

Description

Task

STEP 1: Develop/Draft a plan for how we will conduct a clinical integration needs assessment including components not limited to: carrying out, measuring and reporting common evidencebased protocols and quality metrics, communication between providers across care settings, facilitation of care coordination by employing information technology solutions, and implementation of high-quality clinical programs for targeted populations. Task

STEP 2: Develop/Draft process metrics to track progress and success of plan. Task

STEP 3: Have draft reviewed by appropriate committees for input and submit to Leadership

NYS Confidentiality – High

AV

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Status

Description

Completed

Completed needs assessment document, including documentation of potential barriers/challenges and mitigation steps; Provider directory, task lists detailing provider requirements

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Completed facility review instrurment

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Meeting Minutes, list of shared key data points, list of anticipated challenges in accessing data sharing platform

06/01/2015

12/31/2016

06/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

Meeting minutes, list of key interfaces that will impact clinical integration during care transitions and management

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

On Hold

Final and board-approved needs assessment document and plan; record of ongoing needs assessment analysis methodology, committee meeting minutes

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

In Progress

Clinical Integration Strategy, signed off by Clinical Quality Committee, including: -- Clinical and other info for sharing -- Data sharing systems and interoperability -- A specific Care Transitions Strategy, including: hospital admission and discharge coordination; and care transitions and coordination and communication among primary care, mental health and substance use providers -- Training for providers across settings (inc. ED, inpatient, outpatient) regarding clinical integration, tools and communication for coordination -- Training for operations staff on care coordination and

06/01/2015

06/30/2017

06/01/2015

12/31/2017

12/31/2017

DY3 Q3

AV

for approval Task

STEP 4: Map the providers in the MSPPS network and their requirements for clinical integration Task

STEP 5: Perform assessment of partner facilities, such as patient centered medical homes Task

STEP 6: Identify key data points for shared access and identify challenges partners might face in accessing data sharing platform Task

"STEP 7: Identify key activities that are necessary for clinical integration between providers such as development of shared evidence-based clinical pathways, including care transitions protocols, common IT platforms for care coordination and data reporting. " Task

STEP 8: Finalize needs assessment of provider, establish uniform evidenced based practice guidelinesand establish current process for communicatiton. Present to Clinical and other appropriate committees for approval

Milestone #2

Develop a Clinical Integration strategy.

NYS Confidentiality – High

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

06/01/2015

09/30/2015

09/30/2015

DY1 Q2

Original Start Date

Original End Date

Start Date

06/01/2015

09/30/2015

communication tools Task

STEP 1: Develop a strategy for clinical and other info sharing

Completed

STEP 1: Develop a strategy for clinical and other info sharing

Task

STEP 2: Develop and conduct a risk assessment of the attributed lives within the MSPPS

Completed

STEP 2: Develop and conduct a risk assessment of the attributed lives within the MSPPS

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

STEP 3: Task clinical committee with creating a specific transitions strategy. Also design an optimized admission and discharge process across the MSPPS with some flexibility for tailoring to local and borough specific needs, with approval from the MSPPS

06/01/2015

06/30/2017

06/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

STEP 4: Develop a strategy with IT and Clinical regarding data sharing and interoperability

06/01/2015

03/31/2016

06/01/2015

03/31/2016

03/31/2016

DY1 Q4

In Progress

STEP 5: Ensure that the specific transitions strategy include a consistent measurement strategy to determine risk levels of patients within the PPS and communicate that strategy across the MSPPS. Present to Leadership for adoption.

06/01/2015

06/30/2017

06/01/2015

12/31/2017

12/31/2017

DY3 Q3

Completed

STEP 6: Develop and conduct an assessment of what tools providers currently have and will need in the future for coordinated communication

06/01/2015

03/31/2016

06/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

STEP 7: Develop a training strategy for providers across all settings within the MSPPS regarding clinical integration, tools and communication for coordination

06/01/2015

09/30/2016

06/01/2015

09/30/2016

09/30/2016

DY2 Q2

In Progress

STEP 8: Working with the workforce committee, create a training protocol for providers and their operations staff regarding coordination tools

06/01/2015

06/30/2017

06/01/2015

12/31/2017

12/31/2017

DY3 Q3

Task

STEP 3: Task clinical committee with creating a specific transitions strategy. Also design an optimized admission and discharge process across the MSPPS with some flexibility for tailoring to local and borough specific needs, with approval from the MSPPS Task

STEP 4: Develop a strategy with IT and Clinical regarding data sharing and interoperability Task

STEP 5: Ensure that the specific transitions strategy include a consistent measurement strategy to determine risk levels of patients within the PPS and communicate that strategy across the MSPPS. Present to Leadership for adoption. Task

STEP 6: Develop and conduct an assessment of what tools providers currently have and will need in the future for coordinated communication Task

STEP 7: Develop a training strategy for providers across all settings within the MSPPS regarding clinical integration, tools and communication for coordination Task

STEP 8: Working with the workforce committee, create a training protocol for providers and their operations staff regarding coordination tools

NYS Confidentiality – High

AV

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Task

SYEP 9: Finalize and deploy PPS-wide clinical integration strategy

In Progress

Description

SYEP 9: Finalize and deploy PPS-wide clinical integration strategy

Original Start Date

Original End Date

Start Date

06/01/2015

06/30/2017

06/01/2015

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

12/31/2017

12/31/2017

DY3 Q3

AV

IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

Upload Date

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Perform a clinical integration 'needs assessment'. Develop a Clinical Integration strategy.

Milestone due date has been extended to allow for recent PPS clinical implementation activities to occur. These ongoing activities will influence and provide input to the strategy.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 9.2 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 128 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 9.3 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges or risks that you foresee in improving the level of clinical integration throughout your network and achieving the milestones described above. Describe potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. Risk 1: PPS partners not fully comprehending the IT requirements Mitigation Strategy: Engage in comprehensive community-based partner education through workshops, web-based learning tools and 1:1 interaction at partner sites; development of education materials by provider type to clearly state expectations and requirements. Risk 2: Partners inability to achieve meaningful adoption of IT capabilities to connect to centralized IT services and engage in data sharing Mitigation Strategy: PPS has planned for provision of technical assistance with relation to EHR adoption and PCMH certification. PPS will establish incremental IT adoption milestones and site visits to ensure progress towards defined requirements and performance objectives. Financial incentives will be put into place to encourage IT adoption by partners with DSRIP dollars. Risk 3: Breadth of EHRs and electronic platforms currently in use may pose significant barrier and/or cost for development of interfaces by vendors for HIE connectivity Mitigation Strategy: PPS IT committee will conduct a deeper assessment to better understand vendors within PPS, work to negotiate interfaces for top volume platforms first; as well as work with partners without IT platforms to adopt software from a select set of vendors. Risk 4: Consent process may inhibit ability to access and share pertinent patient data Mitigation Strategy: Continue to coordinate with GNYHA, other PPSs, RHIOs and stakeholders to drive policy change and consent education for patients through providers to continually improve level of consent and mitigate policy barriers. Risk 5: As with any collaborative, stakeholders may not reach consensus on strategic, business or governance decisions in a timely manner Mitigation Strategy: Implementation plan will carefully map out deliverable/decision points and risks of indecision will be raised immediately to PPS leadership for arbitration; PPS will leverage State guidance on key business and technical decisions where appropriate. Risk 6: Funding challenge to attain resources to help realize IT strategy and investments Mitigation Strategy: MS PPS has already submitted a capital request to help fund the IT needs for the PPS. Partners have also been encouraged to apply for a capital request, which many have done. Additionally, the PPS is providing information for alternative funding sources, such as PCIP, for partners to connect with. Risk 7: Partners fail to respond to the needs assessment Mitigation Strategy: MSPPS will reach out to each provider individually to ensure a response Risk 8: Partners do not commit to the new trainings for clinical integration and coordination. Mitigation Strategy: MSPPS will conduct extensive outreach to all partners to determine if the universal MSPPS training process is application or if modifications would serve the partner and community better.

IPQR Module 9.4 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.)

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Clinical integration will require regular collaboration between all committees within the PPS as well as the other work groups created to address implementation planning. IT systems will need to collaborate with Clinical to ensure that universal consent is recognized through the PPS, provider engagement will be critical to ensure that all providers are able to communicate seamlessly when integrating health care delivery. Cultural competency will need to work with Workforce as well as Clinical to ensure that the right training are being provided by and provided to the right individuals.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 9.5 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities

Clinical Committee Co-Chair

Dr. Theresa Soriano

Clinical Committee Co-Chair

Leadership Committee

Ed Lucy

Leadership Committee

MSO

Theresa Dolan

MSO

IT Committee Co-Chair

Kumar Chatani

IT Committee Co-Chair

Workforce Committee Co-Chair

Jane Maksoud

Workforce Committee Co-Chair

Clinical Director of PMO

Edwidge Thomas

Clinical Director of PMO

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 9.6 - Key Stakeholders Instructions : Please identify the key stakeholders involved, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Clinical Committee Members

Data providers and assessments

Finance Committee

Data providers and assessments

IT Committee

Data providers and assessments

Provide feedback for the needs assessment and implement strategy Provide feedback for the needs assessment and implement strategy Provide feedback for the needs assessment and implement strategy

External Stakeholders PAYERS Healthfirst - Dr. Susan Beane, Medical Director CBO's ArchCare - Mitze Amoroso, CIO Housing Works - Miguel Mendez, CTO VIP Community Services - Deborah With, Chief Program Officer Clinics Settlement Health - Warria Esmond, CMO Institute of Family Health - Kathy Cresswell, CIO William F. Ryan Community Health Center Barbara Hood, CIO Community Healthcare Network - Jason Pomaski, CIO Callen-Lorde Community Health Center - Richard Clarkson, CIO RHIOS Patient Advocates IT Departments are represented by the CIO/CTOs from our partnering organizations Clinical and Non Clinical Providers Isabella Nursing Home - Greg Fortin, CIO

Partner in creating an integrated health care delivery system

Provide feedback for the needs assessment and implement strategy

Partner in creating an integrated health care delivery system

Responsible for participating in the needs assessment and implementing the clinical implementation strategy

Partner in creating an integrated health care delivery system

Seeing MSPPS attributed lives before they are admitted through the ER

Facilitating data connectivity Representation of patients Support the assessment and strategy Treat patients

facilitating data connectivity Participate in the needs assessment of providers and potential training protocols actually implement the needs assessment and strategy, conduct surveys implement the strategy

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Key stakeholders

Role in relation to this organizational workstream

City Health Works - Aaron Baum, Director of Technology

NYS Confidentiality – High

Key deliverables / responsibilities

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 9.7 - IT Expectations Instructions : Please clearly describe how the development of shared IT infrastructure across the PPS will support this particular workstream. Clinical integration is the ultimate goal of the MS PPS IT infrastructure, particularly through the widespread achievement of data exchange and interoperability. The PPS Health Information Exchange (HIE), as defined under the proposed architectural model, will build upon the PPS's robust network of Electronic Health Records systems and allow for the bidirectional sharing of information of clinical, behavioral and social determinants of health data across systems, providers and partners. This information will facilitate widespread integration, including data-supported care management and transitions of care. In addition, the MS PPS will deploy specific interfaces and enhancements that support clinical integration including: (1) RHIO interfaces that that allows partners to access a longitudinal patient record through RHIO-supported "subscription" services and to engage in direct messaging across systems; (2) CBO data conversion tools that allow community-based partners to exchange data and track outcomes as well as to produce standardized health data elements; and (3) Closed-loop referral management and tracking tools which will better enable consultation between PCP and Specialty providers. Interfaces to the PPS' RHIO partners will additionally allow for data contained and collected within the PPS, such as data from CBOs, to be accessible to the RHIOs, expanding their role as community clinical integrators.

IPQR Module 9.8 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. Initially, the Clinical Committee will develop the metrics that define success of clinical integration specific to this PPS. Then, progress reporting will be a collaborative process between IT and Clinical committee. Both committees will work together to develop a work plan and a set of metrics to define success. The PPS will accurately and timely submit quarterly reports which will detail the progress the MS PPS has accomplished over each time period. Once the state issues initial benchmarks, the MS PPS will ensure that the needs assessment and the clinical integration strategy are tailored to measure those benchmarks moving forward. To that end, IT will provide a measurement tool to track patient outcomes and present in a dashboard. The IT work stream leadership will develop a comprehensive implementation plan, supplemented by GANTT chart outlining quarterly milestones based on performance requirements (DSRIP) and implementation milestones for the PPS IT strategy. The implementation plan will provide a measurable guide for progress that will be regularly shared with Leadership and collaborating committees to ensure provision of deliverables, services and functionality in line with PPS scale and speed, and overall PPS IT requirements. In addition to IT implementation progress tracking and management, the committee will engage in PPS partner feedback requests through surveys and discussion forums to ensure solutions and services continually meet partner needs, expectations and deliver value.

IPQR Module 9.9 - IA Monitoring:

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Instructions :

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 10 – General Project Reporting IPQR Module 10.1 - Overall approach to implementation Instructions : Please summarize your intended approach to the implementation of your chosen DSRIP projects, including considerations around how this approach will allow for the successful development of concurrently implementing DSRIP projects. MSPPS approach to implementation of its ten DSRIP projects is a delegated governance structure forming an LLC. All partners have a responsibility to the PPS. The PPS lead will facilitate decision making in conjunction with all partners. Also, establishment up of MSPPS Project Management Office will be critical to completing the milestones/metrics of DSRIP. The PPS will have a strong focus on meaningful education, training of best practices and communication throughout the process. As expected of the clinical quality committee, standardization of clinical and operating processes and methodology will be a goal of the overall PPS with MS PMO support. Using a delegated model, transitioning from Leadership committee to the Board of Managers of Mount Sinai PPS, LLC, 29 voting members have been selected reflective of the continuum of care and are geographically representative of the PPS. To ensure the Mount Sinai PPS provider network becomes increasingly integrated, it will be necessary for providers and clinicians to be educated on: (a) what these DSRIP-driven changes mean for their practice and how they will be affected at each step of implementation; and (b) what their role, expectations, and obligations are. Education and provider inclusion will be one of the key roles of our Clinical Quality Committee and its sub-committees for each project. Provider education is also a two-way process and MSPPS intends to work with the State to be involved in both the project breakthrough series and the annual learning collaborative conferences to maximize the impact of our DSRIP. MSPPS invested in training, education and consistent bidirectional communication that is transparent across the PPS. Mount Sinai has been strong in its' stakeholder engagement and community outreach. The approach taken has been inclusive of all partners using weekly meetings, newsletters, webinars, strong notifications and communications to partners, town halls and ongoing opportunities for collaboration from our partners. PPS wide deliverables such as bed reductions have pulled in stakeholders who will be affected by the decrease in the number of staffed bed units. In planning for the bed reduction we included partners from the Brooklyn Hospital Center, Mount Sinai hospitals, SNFs and Board of Managers in helping with the overall plan of the bed reduction deliverable. Mount Sinai PPS is also working towards adapting project plans, evaluating and improving the plan through a continuous quality improvement cycle. This approach was meant to ensure the PMO is constantly tracking the best practices and methodologies that will work in keeping partners accountable. In addition, the MSPPS is working to develop a CRM inclusive of its' network partners contacts and information for feasible and easy to reach of partners within a centralized area. The process of standardizing clinical and operational protocols is likely to be the most difficult task facing the Mount Sinai PMO. It is not just about aligning systems, but also achieving a common language between providers, a common method of performance measurement for the PPS, and a common culture focused on patient outcomes – all of which will underpin the transition to VBP. The following initiatives are central to our drive for increasing standardization across our network: – Development of shared IT infrastructure and data sharing, ensuring that patient information is seamlessly and securely transferred.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) – Care transitions strategy and the buy-in to this strategy from practitioners throughout the network. – The sharing of best practice and performance information, through the network of project clinical committees – Hiring, training, and redeployment of staff that will happen as part of our workforce transition strategy

IPQR Module 10.2 - Major dependencies between work streams and coordination of projects Instructions : Please describe how your approach will handle interdependencies between complementary projects, as well as between projects and cross-cutting PPS initiatives - for example, an IT infrastructure upgrade, or the establishment of data sharing protocols. The Mount Sinai PPS is one of the largest PPS provider network in the DSRIP program. With 10 Projects, interdependencies between projects and between cross-cutting PPS-development initiatives will be inevitable requiring synergy between all projects. Because partners may be in multiple projects, implementation of the 10 DSRIP projects will require surveying to compliment the deliverables that are overlapping and interdependent of each other. Development of current and future state gap analysis, use of tools to find overlapping milestones and metrics, in addition development of a metrics manual to understand the similarities and differences of each project will be imperative in our approach of complementary projects. Additionally, for different projects with similar goals and project requirements, a framework will be developed to capture the overlap of the providers. This framework will entail geomapping and a network analysis of our partners to determine which providers share which projects, their locations and their levels of overlap. For example, managing transitions of care more effectively will be a central part of multiple projects and without a proactive approach to our Care Transitions Strategy there is a risk that different protocols will be developed at different sites or in different projects. Many projects also share same or similar project requirements. Taking that into account, we have taken a robust approach to predicting, planning for, and managing the overlap between project requirements. For those project requirements that are most pervasive, we have set up cross-functional work groups tasked with driving consistent, coordinated implementation. For example, achieving PCMH 2014 Level 3 certification will be a priority for many providers and will be an important success factor in many projects. We have therefore set up a dedicated PCMH Certification Team that will be responsible for all relevant providers meeting this project requirement according to the timetable set out in our project speed of implementation forecasts. We will set up task teams for the following most overlapping requirements to track: - Use of EHRs to track all patients engaged in projects; - Ensure that all PPS safety net providers are actively sharing EHR systems with local HIE/RHIO/SHIN-NY and sharing health information among clinical partners by the end of Demonstration Year (DY) 3; - Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards by the end of DY 3; and - Establish agreements with the Medicaid MCOs serving the affected population to provide coverage for the service array under a specific project. We believe this is a starting point for identifying the clinical, financial, administrative, or technological initiatives that will be most important for the successful delivery of our DSRIP projects. Most likely our approach will change accordingly as we determine what works best for our network and how to assess it accordingly. All projects will be managed and directed by the Mount Sinai PPS PMO.

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 10.3 - Project Roles and Responsibilities Instructions : Please outline the key individuals & organizations that play a role in the delivery of your PPS's DSRIP projects, as well as what their responsibilities are regarding governance, implementation, monitoring and reporting on your DSRIP projects.

Role

Name of person / organization (if known at this stage)

MS PPS PMO

Overarching project management office

Project working groups

Project Management

Mount Sinai PPS Clinical Quality Committee

Oversight of the clinical quality committees for individual projects and project work groups

Key deliverables / responsibilities - PMO will be responsible for delivering quarterly reports to DOH - Project leadership teams will report into PMO - PMO will manage any major risks that are escalated from Project leadership teams - PMO will be responsible for driving the implementation of those projects requirements identified as the most pervasive - PMO will monitor the implementation of cross-PPS organizational development initiatives, such as IT infrastructure development and workforce transformation - PMO will be the link between the Project leadership teams and the Mount Sinai Finance Committee, the Mount Sinai Workforce Committee, the Mount Sinai IT Committee and the Mount Sinai Compliance Committee - Day-to-Day management of progress against Project requirements - Reporting on progress against Project requirements to Forestland PPS PMO - Managing clinical integration at A Project level and Compliance with PPS initiatives such as Care Transitions Strategy - Implementation of Project-specific workforce initiatives – i.e. the retraining, hiring, redeployment required by each specific Project "MS Clinical Quality committee will ensure project-specific clinical quality committees are effectively driving improvements in clinical outcomes and improved clinical integration; Project-specific clinical quality committees will escalate any major quality issues / risks to the MS PPS MS Clinical Quality committee will ensure any overlap between project-specific clinical quality committees is managed (for example, where there is considerable overlap between two of our projects, we may consider merging the two clinical quality committees)

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Role

Name of person / organization (if known at this stage)

Key deliverables / responsibilities MS Clinical quality committee will oversee and sign off the performance metrics for each of the DSRIP projects MS Clinical quality commitee will be educatiing and sharing with network providers on the details of project implementations "

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 10.4 - Overview of key stakeholders and how influenced by your DSRIP projects Instructions : In the below table, please set out who the key stakeholders are that play a major role across multiple DSRIP projects. Please give an indication of the role they play and how they impact your approach to delivering your DSRIP projects.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Mount Sinai Health Partners (Population Health MSO)

Population Health MSO

MS PPS PMO

Overarching project management office

Mount Sinai PPS Clinical Quality Committee

Oversight of the clinical quality committees for individual projects and project work groups

Provide data, IT, clinical integration, care management, and contracting support for PPS and partners PMO will be responsible for delivering quarterly reports to DOH project leadership teams will report into PMO PMO will manage any major risks that are escalated from Project leadership teams PMO will be responsible for driving the implementation of those projects requirements identified as the most pervasive PMO will monitor the implementation of cross-PPS organizational development initiatives, such as IT infrastructure development and workforce transformation PMO will be the link between the Project leadership teams and the Mount Sinai Finance Committee, the Mount Sinai Workforce Committee, the Mount Sinai IT Committee and the Mount Sinai Compliance Committee" "MS Clinical Quality committee will ensure project-specific clinical quality committees are effectively driving improvements in clinical outcomes and improved clinical integration; Project-specific clinical quality committees will escalate any major quality issues / risks to the MS PPS MS Clinical Quality committee will ensure any overlap between project-specific clinical quality committees is managed (for example, where there is considerable overlap between two of our projects, we may consider merging the two clinical quality committees) MS Clinical quality committee will oversee and sign off the performance metrics for each of the DSRIP projects MS Clinical quality committee will be educating and sharing with network providers on the details of project implementations

External Stakeholders

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Key stakeholders

Role in relation to this organizational workstream

PPS partners

Participants in clinical projects

SEIU/1199

Union representation for certain workforce

NYSNA

Union representation for certain workforce

Managed Care Organizations

Payers

Other PPSs

Potential collaborators on projects

Key deliverables / responsibilities Implement integration initiatives and clinical project(s) at respective sites Participate in determining training needs, hiring and recruitment processing, outcomes-based compensation plans for workforce Participate in determining training needs, hiring and recruitment processing, outcomes-based compensation plans for workforce Engage in meaningful relationships with PPS to provide and share data, develop value-based contracts with PPS entity, and/or eventual contracting body Align common projects and/or clinical integration processes to optimize project and provider reach and effectiveness, and patient experience

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 10.5 - IT Requirements Instructions : Information technology will play a crucial role in the development of an effective, integrated performing provider system. It is likely that most projects will require some level of supporting IT infrastructure. Please describe the key elements of IT infrastructure development that will play a role in multiple projects. Two central themes that carry through the MS PPS DSRIP project selection are improved transitions of care between settings and improved disease management. The proposed IT infrastructure will support these objectives in a number of ways. First, a central component of the MS PPS IT infrastructure is the significant expansion of the organizations HIE capabilities. Once fully realized, HIE will allow for the real-time sharing of information on clinical, behavioral and social determinants of health across all participating providers and CBOs -- ensuring that all relevant information is available at the site of care, and that data follows care transitions. A second feature of the MS PPS IT infrastructure that will be imperative for successful project implementation is the development of a data warehouse. This and the associated analytic platforms will drive PPS capabilities to leverage clinical and claims data to drive projects associated with population health improvement as well as care coordination and management activities. Additional tools that will be centrally implemented to specifically target improved care coordination and management will allow for the deployment of disease management platforms, patient monitoring techniques, care alerts, automated data transmission triggers, sharing of and collaboration around patient care plans, referral management and tracking, and development of robust and dynamic patient registries. Additional key IT infrastructure improvements that will be important to overall project success include implementation of a flat file/CBO data conversion process, which more fully links community-based interventions to the PPS, to be integrated, monitored and evaluated by the health system, and a Learning Management System (LMS) which will support the widespread deployment of project-related protocols and procedures. To meet the requirements for population health analytics and sophisticated care management in an integrated network, MS PPS will develop a data warehouse populated with data from the RHIO, PPS partners and other relevant sources. Population health, risk monitoring, and care management applications deployed as a part of the central MS PPS infrastructure will utilize the data in this warehouse. These services will be accessed through a user portal in one consolidated location to minimize disruption for PPS partners in their workflows as they work to enhance care coordination, and actively participate and realize value from these central PPS components. Finally, in order to monitor overall program performance, MS PPSwill develop business intelligence tools including a participant data management system, performance dashboards and measures tracking, and a robust DSRIP reporting system, which include a centralized customer relationship management (CRM) service to track partners' progress and drive partner engagement.

IPQR Module 10.6 - Performance Monitoring Instructions : Please explain how your DSRIP projects will fit into your development of a quality performance reporting system and culture. The Mount Sinai PPS will be using the outcome measures and actively engaged patient definitions provided by the state as a benchmark of achievement to meet the quality performance that it has set each DSRIP Quarter. A system will be created to monitor the quality performance of each project by partner to meet metrics within the committed time frame and total set number of patients. This system will require a robust Health

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) informations exchange technology that pulls the data from all of our partners and RHIOs. Additionally, ongoing data reports will be provided to the MS PPS to get an idea of where the PPS is regarding the specific projects and any outstanding deliverables that need to be met. We will also ensure to track our patient population's improved health and review how this effects hospitalizations with regards to where this will fit. The PPS will also work on incentivizing to partners when meeting the milestones and metrics through bonus payments. Performance reporting and monitoring will be expected by all partners to complete and be successful. With the MS PPS PMO, each project manager as asssigned from the MS PPS Project Management Office will oversee the projects and the deliverables where they will maintain the relationship with our partners to ensure quality measurements and maintenance of an ongoing reporting system. System informatics and data analytic tools will be used by the DSRIP MS PMO office to secure seamless information transfer. Additonally, a stakeholder engagement group will assist in securing partner buy in for projects and understanding the reporting of information to the PMO office.

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 10.7 - Community Engagement Instructions : Please describe your PPS's planned approach for driving community involvement in the DSRIP projects, how you will contract with CBOs for these projects, how community engagement will contribute to the success of the projects, and any risks associated with this. For CBOs in our PPS, we will be entering into the same partner agreement as our other partners and we will evaluate if we need additional CBO engagement throughout DSRIP. We will make a concerted effort to reach out to CBOs, making sure to engage a diverse array of CBOs including Legal Services and God's Love We Deliver. As DSRIP rolls along, we will continue to engage the CBOs in our PPS network by providing opporutnities to participate in the governance structure, and to build upon the services they provide to ensure our PPS meets all milestones and metrics. Additionally, as part of our Stakeholder engagement cross functional workgroup, we will be working on engaging the CBOs more by having a partner CBO lead these efforts. Our Project Advisory Committee will also consist of community board members and some Medicaid beneficiaries to guide the DSRIP projects and contribute to the success. The risks we see associated with our aforementioned approach is how we will get buy-in from our CBOs and community board. We also are concerned in the level of understanding each partner CBO and community board will have regarding DSRIP. We anticipate a significant amount of partner engagement and stakeholder engagement will be needed to make this successful.

IPQR Module 10.8 - IA Monitoring Instructions :

NYS Confidentiality – High

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Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Section 11 – Workforce IPQR Module 11.1 - Workforce Strategy Spending (Baseline) Instructions : Please include details on expected workforce spending on a semi-annual basis. Funds may be shifted from one funding type category to another within the workforce strategy spending table, as long as the PPS adheres to their overall spend commitments. However, the PPS may apply a 25% discount factor to the DY1 Workforce Strategy Spend target. If the PPS applies this discount in DY1, the PPS will be expected to reallocate those funds appropriately in DY2-4 to fully meet their DY1-4 total commitment.

Year/Quarter Funding Type

Total Spending($)

DY1(Q1/Q2)($)

DY1(Q3/Q4)($)

DY2(Q1/Q2)($)

DY2(Q3/Q4)($)

DY3(Q1/Q2)($)

DY3(Q3/Q4)($)

DY4(Q1/Q2)($)

DY4(Q3/Q4)($)

DY5(Q1/Q2)($)

DY5(Q3/Q4($)

131,250.00

131,250.00

612,500.00

612,500.00

612,500.00

612,500.00

359,375.00

359,375.00

87,500.00

87,500.00

3,606,250.00

Redeployment

37,500.00

37,500.00

350,000.00

350,000.00

350,000.00

350,000.00

150,000.00

150,000.00

100,000.00

100,000.00

1,975,000.00

New Hires

65,625.00

65,625.00

175,000.00

175,000.00

612,500.00

612,500.00

437,500.00

437,500.00

437,500.00

437,500.00

3,456,250.00

Other

56,250.00

56,250.00

100,000.00

100,000.00

125,000.00

125,000.00

100,000.00

100,000.00

100,000.00

100,000.00

962,500.00

290,625.00

290,625.00

1,237,500.00

1,237,500.00

1,700,000.00

1,700,000.00

1,046,875.00

1,046,875.00

725,000.00

725,000.00

10,000,000.00

Retraining

Total Expenditures

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA.

Module Review Status Review Status

IA Formal Comments

Pass & Complete

NYS Confidentiality – High

File Description

Upload Date

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 11.2 - Prescribed Milestones Instructions : Please enter and update target dates, as well as breakdown tasks with target dates for prescribed milestones. For milestones that are due within the reporting period, documentation is required to provide evidence of milestone achievement. Any explanations regarding altered or missed target commitments must be included within the textbox, not as narrative within uploaded documentation. Please note some milestones include minimum expected completion dates.

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone/Task Name

Status

Define target workforce state (in line with DSRIP program's goals).

Completed

Finalized PPS target workforce state, signed off by PPS workforce governance body.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Formalize and redefine the scope of the Workforce Committee (with representation from diverse PPS partners and other stakeholders, as needed to ensure appropriate expertise) to execute the research and analysis activities laid out in the Implementation Plan. Additional sub-committees and cross-functional groups will be created on an as needed basis to acomodate the need for more global collaboration.

07/01/2015

07/01/2015

07/01/2015

07/01/2015

09/30/2015

DY1 Q2

Completed

Develop and customize assessment tools to conduct an Organizational and Partner Needs Impact Assessment.

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

Conduct Organizational and Partner Needs Impact Assessment. i. Work with Clinical Committee and clinical project teams to build an overarching staffing framework for clinical delivery. Together, identify/reassess/confirm key workforce impacts, including: - New and redesigned jobs/roles and associated qualifications (i.e., education, licensure, competencies, skills, experience) - Associated training, recruitment, redeployment, and workforce support needs ii. Collaboration will be undertaken by having clinical representation attend Workforce Committee meetings,

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Milestone #1

Description

Original Start Date

Task

Step 1. Formalize and redefine the scope of the Workforce Committee (with representation from diverse PPS partners and other stakeholders, as needed to ensure appropriate expertise) to execute the research and analysis activities laid out in the Implementation Plan. Additional subcommittees and cross-functional groups will be created on an as needed basis to acomodate the need for more global collaboration. Task

Step 2. Develop and customize assessment tools to conduct an Organizational and Partner Needs Impact Assessment. Task

Step 3. Conduct Organizational and Partner Needs Impact Assessment. i. Work with Clinical Committee and clinical project teams to build an overarching staffing framework for clinical delivery. Together, identify/reassess/confirm key workforce impacts, including: - New and redesigned jobs/roles and associated qualifications (i.e., education, licensure, competencies, skills, experience) - Associated training, recruitment, redeployment, and workforce support needs

NYS Confidentiality – High

AV

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

ii. Collaboration will be undertaken by having clinical representation attend Workforce Committee meetings, having the Clinical Committee present to the Workforce Committee, and holding joint targeted committee meetings or focus groups to discuss issues. - Clinical and Workforce Committee leadership will determine if a vendor facilitated process is needed to acomplish this goal, and if so, will follow Mount Sinai's established formal RFP process. - Any formal assessment of partners realted to financial or compensation data will be reviewed by Finance, Legal, and Governance leadership to ensure proper measures are taken to maintain confidentiality.

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

having the Clinical Committee present to the Workforce Committee, and holding joint targeted committee meetings or focus groups to discuss issues. - Clinical and Workforce Committee leadership will determine if a vendor facilitated process is needed to acomplish this goal, and if so, will follow Mount Sinai's established formal RFP process. - Any formal assessment of partners realted to financial or compensation data will be reviewed by Finance, Legal, and Governance leadership to ensure proper measures are taken to maintain confidentiality.

Task

Step 4. Define target workforce state (e.g. what roles will be significantly impacted, what changes to the workforce will be needed).

Description

Original Start Date

Completed

Define target workforce state (e.g. what roles will be significantly impacted, what changes to the workforce will be needed).

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Review and sign off on target workforce state by Workforce Committee, and Clinical Committee leadership.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Completed workforce transition roadmap, signed off by PPS workforce governance body.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 1. Formalize Workforce Committee governance model in acordance with PPS-wide governance model

07/01/2015

07/01/2015

07/01/2015

07/01/2015

09/30/2015

DY1 Q2

Completed

Step 2. Based on the gap analysis detailed in Milestone 3, create a consolidated roadmap of actions, processes, and timelines needed to accomplish MSPPS workforce goals. This will include issues of recruitment, retraining, redeployment, and potential reduction.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Task

Step 5. Review and sign off on target workforce state by Workforce Committee, and Clinical Committee leadership. Milestone #2

Create a workforce transition roadmap for achieving defined target workforce state. Task

Step 1. Formalize Workforce Committee governance model in acordance with PPS-wide governance model Task

Step 2. Based on the gap analysis detailed in Milestone 3, create a consolidated roadmap of actions, processes, and timelines needed to accomplish MSPPS workforce goals. This will include issues of recruitment, retraining, redeployment, and potential reduction.

NYS Confidentiality – High

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Task

Step 3. Review and sign off on workforce transition roadmap by Workforce Committee.

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Completed

Step 3. Review and sign off on workforce transition roadmap by Workforce Committee.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Current state assessment report & gap analysis, signed off by PPS workforce governance body.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 1. Identify tools available for a Current State Assessment. Evaluate reliable and validity of tools; customize and further develop them, as needed; and ensure that any modifications do not negate their validity.

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

Step 2. Conduct a current state assessment of the MSPPS workforce based on the delivery framework and impacted jobs identified in Step 3 of Milestone 1. i. Assess competencies, qualifications, and certifications in current MSPPS workforce. ii. Assess current market conditions for impacted roles, and expected trends.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 3. Combine current and future state assessments with workforce transition numbers in Milestone 4 step 1 to develop a complete gap analysis of workforce needs.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 4. Refine workforce budget needs given outcomes from the gap analysis.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 5. Review and sign off on gap analysis and workforce budget by Workforce Committee, as well as Clinical and Finance Committee leadership.

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Compensation and benefit analysis report, signed off by PPS workforce governance body.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

AV

Milestone #3

Perform detailed gap analysis between current state assessment of workforce and projected future state.

NO

Task

Step 1. Identify tools available for a Current State Assessment. Evaluate reliable and validity of tools; customize and further develop them, as needed; and ensure that any modifications do not negate their validity. Task

Step 2. Conduct a current state assessment of the MSPPS workforce based on the delivery framework and impacted jobs identified in Step 3 of Milestone 1. i. Assess competencies, qualifications, and certifications in current MSPPS workforce. ii. Assess current market conditions for impacted roles, and expected trends. Task

Step 3. Combine current and future state assessments with workforce transition numbers in Milestone 4 step 1 to develop a complete gap analysis of workforce needs. Task

Step 4. Refine workforce budget needs given outcomes from the gap analysis. Task

Step 5. Review and sign off on gap analysis and workforce budget by Workforce Committee, as well as Clinical and Finance Committee leadership. Milestone #4

Produce a compensation and benefit analysis, covering impacts on both retrained and

NYS Confidentiality – High

YES

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

redeployed staff, as well as new hires, particularly focusing on full and partial placements. Task

Completed

Step 1. Determine expected volume of new hires, retrained, and redeployed staff by job type.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 2. Confirm, develop, and/or modify job descriptions of needed jobs.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 3. Research market data for needed jobs.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 4. Survey MSPPS to determine varying compensation and benefits structure across partners for needed jobs.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 5. Complete compensation and benefits analysis.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 6. Review and sign off on compensation and benefits analysis by Workforce Committee.

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

Finalized training strategy, signed off by PPS workforce governance body.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 1. Identify key learning and training needs (e.g. for new hires, expanded responsibilities of existing staff, redeployed existing staff)

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

Step 2. Identify the modality needed of certain trainings to ensure success, as well as who will be responsible for delivering that training.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 3. Determine how success will be defined for each training initiative.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Step 4. Assess the need for strategies and methodologies for sustained learning.

Completed

Step 4. Assess the need for strategies and methodologies for sustained learning.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Task

Completed

Step 5. Determine the timelines for rolling out each training

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Step 1. Determine expected volume of new hires, retrained, and redeployed staff by job type. Task

Step 2. Confirm, develop, and/or modify job descriptions of needed jobs. Task

Step 3. Research market data for needed jobs. Task

Step 4. Survey MSPPS to determine varying compensation and benefits structure across partners for needed jobs. Task

Step 5. Complete compensation and benefits analysis. Task

Step 6. Review and sign off on compensation and benefits analysis by Workforce Committee. Milestone #5

Develop training strategy. Task

Step 1. Identify key learning and training needs (e.g. for new hires, expanded responsibilities of existing staff, redeployed existing staff) Task

Step 2. Identify the modality needed of certain trainings to ensure success, as well as who will be responsible for delivering that training. Task

Step 3. Determine how success will be defined for each training initiative. Task

NYS Confidentiality – High

NO

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Step 5. Determine the timelines for rolling out each training initiative. Task

Step 6. Identify key stakeholders for training.

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

AV

initiative. Completed

Step 6. Identify key stakeholders for training.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 7. Analyze budgetary needs for training initiatives.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

Step 8. Review and sign off on training strategy by Workforce Committee.

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Task

Step 7. Analyze budgetary needs for training initiatives. Task

Step 8. Review and sign off on training strategy by Workforce Committee.

IA Instructions / Quarterly Update Milestone Name

IA Instructions

Quarterly Update Description

No Records Found

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Define target workforce state (in line with DSRIP program's goals). Create a workforce transition roadmap for achieving defined target workforce state. Perform detailed gap analysis between current state assessment of workforce and projected future state. Produce a compensation and benefit analysis, covering impacts on both retrained and redeployed staff, as well as new hires, particularly focusing on full and partial placements. Develop training strategy.

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Ongoing

Milestone #3

Pass & Ongoing

Milestone #4

Pass & Complete

Milestone #5

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.3 - PPS Defined Milestones Instructions : Please enter and update baseline target dates, as well as work breakdown tasks with target dates for PPS-defined milestones.

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

No Records Found

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

No Records Found

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 152 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 11.4 - Major Risks to Implementation & Risk Mitigation Strategies Instructions : Please describe the key challenges and risks that you foresee in achieving the milestones set out above, including potential impacts on specific projects and any risks that will undermine your ability to achieve outcome measure targets. • There is a strong co-dependency between the Clinical Committee and the Workforce Committee. The work task that the Clinical Committee creates must dictate the work structure the Workforce Committee supports in order for implementation to be successful. It is a potential risk, that with such a large undertaking, the work may become siloed within functional groups. To mitigate this risk, the MSPPS will coordinate crossfunctional workgroups to ensure collaboration. This will also serve to make estimates more realistic, as workforce will not examine each clinical project in isolation, but rather as part of a larger system change. • The future state analysis of the workforce is similarly dependent on the outcomes of the Clinical Committee work. Workforce and Clinical leadership will work together to ensure necessary information is provided to the committees in order to achieve milestones. • The MSPPS anticipates significant competition for talent in certain roles with other PPSs as the DSRIP initiative moves forward. The MSPPS plans on collaborating with other PPSs as well as key stakeholders and educational institutions to reduce potential difficulties. • An additional concern is that the MSPPS clinical work will need to scale faster than the training initiatives can support. Once training needs have been identified, curriculum may need to be developed, and the training itself may take time to be done effectively. The MSPPS will work with training providers to ensure we can scale appropriately, as well as collaborate internally to address clinical needs with the resources available. • Each partner and employees at each partner will join the PPS at differing levels of education, experience, and baseline knowledge. The training strategy will take into account these different levels in designing training initiatives and timelines. • Preliminary discussions with some of our community-based providers suggest that there may be regulatory issues impact staffing, roles, and capacity of their workforces. The PPS will work with its partners and NYS to identify and implement solutions to such issues. • The MSPPS may also face a risk of exposing confidential information as a result of sharing data across the various partners. There will be strict controls put in place as part of the assessment steps of implementation plan so as to minimize this risk.

IPQR Module 11.5 - Major Dependencies on Organizational Workstreams Instructions : Please describe any interdependencies with other organizational workstreams (IT Systems and Processes, Clinical Integration, etc.) The success of the MSPPS Workforce Committee hinges on several key interdependencies. The analysis and actualization of the changes in workforce due to DSRIP depend heavily on the work of the Clinical Committee. The transformation of the delivery system and the work tasks that will be done must determine the structure of the workforce deployed in order to ensure success. Similarly, this delivery system change will require financial resources to adequately staff the transformational effort, and support recruitment, redeploying, and retraining costs. The Workforce Committee will also contribute information to inform the decisions of that transformation, and jointly the two committees will inform budgetary

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) decisions made at the Finance and Leadership Committee levels. The Workforce Committee is also dependent on the IT Committee and IT initiatives to support the deployment of assessment and training tools, which is further described in the IT Expectations section below.

NYS Confidentiality – High

Page 153 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.6 - Roles and Responsibilities Instructions : Please list and elaborate upon the key people/organizations responsible for this organizational workstream and describe what their responsibilities involve.

Role

Name of person / organization (if known at this stage)

Workforce Committee Co-Chair

Jane Maksoud, Mount Sinai Health System

Workforce Committee Co-Chair

Linda Reid, VNSNY

Workforce Committee

PPS Members, including partner and union representation

Workforce Project Management

Daniel Liss, Mount Sinai Health System; MSPPS PMO Members

Consultants

Undetermined

Key deliverables / responsibilities Approve policies and procedures; lead and maintain oversight of committee activities and projects Approve policies and procedures; lead and maintain oversight of committee activities and projects Complete implementation plan steps; Assess and define the current and future states of the workforce; conduct a gap and benefits/compensation analysis; create a transition roadmap and training strategy Drive completion of Implementation Plan deliverables; manage community and stakeholder engagement. Help prepare workforce and training analyses and materials.

NYS Confidentiality – High

Page 154 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.7 - Key Stakeholders Instructions : Please identify the key stakeholders involved in your workforce transformation plans, both within and outside the PPS.

Key stakeholders

Role in relation to this organizational workstream

Key deliverables / responsibilities

Internal Stakeholders Mount Sinai Health System

Lead Applicant

Clinical, Finance, and IT Committees

Key partners in developing workforce goals

Leadership; operation of centralized functions Collaborate with Workforce Committee to determine needs, funding, and reporting mechanisms

External Stakeholders VNSNY

Workforce Committee Co-chair Partner

Leadership

Other MSPPS Partners

Partners in PPS

1199 SEIU

Partners in PPS

NYSNA

Partners in PPS

Other, non-MSPPS, organizations and PPSs

External Stakeholder

Participate in Workforce Committee Participate in Workforce Committee; will play prominent role in the coordination of training and other workforce efforts Participate in Workforce Committee Potentially collaborate with Workforce Committee and MSPPS on joint activities

NYS Confidentiality – High

Page 155 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.8 - IT Expectations Instructions : Please describe how the development of shared IT infrastructure across the PPS will support your plans for workforce transformation. The IT infrastructure proposed by MS PPS will be an important tool as the PPS drives workforce transformation. First and foremost, included within the MS PPS IT infrastructure is a Learning Management System (LMS) which will allow the PPS to deploy and track workforce training initiatives, including PPS-developed project-driven protocols. As key priority of the MS PPS, this system will be used to support the advancement of front line staff and team-based care. Furthermore, under the auspice of Rapid Cycle Evaluation, the LMS will allow the PPS to facilitate the learning of processes and competencies in a consistent and standardized manner, particularly as performance improvement opportunities are identified. An additional piece of the IT infrastructure that will support workforce transformation is the MS PPS User Portal. This web-based tool will provide a one-stop-shop for all PPS-related health information and analytic support, including a PPS level performance management and monitoring function, which will be linked to a Customer Relationship Management (CRM) database for provider and performance queries. This tool will support PPS workforce transformation by ensuring high levels of transparency and relevant benchmarking to analyze the impact of workforcerelated interventions and guide provider and partner improvement, all accessible in a consolidated fashion in order to improve efficiency and reduce workflow impacts.

IPQR Module 11.9 - Progress Reporting Instructions : Please describe how you will measure the success of this organizational workstream. The Workforce Committee and Workforce Project Group, as a governance structure, will drive to the completion of each step listed above to ensure the successful completion of each Workforce Milestone. As a general overview, the committee will first develop its structure and assess the tools it will use during DY1, Q1. The committee will then deploy those tools, aggregate results, and report back on the completion of each milestone in DY1, Q1 and Q2. In addition to the individual milestones, the outcome of the DY1 effort will include basline workforce transition process measures and numerical commitments. There will be a Project Management function that will be responsible for coordinating milestone outcomes, pulling together supporting documentation, and submitting them back to the state for review.

NYS Confidentiality – High

Page 156 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 11.10 - Staff Impact Instructions : Please upload the Workforce Staffing Impact (Projections) and the Workforce Staffing Impact (Actuals) tables provided for quarterly reporting.

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text :

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 158 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.11 - Workforce Strategy Spending (Quarterly): Instructions : Please include details on workforce spending. The workforce spending actuals should reflect only what was spent during the relevant quarters and is not cumulative across semi-annual periods. The PPS can shift funding across categories; e.g., from Retraining to New Hires. Please note that the "Cumulative Percent of Commitments Expended through Current DSRIP Year" section is calculated based on the total yearly commitments.

Benchmarks Year

Amount($)

Total Cumulative Spending Commitment through Current DSRIP Year(DY3)

6,456,250.00

Workforce Spending Actuals Funding Type

Cumulative Spending to Date (DY1-DY5)($)

DY3(Q3/Q4)($)

DY3(Q1/Q2)($)

Cumulative Percent of Commitments Expended through Current DSRIP Year (DY3)

Retraining

0.00

0.00

1,298,414.76

47.87%

Redeployment

0.00

0.00

75,000.00

5.08%

New Hires

0.00

0.00

158,708.62

9.30%

Other

0.00

0.00

1,093,830.41

194.46%

Total Expenditures

0.00

0.00

2,625,953.79

40.67%

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA.

NYS Confidentiality – High

File Description

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

Page 159 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 11.12 - IA Monitoring: Instructions :

NYS Confidentiality – High

Page 160 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project 2.a.i – Create Integrated Delivery Systems that are focused on Evidence-Based Medicine / Population Health Management IPQR Module 2.a.i.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. Risk 1: Inadequate patient and community engagement about DSRIP and IDS Mitigation: MSPPS will hold recurring community-based forums to educate and gather feedback from stakeholders about DSRIP project implementation and the IDS. The PPS PMO will create a "patient/community advisory board" which will meet regularly to inform PPS governance of reactions and response to project and IDS implementation. For high-priority communities, staff will be engaged to ensure open and tailored communication and engagement with patients and the community. Risk 2: Inadequate PPS Provider engagement in development of IDS. Mitigation: The PPS will create regional "hubs" to outreach, tailor and implement projects relevant to specific communities' clinical and social service needs, supporting local providers and CBOs to provide services. We are implementing a PPS Stakeholder Committee to gather feedback on operational planning and future decisions across PPS domains. Workforce and Clinical committees are collaborating on a centralized training program to deliver culturally sensitive and competent services that promote health literacy and address social determinants of health specific to the target populations. Risk 3: Difficulty establishing constructive partnerships with MCOs that may hinder timely value-based contracts . Mitigation: We will establish regular meetings between MCOs and PPS leadership, leveraging existing MCO relationships with Mount Sinai and other PPS partners (including affiliated lead Health Homes), to discuss performance metrics and move towards value-based programs among select PPS partners. To educate and engage PPS partners, we will plan training modules in collaboration with payers to understand and operationalize value-based reimbursement. Risk 4 Challenges in workforce recruitment, training, and collaboration with labor groups to successfully implement IDS projects. Mitigation: We will leverage and create collaborative relationships with labor groups (e.g. SEIU, NYSNA) and training/advocacy organizations (e.g. PHI) to communicate DSRIP project plans, identify training needs and develop re/training programs that optimize workforce knowledge and skills in the successful delivery of DSRIP program services. We will work with recruitment agencies, health worker training programs and professional schools of social work, nursing, behavioral and health sciences to educate trainees about career opportunities and hold regular recruitment events.

Risk 5: Inability to secure adequate resources to support IDS infrastructure development . Mitigation: We will leverage existing IT, clinical and care management resources, including PPS partners and Mount Sinai's population health infrastructure, MSHP, to provide the IDS's foundation. The IT, Clinical and Finance committees are meeting to ensure responsible decision-making regarding (1) adequate flow of funds to carry out initiatives at every site; (2) selection of the appropriate applications for a common IT platform that can accommodate existing HIE, EMRs and other application; (3) planning for ultimate financial sustainability of individual projects; and (4) engaging with MCOs to gradually but aggressively shift contracts from fee for service to fully risk-based as groups within the PPS are able.

NYS Confidentiality – High

Page 161 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Risk 6: Inability to achieve successful collaboration and coordination with other PPSs . Mitigation: We have begun to establish relationships with other PPSs (e.g. Bronx Lebanon Hospital Center, Bronx Partners PPS) and plan outreach to other PPSs with overlapping service areas (e.g. HHC) to share best practices, and collaborate on interoperability plans. We will participate in regional and state-wide learning collaborative, using lessons learned from these activities to modify and improve our PPS.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 2.a.i.2 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

All PPS providers must be included in the Integrated Delivery System. The IDS should include all medical, behavioral, postacute, long-term care, and community-based service providers within the PPS network; additionally, the IDS structure must include payers and social service organizations, as necessary to support its strategy.

DY4 Q2

Project

N/A

In Progress

04/01/2015

09/30/2018

04/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

In Progress

04/02/2016

09/30/2018

04/02/2016

09/30/2018

09/30/2018

DY4 Q2

Task

PPS includes continuum of providers in IDS, including medical, behavioral health, post-acute, long-term care, and communitybased providers. Task

Step 1. Create PPS operational infrastructure (PMO) that includes central and regional Stakeholder Engagement teams to promote partner education and engagement in IDSD Task

Step 2. Inventory all providers and social service agencies in PPS by provider type, services delivered, geography served and distribute across regional teams to identify and address gaps Task

Step 3. Identify all managed Medicaid payers in PPS footprint, and establish regular working meetings and learning forums between MCOs and PPS partners Task

Step 4. Set up regular sessions to convene regional providers, social service agencies and payers for PPS update and feedback Town Halls and Networking events Task

Step 5. Establish regular reporting and updating of partner participation, supporting current partners and/or onboarding of new partners as deemed necessary by PPS governance or project needs. Task

NYS Confidentiality – High

Page 164 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 6: PPS includes continuum of providers in IDS, including medical, behavioral health, post-acute, long-term care, and community-based providers. Milestone #2

Utilize partnering HH and ACO population health management systems and capabilities to implement the PPS' strategy towards evolving into an IDS. Task

PPS produces a list of participating HHs and ACOs.

DY2 Q4

Project

N/A

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Participating HHs and ACOs demonstrate real service integration which incorporates a population management strategy towards evolving into an IDS. Task

Regularly scheduled formal meetings are held to develop collaborative care practices and integrated service delivery. Task

Step 1. Engage Mount Sinai Health Partners (MSHP) to provide IT, clinical, care management, and MCO contracting support to establish foundational IDS Task

Step 2. PPS PMO will inventory active population health IT, clinical and care management initiatives throughout PPS Task

Step 3. Through the inventory, PPS partners will convene to establish baseline core competencies, identify gaps, and achieve initial best practice guidelines for implementation of IDS. Task

Step 4. PPS will identify specific providers and CBO's in which to pilot best practices relating to IT, clinical and care management initiatives. Task

Step 5. PPS workgroup will monitor best practice implementation, modify practices as needed, identify successful initiatives to be implemented across the PPS and those best implemented in selected sites. Task

Step 6. PMO will conduct a staged implementation of a common IT platform for communication of PHI within and between PPSs, leveraging existing EMR, HIE resources as much as possible

NYS Confidentiality – High

Page 165 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 7. PMO will develop common PPS clinical and care management training modules for all provider types, a universal patient assessment, and universal care plan Task

Step 8: PPS produces a list of participating HHs and ACOs.

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

04/01/2016

09/30/2016

04/01/2016

09/30/2016

09/30/2016

DY2 Q2

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Task

Step 9. Participating HHs and ACOs demonstrate real service integration which incorporates a population management strategy towards evolving into an IDS. Task

Step 10. Set up a schedule to regularly convene all Health Homes participating in PPS to share best practices and modify operations, providing support as necessary, to align HH activities with IDS priorities Task

Step 11. Regularly scheduled formal meetings are held to develop collaborative care practices and integrated service delivery. Milestone #3

Ensure patients receive appropriate health care and community support, including medical and behavioral health, post-acute care, long term care and public health services.

DY2 Q4

Project

N/A

Task

Clinically Interoperable System is in place for all participating providers. Task

PPS has protocols in place for care coordination and has identified process flow changes required to successfully implement IDS. Task

PPS has process for tracking care outside of hospitals to ensure that all critical follow-up services and appointment reminders are followed. Task

PPS trains staff on IDS protocols and processes. Task

Step 1. Create geographic/community teams for PPS project implementation which will be comprised of local medical, behavioral health, acute, post-acute, long-term care, public health and social service providers

NYS Confidentiality – High

Page 166 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 2. Leverage MSHP (MSO) and partner data analytics to identify baseline performance gaps for key clinical process and outcome measures across PPS, prioritizing clinical and care management support to areas of highest need

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Step 3. Establish universal patient assessment and care plan across PPS for standardized assessment of and goal-setting for medical, behavioral, public health and community support needs Task

Step 4. Establish specific clinical protocols and outcome benchmarks for each PPS project and determine workforce/care team member(s) responsible for carrying out each measure Task

Step 5. For each PPS project, educate all clinical and care management providers across PPS re: provision of services using standardized clinical protocols and care pathways Task

Step 6. Set up a schedule to track and report on a quarterly basis clinical performance metrics at each project site, including patient satisfaction and fulfillment of care plan, providing support and remediation to low-performing practices and spreading best practices from high-achieving sites Task

Step 7: Clinically Interoperable System is in place for all participating providers. Task

Step 8: PPS has protocols in place for care coordination and has identified process flow changes required to successfully implement IDS. Task

Step 9: PPS trains staff on IDS protocols and processes. Task

Step 10: PPS has process for tracking care outside of hospitals to ensure that all critical follow-up services and appointment reminders are followed. Milestone #4

Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including directed exchange (secure messaging), alerts and patient record

DY3 Q4

Project

N/A

NYS Confidentiality – High

Page 167 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

look up, by the end of Demonstration Year (DY) 3. Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements.

Provider

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements.

Provider

Safety Net Practitioner Primary Care Provider (PCP) Safety Net Practitioner Non-Primary Care Provider (PCP)

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements.

Provider

Safety Net Hospital

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Provider

Safety Net Mental Health

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Provider

Safety Net Nursing Home

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2016

03/31/2018

07/01/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements. Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements. Task

PPS uses alerts and secure messaging functionality. Task

Step 1. Assess partner EMRs and identify bi-directional data interface capability / gaps to EHRs and other data source systems Task

Step 2. Develop and agree on the future state and a plan to close any gaps identified in step 1 Task

Step 3. Provision MSPPS HIE eMPI for use with PPS data interfaces Task

Step 4. Develop, implement, and deploy CBO data entry portal and associated flat-file data collection and normalization process Task

Step 5. Implement interfaces from EHRs and other data sources topartnering RHIOs, or directly to MS PPS system Task

Step 6. Develop, implement, and deploy Direct messaging and referrals management tools Milestone #5

Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards

DY3 Q4

Project

N/A

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

and/or APCM by the end of Demonstration Year 3. Task

EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

In Progress

07/01/2016

09/30/2018

07/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Task

PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.

Provider

Safety Net Practitioner Primary Care Provider (PCP)

Task

Step 1. Identify baseline and gaps in adoption of ONC-certified EHR technology among PPS participants as part of the current state assessment and gap-analysis process Task

Step 2. Develop plan, detail around technical assistance services, and timeline for implementation of technical assistance program Task

Step 3. Provide technical assistance, including purchasing decision support, dissemination of EHR implementation best practices via the PPS Learning Management System (LMS), and other modes of implementation support to be determined through the current state assessment and gap-analysis processes to providers that need to adopt a new EHR or upgrade their existing EHR - in time for achievement of PCMH III and adoption of MU eligible EHRs in DY3 Milestone #6

Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers.

DY4 Q2

Project

N/A

Task

PPS identifies targeted patients through patient registries and is able to track actively engaged patients for project milestone reporting. Task

Step 1. Develop plan for population health analytics and care management platform Task

Step 2. Define target populations to develop patient cohorts/registries Task

Step 3. Develop plan for population health interventions for

NYS Confidentiality – High

Page 169 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

specific patient cohorts Task

Step 4. Implement population health analytics platform

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

10/01/2016

09/30/2018

10/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

10/01/2017

09/30/2018

10/01/2017

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2017

09/30/2018

04/01/2017

09/30/2018

09/30/2018

DY4 Q2

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Task

Step 5. Implement care management / care coordination platform Task

Step 6. Develop reports for outcome tracking and audit process to ensure accuracy Task

Step 7. Implement population health interventions for specific patient cohorts Task

Step 8. Incorporate appropriate risk stratified population Health Metrics benchmarks for MS PPS partners from NY DOH (MY2 metrics) and set up quarterly assessment schedule Milestone #7

Achieve 2014 Level 3 PCMH primary care certification and/or meet state-determined criteria for Advanced Primary Care Models for all eligible participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standards by the end of DY 3.

DY3 Q4

Project

N/A

Task

Primary care capacity increases improved access for patients seeking services - particularly in high-need areas.

Project

Task

All eligible practices meet 2014 NCQA Level 3 PCMH and/or APCM standards.

Provider

Practitioner - Primary Care Provider (PCP)

Task

EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria.) Task

Step 1. Develop methodology for tracking PCMH and MU status of all participating PCPs Task

Step 2. Begin tracking PCMH and MU status of all participating PCPs Task

Step 3.Develop initial reporting mechanism for participating PCPs

NYS Confidentiality – High

Page 170 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

that meet L3 PCMH and MU Task

Step 4. Develop technical assistance (TA) program to support participating PCPs, to include EHR system purchasing decision support, dissemination of EHR implementation best practices via the PPS Learning Management System, and specific PCMH training programs and resources to be disseminated via the PPS Learning Management System (LMS).

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2018

03/31/2018

01/01/2018

03/31/2018

03/31/2018

DY3 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Step 5. Implement technical assistance (TA) program to support participating PCPs Task

Step 6. Final report on participating PCPs that meet L4 PCMH and MU Milestone #9

Establish monthly meetings with Medicaid MCOs to discuss utilization trends, performance issues, and payment reform.

DY2 Q4

Project

N/A

Task

PPS holds monthly meetings with Medicaid Managed Care plans to evaluate utilization trends and performance issues and ensure payment reforms are instituted. Task

Step 1. Identify Managed Medicaid payers and schedule monthly meetings to discuss dashboard items such as utilization trends, performance/outcome issues, associated costs and resulting overall efficiencies and improvements in care delivery, including the provision of services within the IDS by non-traditional organizations (e.g. social services, CBOs) Task

Step 2. Share performance data amongst entire PPS and establish more granular PPS provider report card. Compare performance data with other PPS's Task

Step 3. Establish monthly reporting to PPS leadership and the State Task

Step 4. Identify PPS partners who show strong performance based outcomes and elicit their educational assistance with those PPS providers whose performance and outcomes are not as strong Task

NYS Confidentiality – High

Page 171 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 5. Utilize established PPS learning collaborative to meet collectively with the MCO plan to optimize rates, measures and processes and avoid redundancy or inconsistencies among plans and/or PPSs Task

Step 6. Utilize strong PPS partners for participation in pilot valuebased contracts with payers

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

01/01/2018

09/30/2018

01/01/2018

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

01/01/2018

09/30/2018

01/01/2018

09/30/2018

09/30/2018

DY4 Q2

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

In Progress

10/01/2015

09/30/2018

10/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Task

Step 7. Transition PPS providers into separate contracting entity (akin to an IPA) with Managed MCD plans for risk-based arrangements Milestone #10

Re-enforce the transition towards value-based payment reform by aligning provider compensation to patient outcomes.

DY4 Q2

Project

N/A

Task

PPS submitted a growth plan outlining the strategy to evolve provider compensation model to incentive-based compensation Task

Providers receive incentive-based compensation consistent with DSRIP goals and objectives. Task

Step 1. Explore methods and models of payment by identifying partners experienced in performance-based reimbursement, develop payment reform models with the payers Task

Step 2. PPS governance will inventory any established valuebased compensation models among PPS providers (e.g. Mount Sinai Primary Care Institute) to develop benchmark metrics and pilot compensation models for each type of workforce Task

Step 3. Through the collaboration of managed care payers and the finance committee, establish concrete definitions and whenever possible, standardization of value based outcomes for payment purposes, for all disciplines of PPS providers. Task

Step 4. Finance committee along with the IT committee, and in collaboration with payers, will define performance measures and outcomes and then equate dollar values to those defined outcomes and performance measures. The outcomes especially would need to be precisely qualified and measurable. This will result in pilot compensation models for the PPS

NYS Confidentiality – High

Page 172 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 5. Engage and train PPS providers on definitions and agree to standardizations across PPS providers.

Project

In Progress

01/01/2016

09/30/2018

01/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

01/01/2017

09/30/2018

01/01/2017

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

01/01/2018

09/30/2018

01/01/2018

09/30/2018

09/30/2018

DY4 Q2

In Progress

04/01/2015

09/30/2018

04/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Task

Step 6. Pilot and evaluate performance-based compensation models among select providers/organizations, representing all provider types in PPS Task

Step 7. Finalize adoption of compensation models that incentivizes and compensates each type of PPS provider based on performance and outcomes Milestone #11

Engage patients in the integrated delivery system through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations, as appropriate.

DY4 Q2

Project

N/A

Task

Community health workers and community-based organizations utilized in IDS for outreach and navigation activities. Task

Step 1.Hold introductory and recurring PPS-led patientengagement and educational events in which PPS leadership and local clinical and service providers educate community about the PPS programs, population health and DSRIP goals to develop an IDS. During and following these events, the PPS will gather baseline and follow-up attendance, attendee knowledge about current patient/community understanding of clinical integration, participation in projects. Task

Step 2. Establish patient advisory board whose role in PPS governance will be to monitor and advise on outreach, navigation activities and the progress that the PPS makes in engaging patients in IDS. Task

Step 3. Launch online and/or print resources for patients to educate about DSRIP as well as specific clinical and care management programs, including the local organizations which will be providing services. Track utilization of online site, as well as incoming telephone or written correspondence from patients.

NYS Confidentiality – High

Page 173 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 4. Leverage and train local peers, CHWs, and CBOs to provide culturally sensitive education, outreach and care management to immediate patient community, tying in efforts to larger goals of DSRIP and IDS

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

04/01/2016

09/30/2018

04/01/2016

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Project

In Progress

07/01/2015

09/30/2018

07/01/2015

09/30/2018

09/30/2018

DY4 Q2

Task

Step 5. PPS clinical quality committee will utilize established and PPS-specific patient satisfaction assessments to assess monthly outcomes, continually modifying and tailoring programs and communications to meet patients' needs. Task

Step 6. With input from patient advisory board, and PPS IT support, PMO will establish a protocol to promotes use of patient portal for self-management and communication of patients with their providers, including ongoing tracking of portal use and communication. Task

Step 7. Monitoring of integrated delivery system tracked by number of activities, number of participating community health workers, peers and culturally competent community based organizations. Task

Step 8. Stakeholder Engagement cross functional work group will participate and serve as a clearing house of sharing best practices for provider types including CBOs to engage patients in the IDS.

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

All PPS providers must be included in the Integrated Delivery System. The IDS should include all medical, behavioral, post-acute, long-term care, and community-based service providers within the PPS network; additionally, the IDS structure must include payers and social service

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

organizations, as necessary to support its strategy. Utilize partnering HH and ACO population health management systems and capabilities to implement the PPS' strategy towards evolving into an IDS. Ensure patients receive appropriate health care and community support, including medical and behavioral health, post-acute care, long term care and public health services. Ensure that all PPS safety net providers are actively sharing EHR systems with local health information exchange/RHIO/SHIN-NY and sharing health information among clinical partners, including directed exchange (secure messaging), alerts and patient record look up, by the end of Demonstration Year (DY) 3. Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of Demonstration Year 3. Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, for all participating safety net providers. Achieve 2014 Level 3 PCMH primary care certification and/or meet statedetermined criteria for Advanced Primary Care Models for all eligible participating PCPs, expand access to primary care providers, and meet EHR Meaningful Use standards by the end of DY 3. Establish monthly meetings with Medicaid MCOs to discuss utilization trends, performance issues, and payment reform. Re-enforce the transition towards value-based payment reform by aligning provider compensation to patient outcomes. Engage patients in the integrated delivery system through outreach and navigation activities, leveraging community health workers, peers, and culturally competent community-based organizations, as appropriate.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

Page 174 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone #

Review Status

Milestone #5

Pass & Ongoing

Milestone #6

Pass & Ongoing

Milestone #7

Pass & Ongoing

Milestone #9

Pass & Complete

Milestone #10

Pass & Ongoing

Milestone #11

Pass & Ongoing

IA Formal Comments

NYS Confidentiality – High

Page 175 of 932 Run Date : 09/29/2017

Page 176 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.a.i.3 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name Milestone

Status

Completed

Mid-Point Assessment

Original Start Date

Description

Mid-Point Assessment

06/01/2016

Original End Date 06/30/2016

Start Date

06/01/2016

End Date

06/30/2016

DSRIP Reporting Year and Quarter

Quarter End Date 06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.a.i.4 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 177 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 2.b.iv – Care transitions intervention model to reduce 30 day readmissions for chronic health conditions IPQR Module 2.b.iv.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. 1. One risk to implementation is inappropriate identification and engagement of the target population. To mitigate risk, we will: (a) Base patient identification off the PACT model, whose data validates using patient utilization history of 1 in 30 days or 2 in 6 months. (b) Leverage PACT model: recruit staff, train and empower them to interact with patients and their caregivers to establish trust using previously implemented curricula and role modeling (c) Update and use PACT screening tool to identify high risk populations and key causes of readmission (housing, income instability, lack of transportation), (d) Encourage FACE TO FACE interaction between patients and care coordinators, (e) Assure all patients have PCP and follow-up appointment with PCP and subspecialist (if needed), (f) Recruit staff from local neighborhoods who can be matched with patients both culturally and by language (g) Assure that patients with behavioral health or substance abuse needs are reconnected to behavioral health providers and/or referred to the appropriate providers (h) Analyze data to predict who will be best served with these interventions and which engagement strategy may work best, (i) Inform relevant doctor at time of admission (as opposed to time of discharge) if patient is currently undergoing treatment with a PCP. 2. Patients might not accept post acute intervention if they are not approached in a sensitive, patient-focused manner to assure engagement. To mitigate risk, we will: (a) Recruit staff from within communities, being mindful of economic, ethnic, linguistic, and cultural identities (b) Train staff on appropriate patient engagement to reduce likelihood of unintentional alienation of patients and enhance staff's capacity for implementing empathic work (c) Train staff on a suite of tools for effective clinical assessment and intervention (d) Train staff to identify social determinants of readmission (e) Use Motivational Interviewing tactics, assessment of readiness and confidence rulers as indicators and social problem solving styles to inform approach (f) Educate/Empower family/caregivers on how to assist/support patient. 3. Possible risk that we will not be able to ensure access to medical and social services appropriately for patients upon discharge. To mitigate risk, we will: (a) Train staff to educate patients and identify challenges to achieving appropriate post-discharge follow-up (b) Establish early contact with PCP to arrange timely follow-up of post discharge needs, medication reconciliation and other clinical needs during this vulnerable time (c) Establish linkage to appropriate primary care (if without PCP), correct care coordination site and/or behavioral health/substance abuse services. (d) Establish linkage to proper social and legal services depending on patient's needs. (e) Create streamlined communication protocols between PACT SWs and outpatient providers 4. Partners involved in the project may fail to properly communicate in the time following discharge. To mitigate risk, we will: (a) Create standardized process to communicate between organizations regarding patients engaged in the project for days/weeks following discharge. (b) Engage our partner organizations early in the development of project staff training. (c) Develop a mechanism to provide feedback to PPS regarding challenges (d) Develop an interim plan prior to IT solution/supporting infrastructure and a back-up plan for communication exchange of this interim plan (e) Develop monitoring/evaluation process for interim and long-term solutions re: standardized process 5. PPS does not properly address patient coverage issues, which are important to getting patients services necessary to avoid readmission. To mitigate risk, we will: (a) Develop a pre-discharge assessment for any missing entitlement and include it in patient's care plan

NYS Confidentiality – High

Page 178 of 932 Run Date : 09/29/2017

Page 179 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.iv.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

13,750

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

6,188

8,938

11,688

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

3,094

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (3,094) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 180 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 2.b.iv.3 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Develop standardized protocols for a Care Transitions Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency.

DY2 Q4

Project

N/A

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Standardized protocols are in place to manage overall population health and perform as an integrated clinical team are in place. Task

Step 1: Inventory assessments and identify critical elements for all assessments Task

Step 2: Inventory care plans and identify critical elements for all care plans Task

Step 3: Develop care transitions workflow Task

Step 4: Develop a universal patient assessment (2.a.i, Milestone 3, Step 3) Task

Step 5: Develop a universal care plan (2.a.i, Milestone 3, Step 3) Task

Step 6: Develop discharge summary enhancement Milestone #2

Engage with the Medicaid Managed Care Organizations and Health Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed.

DY3 Q2

Project

N/A

Task

A payment strategy for the transition of care services is developed in concert with Medicaid Managed Care Plans and Health Homes. Task

Coordination of care strategies focused on care transition are in place, in concert with Medicaid Managed Care groups and Health Homes.

NYS Confidentiality – High

Page 181 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

PPS has protocol and process in place to identify Health-Home eligible patients and link them to services as required under ACA.

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

09/30/2016

04/01/2016

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

09/30/2016

04/01/2016

09/30/2016

09/30/2016

DY2 Q2

Task

Step 1: Determine MCOs in PPS and engage for participation in project (2.a.i, Milestone 8, Step 1) Task

Step 2: Identify if MCOs provide transitional care services. If MCO does not provide transitional care services, work with MCOs to delineate their roles and responsibilities Task

Step 3: Leverage Care Coordination Cross Functional Workgroup's Managed Care Organizations relationships to collaborate and leverage existing resources Task

Step 4: Cross-map care management and disease management protocols across MCOs Task

Step 5: Develop patient discharge criteria in partnership with managed care organizations Task

Step 6: Review and approval of discharge criteria by PPS leadership Task

Step 7: Implement approved discharge criteria Task

Step 8: Develop protocol for service eligibility with MCOs Task

Step 9: Review and approval of protocol for service eligibility by PPS leadership Task

Step 10: Implement approved protocol for service eligibility Task

Step 11: Develop patient consent protocols for referrals to health homes, MCOs and other community providers Task

Step 12: Review and approval of consent protocols for referrals by PPS leadership Task

Step 13: Implement approved consent protocols criteria Task

Step 14: Create a protocol for required transitions of care steps

NYS Confidentiality – High

Page 182 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

and documentation requirements Task

Step 15: Develop mechanism for Health Home and Managed Care Organization to access/cross reference payor and providers types in PPS

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2016

06/30/2016

04/01/2016

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 16: Establish communication protocols to share information with patients PCP of record. Task

Step 17: Develop consistent tracking and quality improvement over time Milestone #3

Ensure required social services participate in the project.

DY3 Q2

Project

N/A

Task

Required network social services, including medically tailored home food services, are provided in care transitions. Task

Identify the various types of social services by segment a. Care Management and Care Coordination to Manage Conditions and Connect Patients to Needed Services and Resources b. Primary and Specialty Care Providers to Address Physical Health and Manage Chronic Conditions c. Supportive Housing and Community-Based Social Services to Support and Stabilize Patients Task

Step 2: Identify the PPS partners, stratify their needs, interests, strengths (work w. stakeholder engagement cross functional group) (2.a.i, Milestone 1, Step 2) Task

Step 3: Identify specific expectations and responsibilities of social service agencies for 2.b.iv project Task

Step 4: Leverage ongoing stakeholder engagement webinars and/or Town Hall meetings to educate social services in areas of involvement Task

Step 5: Create a platform wherein patient navigators/social workers can access information about each social service agency in order to make appropriate referrals working inconjunction with IT

NYS Confidentiality – High

Page 183 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #4

Transition of care protocols will include early notification of planned discharges and the ability of the transition care manager to visit the patient in the hospital to develop the transition of care services.

DY2 Q4

Project

N/A

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Provider

Practitioner - Primary Care Provider (PCP)

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Policies and procedures are in place for early notification of planned discharges. Providers Associated with Completion:

A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Sapphire Mann Md; Ahmed Zaheer Md; Ahmed Zia Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf Elkomos Soliman; Akoto Edna; Al-Izzi Sawsan Hatim Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Ali Aleem A; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarado Leslie; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Amin Deepak Kantilal Md; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A Md; Androne Louis Cristian Md; Ankireddypalli Arvind; Annan Vivian; Anthony Antoinette Md; Antosofsky Howard Md; Arabelo Howard Anthony De La Paz; Arend Jonathan; Ares Ella; Armington Kevin John Md; Arnon Ronen Md; Aronov Margarita A Md; Arron Martin Md; Arya Vijaypal Md; Asare Vivian; Ascunce Gil Ignacio; Aseme Kamara; Aslam Ahmed Kamal Md; Assadi Mashid A; Astua Alfredo J Md; Asuen Imeutinyan Md; Auerbach Lisa Resnick Md; Austein Lance; Austin Louise; Autz Arthur L; Ayinla Raji Mohammed Md; Azizi Efat; Babaeva Saiera Md; Babb Frank C Md; Back Sara Deborah; Badlani Sachal Md; Bailey Juan A Md; Baird Philip Lee Md; Baird Sara; Bakshi Anjali Md; Banner Burton Md Pc; Banta Erin; Baran Margaret Md; Barrett Conor Dominic; Barsa Jonathan; Bassey Yarromi Augustine Eyo; Bassoul Nissim Moses Md; Batra Kamal Kumar Md; Beaubrun Donnie; Beaubrun Pierre Ronald Md; Bee-Healthy Proffessional Ped; Begun Jay R Md Pc; Belilovsky Anatoly Md; Belotte Marie; Benchimol Corinne Do; Bennett Stephen J Md; Benovitz Harvey L Pc Md; Benrath Michelle; Bentsianov Marie Azer Md; Bergman Michael; Berkowitz Leonard Bruce Md; Berlin Arnold I Md; Berman Paul Jeremy; Bernard Yolande Frances Md; Berwald Cary M Md; Besada Inacia Perez Md; Beth Israel Medical Ctr Act; Beuria Prarthana Md; Bhandari Rekha Md; Bhat Kiran Kumar Md; Bhat Sandeep Md; Bhatia Sonica; Bhatt Anjani A Md; Bhattacharya Sarmistha Md; Bickell Nina Andrew Md; Bilik Ilya V Md; Bioh Dominick Kwasi Md; Birenbaum Ellen Md; Black Andrew D Md; Blackett-Bonnett Terry Md; Blair Seidler Hammond; Blidnaya Lana; Boah William Ofori Md; Bogdanov Assen Petrov Md; Boguski-Filgueira Lisa F; Bonoan Jose Tadeo M Md; Borrego Fernando J Md; Bourne Jeffrey Md; Bowers Daniel; Braswell Lezli; Braun James Frederick; Braun Maureen K; Braza Mary; Brescia Andrea M Md; Briggs Haydn Md; Briones Alan Paul Santos Md; Brody Erica Md; Brody Samuel A Md; Bron Yana Md; Brown Laura E; Brownlow Nathaniel Md; Brunner Steven J Md; Bryant Linda M Md; Buhion Caroline; Bukberg Phillip R Md; Burger Alfred Paul Md; Burke Gary Robert; Burshteyn Ilya Yakov Md; Busta Agustin Md; Bustamante Marco Md; Butt Ahmar Aziz Md; Cadag Stefan; Calabio Rafaela Z Md; Calamia Vincent Md; Callahan Mark; Camargo Edgar Md; Camargo Marianne; Cammerman Daniel Joseph Md; Carcaterra Joann Do; Castillo-Rodriguez Raquel; Castro George A Md; Cataldo Donnalee; Ceballos Clare; Cecilia Griselda Calderon Md; Cespedes Michelle Simone; Cha Yonhee Md; Chadi Ronny M Md; Chafian David Jonathan Md; Chan Chun-Kit; Chan Hang; Chan Sheung-Kwun Samuel Md; Chang Jung Mi Md; Charlotten Kevin Alexander Md; Chasan Rachel; Chase Jennifer C; Chatterjee Lolita Md; Chattooo Premetesh Do; Chaudhry Naeem Akhter Md; Chavez Silvia; Chelouche Julie Anne; Chen Abigail; Chen Chao Do; Chennareddy Swaminathan; Cherian Siby Vengal Md; Chery Roselyne Md; Chetreanu Alexandrina; Cheung Barbara A; Cheung William Md; Chhipa Mohammad Haroon Md; Chitu Carmen Elena; Chiu Gregorio E Md; Cho Hyung; Choe Josefina Luna Md; Chopra Ashok Chanparkash; Chow Desiree; Chow Rita Md; Chu Carolyn Md; Chu Jaime; Chuey John Md; Chumaceiro Rolando Md; Chun Eunmee H; Chung Andrew; Chung Bruce K Md; Chung Derek G Md; Chung Sung Lan Md; Ciechorska Maria Md; Cieloszyk Kinga Marta Md; Clark Cheryl L Md; Clemens Christopher Md; Coghill Alice Victoria Md; Cohen Alan J Md; Cohen Randy Edward; Cohen Roy A Md; Cohen Sandra; Cohrssen Andreas Md; Collins Megan Elizabeth Md; Conde Wright Marie France Md; Contreras Johanna Paola; Cook Heather Tiffany Md; Cook-Mack Jessica Phylis; Corrigan Kathleen; Cortes Jose Alberto Md; Cortijo Amarilys R Md; Cosmatos Andreas Md; Cosme-Thormann Braulio Federico; Coupet Nadege Marie Md; Cox Katherine Anne; Croft Lori Bray Md; Cruz Christina; Cunningham-Rundles C Md; D Oleo Vargas Maximo Jose; D'Souza David J Md; Da Rosso Robert Cian Md; Dadarwala Aashish Dhansukhlal; Daniele Rosemary Ann; Danik Jacqueline Suk; Danik Stephan B; Dantchenko Victoria Md; Daskalakis Demetre Costas; Davidson Morton I; Davis Yonette Md; Decherrie Linda Vandaele Md; Defabritus Albert M Md; Delaet David Edward Md; Dematteo Robert Enrico Md; Dennis Tian-Shu Chang; Depetris Gustavo Raul Md; Descartes-Walker Ingrid Md; Desgrottes Schiller Y M Md; Desikan Sonia; Desir Mergie X Md; Desrosiers Jean Claude; Devito Francis; Devons Cathryn A Md; Dharapak Patricia Md; Dhillon Perminder Md; Di Scala Reno Gennaro Md; Diaz Michael Md; Dick Jeffrey M Md; Dickerson Lauren; Dilmanian Rossana; Disla Eddys Md; Doan-Schultz Yvette Chi; Docu Theodore Costa Md; Domek Maciej Md; Donovan Edmund J; Doshi Dhvani; Douglas Orin Albert; Dove Arthur Renner Md; Drake Victoria; Drazenovic Ivo; Drukman Liliya Md; Drullinsky Alexix Cesar Md; Dubey Sudha; Duddempudi Nagamma; Dumas Marie; Dunn Andrew S Md; Dunner Ricardo Orlando Md; Dvorkina Anzhela Md; Dwarka Regev Ragbardial; DyGuillaume Marie Eve Md; Edano Albert E Md; Edelman Laurie Beth Md; Eden Alvin N Md; Edgecomb Paul Steven; Ednalino Linda Edano Md; Edwards Ayisha Tene; Edwards Donna; Edwards Sharon M Md; Ehrlich Martin H Md; Eidgah Mahyar Md; Eisenson Arlene; Eisner Yvonne; Elbirt Paula M Md; Eliot P Schuster Md Pc; Ellis Earl Anthony Md; Eloi-Stiven Marie L; Emily Otis Taylor Md; Emmer Louis Mark Md; English Cary Md; Enschede Elizabeth; Enu Christopher Chukwuemeka; Eric S Barna; Erlikh Irina; Escalera Elsa Md; Escher Jeffrey Ethan Md; Escobar Christian; Esposito Amy; Esposito Stephen P Md; Etkin Alexandra; Factor Stephanie Hope Md; Faculty Practice Associates; Fafalak Robert G Md; Fakhruddin Dilshad Md; Farhat Hassan Ail Md; Farhat Samir Ali Md; Farrell Cristina; Fatica Nunzia Md; Federman Alex David Md; Fefer Jose Jacobo Md; Feingold Leonard N Md; Felsen Michael R Md; Fenyves Andras Md; Fernaine George Md; Ferris David Craig Md; Field Jonathan Md; Fields Jessie Alfreda Md; Fierer Daniel Seth Md; Fievre Garnes Marie Ft Md; Fine Elyse; Finkelstein Donna Michal Md; Finkielstein Dennis Md; Fiorentino Thomas C Md; Fishman Donald R Md; Fisk Rebecca Saslow Md; Fisse Richard D Md; Fogel Joyce Frances Nahum Md; Fonfeder William; Ford Miriam; Forman Joel Alexander Md; Forman Lisa Diane Md; Forsyth Beverly Alison Md; Fox Kelita Louise; Frankel Etta Md; Franzetti Carl John Md; Frederic Bakhchi Md; Fresneda Caridad; Friedman Samuel; Friedman Scott L Md; Fteha Elie Md; Fuchs Thomas Md; Galal Nehal; Galvez Maida P Md; Ganatra Anjna Nain; Gandhi Vani Pragnesh Md; Ganea Gheorghe Romeo Md; Garankina Olga; Garber Julia; Garcia Quinones Saribel; Gardenier Donald; Gati Allison; Gault Allison Tamara Md; Gayle Eric George Md; Gazali Radfan M; Gebrezgi Sebhatu Tewolde; Gellis Sara; Gentes Meredith; Geraldine Yasmine Joseph; Gerdis Michael Md; Gerges Salwa Mikhail Md; Gerner Jenny; Gerolemou Louis N Do; Gershengorina Sofya Md; Gervais Carole E; Gharpure Anil Md; Ghooi Ashok Md; Ghosh Anita; Gibbons Olga; Gidfar Niloufar Md; Gidwani Sonia Md; Giegel Melanie Joy; Gilgoff Hugh L Md; Gillespie Ginger Md; Ginde Ranjan; Glasser Lynne Ann Md; Gliatto Peter Matthew Md; Goetz Celine; Goforth Thomas; Goldberg Tamara; Goldblum Louis M Do; Goldman Adam Y Md; Goldstein Lissa Kary; Goldstein Zil; Goldstone Elaine Brown; Gomez

NYS Confidentiality – High

Page 184 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Gomez Veronica Del Carmen; Gomez Tessa S Md; Gomolinski Eva Md; Gondal Zoha F Md; Gonzalez Leticia Md; Goodman Eric; Goodman Karl Richard Md; Goodman Stephanie Michelle; Gorny Mark A Md; Gottlock Robbins L; Gould Sanford Md; Gounder Celine Rani; Goyal Ravindra Kumar Md; Grabscheid Erica Md; Grand Mark Alan Md; Graney John Md; Grant Jessica J Md; Graziano Michelle; Greely John Stephen Md; Green Stuart Md; Gressel Irina Md; Gribetz Irwin X; Grimm Katherine Teets Md; Grossman Howard Alan Md; Groves Jill Elizabeth Md; Gruber Steven Jeffrey Md; Guevara Elizabeth D L A Md; Guillen Rafael A Md; Gulrajani Ramesh S Md; Gupta Ashita; Gupte Amrita K Md; Guy Judath Philip; Hackenburg Emily; Hailey Patricia C Md; Hailu Mekdes Md; Hak Virender Md; Halberstam Meyer S Md; Hameed Rizwanullah Md; Hana Ehab Joseph; Hanna Emad; Haque Sayera Md; Harbord Nikolas B Md; Hariri E; Hashemian Nezhat Md; Hassan Yasmin Akbar Md; Hawkins Katherine A Md; Hazel Edovard Joseph Md; Hefferon Susan; Hernandez Cameron Roland Md; Hesse Frederick R; Hewitt Ross G Md; Hill Keran; Ho Wesley Hok Man; Ho Wing Wah Md; Hobson Steven; Hodjati Ramin; Hoffman Judith; Hofmeister Stephen Frank Md; Hollman Dominic; Horn Ansell Np; Horowitz Carol Rose Md; Hsiung Ahmed Leslie; Hudesman David Philip; Hui Yiqun; Hupriker Shirish S Md; Husain Syed S Md; Hussaini Batool M Md; Hussaini Syed Zabeehullah Md; Hwang Andrew; Iglesias Alejandro D Md; Inada Victor Katsuji Md; Indio Lillian R; Institute For Family Hlth; Iocolano Carolyn F; Iqbal Muhammad Z Md; Irani Dinaz; Ismailova Kyamalya A; Israel Ezra Ceasar; Issa Ricardo Fabian Md; Issack Joshua; Itzkovitz Ina S Md; J Barbazan-Silva M D P C; Jaber Nadim; Jacobson Robin; Jagger Samantha Jane; Jahan Mumtaz Md; Jan Ren Bang Md; Janice Prime Care Medical Pc; Jao Jennifer; Jaradeh Issa E; Jasti Harish Md; Jasty Babu N Md; Jawaid Mohammad Md; Jennifer B Cerasoli Md; Jennifer Kar Yee Hui; Jervis Ramiro Md; Jhagroo Omesh; Jhagroo Vishnudatt Md; Jimenez Mariela; Jimenez Roxanna; Jimmy R Sitt; John Bertha; Johnson Golda O Md; Johnson Livette S Md; Johnson Timothy Curtiss Md; Jones Elizabeth Mary; Jones Michael Abou Md; Jones Vivian Lynn; Joseph Marjorie Md; Judeh Hani; Jung Tiffany Maysu; Kacin Christophe; Kale Minal Sharatkumar Md; Kan Sang Md; Kannry Joseph L Md; Kaplan-Weisman Laura; Karakas Serife Eti Md; Karp Sara; Kashan Glenn Lawrence Md; Katz Cynthia J Md; Kensaint Pascale Md; Kent Jennifer Ames Md; Kerr Leslie Dubin Md; Khabyeh Shaya; Khaim Rafael Np-C; Khalid Nazneen Md; Khalil Richard Md; Khan Shumaila; Khorets Boris A Md; Kilinski Benjamin; Kim Julie; Kim Kyu-Han Md; Kim Sarah K; Kim Tonia K. Md; Kimble Christine Md; Kirkham Elizabeth; Kirschner Eric Md; Kitson Kwame A Md; Klein Daniel P Md; Klein Oscar Md; Kletsman Igor Md; Klimenko Elena A Md; Knorr Alexa; Ko Fred Chau-Yang; Koicke Betsy C; Kondamudi Vasantha Kumari Md; Kondaveeti Harika; Kopke Mary; Koshy Sanjana Cherian; Kothari Vipul Chandrakant; Kozlov Natalya; Krausz Robert B Md; Kulina Georgia; Kuwama Yuichiro; Lai Anne; Lai Joanne Md; Lalia Madeline R Md; Lamb Angela; Landerer David; Lane Matthew John Md; Lantz Howard Md; Lao Henry S Md; Latt Ko Ko; Lau Christopher Yu-Yen Md; Law Singwu David; Lawrence Donald P Md; Lawrence Donna Anthea; Lazala Polanco Carmen Md; Lazarin Margaux Helene; Leasy Menachem Jeremy; Leber Robert J Md; Leder Marvin A Md; Lee Hanna; Lee Jeong Ran Oh; Lee Marjorie Pc Md; Lee Namhi; Lefevre Lionel Md; Lefevre Marie Edith Faublas; Leinbach Lindsey; Lekht Vladimir; Lempel Herbert Sheldon Md; Lerner Gary; Lesnewski Ruth F Md; Levin Marc William Md; Levine Claudia Md; Levine Steven Barry Md; Levine-Tanco Karen; Li Ka Md; Liang Elizabeth; Liao Emilia Pauline Md; Liberman Dina Md; Lin Elaine Patricia; Lin Jenny Jen-Yi Md; Lin Lee Yulee; Linetskaya Irina; Lombardi Paul Md; Lopez Clark Faafp Md; Lopez Janice; Lopez-Santini Jaime; Lovenvirth Wendi Jennifer Md; Lowe Rajani; Lu Haiyan; Luo Anming Md; Lurio Joseph Glen Messner Md; Luz Amarilis Lugo Md; Lwin Yinphyu Win; Ly Rose Vay Luong Md; Lyman Andrea Md; Lynch Colleen; Lynch Gina Adriana Md; Lynch Rashanna Denise; Mack Theresa Adele Md; Mackay Richard E Md; Madhava Valsa S Md; Madrid Tanya M Md; Mahale Rekha; Majmudar Sejal; Malachovsky Martin; Malanum Teofila Md; Malieckal Jubil Md; Mamoon Nahreen Md; Manasia Anthony Robert Md; Mandac Carmen Aguilar; Mantia Augustus G Md; Mantia Philip Anthony Md; Manvar Buddhadev Nathabhai Md; Mararenko Larisa Md; Marcantonio Colomba A Md; March Anika Jolene; Maritato Andrea F Md; Markoff Brian A Md; Marseille Beatrice; Marsh Franklin Jr Md; Martin Monica A; Martinez Ofelia Md; Maselli Frank Joseph Md; Masson Ella; Mathews Premila Maria; Mathieu Claudine; Matthew S Cohen Md Pc; Matti-Orozco Brenda Marcia; Mattoo Uijay Kumar Md; Maw Myo Md; Maybody Shideh; Mayer Amir Md; Mayer Victoria Lee; Mazza Michael Anthony Md; Mccormick Elizabeth T; Mcdonagh Mary Valentine; Mcgoldrick Patricia Engel; Mckinney Robin Cylinthia; Mclaughlin Mary Ann Md; Mclendon Lucia Cogswell; Meacher Peter; Meah Yasmin Sultana Md; Medder Nia; Medina Leonel Delos Reyes; Meed Steven D Md; Meer John Fredric Md; Mehandru Saurabh; Mehra Sweeti Md; Mehta Davendra Md; Mehta Viplov K Md; Melis James Mark; Meltzer Elyse Michele; Menon Rakesh; Menon Rekha; Mensah Doreen Akosua Md; Merchant Yuko Md; Meredith Wepner Grossman; Merkler Richard G Md; Messinger Meridith L Md; Mettu Sudhakar Reddy Md; Mezheritsky Eleonora Md; Michael M Gaisa; Mikhail Imad Md; Mikkola Eeva Johanna; Milani Haleh Md; Miller Elizabeth; Miller Hanan G Md; Miller Marc Andrew Md; Miller Sarah; Milman Alisa Md; Min Insung; Mino Rosa Elena Md; Mir Mohammad Arshad Md; Mirlohi Hooshang Pc Md; Misra Deepika Md; Mitchell Harrison Md; Moarefi Mehran-Reza Md; Moberg Kenneth A; Mocombe Lucien D Md P C; Modern East West Medical Pc; Moe Khaing Md; Mogilner Leora Naomi Md; Mohammad Sajjad; Mohanraj Edwardine Mirnalini; Moise Wesner Md; Moose Lauren A; Moreno Lisa Belinda; Motiram Savitri Ramdass Md; Mozayan Mahboobeh; Mui Wingtat Md; Mullen Michael Patrick Md; Muller David; Mumford James M Md; Muneer Imam Md Pc; Murayama-Greenbaum Robert Md; Murphy Barbara Therese Md; Murray Carolina; Muse Jessica Md; Myint Moe Moe; Myint Richard Md; Mountsianihealthsystem; Mountsianihealthsystem; Naeem Muhammed; Naing Zaw Md; Nandi Anukul C Md; Nasr Sherif; Nasreen Tahera; Nassif Neven Ibrahim; Natarajan Rupa Narayani; Naughten James Kevin Do; Nautiyal Preeti Md; Navid Kathy Farima Md; Neretin Nicole; Nghi Phuong M Md; Nguyen Henry Van; Nguyen James K; Nguyen Thomas Thang Md; Niaz Mohammad Khalid Md; Nichols Andrea Marisa Md; Niforos Fotis; Nisanian Anahid Jaquelline Md; Nissim Julie Md; Nosal Sarah Catherine; Novak Bethany Randi; Novarro Leonard Gerard Md; Nowak-Wegrzyn Anna Halina Md; Nowakiwskyj Theodore Md; Nucci-Sack Anne Terese; NwekeChukumerije Obiageli Md; Obonaga Sheila; Ofosu-Amaah Sophia Md; Ogbovoh Daniel Obaroakpor Md; Oji Ngozi Afiazu Md; Okhravi Siavash Steve; Olajide Bolanle A Md; Oliver Kristin; Orbe Jessica Md; Orin Gary Bruce Md; Orris Maxine Md; Osher Annette; Osoba Olumide Obafunmilayo Md; Osorio Georgina; Ostrager Jill Beth Md; Ostrowska Aneta; Ostrowski Roman M Md; Othoniel Marlene; Ottaviano Lawrence John Md; Paa Remedios Caparas; Pachman Jason Lee Md; Paddu Upadhyaya Padmanabh; Pagan Diane Elizabeth; Page Cameron Stuart; Pandya Amy Arun Md; Paredes Tessie Timitiman Md; Parikh Rita Md; Parkas Valerie Md; Parnes Eliezer L Md; Patel Deepti Dev; Patel Dipal Md; Patel Girishkumar Md; Patel Shamit P Md; Patel Sunil Md; Patel Truptiben; Patel Vidya; Patel Vinisha Md; Patrick Dalton Md Pc; Peccoralo Lauren Alise Md; Peimer Marta Silvee; Pena Armando Juan; Pennant Ainsley Md; Perry Andrea; Persaud Indrani; Perumareddi Krishna; Petelin Andrew Patrick Md; Peterson Monte Harold Md; Petilla-Onorato Jessica Isabel Md; Petrov Manana Md; Phillip Sohn; Photangtham Punyatech Md; Pickering Jean; Pierce Carolyn Marie; Pierre Louisdon Md; Pierro Hugo Md; Pileta Lourdes X; Pinkas Adina Md; Pinzon Robin Ramos; Plokamakis Michael Md; Poff John Edward; Polavarapu Hari Kishan Md; Ponce Sara; Ponieman Diego Andres Md; Poomkudy Liz; Posada Roberto Md; Pressler James Md; Prigollini Alejandro Md; Prine Linda Whisler; Pristoupa Olga Md; Psevdos George Jr Md; Puente-Guzman Soledad Elvira; Pumarol Alba; Purohit Amar Lal Md; Quick Melissa Kaufman; Quinn Carrie; Racanelli Joseph A Md; Radix Anita Eileen; Rafailov Danil Isakovich; Rafatjah Soyona; Rafiaa Amer; Rahman Rummana Md; Rahman Shafiqur Mohammed Md; Raifman Leonard I Md; Rajda Geetanjali Md; Raman Bharathi Md; Ramkeesoon Rosemarie Np; Ramnarine Jotir; Ramos Tapia Alberto M Md; Ramos-Ramirez Berta; Rana Shital; Rathi Dwarka P Md; Raufman Joshua; Ray Roona; Ray-Schoenfeld Naomi; Read Dalan Md; Reckrey Margaret Jennifer; Reddy Chenna B Md; Reddy Lalitha Mary Md Pc; Reddy Vidya Mettu Md; Rehman Abdul Md; Reich Danya; Reister Robin; Remde Alan Hugh; Reminick Marshal Md; Renaud Jean Leopold Edwrin Md; Rendeiro Susanne; Reuben Stephen W; Reyes-Arcangel Fe T; Rezvani Mitra Md; Rice Laurie A Cochran Md; Rios Carlos Md; Ripp Jonathan A Md; Rivera Graciano Md; Rivera Veronica; Rizk Dahlia Md; Robert Joyce Folashade; Robie Kristin; Robinson Roberto H Quinonez Md; Rodgers Stephen L; Rodriguez German; Rodriguez Navarra; Rodriguez-Caprio Gabriela Md; Rodriguez-Jaquez Carlos R; Roedan Socrates; Rogers Linda Md; Roman Jasmin; Rosales Avelino S B Md; Rosch Elliott C Md; Rosen Carolyn Michelle Md; Rosenberg Rachel; Rosenbloom Sylvie; Roshchina Yelena; Roth Rachel; Rubenstein Marc D Md; Ruhe Jorg Joachim; Rule Erin Eileen Mdf; Russak Lisa; Sacco Joseph P Md; Sacher Mandy Lauren; Sacolick Benzion Md; Sacolick Daniel; Saftchick Stuart L Md; Sagalovich Boris Md; Saha Prantik Md; Saigh Orit Md; Saint-Laurent Mario; Saint-Louis Frantz Fils Md; Salinas Jean-Louis Md; Salomon Nadim Md; Sam Tanyka; Samaniego Robert Md; Samra Faraj; San Myat Md; Santiago Allan Realin Md; Saporito Anna Gabriella Md; Sara Danielle Lorenz Md; Sarin Aparna; Satsky Mindy B Md; Savransky Alla Md; Saw Thazin Md; Sayegh Nadem Jamil Md; Sayegh Osama Elias Md; Sazan Inga; Schiller Robert M Md; Schirripa John Piero Md; Schneebaum Cary Md; Schwartz William J Md; Scrimmager Leon Md; Seidler Afet Md; Seigel Rebecca Rae Md; Selzer Jonathan David I Md; Semanision Kristen; Senzamici Camille Md; Sessions Jessica; Setaruddin Sazia Loqman Md; Setia Deepak K Md; Shah Harshida R Md; Shah Jilan Md; Shah Kumarpal A Md; Shah Sumatilal C Md; Shahkoohi Afshin

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Md; Shaikh Aftabahmed F Md; Shalhoub Robert Francis Md; Shein Ruvan Md; Sheinfeld Joanna; Shen Kuan Hung Md; Shenko Christina Angela; Sherman Frederic M; Shieh Jong-Chuan Md; Shimonov Josef Md; Shirwaikar Anil B Md; Shukla Mayank Arun Md; Shust Gail; Siddiqui Ayesha; Siegel Howard Md; Siegel Stephen D Md; Sierros Vasilios Md; Sigel L Keith Md; Sigrest Barbara Md; Simon Margo; Simpao Jose Rodriguez Jr Md P; Sindhwani Rajeev Md Pllc; Singal Anita; Singh Amarjit Md Pc; Singh Jagjit Md Pc; Siroya Pushplata B Md; Sisser Rachel; Sloan Barry; Small Katherine Morgan; Smith Alford Alexander Md; Smith Sharon Ellen Md; Smith Verta I Md; Sokolova Ekaterina; Solis Edward; Solomon Rachel; Soriano Theresa A Md; Sosinsky Jeffrey H Md; Sotnik Regina Md; Sourial Lucy A Md; Spieler Leah Matisse; Spitzer Matthew; Spivak Dana Md; St Louis Emmanuel Lesly G Md; Sta Ana Victor; Stallings Shavonn; Starpoli Anthony A; Stauber Stuart L Md; Steever John B Md; Stein Alan J Md; Stein Janet Laurie Md; Steklova Olga Md; Stivala Alicia Christina; Straus Emily L Md; Strauss Michael Leopold Md; Strong Jennifer Elizabeth; Suden Stacy Allisa Md; Sugandhi Nandita; Suja Vinod; Suma Dasari; Suprin Gregory Md; Suter Maureen Natalie; Syed Ahmad Physician Pc; Syed-Naqvi Samina Altaf Md; Szalyga John Md; Taha Hesham Mohamed Md; Talavera Wilfredo Md; Talcott James; Tam Cynthia J Md; Tamdji Natacha; Tan Wu; Tang David J Md; Tang Ian Tsai-Leu Md; Tao Chenguang Tony; Teets Raymond; Teich Marvin L Md; Tenney Nancy Lee; Tesler Peter Jon Md; Thomas David Charles Md; Tikhonova Elizaveta; Tikko Suraj K Md; Tio Ruy Chen Md; Tkachenko Natalya Md; Tolbert Jerome V Md; Trager Abigail Hope; Trenton Brooke; Truglio Joseph; Truong Tuyettrinh Nguyen; Tsai Tien-Tsai; Tso Alan Ying Yeung; Tun-Chiong Yolanda Do; Tung Keith; Turetsky Risa Ross; Turner Stephen B Md; Udesky Robert A Md; Uleis Keith Harris Md; Urbina Antonio E Md; Uribarri Jaime V Md; Uribe Alejandra Maria Md; Vail Rona; Valasareddi Lalasa Reddy Md; Vamadevan Nallasivam Md; Van Gilder Max F Md; Vanegas Edgar Z Md; Vangeepuram Nita Md; Varghese Betsy; Varma Sudha Md; Vasa Chiroq V Md; Vasiliadis Athanasia S Md; Vavasis Anthony P Md; Veeramachaneni Saimamba Md; Vega Aida; Velazquez Belinda Melissa Md; Veluswamy Rajwanth; Vero Erica; Vicencio Alfin G Md; Villani Gina M Md; Villi Roger A Md; Vilnits Anatoliy Md; Vinas Sonia Miliza Md; Vindhya Rajesh Kumar Chand Md; Virani Zahra; Vizel-Schwartz Monique; Voddi Madhu D Md; Volokh Vladimir Md; Waite Eva Ann Md; Wajnberg Ania Md; Waldron Mary Violet Md; Walker Jenny; Wallach Frances Robin Md; Walsh Margaret Mary; Wang Emily H; Wang Jing Wa; Wang Stephanie Chih-I; Wang Zhong; Warman Jacob I Md; Waseem Faisal Md; Watkins Isheka S; Weintraub Jennifer; Weir David C; Weissman Sam Md; Wen-Ray Thomas Hsu; Whipple Clare; White Camele; White Elizabeth Stuyvesant Md; Wiener Joseph M Md; Wilder Venis Tiarra; William F Ryan Comm Hlth Ctr; Win Khin; Wong Chun Tung Md; Wong Hok; Woodley Walter Md; Xu Tao Shiwei; Yanagisawa Robert Takahiro Md; Yancovitz Stanley R Md; Yap Marcelo Janette Md; Yen Vincent Md; Young Edwin Reynolds Md; Yousaf Ali; Yu Chin Hsien; Yudelman Ian M Md; Yuen Jacqueline; Zalavadia Deepti; Zaremski Benjamin Md; Zedeck Beth; Zelenetz Michael Ivan Md; Zewde Mulubrhan; Zhang Jian Wei; Zhang Meng; Zheng Hanbin Md; Zilberman Alla; Zinger Yevgeniya Oskarovna Md; Zoubtsova Minzalia Md; Zuger Abigail Dell Md; Zylbert Susan Lynn Md Task

Policies and procedures are in place for early notification of planned discharges.

Provider

Practitioner - Non-Primary Care Provider (PCP)

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Providers Associated with Completion: Aaron Patrick Tansy; Abascal Vivian M Md; Abboud Joseph; Abdel-Wahab Nancy Hussein; Abdelmalak Nabil N Md; Abdelrahman Hanan; Abebe Mekonnen; Abeckaser Anat; Abed Antoine Tony; Abed Jean; Abi Aad Simon; Abiri Manouchehr Md; Abraham Bessie; Abraham Sherley; Abraham Suja Md; Abramov Natela Rpa; Abrams Lauren Cnm; Abrams Robert C Md; Abramson Austin Wayne Md; Abulencia Armand Emmanuel; Acerra Frank L Do; Acholonu, Jr. Uchenna; Acquah Samuel O H S; Adam Antoine; Adam P Grant; Adam S Morgenthau; Adams Benjamin Donald; Adams David H Md; Adams Rachel May; Addes Alvin David Md; Addo Emilia Np; Adebayo Adebukola; Adelman Randi; Adelman Ruth M; Adelson Mireilla; Aderholdt Karen; Adesuwa Okesanya Md; Adika Yona Sasson; Adler Arvin Jay Do; Afzal Omara; Agarwal Ruchi; Agarwal Shradha; Agarwala Neena Md; Agdere Levon Md; Aggarwal Aakash; Agha Rabia Md; Agnant Joanne Michele; Agvent Nicholas; Agyare Samuel K B Md; Ahilan Paramanathan Md; Ahmad Jawad; Ahmad Mejoi Md; Ahmed Tanveer; Ahn Young J; Aikawa Taro; Ainspan Jeffrey Louis Md; Aivazi Zaza Joshua Md; Ajani Nazia; Akhtar Joyce Mary; Akhtar Saadia Md; Akingboye Adekemi Olufnmilayo; Akuamoah Latrice Akosua; Aladdin Mohammed Md; Alagesan Ramdas Md; Alagesan Rita Md; Alaverdian Artur; Albertini Elizabeth Streicker; Alberto Escallon Md; Albu Jeanine Md; Alcantara Angel Maria Md; Alcaraz Alvarez Jose; Alcontin Evelyn; Aledort David E Md; Aledort Louis Md; Alexander Steven Craig Md; Alexandrou Nikolaos A Md; Alexandru Burducea; Alexeenko Lada; Alexis Andrew F Md; Alexis Quentz; Alieva Tamara Rpa; Alikakos Maria; Aliyeva Nargiz; Aljian John M Md; Alkurdi Nasser Md; Allen Marcella Md; Allis Barbara A Md; Allison Karen Melanie Md; Allison Margaret Jacqueline; Almee Lee Lucas Md; Almira Sigrid Lagrosas Galdo; Aloysi Amy Starr Md; Alpern Amy; Altchek Douglas D Md; Altin Lisa A; Altiner Ahmet; Altman Deena Rose; Altman Robert Keith Md; Altschul Rebecca; Altstein Samuel Harvey Md; Alvarado Sandra; Alvarez Elsie Md; Alvarez-Downing Melissa Marie; Alyeshmerni Bahram Md; Alyskewycz Mykola Roman Md; Amanda J Rhee; Ambrose Anne F Md; Amerling Richard Md; Ames Scott Alan Md; Amin Kwame; Aminzay Aman; Amiraian Richard Harold Md; Amler David H Md; Ammirati Michael Md; Amorosa Jennifer; Amoroso Nicholas Dr.; Amy Kelley; An Seonhee; Anand Anjoli; Anand Om; Anand Suryanarayan Md Pc; Anca Diana Md; Anderson Ann E Md; Anderson Lisa Md; Anderson Michael Ryan; Andrade Allen D; Andrea E Perez; Andrew Mathew Perez; Andrew W Pearson Md; Androne Ana Silvia Md; Andrus Jason M; Andrus Phillip Md; Ang Celina Su-Ping; Angelo G Pilla; Anger Katharina; Angioletti Louis Scott Md; Angrisani Christine M; Angus Heather Lynn; Anik Karishma Amina; Ankola Pratibha A Md; Anna Castelli; Annette M King; Annunziato Rachel; Anthony Kopatsis Md Facs Pllc; Anusionwu Reagan; Anyanwa Anelechi C Md; Aouchiche Hakima Md; Apoeso Olusegun; Appel Cheryl; Appel Jacob M; Appleman Warren Md; Aquila Ralph Md; Arabadjian Milla Eddie; Arabov Yosif; Arcuri Joseph; Argiriadi Pamela; Argulian Edgar; Arias Wilma Mercedes; Arida George N Md; Arinsburg-Brooks Suzanne; Ariyarajah Vignendra; Arjomamd Farhad Md; Armand P Asarian Md Pc; Arnett Maria F Md; Arnon Rica Md; Arnouk Johnny Issam; Aron Alan M Md; Aron Narcis Bernat Md; Aronoff Jeffrey S Md; Aronson Andrew Charles Md; Arpayoglou Beatriz C Md; Arroyo Hansel; Arsht Steven J Md; Arta Seitaj; Arvelakis Antonios; Asbell Penny A Md; Ascheim Deborah V Davis Md; Ascher-Walsh Charles J Md; Asher Megan; Ashikari Andrew Y Md; Ashina Sait; Ashley Kenneth B Md; Ashley Kimberly N; Ashley Phillip Rpa; Ashmead Graham G Md; Aska Glenroy Anthony Dpm; Askanas Alexander Md; Aslam Ahmed Faraz; Assadi Cyrus A Md; Asuncion Arsenia; Atakent Yucel S Md; Atallah-Lajam Farah Elias Md; Atileh Haytham Md; Atreja Ashish; Attenborough Julia; Attia A Lawrence Md; Attiyeh Fadi F Md; Attoe Linda S Md; Augello Sabino A Md; Augustin Wisly Gerald Md; Ault Kathleen; Ava Regina Sierecki; Avdija Valbona; Avent Michele D; Averbukh Ella Slp; Avezbakiyev Emanuel; Aviles Martin; Avni Thakore; Avolio Jock A Md; Awerbuch Elizabeth Do; Axe Harold Md; Axt Lindsey E; Ayala-Rodriguez Cesar Esteban; Aybar Luis; Aycart Samantha N; Aye Thida; Ayzenberg Victor Md; Azbel Vadim Md; Aziz Emad F; Aaranbrookedrake; Aaronsavedoff; Aliciam.Hurtado; Alvinm.Alfonso; Andreanimmons; Andrewj.Ciancimino; Antonias.New; Baber Usman Md; Babitz Lisa Ellen Md; Bach Nancy Md; Badani Ketan Kishore; Badhey Vasantha Md; Bae Peter Sangdo; Bagley William H Md; Bagner Michael R Md; Baharlou Shahla Md; Bahl Naresh Bala; Bai Matthew; Bailly Edward; Bair Melissa; Baird William T Dpm; Bakal Ron S Md; Baker Robert H Md; Bakst Richard L; Balaram Sandhya K Md; Baldino Michael; Balmir Sacha Do; Balwani Manisha Chandru Md; Bander Jeff; Bania Theodore Casimir Md; Banik Rudrani Md; Bansal Anip; Bansal Haghav; Bansal Meena B Md; Bansilal Sameer; Bar-Chama Natan Md; Barash Irina Md; Barclay Ruby; Barczewska-Hillel Anna Md; Barenboim Arkady Z; Barinstein Laura V Md; Barkoff Matthew W Dpm; Barkoff Steven Lawrence Dpm; Barletta Nancy Montero; Barnea Amnon; Barnett Barbara Jean Md; Barnswell Carlton B Jr Md; Baron Elisabeth; Barr Rachel Lynn; Barrett Kathleen; Barricelli Florence; Barrie Michelle Weinstein; Barron Otis Alton Jr Md; BarschowMarton Patricia Lynn; Bartoc Cristian D Md; Bartoli Lisa M Md; Baruch Jeffrey David; Baruch Lawrence Md; Basdeo Donald; Basile Maria; Baskin David Md; Baskin David Sathya; Baskin Martin I Md; Bassily-Marcus Adel Makram Md; Bassiur Martin Dds; Basso Alan Matthews Phd; Batista Sharon; Batri Adel Md; Batta Priti Md; Battu Vijay K Md; Bauer Ross; Baum Sabra; Bauman Phillip A; Baumlin Kevin Michael Md; Baxter Daniel Jay Md; Baxter Kathryn M; Baxter Peter Carl; Bazile Valerie;

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Beasley Mary; Beautyman Elizabeth J Md; Becker Daniel Jacob; Becker Lucy; Beckhardt Russell N; Beddoe Dottino Ann Marie Md; Bederson Joshua Benjamin Md; Bednarek Karl Thadeus Md; Beer Joshua David Md; Beilin Yaakov Md; Beitia Laura Grace Md; Belayneh Lulenesh Md; Beldner Steven; Belisova-Gyure Zuzana; Belkin Tamara; Belsley Scott John Md; Belyakova Ulyana; Ben-Zacharia Aliza; Bender Catherine Jane; Benedicto Socorro A Dmd; Benevento Joseph; Beniaminovitz Amnon; Benias Petros; Benkov Keith J Md; Bennett Stephen J Dpm; Benson Carolyn Mararet; Benvenisty Alan I Md; Benzakein Ralph Dpm; Berberena Frances; Berdella Maria Md; Berdoff Russell Lindsay Md; Berenstein Alejandro Md; Berg Debra; Bergen Michael Howard; Berger Abraham Md; Bergstein Michael J Md; Berkowitz Rachel; Berland Doris Garcia; Berman Michael; Berman Peter D; Berman Steven Marc Md; Bermudez Rogelio P; Bernik Thomas R Md; Berns Stephen; Bernstein Alan L Md; Bernstein Brett B Md; Bernstein Chaim J Md; Bernstein Joseph; Bernstein Robert S Md; Bershad Susan; Bertiz Tracy Valerie; Besser Walter Md; Betchen Simone Alise Md; Beyda Ellen Michelle Phd; Bhamre Shrikant Suresh Md; Bharat Sanghavi Md; Bhardwaj Aarti; Bhatt Himani V; Bhattacharya Sunita Md; Bhatti Saad; Bhavsar Rajesh; Bhimsen Tulawattie Devi; Bhora Faiz Yahya Md; Bhowmick Debjani; Bhutia Phintso Pd; Bialek Sydney Jeanne; Bianco Angela T Md; Bietry Raymond Emile; Biggs Carina G Md; Billington Kaitlyn E; Bird Anne F; Birnbaum Stuart C Dpm; Biviano Bernard John Jr Md; Blackham Janice; Blancaflor Ginno C Md; Blanchard Karen; Blanco-Franco Oscar Md; Blank Andrew Md; Blank Wesley S Md; Blass Joel Mitchell Md; Blaufarb Ira Stephen Md; Blechman Michael Bruce Md; Blei Francine Md; Bleier Howard Md; Bleiweiss Ira Md; Blissett Kecia-Ann May; Blitzer Andrew Md; Blouin Amanda Germaine; Blum Jessica E; Blumenthal Celia; Boakye Naana Agyeiwah Md; Boateng Percy; Bock George H Md; Boggio Nelly T Md; Boguslavskiy Boris; Boniece Irene R Md; Bonura Jessica A; Boockvar Kenneth Stephen Md; Boolbol Susan Md; Borcich Anthony S Md; Bordia Sonal; Bordowitz Richard Alexander; Borg Morton David Md; Borrero Charin Marie; Boshakova Alina; Bosworth Jackie; Bottner Joseph Md; Bouvier Nicole Marie; Bovino Brian F Dmd; Bowe Adraenne; Bowne Helen Yoo; Boxer Jonathan A Md; Boyce Ricardo A; Braden J Hexom Md; Bradley Katrina Md; Bradley Sara M Md; Bradley Shy Md; Brady Michael; Braha Jack; Brahm Bernard Daniel Md; Braman Sidney; Brathwaite Brenda L; Brau Norbert; Braun Carl W Md Pc; Brazzo Brian Gerald Md; Breed Sabrina Theoposia; Breen Tracy Lynn Md; Brennan Timothy Koehler; Brenner Hillary Beth; Bresler Priscilla Ann; Bressman Susan B Md; Brewster Joe Cephus Jr Md; Brian Kearney; Brian Mcdonald Hall; Briley James; Brill Joseph J Md; Brockington Carolyn Doreen Md; Brodie Scott E Md; Brodman Michael L Md; Brodman-Grimm Karen F; Brody David W Md; Brody Joshua; Brohl Andrew Scott; Broker Martin Md; Bromberg Kenneth Md; Bronheim David Samuel Md; Bronn Donald George; Bronson Michael Md; Brosgol Yuri Md; Brountzas Maria; Brous Patricia Md; Brown Barry L Md; Brown Donald B Md; Brown Robin R Md; Brown William H Md; Bruce Eric Sands; Brucia Laurie Jane; Bruck Elena; Brunner Robert J Md; Brunner Sarah Devlin; Bruno Anthony M Md; Brustman Lois E Md; Bruzzese Nicole Josephine; Bryce Thomas Nathaniel Md; Bryson Ethan Oliver Md; Bryson Juline Michele; Buchbinder Daniel; Buchbinder Mitchell I Md; Buchbinder Shalom S Md; Buchholz Robin M Md; Buckstein Michael; Budasoff Caroline L; Buettner Christoph Md; Buggie Brian Gregory; Bukharovich Inna F Md; Bulkin Eugene; Bunac-Cuevas Cristina M; Bunyavanich Supinda; Bunza Gregory N Dds; Burgoyne Brian; Burnett Michael Charles Md; Burstein David E Md; Burt Matthew Lawrence Md; Burton Rebecca Lyn; Busingye Jacqueline Rukanshagiza; Busse Paula Jane Md; Butler Brian Joseph Dpm; Butler Toni C; Butoi Irina Md; Butvick Kathryn Maher; Buxton Douglas F Md; Buyuk Arzu; Bybordi Bahar; Byer Erroll Ignatius Jr; Byer-Henry Yvette Oreta Cnm; Cabbad Michael Frederick Md; Cacciarelli Armand Gerald Md; Caces Phyllis Adrienne R; Cafferty Maureen Sarah Md; Caggiula Amy Beth; Cahill John Donald Md; Cahn Elizabeth Ann; Cai Athena J; Cai Steven; Cajulis Corazon Bautista; Cajuste Muriel; Callahan Eileen Helen Md; Callan Felicia Tirico Md; Callender Kimberly; Callipari Francesco Md; Calvin Chen-Hwan Wei; Campbell Ann Harper; Campbell Kirk Nicholas Md; Campione Michele Md; Campton Kristina; Canter Murray A Md; Cantor Gordon Michael Md; Caplivski Daniel Md; Caporuscio Jessica L Md; Caputo William Edward; Carabello Blase; Cardasis John; Cardillo Edward Paul Phd; Carey Abigail S; Carey Patricia Mary Md; Caridi John; Carl Julia Ann; Carlos Maureen Ann Barlaan; Carlton Lawrence S Dpm; Carluccio Alessia; Caroline Columbres Md; Carpio Orlando B Md; Carr-Locke David Leslie; Carrao Vincent Md; Carrera Rosa Flores; Carrera Rose-Marie Md; Carryl Stephen Samuel Md; Carter Robin Stephanie Dpm; Cartwright Robert Mclain; Casagrande Lisette; Cascetta Krystal Pauline; Casden Andrew M Md; Casey Mairead Ms.; Cash Bradley S Md; Casiano Evelyn J; Caskey Marina Fernandes De Barros; Cassano Kelly; Castanaro John; Castellano Bartolomeo Vincent; Castello Donna Ann Md; Castillo Maria Dolores Md; Castillo Rafael A; Castro Garcia Jose Luis Md; Catalano Louis W Iii Md; Catamero Donna Domenica; Cate Sarah Patricia; Catherine Conway; Cattafi Paul David; Cavaliere Raymond G Dpm; Cavalli Adele L Md; Cayton Alberto L Md; Cedeno Stacey V; Celebi Julide; Celena Dancourt Md; Celestin Gregory Cuthbert; Cerra Luis R Md; Chabus Brent Ira Md; Chadha Manjeet Md; Chae Patrick; Chahil Tina Jasjit Md; Chai Emily Md; Chai Raymond; Chakrabarti Chhaya Md Pc; Chalker Dana F; Cham Matthew Dy Md; Chamdawala Hammid Shabbir; Chan Andrew Hing Kin Md; Chan Andrew Joseph; Chan Germaine Zenia Md; Chan Jacqueline; Chan Michael; Chan Sherman Md; Chan Takyan Dds; Chan Yu-Feng Md; Chanamolu Sravanthi; Chandrashekhar Sarayu; Chang Charissa Yuhua Md; Chang Cheryl K Md; Chang Christine Md; Chang Helen Md; Chang Jennifer; Chang Lena; Chang Mark Md; Chang Nadine Ann; Chang Paul Potsung Md; Chang Peter L; Chang Thomas T M Md; Chang Woo Taek Md; Chang Ya Ju Md; Chao Faye; Chao Steven S Md; Chapa Josephs Jacaranda; Chapman Eugenia Valerie; Chapman Mark L Md; Charap Peter Jeff Md; Chardavoine Josee; Charen Elliot Michael; Chari Ajai Md; Charles H Kellner; Charlot Cascyarnoux Md; Charney Richard E Md; Chason Kevin W Md; Chatterji Manjil; Chaudhary Sapna; Chaudhry Ahmed Do; Chaudhry Farooq Ahmed Md; Chaudhry Hina W Md; Chaudhry Nadeem Ahmad Md; Chavarria Patricia Diana; Chaves Amber Elizabeth Ruth; Chawla Preety Md; CheKai Tsao Md; Chehade Mirna Abdul Monhem Md; Chen Darwin; Chen Henry C; Chen Jennifer Ann; Chen Junping; Chen Katherine Tsia-Huey Md; Chen Zijian; Cheng James Md; Chenna Jayapratap Reddy Md; Cherazard Regine; Cherezova Diana; Chernobilsky Boris; Chernyavsky Svetlana; Chesoni Laura; Chetrit Sally; Cheung Angela Yuen Man; Cheung Angeles; Cheung Janice M; Chew Edward Md; Chew Kit-Ling Miss; Chhabra Amit; Chida Rakhshan M; Chideckel Norman Jay Md; Chietero Michael Md; Chikwe Joanna Yvonne Md; Chin Edward H Md; Chin Maxine Grace; Cho Catherine Md; Cho Hearn Jay Md; Cho Samuel; Choi Christina; Choi Mark Md; Choi Ran; Choi Walter Hyunmin Md; Chokshi Niti Y; Chong Ji Young Md; Choo Sung Yoon Md; Chotkowski Gregory Dds; Choua Clement; Choudhri Tanvir Fiaz Md; Choudhury Sourab Patrick Do; Choy Youyin Md; Christian Dirk Becker; Christina Flores; Christine H Kim Md; Christopher Chow; Christopher Gannon Strother; Christopher James Diblasio; Chu Jason Md; Chu Kristine; Chuang Linus Md; Chukwuocha Benjamin; Chun Audrey Kyjung Md; Chun Woo H Md; Chung Jenny H; Chuu Louise A Md; Ciaramitaro Yessenia Elizabeth; Ciccone Jeffrey Michael Md; Cilmi Salvatore Anthony; Cimafranca Daniel Lopez Md; Ciment Avraham Yitchak Dpm; Ciocon David; Cioroiu Michael G Md Facs; Cipolla James Charles Md; Clare Frederick S Md; Clark Denise C Md; Clark Mark Andrew Md; Clarkson Earl I Dds; Clayton Lindsay Marie; Clements Cheryl; Clements Jerry Eugene Md; Clunie Garfield Ashford Md; Coad Christopher T Md; Cobblah Vincent Quao Md; Coca Steven; Cochran Lynn E; Cohen Aaron Howard Md; Cohen Adam B Md; Cohen Barry; Cohen Ben Zane Md; Cohen Benjamin; Cohen Bernard Md; Cohen Carmel Jonathan Md; Cohen David L Md; Cohen Douglas Stephen Md; Cohen Edmond Md; Cohen Eric J Md; Cohen Harley Joseph; Cohen Jean-Marc; Cohen Jeffrey Md; Cohen Joel M Md; Cohen Joshua Marc; Cohen Lee Steven Md; Cohen Leeber Md; Cohen Lisa; Cohen Louis; Cohen Mia Gintoft; Cohen Paul; Cohen Richard; Cohen Richard B Dpm; Cohen Rory Scot Dpm; Cohen Samantha; Cohen Seth A Md; Cohen Seth Matthew Md; Cohn Howard Irwin; Colantoni Matthew S; Cole David S Md; Coleburn Norman Hope Md; Coleman Tia; Coliseum Surgical & Medical Pc; Colletti Mario Charles; Collins Shonette V; Colman Rachel; Colombel Jean-Frederic; Colon Federico Ernesto Md; Colon Modesto J; Colon Vilar Giancarlo; Colton Jana Alexandra; Colvin Alexis; Compito Catherine A Md; Concepcion Maria Donna; Concert Catherine Marie Np; Connell Brendan David; Conrad Anne E; Constantino Jennifer C Rpa; Conway Edward Jr Md; Cook William A Md; Cooke Kenneth Md; Copulsky Robert Md; Corbett Shonda Marcia Md; Cordero Kenneth Md; Cordova Matthew Alexander; Corey Patrick Spencer; Coritsidis George N Md; Corn Beth E Md; Cornwall John W Md; Corpuz Glorilyn Montesa; Cortes-Ladino R; Cortez Roberto J Dpm; Cosme Jacqueline Md; Costakis Anna; Coupet Mendel C Rpa; Coven Todd; Cox Anika Jonnelle; Coyle Andrew; Cozien Dominique A Md; Craig Jon Moskowitz; Cramer Kyle Nolan; Crane Michael A Md; Crary John; Crimi Joseph; Cristina A Tennyson Md; Crowley Alexandra; Crumbley Terry Deshawn; Cruz Giselle; Cruz Madeline Dpm; Culang David Phillip; Culliford Daniel Joseph; Culliney Edward Bruce Md; Cummings Allegra Md; Cummings Jeanne Ann; Cuomo Frances Md; Cuomo Linda Janine Md; Curreri Anthony Gino Md; Cuttner Janet Md; Czer Anthoney Enriquez Lim; Dabney Lisa Md; Dadvand Laila; Daefler Simon Md; Dagan Tal; Dakhel Mahmoud Md; Daliah John; Dams-Oconnor Kristen; Danaher Julie Ann Md; Danesh Houman; Dang David T; Dangas George D Md; Dangayach Neha; Dangelo Joseph P Md; Daniel Casper Pa; Daniel Celeenamma B Md; Daniel Egan Md; Daniel Samuel J Md Pc; Danilov Tatyana; Dano Ivy Nicole Wee-Sit; Danzer Brett I Md; Darren Fitzpatrick Md; Darrow Bruce Jonathan Md; Das Piali; Das Seshadri Md; Dass Punam; Dattwyler Raymond J Md; David Jason Ellenbogen

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Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Dpm; Davies Terry F Md; Davis David J; Davis Jaclyn C; Davis Norma V; Davis Renee Louise Md; Davy Andrew Michael G Md; Davydov Oksana; Day Philippe Jmm Md; Dayal Shivani; Dayan Alan R Md; De Leacy Reade Andrew; De Palo Louis R Md; De Souza Sylvie Dominique Md; Dean Deborah Nicholls Md; Dean Gillian Md; Debra Shabas Md; Deegan Erin Marie; Defilippis Jeannette Ann; Defrancisco James A Dpm; Degi Keith; Degiarde Massimo Pc Md; Degregorio Paola Rpa; Deiner Stacie Gail Md; Del Guzzo Luciano Md; Delaney Kathleen Ann Md; Delaney Veronica Bridget Md; Delara Francisco Arturo Jr Md; Dele-Michael Adebola; Deleo Vincent A Md; Deleon Isabelle A Md; Deleon Yasmin Teresa; Delfiner Joel S Md; Deli Barbara Md; Deligdisch Schor Liane Md; Della Rocca David A Md; Della Rocca Robert C Pc Md; Delman Bradley Neil Md; Delmoral Chastity Ann; Delrosario Eduardo Santos; Delson Jeffrey Md; Deluca Peter Salvatore Md; Delvalle Michelle Md; Demaria Samuel; Demattia Joseph Md; Dembitzer Francine Rachel; Demetrius Charmaine; Demicco Elizabeth; Denneke Tsega Md; Densy Johnson; Deprima Thomas J; Dermksian Jeffrey V Md; Desai Neil Kiri; Desai Rajen Uday; Desai Sunil; Deshpande Priya Prakash; Desman Garrett; Desravines Cynthia Pa; Deutsch Vicki-Jo Md; Devine Jeanne M Phd; Dewitt William Liddell; Dhallu Manjeet; Dhamoon Mandip Md; Dhar Sonya; Dharia Sumit Shailesh Dpm; Dharmarajan Kavita Vyas; Dhawan Vikram; Di Blasio Ferdinand C; Diamond Ezriel Md Pc; Diaz George Alfred Md; Diaz Maria Delourdes Md; Dibbell Adonia; Dickoff David J Md; Dickstein Elisha Joseph Md; Didonato Kim E; Dieterich Douglas Thomas Md; Difabrizio Larry Md; Difiore Maria A; Digiacinto George V Md; Digiorno Michael A Md; Dimaio Christophe; Dimitrov Nadya E; Dimitrova Kamellia Rangelova Md; Dinh Linh Thi Thuy Md; Dinlenc Caner Zeke Md; Director Tara Md; Dispaltro Frances X Md; Distefano Douglas C Md Pc; Divack Steven Marc Md; Divino Celia M F Md; Diwan Ravi; Dixon David Dpm; Dixon Marsha Rpa; Do Brian; Do Ouro Suelane Sousa Md; Doberczak Tatiana Marta Md; Dobrowski Katie Miss; Dokko Yoni; Domanski Michael John; Donovan Diana Olga; Dori Ten Pa; Doshi Amish; Dottino Peter R Md; Doty Nora J; Dou Si Yan D; Douge Claude Md; Dow Lindsay Alexandra; Drayer Burton Paul Md; Dreisinger Naomi A Md; Drescher Ira; Dresser Samantha Jane Gordon; Droller Michael J Md; Drucker David A Md; Du Diane; Dua Sakshi; Dube Niti Md; Dubinsky Marla Cindy; Dubois Nichola; Dubos Sheba; Dubowsky Jay Jack Md; Dudas Melissa Maureen; Duddempudi Sushil Md; Dudkiewicz Michael; Dufresne Alix Md Pc; Dunkin David Md; Dunn Mona L; Dunn-Murad Ianthe; Dunsky Kevin Gerber Md; Duperval Jacques Md; Duran Nancy; Durango Alejandra; Durkee Mary Caroline Acnp; Duvvuri Srinivas Md; Dweck Monica Michele Md; Dworecki Roman Md; Dym Harry Dds; Dzanic-Cemalovic Naida; Danv.Iosifescu; Deborahoyedeji; Diana Dejesus; Donnao'Malley,R.D.,Cdn; East Carolyn Alicia; Eaton Margaret M Phd; Ebcioglu Zeynep Ayse Md; Eber Corey C Md; Eddleman Keith Arnold Md; Ededet A Udo; Edelson Charles W Md Pc; Edelstein David Joseph Md; Edelstein Jamie; Eden Edward Md; Edman Maria Dr.; Edwards Eric David Md; Effron Charles; Efremov Mary H Md; Efros Mitchell Douglas Md; Egol Claudine J; Ehrlich Michelle E Md; Ehrlich Paul M Md; Eiland Lisa Renee Md; Eiref Simon David Md; Eisenberg Evan R Md; Eisenkraft James Md; Eisenstadt Ellen Beth Md; Eisenstein Lucy X; El Dakkak Mohammed Selim Md; El Salem Fadi; El-Eshmawi Ahmed Mahmoud; Eliades Melto James; Eliav Chaim B Md; Elikashvili Inna; Elina Bekker Pa; Eliot Megan; Elisa Bocchieri-Bustros; Elitch Nicole G; Ellant Jonathan Philip Md; Ellis Charles C Md; Ellozy Sharif H Md; Elmore Sherlette; Emma Leonard John Md; Enekwechi Nonso Ekene; Eng Lisa Md; Engel Harry Mark; Ennis Ronald D Md; Epelbaum Alexander Md; Ephrat Moshe Md; Epstein Geoffrey C Dpm; Epstein Jonathan Nachman Md; Epstein Lawrence Jay Md; Erber Jonathan Ari Md; Erber William F Md; Erickson Candace J Md; Erika S Gutter; Ernst Carrie L Md; Escalon Juliet Bejarin; Escalon Miguel Xavier; Eslava Dayana; Esposito Donna M Md; Esposito Mariah; Esrig Cynthia W; Estabillo Joel R; Estabrook Alison Md; Estrella Lissette; Ethylin Wang Jabs; Etwaru Dhanan Jai Md; Etwaru Kumarie; Eugenio Paul L; Evans Adam Stuart; Evans Andrew John Md; Evans Richard M Md; Evdos Olga; Evgeny Fink; Eviatar Joseph Alexander Md; Evin Mccabe; Fabel Andrew J Rpa; Fabian Michelle; Facciuto Marcelo Enrique Md; Fahimeh Sasan Do; Fahmy Ramy Hany Fouad; Faiella Louis Iii Md; Failmezger Theodore C Md; Fakhuri Ramsey John; Falk Michael; Faller Jason Md; Fallick Frederick S Md; Fallis Andrew J Md; Fan Wen Md; Fang Hui Elizabeth Md; Fantl John Andrew; Faraj M Faour; Farber Jeffrey Ian Md; Faries Peter Lynn Md; Farnad Shahbaz; Farraye Joseph Md; Fasano Julie; Favila Kristine; Feda Andrew Md; Feder Adriana Md; Feder Samantha Beth Md; Feely Cheng Cindy; Feinberg Todd E Md; Feinsilver Steven Henry Md; Feistmann Jonathan Md; Felberbaum Marc Md; Felcone Michael F; Felder Kenneth S Md; Felderman Theodore Paul Md; Feldman David M Md; Feldman Hannah; Fenig Arielle Ochoa Md; Fergus Icilma Veronica Md; Ferguson Christopher J Dpm; Fernandes Ajit Savio Md; Fernandez Gerardo Javier; Fernandez Helen Maria Md; Fernandez Jennifer; Fernandez Ranvier Gustavo G; Fernando Anusha Rosanne Md; Ferrara Joseph Md; Ferrara Lauren Md; Ferrell Amber; Ferstenberg Henry Md; Festa Joanne Phd; Fetterman Alan David Md; Fetto Joseph F; Ficazzola Michael A Md; Fiel Marie Md; Fietti Vincent G Md Jr; Fievre-Hamilton Natasha Md; Fifi Johanna T; Filatov Alexander V Md; Filip Teller; Filipovic-Jewell Zorica; Filsoufi Farzan; Finegold Ira Md; Fineza Belen A Md; Finkel Jennifer Meredith Md; Firpo-Betancourt Adolfo; Fisch Joseph Md; Fischer Gregory Walter Md; Fischer Harry D Md; Fischer Laura Meyers; Fischer Robert Michael Md; Fischman Aaron Marc; Fishberger Jeffrey Md; Fitterman Jennifer Anne; Fitzig Lorenzo Md; Flanagan John C Md; Flatow Evan L Md; Fleckman Adrienne M Md; Fleckman Fern; Fleischer-Black Jessica Md; Fleischmann Jonathan D Md; Fleischmann Nicole Md; Florendo Angelita Fulgar; Florman Sander Scott; Fordjour Lawrence; Forman Edwin; Foronjy Robert Francis Md; Foroutan Janelle; Forsh David; Fory Elissa Kay; Fourati Samy S Md; Fowkes Mary Md; Fox Donald M Jr Md; Fox Herbert A Md; Fox John T Md; Fox Lewis Md; Fox Serena Joan; Fraiman Mitchell Md; Frances Sylvaine; Francis Michelle Y Md; Frankel Richard Harris Dpm; Frankenberger Oliver Md; Frasca Suzanne Md; Frazier Daveed Damon Md; Fred J Delucia; Fredrickson Lauralyn Md; Freedman Beth; Freedman Jeffrey Bruce Md; Freeman Melissa M Md; Freepong Tameisha; Freilich Aaron Md; Freilich Abraham R Md; Frenkel Maxim Md; Frieden Richard A Md; Friedlander Philip Adam; Friedman Alan H Md; Friedman Arnold Jay Md; Friedman Esther; Friedman Frederick Jr Md; Friedman Howard S Md Pc; Friedman Ira H Md; Friedman Joseph Irwin Md; Friedman Larry D Rpa; Friedman Lynn Md; Friedman Mark Do; Friedman Mark Md; Friedman Nadya; Friedman Richard Lawrence Md; Friedrich Douglas Bennett Md; Frucht Steven Joel Md; Fu Pauline; Fuksbrumer Moshe Saul Md; Fullar Michael; Fulmes Mychailo; Furman Alice Cary; Furman Margaret L; Fusco Heidi Md; Fuster Valentin Md; Futrell Junie Cynthie; Futterman Henry A Md; Gaba Michelle; Gabriela Rosas-Garcia; Gabrilove Janice L Md; Gage Dennis Md; Gagliuso Donna J Md; Gainsburg Daniel Martin Md; Gal Jonathan Stephen; Galao Malo Roberto; Gale Gregory Mark; Galizi Marlene Denise Md; Gallagher Emily Jane; Gallane Dabela Abraham; Gallego Mariel; Galli Claire; Gallina Jessica Blair Md; Galsky Matthew David; Galynker Igor I Md; Gambrell Marian Lavette Md; Gandhi Hardik Atul; Gandhi Jayant H Md; Gandhi Nipa Dilip Md; Gannon Brighid Armstrong; Ganz Eric Michael Md; Gao Weiyi; Gao Yan Ling Md; Garau-Gonzalez Marisela; Garay Miryam D; Garcia Arlene Marie Md; Garcia Dairon Manuel; Garcia Haydee; Garcia Jose Gilberto Dds; Garcia Roberto; Garcia Rosario Md; Garcia-Figueroa Sylvia K Md; Garfield Karen Lisa Kodsi Md; Garjian Lori Ellen Md; Garland Amy Tudor; Garo Nicholas; Garofalo Raffaele Md; Garwood John William Md; Garyali Samir; Gass Gregory; Gave Asaf Asi Md; Gaveras Georgia; Gavriil Eleftherios S; Geer Eliza B Md; Gehrie Erika; Geier Jacqueline; Geiger Miwa Karen Md; Gelb Bruce D Md; Gelbfish Gary Md; Geldwert Josef J Dpm; Gelfman Laura P; Gellen Joel L Dpm; Geller Charles Moss Md; Geller Lauren; Geller Martin Robert Md; Genato Romulo L Md; Genden Eric M Md; Genovese Mario Nicholas Dpm; Gentile Ronald C Md; Genuth Rachel C; George Andrea L; George Erik Md; George James Md; Gerardi Carl Md; Gerdes Kenneth J Md; Gereau Haddon Sezelle; Gerlach Kecia; Germano Isabelle M Md; Gershengorn Hayley Beth; Gerz Erika Antoinette; Gettes Mark A Md; Ghali Violette Saleh Md; Ghasri-Zarghami-Sabet Shahla; Ghassibi Joseph M; Ghatan H Eliot Yedidiah Md; Ghatan Saadi Md; Ghaw Olivia; Gheewala Anup Md; Gheitani Pegah; Ghillani Richard Md; Ghodsi Newsha Zahra Md; Giambruno Clara Md; Giashuddin Shah; Gibbs Kathleen Md; Gibralter Richard P Md; Gibson Charlisa; Gidwani Umesh K Md; Giedd Kenneth Noah Md; Giella John Gerard Md; Gilad Ronit; Gilbert Elyse; Gilbert Fred Md; Gilbert Melvin R Md; Gilbert Richard Md; Gill Felicia Ann; Gillego Alyssa Minerva Md; Gilleran Suzanne M; Ginelli Paul; Ginsburg Robin Nina Md; Giordana Lorraine Md; Giorgi Diane Frances-Lucia Md; Girardi Sal A Md; Gitig Alon Md; Gitlin David; Giudice Richard A; Gladstone James Nathaniel Md; Glaser Jordan; Glass Jessica; Glassberg Jeffrey Avins Md; Glassberg Stephen Md; Glassman Charles Norman Md; Glickel Steven Z Md; Gliedman Paul R Md; Glinik Galina; Glubo Les Jay Dpm; Glyptis Andrew Md; Go Alan R Md; Go Ronaldo C Md; Godbout Brandon J; Goel Anupama Md; Goertz Jacob K Md; Gohari Arash Md; Goldberg Andrew Todd; Goldberg David; Goldberg Deborah Baron Md; Goldberg Naomi; Goldenberg Elvira; Goldenberg Gary; Goldenberg Kristina; Goldfinger Judith; Goldman Jane Cleary Md; Goldman Mark; Goldman Martin Elliot Md; Goldman Thomas I; Goldstein Jaime A; Goldstein Martin Adam Md; Goldstein Michael Md; Goldstein Michael T Md; Goldstein Nathan E Md; Goldstein Norman; Golinko Richard J Md; Golombeck Arel; Goluboff Erik Todd Md; Gomes Joseph Anthony Md; Gomez Jorge Enrique; Gomez Richard; Gomori Elisabeth; Goncharov Alexander; Gonzalez Susana; Goodchild Malcolm Ingram; Gooden Shanti Lila; Goodheart Herbert P Md; Goodman Elliot Richard Md; Goodman Warren Jay Dpm; Goodman Wayne Dr.; Gopalan Radha S; Gopi Patel; Gordin Inna Md; Gordin Stella; Gordon Barbara F N Md; Gordon Eric; Gordon Errol Lloyd Md; Gordon Gregg E Md; Gordon Jonathan Craig Md; Gordon Marsha; Gorevic Peter D Md; Gorman B

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Original Start Date

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Start Date

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Quarter End Date

DSRIP Reporting Year and Quarter

David Md; Gorman Elaine Mary; Gorrin Harvey Md; Goschin Simona; Gossner Gabrielle; Gotlin Robert Do; Gotsis William; Gottesman Lester Md; Gottlieb Aren Leslie; Gotts Michael David Md; Govindaraj Satish Md; Gowda Ramesh M Md; Goyal Naveen Md; Gozenput Galina; Grafstein Neil H Md; Graham Virginia; Grant Dov Z Md; Grau Carmen; Gray Mark D Md; Grayson Douglas K Md; Green Karen Meryl Md; Green Mark W Md; Green Michele O; Green Robert Spencer Md; Green Sheryl Md; Greenberg Carl Md; Greenberg Howard J; Greene Paul E Md; Greenstein Adrian Md; Greenstein Alexander John Md; Greisman Stewart George Md; Greller Howard Md; Gretz-Friedman Elissa M; Grewal Priya Md; Grice Dorothy; Griepp Randall B Md; Grif Oksana; Griffin Joyce; Grima Kathleen M Md; Grimes Stephen; Grin Michael S Md; Grinberg Daniel Md; Grinberg Manuel E Md; Grinberg Mikhail Md; Grinspan Ari Matthew; Grinstein Gabrielle P Md; Grogan Ann Marie; Gropper Charles A Md; Grosman Igor; Grosman Kyra Taylor; Gross Michael Md; Grossi Robert J Md; Grosso Michael B Md; Grotas Aaron Brett Md; Grover Jillian; Groves Mark Md; Gruen Alison; Gu Yongpeng; Guardarramas Gabriel R Md Pc; Guarino Anthony C Dpm; Guerrero Jihan Mogol; Guerriero Paul Neil Md; Guglielmo Roseann; Guia Howard; Guillaume Carl Md; Guillaume Melissa Daniella Md; Guimaraes Tania Csw; Gujja Karthik Reddy; Guleyupoglu Nilufer A Md; Gulko Percio; Gulmatico Constantino V Md; Gumaste Vivek Md; Gunasekaran Ganesh; Gunopawiro Jo Anne; Guoping Zhou; Gupta Anita; Gupta Anjali Rani Md; Gupta Mantu Md; Gupta Meenakashi; Gupta Nitin; Gupta Vishal; Gursoy Erdal Cumhur; Guthrie Clayton; Gutkovich Zinoviy Md; Gutman Dianna Valeria; Gutman Harvey Md Pc; Guttikonda Lakshminarayana; Guttikonda Veeranjaneya V Md; Guttman Emma; Guzman Ida C; Gwertzman Gary Alan Md; Gwengoodman,M.S.,R.D.,Cn; Haas Susan Marian Cnm; Habboushe Joseph Peter Malcom; Haber Richard S Md; Haberman Jeffrey Md; Hackett Alyssa; Hadley Sallie Joellin Md; Hahn In-Hei; Hahn Sigrid A Md; Haines Elizabeth Jane; Haines George; Hakimian Navid Md; Hall Kimberly Terese; Hall Lisabeth Sara Md; Halle Steven Garry Md; Halligan-Luca Anne Rose; Halper Jason J Md; Halperin Diana; Halperin Jonathan Md; Halpern J0shua Noah; Halton Kathleen P Md; Halweil Ronald Md; Hamilton William G Md; Hammer Arthur W Md; Hammond Isaac Rpa; Han Daniel Md; Han-Faver Doreen D Md; Handelman Michele; Handler Bradley Md; Handler Toby F Md; Handsschuh Caroline; Hanen Suzanne; Hanna Lily; Hanon Samuel Md; Hanretta Kelly Colleen; Hansen Thoms Paul; Harbison Madeleine D; Hardart Anne Md; Harel Noam; Harizman Noga; Harkin Timothy Joseph Md; Harmaty Marco A Md; Harooni Mark Md; Harpaz Noam Md; Harrington Matthew; Harrington Thomas; Harris Mary; Harrison Kristin A; Harrison Louis B Md; Harrison Theodore Joel Md; Harshan Manju Md; Hartzog Sarah; Harvey Eugenius John Md; Harwin Steven F Md; Hasan Choudhury Md M Md; Hasan Zainab Md; Hasen Ashraf; Hashemi Ghonche; Hashim Sami A Md; Haslett Jeanette; Hassan Khalid Kamal; Hassan Sheref E; Hasselmark Fairouz; Hatcher Virgil; Hausman Laurence M Md; Hausman Lionel Glen Dpm; Hausman Michael R Md; Haveson Stephen Pc Md; Havryliuk Tatiana; Hawkins Denis Lawrence; Hayashi Fumitaka; Hayashi Naomi; Hayes Earle; Hayes Monica Prasad Md; He Chen; He John Cijiang; Heath Candrice Rachelle; Heath Stacy Pipes; Heather Lynn Macadam; Hecht Alan Jay Md; Hecht Andrew C Md; Hecht Harvey Stanley Md; Hecht Susan Md; Heiba Sherif Ibrahim Md; Heiderhoff Clemens Md; Heidi Bender; Heimann Tomas Md; Heisman Alexander; Heller Mark L Md; Heller Michael B Md; Hembree Wylie C Iii; Henderson Kimberly Joan Md; Heneghan William F Md; Hennig Nils Md; Henry Heather M; Henry Mark W; Henry Sean; Henschke Claudia I Md; Hermann George Md; Hermann Luke Kennan Md; Hermos Julia; Hernandez Adam Breaux; Hernandez Colon Agdel Jose; Hernandez Grissel; Hernandez Prera Juan; Hernandez Stephanie Hortencia; Heron Abigail Jane; Herrera Joseph Everard Do; Herrera Kimberly; Herron Daniel Martin Md; Herscher Michael; Herschorn Brian Jacob Md; Hersh Melissa; Hershberger David Hugh Md; Herstik Barry Glenn Dpm; Herstik Ivan Greg Dpm; Herzog Eyal Md; Heslop Christine Cnm; Hessdorfer Anika D; Hew Lorna Marie; Heyman Jacob H Md; Hidalgo Laurita; Hiensch Karen Allison; Hill Jessica Laughrey; Hillel Zaharia Md; Hiltzik David Henry; Himel Harvey Norman Md; Hines Elizabeth Quaal; Hinke Christine Md; Hinojosa Franz; Hinrichsen Gregory A Phd; Hiotis Spiros P Md; Hipkens Sarah; Hirsch Jack Dds; Hirschl David Avishay; Hirschman Richard J Facp Md; Hirshaut Vivian Md; Hirshfield Gary S Md; Hirshson Chari Ilana; Ho Alexander Weihan Md; Ho Yan Wood; Hobeika Paul Bowlos Elias; Hochberg Eric Mitchell Md; Hochsztein Paul Md; Hodulik Sarah; Hoetzel Richard Md; Hoffman Cindy Md; Hoffman Darryl M Md; Hoffman Ronald A Md; Hoffman Ronald Harvey Md; Hoffstadter-Thal Kathy; Hojraj Diego Gabriel Md; Holcombe Randall Frank; Holland Claudia Md; Holland James F Md; Holland Sally Ann; Hollinger Ingrid Md; Hollinger Jessica; Holmgren Anna; Holson Dave A Md; Holt Kimberly J Phd; Holzman Ian Ronald Md; Hong Albert Md; Hong Alice; Honikman Rafael; Hops Pamela; Horak Bradley Thomas Md; Hormigo Adilia; Hornfeld Mark Louis Do; Horowitz Deborah Ronnie Md; Horowitz Mark; Horton Andrea Barron; Horton Jay Robert; Hotchkiss Hilary; Hourizadeh Yassaman; Howard J Reifer Dme; Howe Alexandra S Phd; Hryhorowych Artur Nicholas Md; Hsiao Tso-Jen Md; Htin Thanda; Hu Kenneth Shang Md; Hu Michael; Huang Amy Md; Huang Jeniffer Vivian Md; Huang Min; Huang Tiangui; Huang Wendy Wen-Ee; Huang Yili; Hubbard Christopher Eric Md; Huh Sun Haeng Md; Hui Hilltone; Hulbanni Anjali Shivappa; Hung Kenneth; Hung William W; Hunt Ann L; Huppert Barry L Md; Hurlet Jensen Anne M Md; Hussain Nazia Md; Hutman Sammy Aaron Md; Hwang Calvin Hsing-Kuo; Hwang Peter Myung; Hyman Jaime Berg; Hyun Grace Soo Jung Md; Hussain,Syedasif,Md; Iacob Codrin; Iacovone Frank Michael Md; Idicula Susamma T; Ileane Alicea; Ilionsky Natalia; Iloreta Alfred Marc Calo Jr; Ilyayev Aleksandr Md; Im Gene; Inabnet William B Iii Md; Ingber Scott Md; Ingram Donna Md; Intsiful Harry H; Iofin Ilya; Ionescu Gabriel Md; Iordanescu Alexandra C Md; Irie Hanna Yoko Md; Irina Ilyasov; Isaacson Ernest Louis Dpm; Islam Khaleda K; Islam Thaniya Sultana; Isola Luis Manuel Md; Israel-Maclin Michelle Sophia; Israelovitch Melanie; Itzkowitz Steven H Md; Ivanov Iliyan Stoyanov Md; Iyarsami Antonio N; Iyer Kishore R Md; Izaak Avytal R; Izquierdo Thomas Joel Md; Jablin Louis David Dpm; Jabs Douglas A Md; Jack Madeline; Jackson Norma Jean Do; Jackson-Rabinowitz Claire Louise; Jacob-Ali Jenna Md; Jacobi Adam Howard; Jacobs Adam R Md; Jacobs Jordan Ms; Jacobson Barry Laurence Dmd; Jaffer Shabnam Md; Jaffin Barry Wayne Md; Jagannath Sundar Md; Jagoda Andy Sam Md; Jahn Anthony F Md; Jahng Stefan Md; Jajoo Parul; Jakubowski Rita Mary; Jamal Joseph E; James Monique Elesha; Janapana Himani; Jani Sonal Balmukund Md; Janis Gregory Stephen; Jankowski Irene; Jann Adelene Emerald; Jasmine Jo-Tsui; Jason W Krellman; Jaundoo Cassandra Juanita; Javed Suleman Md Pc; Javier Noel Salvador Coloma; Jean A Frederic Pa; Jean Carl; Jean Gilles Max Md; Jean Raymonde Ernest Md; Jean Yves Antony; Jean-Gilles Yves Richard Md; Jean-Louis Vasthy; Jeanniton Chaneve; Jeff D Kopelman M D F A C S L; Jeffrey Rothman; Jelin Abraham Md; Jemiolo Ursula; Jeng Christina Li-Hong Md; Jenkins Arthur L Iii Md; Jennifer Galjour L; Jennings Vena Wendy; Jeudy Sabine Cnm; Jew Edward Md; Jhang Jeffrey; Jhaveri Jigna Desai; Jindal Kumud Bandhu Md; Jindal Monica; Jn-Pierre Carl Edouard; Jogendra Mather Reginald Dilan; Johannes Barry G Rpa; John Percival Valonzo Pena; John-Hull Carlota H; Johnson Amy L Md; Johnson Janet Helene; Johnston Gregory Scott Md; Jones Ardella Marilyn; Jones Jacqueline Md; Jones James Peter; Jonnathan Figueroa; Jordan Adrienne Christine; Jordan Alan J Pc Md; Joseph Henry Dayan; Joseph R Podhorzer Md Pllc; Joseph Robert Michael; Joshi Suresh K Md; Joshua Shatzkes; Joshua Wayne Bonsell; Judith M Fierstein; Jue Andrea; Juliano Courtney Elizabeth; Jaclyne.Tucker; Jaimej.Michalski; Jenniferv.Charles; Jilpapatel,Pa; Juliew.Fung; Ka Ming Ngai Gordon Md; Kaban Nicole Lara; Kadian-Dodov Daniella; Kagen Alexander; Kahn Abigail; Kahn Gary Lee; Kahn Hirshel; Kahn Judith Eve; Kahn Max A Md; Kahn Ronald A Md; Kahn Stuart B Md; Kahn-Kapp Evelina Lucia Md; Kalir Tamara Md; Kamal Linda Ann Md; Kamhi Edouar D Md; Kamran Mazullah Md; Kamthan Gautam; Kancherla Pushpa; Kandarakis Stylianos Artemios; Kandler Charles J Md; Kandov Ruben; Kane Maureen Ann Np; Kanei Yumiko Md; Kang Harriet Md; Kang Patrick S Md; Kaniyarathinkal Laly Sreedhar; Kanjilal Debasis Md; Kano Maki; Kanos Jason N Md; Kantrowitz Joshua Tolkien; Kapadia Pankaj Kanubhai; Kaplan Evan; Kaplan Matthew R Md; Kaplan Mitchel A Md; Kaplan Ronald Md; Kaplowitz Michael Md; Kapoor Deepak A Md; Kapoor Moyna Md; Kapur Vishal; Kapusuz Tolga Md; Karafin Felix Md; Karani Reena Md; Karanikolas Kathleen Md; Karen Adam Kenneth; Karen Clemente; Karpenko Oleg; Kartina N Bell; Kasahara Takehiro; Kashyap Satish Md; Kashyap Yogita; Kaskowitz Susan; Kasmin Franklin E Md; Kassapidis Dimitrios Md; Kassapidis Elias; Kastell Paul H Md; Kastenbaum Donald Mark Md; Kathpalia Kusum Md; Katkovskiy Dmitriy Do; Kato Kyle S Md; Kats Lyudmila; Kattan Jacob Daniel; Katz Albert S Md; Katz Bruce E Md; Katz Craig Lawrence Md; Katz Daniel Joshua; Katz Michael Dpm; Katz Sand Ilana Beth; Kaufer Michael Edward; Kaufman Allen M Md; Kaufman Andrew Jonathan Md; Kaufman David M Md; Kaufman Elan; Kaufman Lewis Md; Kaufman Stephen Z Md; Kaul Raman Md; Kawam Linda Renee; Kawano Thomas; Kaylakova Irina Md; Kazam Tal Manor; Kechejian Joanne M Md; Keil Katherine Md; Kelemen Pond R Md; Keller Roni Meredith; Kelly Mary K; Keltz Nartin David; Kemether Eileen; Kenel Pierre Joseph Carl; Kenia Rachna; Kennish Arthur Jay Md; Kent Rebecca; Keoninh Delta; Kepecs Migdana Rachel Md; Keppel Emma; Kernisant Lesly Md; Kerr Angela D Md; Kesanakurthy Srinivas Md; Kesselman Paul Dpm; Kessler David A Dds; Keyzner Alla Md; Khaitov Sergey; Khaitova Viktoriya; Khan Fahad R Md; Khan Khalid M Md; Khan Rubina Rpa; Khan Samaira J; Khaneja Amit; Khanna Suresh Md; Khattab Ahmed M; Khatun Mahbuba; Khetsuriani Irina; Khorasani Hooman; Khosh Maurice M Md; Khouli Hassan E Md; Khoury Mona Dpm; Khuwaja Abdul Ali Md Pc; Kikuoka James Sei Md; Kil Erin; Kim Bette Md; Kim Edward; Kim Eunae Christina; Kim Grace Jane Md; Kim Hae-Ok Ana Md; Kim Hanna; Kim Harold Md; Kim Hyung Leona Md; Kim Jaehon Michael; Kim Jessie; Kim Jinu;

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Kim Joyce M Md; Kim Jung; Kim Kun-Kil Md; Kim Michelle Kang; Kim Sanghyun A Md; Kim Soo; Kim Su Haeng; Kim Sung Yup; Kimberly Marie Mchugh; Kimmelstiel Fred M Md; Kimura Keiko Md; Kindschuh Mark William E Md; King Lashawna Cnm; Kini Annapoorna S Md; Kini Subhash Ullal Md; Kinsella Gregory Patrick Md; Kinyungo Ngugi M; Kirchman Ernest H Md; Kirpekar Madhuri Md; Kirsten Jonathan Ariel; Kiss Lawrence Philip Md; Kivell Howard Neil Md; Kizhner Victor; Klahr David M Md; Klapper David A; Kleeman Michael William Md; Klein Eitan M Md; Klein George Md; Klein Janice F Md; Klein Michelle Lee; Klein Paula Md; Klein Susan; Kleinman Yehuda E Md; Kligler Benjamin Eli Md; Klineova Sylvia; Kliot Benjamin L Md; Klipstein Kimberly G Md; Knaupp William Frederick Md; Knibbs Nakiyah Aisha; Knobel Jeffrey M Dpm; Knoll Charles L Md; Ko Huai-Bin; Ko Jonathan Md; Kobeckis Elizabeth Carpio; Koblentz Daniel E Md; Koch Lauren M; Kochlatyi Sergei Gennadi Md; Koduru Sunaina; Koenig Edward S; Kohan Alfred D Md; Kohli-Seth Roopa Md; Koichi Nomoto; Kokoszka Agnieszka; Kolev Valentin; Kolevzon Alexander Md; Kolker Valentina; Koll Brian Seth Md; Komal Rashida; Kominos Vivian; Kondamudi Noah Praveen K Md; Koo Timothy; Kopell Brian; Koppel Barbara Sue Md; Korban Tarek; Kore Nissenson; Kornberg Robert J Md Pllc; Kornitzer Benjamin S; Korobow Amy; Korongy Richard Vincent Md; Koruth Jacob; Koshy Ninan Md; Kosmas Constantine Elias Md; Kostadinov Jane E; Kostakoglu Lale Md; Koster Harry Robert M Md; Kostko Oksana Md; Kotler Donald P Md; Kottiech Samer Md; Koty Richard E Md; Koulos John Peter Md; Koumasidis Pa Sarra; Kovacic Jason Ciril; Kovacs Akos Laszlo Md; Kovar Lance Ira Md; Kowalsky Shanna; Kozlovsky Chaim; Kozuch Peter Sean Md; Krakoff Lawrence R Md; Kramer Arin; Kranitzky Bethany Gaskill; Krata Lewis; Krauss Joel M Md; Krebs Nadezhda; Kremer Anna A Md; Kremyanskaya Marina; Kreutzer Eric R Md; Kriegel David A Md; Krieger Paul H Md; Krieger Stephen; Krikhely Merab Md; Krilov Meg Allyn Md; Krishna Ranga Chelva Md; Krishnaiah Mahesh Kumar Md; Krishnan Prakash Md; Kroll Richard Md; Krumholz David; Krym Olga B; Kuflik Paul Larry Md; Kuhn Kris Elisabeth; Kukadia Ashok N Md; Kukar Atul Do; Kukar Narinder M Md; Kukin Marrick Md; Kulman Ilana; Kumar Nanjundaiah Md; Kumra Vandana Md; Kunjumon Bgee Elizabeth; Kuo Felix; Kupersmith Mark J Md; Kuritzky Jeffrey I Md; Kurtz Leon Elliot Md; Kurtz Susannah Lauren; Kushnick Steven Md; Kusmierska Grazyna T; Kwa Winston C Md; Kwak Charles; Kwan Tak Wai Md; Kwasniak Megan M; Kwasnik Herbert Md; Ky Alex Jenny Md; Kyriakou Victoria M; Kennethl.Davis; La Puma Vito; La Voy James Earl; Labow Daniel Mark Md; Lachman Leigh Jay Md; Lacina Susan; Ladetsky Lynn Md; Lagman Noreen Dimatulac; Lai Christine; Lai Katherine M Dpm; Lai Yan H; Lajam Fouad E Md; Lajos Paul; Lakhani Shamsah; Lall Ajay Md; Lalli Corradino M Md; Lalli Robert G Md; Lally Sean D Md; Lalwani Anisha M; Lam Andrew Ho-Yin; Lam David Wing-Hang; Lam Patrick Wai Ming; Lam Stephanie Md; Lam Wan Ling Md; Lamarre Winnifred; Landa Gennady; Lane Richard; Lang Stephanie Ann; Langan Marie-Noelle S Md; Langer Hope S; Lanigan Michael D Md; Lansey Stephan Cooper Md; Lantin Jose Antonio R L Md; Lantis John Carlos Ii Md; Lantz Melinda S Md; Lapointe Dianne Rudow; Lapsia Vijay Harish; Larian Amir; Laroche Daniel Md; Larock Kenneth A; Larson Carol Tracy Md; Larusso Melissa Lucy; Lashley Bruce W Dpm; Laskova Violetta; Laskowski Larissa Kim; Latimer Michelle; Latino Kathleen Louise Md; Latkany Paul Alexander Md; Latkany Robert Adam Md; Latmore Malikah; Latte Shelly; Lau David Hai-Pong; Lauer Simeon A Md; Lauriello Gloria M S Md; Lavine Elyse; Law Linda W; Law Patricia; Lawrence J Caliari; Lawson Anne; Lawson William Md; Lax James D Md; Layliev Elizabeth; Layne Jeffrey; Lazarciuc Mirela Nicole; Lazarevic Sonya; Lazarus Karen; Lazic-Struger Tamara; Leader Alexandra Pfeifer; Leal Angel Manuel; Leber Mark J Md; Leber Melissa Dee; Leblanc Patrick Elie Md; Lebo Debra Beth; Lebovics Robert Samuel Md; Lebowicz Joseph Md; Lebwohl Mark G Md; Lechich Anthony J Md; Lee Alan W; Lee Alexander Jong-Suk Md; Lee Bryant B Md; Lee David S Md; Lee Dong-Seok D; Lee Edmund Md; Lee Godwin Md; Lee Harry S Md; Lee Jane Ahn Md; Lee Jay Yung Md; Lee Jennifer S; Lee Johnny Md; Lee Karen; Lee Karen Ann; Lee Karen M Md; Lee Kathleen; Lee Kyusang S Md; Lee Men-Jean Md; Lee Michelle H Md; Lee Mikyung; Lee Richard; Lee Richard Md; Lee Sana; Lee Tricia D; Lee-Wong Mary F Md; Leeds Jeffrey Gordon Dds; Leena Thomas; Lefer Gary Md; Lefkowitz Gary K Md; Legnani Peter E Md; Lehman David A Md; Leibovitz Alon; Leibowitz Andrew B Md; Leibu Evan; Leifer Andrew G Md; Leila Hosseinian; Leinung Kristen Marie; Leipzig Rosanne M Md; Leisman Staci; Leitman Michael I Md; Lemaire Glenda M Np; Lemer Matthew; Lempert Larissa Md; Lempert Leonid; Leo Angela; Leon Stuart Brian Dpm; Leonard Katherine Md; Leonard Kathleen A; Leong Jennifer Md; Lepore Frank Louis Dpm; Lercher Kirk; Lerebours Louis Jjmi Erwin; Lerman Svetlana; Lerman Vadim; Lerner Rachael A; Lerner Seth Edward Md; Lerner Susan M Md; Lese Lauren J Cnm; Lesperance Mayra Cabrera; Lesser Jonathan Baird Md; Lessner Seth Joseph; Lester Neil; Leung Sui Rong Md; Leuthauser Amy Denise Md; Levatino Jessica Lynn; Levesque Annie; Levi Gabriel S Md; Levin Matthew A; Levin Yulia; Levine Adam I Md; Levine Alice Md; Levine Elisheva; Levine Jeffrey Mark Md; Levine Jeffrey Md; Levine Jun; Levine Michael Alan Md; Levine Randy L Md; Levine Stewart A Md; Levitin Gregor M Md; Levitt Jacob Oren Md; Levitt Jane Md; Levy Benjamin; Levy Brian Keith Dpm; Levy Carol J Md; Levy Elan S; Levy Paul Justin Dpm; Levy Roger N Md; Lewis Blair S Md; Lewis Bruce Rappaport; Lewis Dawnette Ann-Marie Md; Lewis Jacqueline; Lewis Sara Catherine; Lewis-Morris Valerie Md; Lewkowicz Richard Md; Li Henrietta; Li Jianjun; Li May Hsiao Hoan; Liakeas George; Liao Janice; Liao Steve Lin; Liaw Bobby; Libby Charles; Liburd Jennifer D Md; Licciardi Ludwig M Md; Licht Arnold L Md; Licht Michele Stacy Md; Lichtblau Sheldon Md; Lichter Stephen M Md; Lidagoster Lidia Md; Lie Jimmy Y Rpa; Lieberman Elliott Md; Lieu Hsiao-Mei Md; Liggio Carlo; Lightbody Jason M; Likhterov Ilya; Lim Sabina Md; Lim-Sulit Nanita F; Limaye Atul M; Lin Fan M Md; Lin Fred Y Md; Lin Jing Md; Lin Judith C; Linares Lisa M; Linden Ellena Alexandra Md; Linden Todd B Md; Lindenberger Elizabeth C; Lindsey Abbe M Md; Linetskaya Diana; Linhares Daniel Faver; Linstrom Christopher J Md; Liou Michael Md; Lipelis Konstantin Md; Lipper Justin; Lippman Jay I Pc Md; Lipshutz Rochelle; Lipskar Aaron Michael; Lipson Scott D; Lipyansky Alexander Md; Lisa Nicole Jackson; Lish Bruce Jared Dds; Littwin Sanford Matthew Md; Liu Alan; Liu Jennifer Md; Liu Jerry Tsuning; Liu Lawrence Chad Uytengsu Md; Livingstone Dave A F; Lo Yunyun Andrew Md; Loberas Karen Katherine Capistrano; Loft Lloyd Mark Md; Lombardo Gerard T Md; Longtine Janina Ann; Lonner Baron Stuart Md; Lookstein Robert A Md; Lopachin Vicki Lynn Md; Lorieo Danne R Md Pc; Lorin Scott Michael Md; Lorinsky Marc H Dmd; Losev Alexander Md; Loudon Holly C Md; Louie Dina; Love Barry Allen Md; Lowe Sandra M Md; Lubarr Naomi Md; Lublin Fred David Md; Lubliner Eric D Md; Lubliner Jerry A Md; Lubrano John Michael; Ludlow Sarah Beth; Lujack Anthony M; Lukoschek Petra M Md; Lunde Britt Marie; Lung Edward Md; Luntz Robert Kevin Md; Luong Khoi Quoc; Lurch Mellessa N; Lurie Heather L Md; Lurie Scott Robert Dpm; Lutter-Hoppenheim Martine; Lyn Michelle S; Lynn Abigail; Lynn Howard S Md; Lytrivi Irene Md; Lukose,James,Pa; Ma Aye Moe Thu Md; Ma Peter; Macatangay Abigail Tayamen; Macaulay Grant Robert Md; Macgowan Daniel J L Md; Machernis Edward Alan Md; Maciag Emanuela Maria Md; Macisaac Laura; Mack Lian; Macri Mirtha J; Madeb Isaac Md; Madeline Cara Fields; Maderazo Alex Baer Md; Magid Margaret Md; Maglione Paul Joseph; Magnas Tamar; Mahdi Ahmad; Maher Elizabeth A Md; Mahir Palwasha A; Mahmood Dawar Md; Mahmoud Mohamad; Mahoney Bryan Patrick; Mahoney Tara; Mailloux Lynn; Maini Atul Md; Maisel Louis M Md; Maitland Maisha; Majeske Matthew F Md; Majo Joseph; Maker Howard Md; Maki Robert Glenn; Makower Bryan L Dpm; Malamud Stephen Charles Md; Malbari Alefiyah; Malhan Rishi; Malhotra Anuj; Malik Rajesh Kumar; Mallett Errol Md; Malloy Erica L; Malone Adriana Md; Maloutas Eleni; Mamik Mamta Muralidhar; Mandel Edmund Md; Mandelbaum Chaim Y Md; Manera Joseph John Psyd; Manghisi Stephen V Md; Maniker Allen Howard; Manjula Chatterjee; Mannino Michael M; Manusis Kira Md; Manvar Dolly B Md; Mapp Samuel E Md; Mar Yin; Marc A Rosenblatt Md Llc; Marcilla Oscar A Md; Marco Marzantan; Marcovici Eli Md; Marcus Robert S Dpm; Marcuse Lara Vanessa Md; Marenco Julio Md; Maresca Angela J; Maret Rajani; Margolies Laurie Renelle; Maria D Linden; Marin Michael L Md; Marion James F Md; Mariotti Gabriele; Mark Katherine; Mark Stein; Markinson Bryan Craig Dpm; Markman Lisa Hannah; Markowitz Orit; Marlar Khin Md; Marn Richard Yee; Marolda Hojsak Joanne R Md; Marshall Roy Posner; Marti Jennifer; Martin Dean Randolph Md; Martin Glenn Andrew; Martin Jane Phd; Martin Melissa Lee; Martin William Michael Md; Martinez Caroline; Martinez Miriam; Martinis Francis Gera; Martino Jennifer M Md; Martiny Vanessa Lorena; Martz Joseph Md; Maruyama Nancy Chiyo Md; Mascarenhas John Omar Md; Masch Rachel J Md; Maser Elana Anne Md; Mashkevich Grigoriy; Maslak Stephen; Mason Daniel Gordon; Masri Daniel; Mass Lawrence D; Matamala Ximena Andrea Md; Math Kevin R Md; Matheson Donald S Md; Mathew Matthen; Mathew Shiny M; Mathews Kusum; Mathews Shyama Sara; Mathewson Gretchen K; Mathney Edward R Md; Matsuki Takashi; Matte Jennifer L; Matthew Bremer; Mattimore Melissa Diane; Matut Jay Md; Maule Cordell Laferne; Maulella Mimi Cnm; Maurer Wayne Martin Dds; Mauro Jr. Dionisio; Max Masgudov; Maxim Kreditor M D Pllc; Mayer Richard; Mayer Stephan A Md; Mccabe Patricia; Mccann Peter D Md; Mccarty Kristen Elizabeth; Mcclelland Mary Therese; Mccormick Patrick J; Mccullough Gene P; Mcdonald Brendan; Mcfarlane-Ferreira Yvonne; Mcfarlene Kirk O; Mcginty James J Md; Mcgovern Peter; Mckelvey Jennifer S; Mckeon- Simone Maureen Ann; Mckinley George F Md; Mckinsey James Frederick Md; Mcknight James Md; Mckoy Harry Lee; Mclaughlin Jonathan Andrew; Mclenan Orville Wayne Md; Mcnamara Shannon Ohern; Mcpherson Philip E Md; Meadows Warner Earl Iii Md; Mecca Joanna; Medeiros Daniel M Md; Medlej Kamal; Meguerdichian Michael John; Mehran Roxana Md; Mehrazin Reza; Mehrotra Anita Md; Mehta Jaydev Divyakant Md; Mehta Lakshmi Md; Mehta Navin C Md Pc; Meier Diane Eve Md; Meisels Ira S Md; Meliambro Krisitn

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Ann; Melissa Elaine Peard; Mella Maria Teresa; Mellinger Brett C Md; Melone Charles P Jr Md; Meltzer Murray A Md; Menachem Mendel Weiner; Mendelson David S Md; Mendes Donna M Md; Mendez Antonio Md; Mendez Stephanie M Lpn; Mene Matthew P Md; Menezes Nelson Socorro; Menikoff Howard Md; Menkes Leo; Menon Madhav C; Mentus Nicholas L Md; Mercader Carolina; Merianos Demetri J; Merino David A; Merkin Michael; Merling Andrew Neil Phd; Mermelstein Joseph; Merns Karen Phd; Merola Pamela Rios Md; Merrell Woodson Md; Merrill Eve Rachel; Merson Elisabeth; Messenger Christie Lynn; Meyer John; Micelotta Noa; Michael Dourmashkin Md; Michael Eric Rosen Md Pc; Michaels Emil Md; Michaels Ilene Karp Md; Michel Jane; Michelson Linda N Md; Michnovicz Jon J Md; Midulla Peter S Md; Mikhail Maryann; Mikler Evgeny; Mildvan Donna Md; Miles Brett A; Milite Fulvia; Miller Aaron E Md; Miller Albert; Miller James; Miller Ricardo Anthony; Miller Sheryl Robin Md; Miller William; Millman Howard E Md; Mills Christopher B Md; Milman Lyudmila; Min Albert Daeki Md; Minara Ryan; Mincer Joshua S; Mindel Joel S Md; Mindlin Galina Md; Minkin Mikhails Md; Minkin Ruth Md; Minsky Noga Chlamtac Md; Mintah Afua; Mintz Betty Jane Md; Mir Waseem Md; Miravite Joan Marie; Mirels Hilton Md; Mirensky Tamar; Mirica Marilena Md; Mirzaga Mariam; Misiukiewicz Krzysztof; Mitchell John P Md; Mitchnick Eric Ira Md; Mitelman Serge A Md; Mittal Niranjan Kumar Md; Mittnacht Alexander Md; Miyasaka Kenji C Md; Mizuguchi Richard S Md; Moazed Kambiz Thomas Md; Mocco J; Modhwadia Kanan; Modi Jayaprakash J Pc Md; Modica Ippolito Md; Mohabir Jason; Mohajer Babak Md; Mohamed Shahana; Mohammadi Shahrzad Md; Molinas Sandra; Molofsky Walter J Md; Mon Myat Myat Md; Monioudis Gus Dds; Monteith Sharifa Amelia Md; Montgomery Kaitlin Blair; Moon Jang Il; Moorley Maya Devi Md; Mor Milana; Mor Trisha; Morales Rose Marie; Morales Yesenia; Moreno Pedro R Md; Morgello Susan Md; Morimoto Toko Md; Moritz Jacques L Md; Morocco Sarah B; Moros Daniel Aaron Md; Morrisett Nancy; Morrison Rolfe Sean Md; Morrow Jon D Md; Mortati Katherine Alexandra Md; Morton Titus Aruna Md; Moss Douglas G Md; Mosseri Maurice Md; Motamed David B; Motivala Soriaya; Motiwala Rajeev Md; Moucha Calin; Moulton-Levy Natalie; Moy Judy Lee Dds; Moye Elizabeth; Moyle Henry; Mra Zan Md; Mufti Mahtab Ahmed Md; Muldoon Thomas O Md; Mullings Maverly V Np; Multz Alan S Md; Mun Son Hui Md; Mungekar Meaghan Md; Munjal Kevin; Muralikrishnan Kannan Md; Murillo Mauricio Md; Murphy Christine Miss; Murzakhanova Inna; Muttana Ramakrishna Reddi Md; Myerson Merle Md; Mylonakis Toula; Manhpham; Melissabenzuly,L.M.S.W.; Michelefeldman,L.C.S.W.; Mirnasambula,L.M.S.W.; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Mountsianihealthsystem; Nabatian Farzad Md; Nachamie Benjamin Abraham Md; Naco Elva Md; Nadar Christina; Nadelson Elliot J Md; Nadkarni Girish Nitin; Nagar Michael Shaun; Nagarsheth Nimesh P Md; Nagel Dalia; Nagler Harris Mark Md; Nagy Joseph; Naib Tara; Naidich Thomas P Md; Naik Hetal Babubhat Dpm; Naik Jahnavi R; Najac Richard David Md; Nakamura Hachiro Md; Namdar Isaac Md; Nandi Anindita; Narag Kevin Michael; Narayanswami Gopal Md; Narula Jagat; Nason Lisa Md; Nasrallah E John Md; Nassisi Denise Md; Natelson Benjamin; Navarro Pablo C Md; Navarro Thelma Myers; Naveh Marcia Spiegel Md; Nawaratne Upulie; Nayak Anupma; Nayak Asha D Md; Nayak Mansi Manohar; Naymagon Steven; Nedelcu Ciprian Md; Nejat Morris Md; Nelken Alexander Zev; Nelson Bret P Md; Nelson Marcia P Md; Nelson Sabina Md; Nembhard Nicole Md; Nemes Andreea Sefania; Nemesdy Gabor Md; Nentin Farida; Nerantzakis George; Neufeld Richard R; Neumann Deborah Jody Md; Neustein Steven Mark Md; Neuwirth Michael George; New Maria Iandolo Md; Newcorn Jeffrey H Md; Newman Cara Bristol Rpa; Newman David H Md; Newman Lawrence Craig Md; Newman Marissa; Newman-Hernandez Roberta; Newmark Alan Jay Dpm; Newsam Margaret Ann Md; Newton Michael J Md; Nezhat Farr R Md; Ng Jennifer; Ng Ka Chun; Ng Michel; Nguyen Khanh Huu Md; Nguyen Ngoc Tram Md; Nguyen Scott Q Md; Nguyen Thu-Ha T; Nguyen Trinh T; Nguyen Van Hong Duong Md; Nguyen Vinh-Tung Phuoc; Nicastri Daniel Gilbert; Nicell Donald Thomas Md; Nicholas Genes Md; Nicholson Tara Anne; Nicosia Thomas A; Nieves Rosado Sandra; Nightingale Andrew Bradley; Nightingale Jeffrey D Pc Md; Nikiforov Konstantin Md; Nir Yair Jacob Md; Nitkin Leon Md; Nobel Mehdi A; Nobert Craig Francis Md; Noel Camille; Noel Edwin Blackman Md; Norris Marlaina M Md; Noryang Tenzin; Nottingham Fatima I; Noumi George Md; Novack Henry Frederick Md; Novakovic Vladan; Nowakowski Francis Scott Md; Nunez Domingo C Md; Nyein Roland Md; Ninazparks-Taylor; Nivmor; O'Boyle Margaret M; O'Brien Julie; O'Dea Denise Gayelle; O'Donogue Meghan; O'Hara Mandy A; Obadia Marc Md; Obadiah Barry Md; Obedian Edward Md; Obekpa Adah Edache; Oboler Lara S Md; Obrien Betsy S; Obrien Meagan; Odes Lyubov N; Odin Joseph Alan Md; Oh Chunkeun Md; Oh William Kyu; Ohnuma Takao Md; Oishi Kimihoko; Oishi Marisa; Ojo-Carons Mary; Olin Jeffrey Wayne Do; Oliva Namik; Olivares Margarita; Olivier Wendy-Ann Md Pc; Olivieri Florida Gisele Md; Olivos-Asarian Alma Janet Md; Olmedo Ruben Eduardo Md; Oloomi-Yazdi Mohammad Mehdi; Olorunnisomo Vincent Dr.; Olsson Carl A Md Pc; Olupona Tolulope; Omidvari Karan Md; Oneill Cara L; Ong Kenneth Md; Opio George Md; Oransky Matthew; Orbegoso Lisa; Orlando Barbara Sarah; Oropello John Mark Md; Orozco Juan C Md; Osei-Tutu Achiamah; Osman Keren Md; Osofisan Olatunde; Oster Stuart Md; Osullivan Mary M Md; Oswald Elizabeth Marie; Otello Toni Anne; Otte Kelly L Md; Oustecky David Henry; Ovchinsky Alexander Md; Ovodenko Boris; Owen Randall Paul Md; Owens Crystal; Owens George Francis Md; Ozden Aykut; Paccione Jeffrey Charles Md; Pacholka-Moran James Md; Paddu Nalini Upadhyaya; Padi Abhilash; Padilla Maria L Md; Paek Changhee; Pahk Patricia; Pai Satishchandra S Dds; Paik Il Joon; Paka Renuka D Md; Pakawadee Khovidhunkit Md; Pal Carmen Elena Md; Palatucci Gary Benjamin Md; Palazzo Angela M Md; Palep Sapna; Palese Michael Md; Paley Charles W Md; Palkhiwala Sameet Arun Md; Palma James Md; Palmer Lane Stuart Md; Palmese Christina A Phd; Palmiero Pat-Michael; Panarelli Joseph Francis; Pandya Paru Kunjvhari Md; Panos Amber A; Pantelides Harry; Papapietro Nicholas V Md; Paramasivam Srinivasan; Parekh Raj; Parekh Samir Md; Parikh Purvi S; Parikh Rahul R; Park Jay H; Park Ju Hyung; Park Koji; Park Sung; Parker Judith M; Parness Ira A Md; Parsons Bradford Md; Partnow Joshua Lee Md; Parvin Synthia; Pashmena Ahmadi; Pasley Peter Macpherson Md; Pasternak Roey; Patel Aditya Mahendra; Patel Aman B Md; Patel Anupkumar K; Patel Chirag; Patel Devendra Anantrai Md; Patel Devina; Patel Jayantilal M Md; Patel Kamini Rpa; Patel Miksha Jitendra; Patel Nirav; Patel Rahul Sidartha; Patel Sesha; Patel Sujan; Patel Vaishali Raojiohai Md; Patel Vipul; Patil Ninad Mohan; Patrick Sharon Lynne Md; Patterson Aaron Ronald; Patterson Miquelle Rukia; Patterson Shanna; Patton Erin; Paul

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Quarter End Date

DSRIP Reporting Year and Quarter

Audrey Z; Paul Elliot Mark Md; Paul Nicole Alyse; Pawa Sapna; Pawale Amit Audumbar; Pawha Puneet; Payami Ali; Pearl Richard E Md; Pearlman Andrew Douglas Md; Pearlman Charles Joseph; Pechter Patricia M; Pedraza Juan D; Pelaez Oscar Md; Peller Paul Ahron Md; Peloquen James Lloyd Md; Penacerrada Leonard Victor Md; Penstein-Hirt Rivkie Md; Pepe Anthony J Md; Perez Maritza I Md; Perez Water Hernan Dpm; Perkel Charles Alan Md; Perkins Anthony Ray; Perlman David C Md; Perlman Hillary; Perna David; Perrone Stephen C Md; Perrotta Lucille Md; Persaud Vyas Durga Md; Pessolano Ashley M; Peter Howell Pa; Peter J Pappas Md; Petersen Bruce; Peterson Shane Ember; Petryna Olga; Pezzollo Eugene Peter; Pfaff H Charles Md; Pfail John Lawrence Dds; Phelps Robert G Md; Phillip Kasra; Phillips Courtney Ki Md; Phillips Edward C Md; Phillips Geoffrey Isaac Md; Phipps Emily E Np; Pieh Nyota May; Pike Sheldon Bruce; Pillalamarri Eswar Dutt Md; Pillalamarri Harinath Md; Pilly Parik Kumar; Pinney Sean Patrick Md; Pino Alejandro E; Pinto Rohit Ivor Agnel Md; Pintova Sofya; Pitman Michael Jay Md; Pittman Nanci S Md; Plaitakis Andreas Md; Plantin Patrick Md; Plotycia Steven Michael Md; Podell Robert M Md; Pohja Ervin; Polis Laurie J Md; Polistina Dean Carl Md; Polsky Bruce W Md; Polycarpe Myreille Md; Polydorides Alexandros Demetrios Md; Ponni Vijaya Perumalswami; Poor Hooman Dadkhahi; Popa Laurentiu Md; Poretsky Leonid Md; Poroye Afolabi O; Port Elisa Rush Md; Portnoy Ruben; Portnoy William Marshall Md; Post Kalmon D Md; Pou Ricardo E Md Pc; Poulard Jean-Bernard; Pour Trevor Robinson; Powell Charles A Md; Prasad Ankineedu N Md; Preblick Christine E Md; Presti Salvatore Md; Preval Angenie; Price Andrew E Md; Prince Rosemary; Probst Marc; Pruchnicki Alec Md; Prufer Neil Lewis; Prushik Kenneth Howard Md; Pui Yin Wong; Pulido Kristelle Olanka; Pullano William E Md; Punnapuzha Sheena; Punzalan Betty N Md; Purohit Dushyant P; Purugganan Romeo Sison Md; Puskas John Daniel; Pustovoytov Vadim Md; Pyburn Dewitt D Md; Perez,Diana,Np; Qian Cheng; Qiu Fen; Qiu Libo Md; Quaas Joshua Walter Md; Quentzel Stephan Jeremy Md; Quinn Brian P Dpm; Quirolo Adrienne; Quitangon Gertie; Qureshi Sheeraz Ahmed Md; Raab Edward L Md; Raacke Lisa M Md; Rabin Elaine J Md; Rabinovitz Asaf; Rabinowitz Jack G Md; Rachko Maurice Md; Radbill Brian; Radzik Andrew Md; Ragnarsson Kristjan T Md; Rahal Sarah; Rahim Arshad; Rahimian Vahid; Raiford April Alcenia; Rainey Mary Chandler; Raja M Flores; Rajpal Sanjeev Md; Rajs-Nepomniasky Roma Md; Ramaseshu Anne Md; Ramaswamy Kavishankar; Ramdhani Ritesh Anand; Ramirez Ivonne; Ramnandan Jeanetta; Ramos Timothy D; Rana Meenakshi Mehrotra; Rapaport Robert Md; Rapoport Gloria Md; Rapoport Irina; Rappisi Kristen D; Rasamny Linley; Raskin Jonathan M Md; Raskin Simon Dpm; Rastogi Shobit Md; Ratcliffe Justin Anthony; Rathibhan Hemnarine; Ratner Desiree Md; Rattner Peter; Ravich Steven J Md; Rawstron Sarah A Md; Raymond Alan R Md; Raynes Hillary Ruth Md; Re Louis Peter Md; Rebecca Fisher Md; Rechtschaffen Thomas Hartley; Reda Dominick Frank Md; Reddy Harsha; Reddy Madhavi Md; Reddy Ramachandra Md; Reddy Sreerangapalle S Md; Redlener Michael; Reed Allan Md; Regelmann Molly Oliver; Rehwaldt Lise M Md; Reich David Louis Md; Reid Malcolm D Md; Reid Paula; Reid-Adam Jessica Md; Reid-Thornton Ruth Anne Md; Reiff-Pasarew Faye; Reina Grace E Md; Reish Richard; Reiss Wojciech Zygmunt Md; Reiter Joel D Md; Renteria-Azevedo Anne; Reppucci Vincent S Md; Rescigno John Md; Resnick Elana; Respler Mark Allan Md; Resta-Flarer Francesco Md; Rethy Michael Md; Revan Sharon Levina Md; Reverte Christopher Michael; Reyes Frank E Md; Reyna Maria Anaizza A Samson; Reynolds Gregory; Rhee Anna Jeong Eun Md; Rhee Michelle K Md; Rhim Eugene; Rho Lisa Md; Ricci Rosamaria; Ricciardi Riccardo Jr Md; Riccio Lisa; Rice Timothy Reynolds; Richardson Lynne D Md; Richmond Gynecologic Oncology Pc; Rider Amanda Marie; Rimpel Bernard Md; Rindfuss Richard Thomas Md; Rivera Victoria; Rivka Sachdev; Roane David; Robbins Eric Adam; Robbins Michael Jonathan Md; Roberts Michael Phd; Roberts Robin Del-Campo; Roberts Tahneemarie; Robin Varghese; Robinson Dorothy Albina; Robinson Emmett J'On; Robinson Jessica Md; Robinson-Brown Melissa; Robles Juan Carlos; Robles Narcisa Borja Md; Rocco Melissa L Md; Roditis Nicholas Md; Rodriguez Gloria Josefina Md; Rodriguez Oscar D Md; Rodriguez Zoe Md; Rodriguez-Diaz Cesar; Rokhsar Cameron K; Rolnick Reuben Md; Romain Sandie; Romano Constance; Romanoff Robert; Rondel Irina Md; Roonprapunt Chanland Md Phd; Rosales Rowena Concepcion G M; Rosas Maria; Rose Gabriel; Rose Keith Martin Md; Rose Samantha; Rosen Alan Jeffrey Dpm; Rosen Ally Md; Rosen Daniel D; Rosen Richard Bruce Md; Rosenbaum Smith Sharon Md; Rosenberg Amy S Md; Rosenberg Henrietta Md; Rosenberg Joshua David; Rosenberg Joshua Md; Rosenblatt Marc Do; Rosenblatt Meg Amy Md; Rosenblum Harvey Sheldon Md; Rosenfeld Jonathan E Md; Rosenfield Paul Jacoby; Rosenn Barak Md; Rosenson Robert Sidney; Rosenstadt Benjamian E Md; Rosenthal Amy I Cnm; Rosenthal Jeanne Lorraine Md; Rosenthal Kenneth J Md; Rosenzweig Kenneth Eric; Rosero Hugo O Md; Rosett Glenn Martin; Ross Donald Md; Ross Emily Janine; Ross Michael John Md; Ross Randall M Md; Rossettie Kate P; Roston Vivian E Md; Roth Ram Md; Rothberger Melvin J Md Llc Md; Rothenberg Susan D Md; Rothlauf Elizabeth B; Rothstein Robert Md; Rotman Michael Md; Rottenberg Eric Charles Md; Rotzman Roman Y Md; Rousso Joseph J; Roy E Bachar Md; Rozanski Alan Md; Rozbruch Jacob D Md; Rozenfeld Mariya Do; Rubenstein Robert J Md; Rubenstein Scott Dpm; Rubin Trudy; Rubinstein Marc G Md; Rubinstein Valeria Jessica Md; Rucker Wilder; Rudman Inna; Rudowsky Asher; Ruggiero Joseph Stephen; Ruggiero-Decarlo Rosemary Md; Rughwani Nisha Md; Ruiz Kenneth J; Russo Charles L Dpm; Rustamova Shahnoz; Rutenberg Kathryn Peck Md; Rutstein-Shulina Zhanna Md; Ruttenberg Margaret B Md; Rachelleveasley,L.M.S.W.; Radiantsmalls,R.N.; Rafaelramos; Ryanungaro; Saber Alen; Saccente Erica; Sachs Bracha Yaffa; Sadanandan Swayamprabha Md; Sadiq Asma J Md; Sadoughi Babak; Sadowsky Marc Samuel Dds; Sadrazodi Kamran Md; Saeed Madeeha; Saenger Paul H Md; Saffra Norman A Md; Safin Daniel S; Safro Bradley; Sahni Gagan D Md; Sahulee Raj; Saland Jeffrey Martin Md; Saleem Sophia Mirza; Saleh Jean W Md; Saliby Aida H Md; Salky Barry A Md; Saloum Migdalia; Salsitz Edwin Arnold Md; Salter Benjamin S; Salvacion Fervic Morante; Salvatore Mary M Md; Salzer Elizabeth Anne Joan; Sam-Deriggs Gina Rhona; Samad Reza; Samandarov Albert; Sampson Hugh; Sampson Ian H Md; Samson C Michael; Samson William Md; Samuel Diana; Samuel Ossama R M Md; Samuelson Robert Jeffrey Md; Sanborn Kevin Md; Sanchez Maricela; Sanders Jennifer Elizabeth; Sandhu Gagangeet Singh; Sandhu Shiraz M; Sandler Raymond Md; Sanfilippo Denise M Md Pc; Sangeet Khanna Md; Sanghavi Moushumi Bharat; Sanjay R Kedhar Md; Sanon Martine; Santoni Rugiu Francesco Md; Santos Gutierrez Lorenzo; Sanz Salvo Angel Javier; Sara Gabriel Albert Md; Sarabanchong Voravut O Md; Sardar Henry Do; Sarlin Jonathan G; Sarnelli Crissaris; Sarpel Umut Md; Satchell Margaret Ansell Md; Satlin Lisa M Md; Saul Turandot Md; Saunders Convard Alicia C; Saunders-Pullman Rachel Md; Sayed Hosam Aldin Md; Scanlon Robert Francis Jr Md; Scarborough Bethann M; Scelsa Stephen N Md; Schaberg Madeleine Rita; Schachter Edwin Neil Md; Schaefer Michael John Jr; Schaefer Sarah Hall; Schantz Stimson P Md; Scharer Lawrence Pc Md; Schattner Thomas John Phd; Schecter Stuart O Md; Schiano Thomas D Md; Schick Alexander Md; Schimler Michael E; Schlachter Leslie Mrs.; Schmelzer Naomi Ariel; Schmertz Anthony; Schmidt Paul Henry; Schmitz George M Md; Schnapper Debbie Gail; Schneider Donna Marie Md; Schneiderman Adam; Schoenholtz Sharon Elyse; Schorr-Lesnick Beth Md; Schuetz-Mueller Jan; Schultz Atara; Schumacher Michael Arthur Dpm; Schumann Marc Seth-Jon Dpm; Schumer Marc Allan Md; Schundler Rebecca Lynn; Schwartz Andrew David; Schwartz Arthur E Md; Schwartz Elliot I Md P C; Schwartz Lawrence P Md; Schwartz Myron E Md; Schweitzer Paul Md; Schwimmer Alan M Dds; Scigliano Eileen Md; Scimeca Michael M Md; Scobie Janice Vincia; Scott Elizabeth; Scott L Cooper; Scott Matthew; Seales-Bailey Chloe; Sebaoun Tova R Md; Sedrak Aziza; Seecoomar Leslie Md; Seema Varma Md; Seeriram-Saine Savita; Segal Barry J Md; Sehgal Vinita Md; Seicaru Florin Stefan Md; Seiden Howard S Md; Sekhon Jaspreet; Sekhon Lucky; Selitsky Lana; Sellman Robert Rpa; Semenovskaya Zina; Sen Urmi; Sengupta Partho P Md; Senkler Carol Elizabeth; Senor Maria Cristina Md; Seo In Suk Md; Serban Stelian Joan; Serby Michael Joseph Md; Serio Jane F Md; Serle Janet Barbra Md; Serseni Dragos M Md; Servay Elsbet; Sett Suvro; Severt William L Md; Sewell Margaret Cooper Phd; Sfakianos John; Sforza Paul D Jr Md; Shafizadeh Farshad Md; Shah Anar D; Shah Ankur; Shah Arti Md; Shah Bhadra B Pc Md; Shah Brijen; Shah Hetal Mrs.; Shah Kaushal Hemendra Md; Shah Nirali A; Shah Rasik V Md; Shah Sejal K; Shah Shefali; Shah Sooraj Malay; Shah Sovrin M Md; Shah Vijaykumar Prabhulal Md; Shakalis Peter; Shanker Vicki Md; Shao Theresa Hua; Shapira Ilan Md; Shapiro Chalres Louis; Shapiro Gabrielle; Shapiro Janet M Md; Shapiro Jason Scott Md; Shapiro Victoria Do; Shapsis Alexander Md; Sharabi Abdelsalam Md; Shariat Ali Nima; Sharma Ajay Kumar Md; Sharma Samin Kumar Md; Sharma Sharad Kumar Md; Sharma Shuchita; Sharrieff Tanya; Shasha Daniel Md; Shaw Stephen Gerard Md; Shawn Lauren M; Shearer Peter L Md; Sheffield Perry; Sheflin-Findling Shari M; Sheikin Noa; Sheinart Kara F Md; Shendrik Irina; Shenoy Akhil Md; Shenoy Rajesh Upendra Md; Shepard Richard; Sherif El-Masry; Sherman Edward M Dds; Sherman Peter M Dds; Sherr David L Md; Sherrid Mark V Md; Sherzoy Ali; Sheth Nitin D Md; Sheth Parag Md; Sheth Seema; Shetreat-Klein Avniel N; Shetye Swapnil Sharad Md; Sheynshteyn Yelena Y; Shi Susan You Md; Shilkoff William Dean Md; Shim Brian; Shim Mark Inbo; Shim-Chang Helen Md; Shimkus John W Md; Shimony Rony Y Md; Shin Deborah; Shin Edward John Md; Shin Susan Crystal; Shineman Paul Waner Md; Shinhar Shai Yeshajahu Md; Shinnar Meir Md; Shipman David L Md; Shishlov Kirill Sergeyevich; Shlasko Edward Md; Shmerkovich Dmitry; Shohet Michael Md; Shouhed Daniel; Shrestha Binaya Md; Shreves Ashley E Md; Shrivastava Raj Kumar Md; Shu David Ka-Hing Md Pc; Shulimovich Maxim; Shulman Evan; Shulman Julius Md; Shur Vladimir B Md; Shuster David Dpm; Shustorovich Yuliya A Md;

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Shyamala Chendeal Navada; Si Qiusheng; Siadecki Sebastian Daniel; Sicat Michael Alan Gueson Md; Sicile Dominique Margaret Acnp; Sicular Serge; Siddique Mohammad Abubakar Md; Sidhu Gurcharan S Md; Sidoti Paul A Md; Siegel Jerome H Md; Siegel Mark I Md; Siegell Michael Warren Md; Sierecki Mitchell; Sigamony Manohar Md; Sigler Lawrence J Md; Sikorski Christopher; Silberzweig James Md; Siller Walter F Jr Md; Silvay George Md; Silver Jonathan J Md; Silver Lester Md; Silvera Charles T; Silverberg Nanette B Md; Silverman Bernard Allan Md; Silverman Gary Md; Silverman Lewis R; Silverman Sarah; Silverman Suzanne Kessler; Silverstein Jeffrey H Md; Silverstein Jessica K; Sim Alan J; Simmons Sylvia; Simon Asher; Simon Claude Md; Simon Sheldon Roy Md; Simonetta-Paglino Jacqueline; Simons Calvin J Md; Simonson Rayze Md; Simpson David Martin Md; Simpson William Louie Jr Md; Sinanan Indra; Sinclair Catherine; Singer Elizabeth Kara Md; Singer Mark Adam Do; Singh Akhilesh Md; Singh Anjali; Singh Ila; Singh Monika Md; Singh Prameet Md; Singh Rajendra; Singh Sanjosh; Singh Vijay; Singla Montish; Sinha Ajoy Kumar Md; Sinha Animesh A Md; Sittler Patrick Lynn Md; Sivak Mark A Md; Skalina Nicole A; Skamagas Maria Md; Skinner Carly; Skliut Maryna Md; Skloot Gwen S Md; Skovran David; Slaff Ilana Michelle; Slater Gary I Md; Slovis Benjamin H; Small Elizabeth A Md; Smith Angela Lantz; Smith Barry L Md; Smith Cardinale B; Smith Donald A Md; Smith Linda L Md; Smith Lizette Joan Md; Smith Mark Lawrence Md; Smith Peter R Md; Smith Sandra L; Smith Steven Douglas Md; Smouha Eric Ezra Md; Snyder Andrea Madeline Md; Sobral Filipe Anacleto; Soffer Daniel Md; Sohal Ranjeet Md; Sohmer Samantha Rachel; Soifer Todd Barrett Md; Soleimani Laili; Sollaccio Peter A Md; Solomon Betelhem; Soltanpour David Md; Som Peter M Md; Soni Sonia; Sonnenblick Emily; Soo-Hoo Dorene M; Soones Tacara; Sordillo Emilia M Md; Soriano Rainer P Md; Sosner Julian Md; Sotelo Andre Md; Sotirakis Ivicos S Md; Soyfer Amanda; Sparks Ann Martha; Speaker Mark George Md; Spektor Gary Md; Sperber Kirk E Md; Sperling Rhoda Md; Spigland Nitsana A Md; Spiguel Eugenie A; Spina Louis A Md; Spingarn Aaron Md; Spinner David A; Spinner Ruth M; Spiridis Kyriaki Kiki; Squires James Jerome Md; Srinivas Rao Dukkipati; Srivastava Jena; Srivastava Shubhika Md; Srivastava Sudhesh Kumar Md; St Hilaire Wilgyms; Stachel Sheldon; Stacy Charles B Md; Stathakes Larissa A; Staton Frederick Md; Stauffer Chanan; Steele Justin Gregory; Steigman Shaun; Stein Deborah J Md; Stein Mark Md; Stein Richard M Md; Steinberg Amir Simon; Steinberg Daniel I Md; Steinberg Eric; Steinhagen Randolph M Md; Stelzer Paul Md; Stember Doron; Stephanie Bussmann; Stephen-Johnson Gail Allison; Stephens Evelyn Afif; Stephens Gary Almedo Md; Sterlin Myriam; Stern Aaron Saul Md; Stern Avichai; Stern Eric Howard Md; Stern Eric Kimberly; Stern Richard Hersh Md; Stets Kelly; Steven Chin-Sing Yung; Steven Dale Boggs; Stewart Allan Scott Md; Stewart Robert David; Stickles Scott Michael Do; Stieber Jonathan; Stier Alison Hunter; Stimola Aubrey Noelle Rpa; Stock Jeffrey A Md; Stollman Aryeh Lev Md; Stone Gary Carl Md; Stone Joanne Md; Stone Marc Elliot Md; Stone Peter Lyle Md; Stork Caitlin E; Stratchan Nicole Erica; Stratton Jennifer Britt Md; Strauchen James Arthur Md; Strauss Elton Md; Stroe Angela; Strong Noel Kristi; Strostrup Ann Marie; Stumacher Barbara; Sturman Ira M Dds; Su Emiily; Suarez Vivian; Subramaniam Arumbi Pc Md; Suero-Wade Mayra Dds; Sugay Joshua L; Sulica Roxana Md; Sullivan Eve; Sullivan Jeanne Marie; Sullivan Lisa; Sullivan Richard C; Sullivan Timothy F N; Sultan Saima; Sun Wei Yue Md; Sundel Siobhan; Sunderwirth-Bailly Ramona Md; Sung Max Md; Sunil Kurien George; Sunshine Robert D Md; Suozzi William G Md; Suozzo Dana Lynn; Surach Cristina J; Surick Burton G Md; Susser Rhona S; Sussman Daniel Richard Rpa; Sussman David J Md; Sussman Shawn J Rpa; Sutherland Leroy Nichelous Md; Svahn Jennifer K Md; Swain Gary; Swain Susan Quiney; Swartz Jordan Louis; Swartz Talia H; Swarup Rupendra Md; Sweeny Joseph Michael Md; Swidler Mark A Md; Swido Anne Bernadette; Swope David M; Syeda T Hossain Md; Syros Georgios; Szabo Janet Rose Md; Szporn Arnold Md; Salmarahimi; Schehr, Jaime, Rd; Soniaaracena; Susuaung; Suzannecalvert; Suzannem.Connolly; Tabaee Abtin Md; Tack Kevin L; Tadros Nardin; Tadros Rami Odeh; Taft James Daniel Md; Tai Tak Yee Tania; Taitt Michael R Md; Tak Vinay Manohar Md; Talbert Susan M Md; Talbott Maite Del Carmen Md; Tamis Jacqueline Elvira Md; Tamler Ronald Md; Tan Doris Uy Md; Tan Jian-You; Tanenbaum Lawrence N Md; Tang Jian J; Tangredi Angela M Md; Tannen Bradford Laurence Md; Tannous Henry; Tannous Leigh A; Tanya Williams Pa; Tanzi Aria; Taouli Bachir Md; Tapper Rosenberg Marcia Md; Tarlowe Michael Harris; Tarr Diane E Md; Tartter Paul Ian Md; Tasca Robert; Tastet Heidi Hope; Tate Derek Mitchell Md; Taub Peter James Md; Taurani Christopher R Md; Tawil Joseph B; Tay Ee; Tayaba Roland G Md; Taylor Jane; Taylor Jerome D; Teaiwa-Rutherford Maria Md; Tefera Lemeneh Md; Teitcher Arielle; Teitel Michael G Md; Teitelbaum Stephen Md; Teixeira Janice; Tejwani Natasha; Telsey Aimee M Md; Teng Marita S Md; Teo Arnold Porcia Md; Teodorescu Victoria J Md; Teodorowicz Marino Wanda Md; Terraciano Anthony J Md; Terrone Gillian D; Tewari Ashutosh Md; Thaker Harshwardh Monohar; Thall Eric Hayim Md; Than Naw Susan; Theise Neil; Thiagarajah Somasundaram Md; Thiboutot Jeffrey; Thomas Albert George Md; Thomas Gary Paul Md; Thomas Kurian Md; Thomas Nicole L; Thomas-Paulose Deepti Md; Thompson Cecilia D; Thompson Michael F Dpm; Thompson Paul Md; Thornton Karen; Thukha Henry S; Thum Frederick Lorenz Iii; Thung Swan N Md; Thys Daniel M Md; Tierney Lauren C; Tiersten Amy Diane Md; Tikko Sirisha Rani Md; Timmireddy Arunakumari Md; Ting Andrew Shih-Heng Md; Ting Jess Md; Ting Windsor Md; Tioczkowski John; Tissot Todd Anthony Md; Titelis Joann Alexandros Md; Tobias Michael Eric; Tobik Sandra M; Todd George J Md; Tokita Joji Erik; Tolba Khaled Ahmed Md; Tolentino Antonietta; Toma Mirela Md; Tomei Nina A Md; Tomer Yaron Md; Tong Carrie Lilynn Md; Toni Shih Pearson; Topsis Julie Md; Torabi Mandana; Torgalkar Sohita Mittal Md; Torina Phillip; Tornatore Angela; Torres Omar; Torrico Pedro Javier; Tosi Michael Francis Md; Towner Robert A Md; Tracy Bridget Anne; Traenkner Jessica J; Trainor-O'Malley Peggy Mr.; Tran Christina Ngoc Tram; Tran Teresa Tuyet-Phuong N Md; Tranbaugh Robert F Md; Tranchina Stephen A Md; Trauzzi Stephen Md; Travis Jeanne D Md; Travis Lisa Beth Md; Treitel Stuart Allan; Tretter Theresa M Md; Triesch Kristen M; Trimba Michael; Trinh Muoi A; Trivedi Shefali; Trlica Kara L; Troia Rosanna; Trop Cynthia Sires; Troy Kevin Md; Trubelja Nenad Md; Tsai Gregory P Md; Tsai Tony Potung Md; Tsankova Nadejda; Tse Winona Md; Tsega Surafel; Tsin Daniel A Md; Tsioulias George John Md; Tsung James W Md; Tucci James John Md; Tuchman Joseph G Pc Md; Tuggey Erica M; Tuhrim Stanley Md; Tun Hla Md; Tun Khine; Tun Nilar; Tung Frank K Md; Tupper Thomas V Md; Turano Gerard Md; Turi Teresa Cnm; Turino Gerard M Md; Turner Alyson Ms.; Turner Michael Dov; Turok Alisa; Twardon Andrew Andrzej; Tyler Ira M Md; Tyson Jasmina; Ukomadu Uzoma Nwaeze; Ukrainsky Gennady Md; Ullman Jennifer Taylor; Ullman Thomas Anthony Md; Umali Sofia; Umpaichitra Vatcharapan Md; Underwood Nicolle; Unis Douglas B Md; Unis George L Pc Md; Uppu Santosh Chakraverthy; Urken Mark L Md; Useda Claudia A Md; Usher Sol M Md; Uysal Suzan; Vadada Amita; Vaidya Dipak N Md; Vaidya Swapna X Md; Vail Lucia Phd; Vainstein Zlata; Valauri David Van Dds; Valdes Maurico; Valeriano Allison Manalastas; Van Leer Patricia Elizabeth; Vangronigen Peter Md; Vardarajan Asha; Varghese Geeta; Varley Cathleen B; Varma Mala Md; Varughese Christopher J; Varvara Maria; Vasavada Balendu C Md; Vassalotti Joseph Alfred Md; Vassar Jack Kevin; Vastardi Maria-Anna; Vasudevan Viswanath P Md; Vaughan Barney; Vedanthan Rajesh Md; Veith Gary Edwin Md; Velasco Debora; Velcek Francisca T Md; Velickovic Miodrag Md; Vella Adam Md; Veridiano Norma P Md; Verina Daniel J; Via Michael; Vijay Venkataramana Md; Vijayan Radhika Md; Villarosa Teresita Lacanale; Viloria Edermiro Md; Vinay Nair; Viron Anna; Virzi Peter Joseph Md; Vitale Salvatore Giacomo Md; Vivek Yerrapu Reddy; Vivona Cherie Christine; Vogel Donald A; Vogel Samantha R Pa; Vohra Rishi; Volfson Marina; Volkerts Elston Leroy; Volkin Yakov Md; Vomvolakis Maria Antonios; Vorchheimer David A Md; Vorobyeva Larisa; Votava Henry John Md; Vouyouka Ageliki Md; Vreeland Thomas H Md; Vincci Ngan; Wachtel E Vasilievna Md; Wadhera Vikram; Wagner Brian James Md; Wahl Eric M Md; Wain Abbe Michelle Md; Wald Kenneth J Md; Waldorf Heidi Ann Md; Walker Patricia Ann Md; Wallace Brallier Jess Md; Wallach Elizabeth Md; Wallack Joel J Md; Walsh Christopher E Md; Walsh James Joseph Md; Walsh Joseph B Md; Walsh Kenneth A Md; Wan Stephen; Wanderwall William; Wang Eileen; Wang Jen C Md; Wang Jian; Wang John K Md; Wang Julie Md; Wang Mei; Wang Mingke; Ward Michael Francis Md; Ward Stephen; Warmsley Amber; Warner Richard R P Pc Md; Washington Bradford Clyde; Wassef Fady Wagdy; Wassermann Jonathan S Md; Wasserstein Melissa Pittel Md; Watanabe Melanie Ann Md; Watkins-Laptiste Terese; Wax David Bennett Md; Wayne Michael Gerard; Webb Bryn; Webber Barry R Md; Weber Lori Marie; Weber Renata Vanja Md; Webster Stephen James; Wedderburn Raymond V Md; Weerahandi Himali M; Wei Alex; Weichenberg Deborah Md; Weinberg Barry J Md; Weinberg Jeffrey Mitchell Md; Weinberg Jerry Charles Md; Weinberger Jesse Michael Md; Weinfeld Steven Bennett; Weinreich Leo Md; Weinstein Kenneth N Md; Weinstein-Shama Cheryl Sue; Weintraub Andrea Suzanne Md; Weintraub Dina B; Weintraub Elizabeth C Dpm; Weisbard James Joseph; Weise Eugene E Md Pc; Weiss Anthony Alan Md; Weiss Deborah Joy Md; Weiss Jeffrey; Weiss Laszlo Md; Weiss Nirit Md; Weiss Robert Allen Md; Weissbluth Jay E Md; Weissman Laurence Roy Md; Weissman Scott Stuart Md Pc; Weisstuch Zvi Samuel Md; Weitzner Eric; Weiwei Li; Welch Alison Kate; Welch Kate; Welsh Lois-Ann C Rpa; Weltz Christina R Md; Wen Angie; Wenig Bruce M; Werter Ronald M Dpm; Westchester Neurological Cnsl; Westreich Richard W Md; Whelan Richard Lawrance Md; Whitaker Beatrice Rose Md; White Margaret Mary; White Taylor Douglas; WhiteEdwards Judith; Wicker Jordan; Wiener Dan E Md; Wiener Jill A Md; Wientzen Gelber Marianne P Np; Wiesel Sharon; Wilck Eric Jay Md; Wilentz Seth Edward Md; Wiley Jose Maunel Md; William Schell; Williams Arthur; Williams Francis Md;

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Wimmer Alicia; Winchester James Frank Md; Wind Richard M Md; Winell Jeremy M Md; Winn Julia; Winston Jonathan Allan Md; Wirtner Amy Sue Md; Wisnicki Herbert Jay; Wisnivesky Juan P Md; Wisotsky Burton J Md; Wistinghausen Birte Md; Witanowski Stephen John Md; Witman Danielle; Wojtaszek Anna Lidia; Woldenberg David Harold Md; Wolf Andrea Shari; Wolf Frank Robert Dpm; Wolf Joshua; Wolf Steven Md; Wolin David A Md; Wolinsky Steven Md; Wolk Lora Hilary; Wolny Peter J; Wong Benjamin C Dds; Wong Lily Md; Wong Soman Mary; Wong Steven Md; Wong Timothy; Wong Tommy Yuk Shu Md; Woo Kar-Mun Carmen; Wood-Smith Donald; Woodrell Christopher David; Woolley Matthew L Md; Worrell Helaine; Wright Kevin; Wu Albert; Wu Amy; Wu Jane R; Wu Shiming; Wu Simon; Wu Zhenqing Brett Md; Wyatt Christina Marie Md; Wagner,Rita,Cnm; Winstonjoseph; Xian Sandy; Xiao Philip Q Md; Xie Meikuen; Xu Ruimin; Xu Wei Hong; Yakov Semenov; Yan Richard X; Yan Yuhui; Yaneth Estrada; Yang Amy; Yang Ann Hae Inn; Yang Edward Charles Md; Yang Roy Md; Yankelevitz David Md; Yanowitch Philip Md; Yao Jiaming; Yao Mike; Yau Mabel; Yella Laksihmi K Md; Yeo Jonathan; Yeung John; Yevgeny Azrieli Md; Yi Christie Hyunsu Md; Yim Victor J Md; Yland Kathrynne F Md; Yohai David Md; Yohannan Robert B Md; Yong Raymund; Yoo Ji Yeoun; Yost Sharon Lynn Md; Young Christine S; Young Michael C Md; Young Simon Dpm; Youngewirth Elizabeth Dpm; Youshko Dmitry; Yu Aenid Marie Mercado; Yu Annie Christie; Yu Irene; Yu Lo; Yuan Chia-Hung Dds; Yuan Songyang; Yudkowitz Francine S Md; Yuen Joseph; Yulis Irina; Yury Khelemsky; Yusupov Dmitriy Rpa; Zaback Yehoshua H; Zackai Sheemon Pinhas; Zafar Monaa; Zafirova Zdravka; Zaghi Ramin; Zahn Jeffrey Md; Zaidi Mone Md; Zaidman Gerald Walter Md; Zajac Joseph; Zakashansky Konstantin Md; Zalinyan Heghine; Zambetti George J Jr Md; Zane Debra Ruth Md; Zaster Yulia; Zauderer Jeffrey Md; Zbar Lori Goldman Md; Zeichner Joshua Adam; Zeizafoun Nebras; Zerillo Jeron D; Zhang David; Zhang Linda Ping; Zhang Zesong; Zheng Zimu Md; Zhou Lan; Zhu Hongfa; Ziegelbaum Michael Mark Md; Ziets Robert Jeffrey Md; Zilberg Neil G Md; Zimberg Shawn Howard Md; Zimbler Marc; Zinberg Adele Dr.; Zisu Manuela Pascolina Md; Zitner Deborah Md; Zodda Richard J; Zoltan Robert Md; Zou Hongyan; Zumoff Barnett Md; Zumrat Khaimova; Zurita Omar; Zwick Dalia Epstein; Zylberman Ilana Md Task

Policies and procedures are in place for early notification of planned discharges.

Provider

Hospital

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Providers Associated with Completion: Beth Israel Medical Ctr Act; Brooklyn Hospital Center; Calvary Hospital Inc; Mount Sinai Hospital; N Y Eye And Ear Infirmary; St Lukes Roosevelt Hsp Ctr Task

PPS has program in place that allows care managers access to visit patients in the hospital and provide care transition services and advisement.

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Task

Step 1: Identify hospital staff who facilitate discharges to participate in project work group to help plan with Care Coordination Work group Task

Step 2: Work with IT to develop protocol for community primary care provider to receive notification when patient enters the hospital Task

Step 3: Train hospital staff in notification protocol for patient care providers Task

Step 4: Conduct pre- and post-testing to monitor continuous quality improvement Task

Step 5: Assess current discharge planning protocols across Phase 1 PPS hospitals Task

Step 6: Collaborate with CCCFW to develop CCCFW processes, workflows, and protocols as they relate to the CCCFW Charter with regards to discharge planning and case management in the hospital. CCCFW's charter and deliverables to be found in

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Clinical Integration Section 09- MAPP Module 9.1 Task

Step 7: Identify provider types that will need early notification of planned discharges and patient admitted to hospital

Project

Completed

01/01/2016

03/31/2016

01/01/2016

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 8: Modify current discharge protocols and create new protocols working with IT to integrate notifications for care managers to work with providers to visit patient in hospital before discharge Task

Step 9: Develop training tools to train hospital staff in collaboration with Workforce including care managers, identified discharge hospital staff and partners on discharge planning protocols Task

Step 10: Develop policies/procedures that allow care managers and provider representation on-site at hospitals to meet with patients advise on care transition services Task

Step 11: Develop policies/procedures that allow PPS providers access to hospitals outside of the PPS to develop care plan and arrange for transitional care services. Milestone #5

Protocols will include care record transitions with timely updates provided to the members' providers, particularly primary care provider.

DY2 Q4

Project

N/A

Task

Policies and procedures are in place for including care transition plans in patient medical record and ensuring medical record is updated in interoperable EHR or updated in primary care provider record. Task

Step 1: Engage IT to identify solution/platform that will be used for documenting and sharing discharge and care plan Task

Step 2: Discuss with IT how care plan will be integrated into electronic medical record Task

Step 3: Actively participate in Care Coordination Cross Functional Workgroup sessions to ensure care transition plans are incorporated into patient medical records

NYS Confidentiality – High

Page 195 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Milestone #6

DY2 Q4

Ensure that a 30-day transition of care period is established.

Reporting Level Project

Provider Type N/A

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2016

09/30/2016

07/01/2016

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2016

12/31/2016

07/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Task

Policies and procedures reflect the requirement that 30 day transition of care period is implemented and utilized. Task

Step 1: Recruit new staff from the communities where our target patients live and work to best meet cultural and/or linguistic needs Task

Step 2: Have case managers setup in person and face-to-face interactions with patients to build relationships Task

Step 3: Establish availability of 24 hour hotline (part of call/command center) Milestone #7

Use EHRs and other technical platforms to track all patients engaged in the project.

DY2 Q4

Project

N/A

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

Step 1: Work with IT Committee to identify and track patients Task

Step 2: Create a disease specific dashboard that can be shared across client care stakeholders

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Develop standardized protocols for a Care Transitions Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency. Engage with the Medicaid Managed Care Organizations and Health

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed. Ensure required social services participate in the project. Transition of care protocols will include early notification of planned discharges and the ability of the transition care manager to visit the patient in the hospital to develop the transition of care services. Protocols will include care record transitions with timely updates provided to the members' providers, particularly primary care provider. Ensure that a 30-day transition of care period is established. Use EHRs and other technical platforms to track all patients engaged in the project.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Complete

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Complete

Milestone #5

Pass & Complete

Milestone #6

Pass & Complete

Milestone #7

Pass & Complete

IA Formal Comments

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.iv.4 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name Milestone

Status

Completed

Mid-Point Assessment

Original Start Date

Description

Mid-Point Assessment

06/01/2016

Original End Date 06/30/2016

Start Date

06/01/2016

End Date

06/30/2016

DSRIP Reporting Year and Quarter

Quarter End Date 06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.iv.5 - IA Monitoring Instructions :

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 2.b.viii – Hospital-Home Care Collaboration Solutions IPQR Module 2.b.viii.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. 1. Caregiver unavailable or unidentified at the time of patient discharge. To mitigate risk, will (a) Assess level of caregiver support per patient upon admission (b) Link caregivers to supportive services (c) Employ language concordant care coordination staff and recruit staff from neighborhoods we serve to optimize community engagement. 2. Without a shared EHR system, there is risk of ineffective communication between hospital and home-care services, leading to disruption in care coordination. To mitigate this risk, will (a) Integrate HIT/EHRs to facilitate health information exchange between hospitals and SNFs/home care agencies. 3. If we do not address and document advance directives goals of care and patient/caregiver preferences at each transition, we risk fragmenting care. To mitigate risk, will (a) Leverage existing RN home services and care coordination, primary care and/or sub-specialty care services to increase goals of care training (b) Increase home and office-based palliative care consultations for chronically ill (c) Educate staff about Medical Orders for Life Sustaining Treatment (MOLST) (d) Work to communicate these wishes throughout patients' care pathways, within and outside our PPS 4. Collaboration with multiple experts and disciplines can lead to disagreements and delay completion of evidence-based care pathways. To mitigate risk, will (a) Establish clear protocols and evidence-based guidelines for co-morbid patients (b) Develop a learning collaborative, training guides, and opportunities for providers from various settings to meet face-to face (c) Identify and appoint a "Lead" and create an escalation process; the escalation pathways are stratified on actual/potential domains (clinical, medical, psycho-social, behavioral, finance) 5. Patients may not have strong links to health care sites, particularly when patients leave facility AMA, "early dismissal". To mitigate risk, will (a) Trigger a process for activation of Rapid Response Team (RRT) for such conditions; targeted skill set, explore possibility of Mobile RRT in community 6. Lack of integrated health IT infrastructure, need for expanded telemedicine services, and parsimony resource allocation and sharing. To mitigate risk, (a) Significant investments to be made in shared HIT infrastructure, functioning HIE, and telemedicine services, requiring innovative payment models (b) Early and continued engagement with MCOs and policy/regulatory changes will facilitate integration and collaboration among competitive parties (c) Stratification method will be needed based on established criteria for assigned resources up to and including diffusion of care and intervention mapping 7. Regulations impacting provider-to-provider hospital-home care. To mitigate risk, will (a) Work with DOH to seek regulatory relief if regulatory barriers are identified 8. Patients may be faced with psycho-social strain (unstable housing, limited access to phone). To mitigate risk, (a) Rapid Response Team (RRT) will assess patients for psycho-social strain and refer to Health Home, NORC program, Senior Center or other CBO to address these. 9. May be difficult to engage CHHAs, SNFs and patients with INTERACT-like principles. To mitigate risk, will train all providers through validated methodology (motivational interviewing, patient centered assessments, etc.) to deal with culturally diverse patients with poor health literacy. Our PPS partners have experience with this and will share best practices to improve engagement and retention with INTERACT principles.

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Page 199 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) 10. Another potential risk is some Home Care agencies might become overburdened trying to meet the requirements of this project (resulting in lower performance). To mitigate risk, we will assess staffing, financial or compliance challenges on ongoing basis and support partners to improve quality

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.viii.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

19,000

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

8,550

12,825

17,100

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

4,275

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (4,275) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 202 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 2.b.viii.3 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice.

DY3 Q2

Project

N/A

In Progress

07/01/2015

09/30/2017

07/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Task

Rapid Response Teams are facilitating hospital-home care collaboration, with procedures and protocols for: - discharge planning - discharge facilitation - confirmation of home care services Task

Step 1: Assess any current hospitalist program(s) that involve discharge planning, facilitation, or confirmation of home services Task

Step 2: Identify staff roles currently involved in facilitating discharges Task

Step 3: Engage hospitalists in project workgroup Task

Step 4: Identify roles required and responsibility of Rapid Response Team members Milestone #2

Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence-based medicine and chronic care management.

DY2 Q4

Project

N/A

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Provider

Home Care Facilities

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Staff trained on care model, specific to: - patient risks for readmission - evidence-based preventive medicine - chronic disease management Providers Associated with Completion:

A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Zaheer Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf Elkomos Soliman; Akoto Edna; Al-

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Page 203 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Izzi Sawsan Hatim Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Ali Aleem A; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A Md; Androne Louis Cristian Md; Ankireddypalli Arvind; Annan Vivian; Anthony Antoinette Md; Antosofsky Howard Md; Arabelo Howard Anthony De La Paz; Arend Jonathan; Ares Ella; Armington Kevin John Md; Arnon Ronen Md; Aronov Margarita A Md; Arron Martin Md; Arya Vijaypal Md; Asare Vivian; Ascunce Gil Ignacio; Aseme Kamara; Aslam Ahmed Kamal Md; Assadi Mashid A; Astua Alfredo J Md; Asuen Imeutinyan Md; Auerbach Lisa Resnick Md; Austein Lance; Autz Arthur L; Ayinla Raji Mohammed Md; Azizi Efat; Alpine Home Health Care; Babaeva Saiera Md; Babb Frank C Md; Back Sara Deborah; Badlani Sachal Md; Bailey Juan A Md; Baird Philip Lee Md; Baird Sara; Bakshi Anjali Md; Banta Erin; Baran Margaret Md; Baron Natacha Adele; Barrett Conor Dominic; Barsa Jonathan; Bassoul Nissim Moses Md; Batra Kamal Kumar Md; Beaubrun Pierre Ronald Md; Bee-Healthy Proffessional Ped; Begun Jay R Md Pc; Belilovsky Anatoly Md; Benchimol Corinne Do; Bennett Stephen J Md; Benovitz Harvey L Pc Md; Benrath Michelle; Bentsianov Marie Azer Md; Bergman Michael; Berkowitz Leonard Bruce Md; Berlin Arnold I Md; Berman Paul Jeremy; Berwald Cary M Md; Besada Inacia Perez Md; Beth Israel Medical Ctr Act; Beuria Prarthana Md; Bhandari Rekha Md; Bhat Kiran Kumar Md; Bhat Sandeep Md; Bhatia Sonica; Bhatt Anjani A Md; Bhattacharya Sarmistha Md; Bickell Nina Andrew Md; Bilik Ilya V Md; Bioh Dominick Kwasi Md; Blackett-Bonnett Terry Md; Blair Seidler Hammond; Blidnaya Lana; Boah William Ofori Md; Bogdanov Assen Petrov Md; Boguski-Filgueira Lisa F; Borrego Fernando J Md; Bourne Jeffrey Md; Bowers Daniel; Braswell Lezli; Braun James Frederick; Braun Maureen K; Braza Mary; Brescia Andrea M Md; Briggs Haydn Md; Briones Alan Paul Santos Md; Brody Erica Md; Brody Samuel A Md; Bron Yana Md; Brown Laura E; Brownlow Nathaniel Md; Brunner Steven J Md; Bryant Linda M Md; Buhion Caroline; Bukberg Phillip R Md; Burger Alfred Paul Md; Burke Gary Robert; Busta Agustin Md; Bustamante Marco Md; Butt Ahmar Aziz Md; Bestcare, Inc.; Cadag Stefan; Calabio Rafaela Z Md; Calamia Vincent Md; Callahan Mark; Camargo Edgar Md; Camargo Marianne; Cammerman Daniel Joseph Md; Carcaterra Joann Do; Castillo-Rodriguez Raquel; Castro George A Md; Cataldo Donnalee; Ceballos Clare; Cecilia Griselda Calderon Md; Cespedes Michelle Simone; Cha Yonhee Md; Chadi Ronny M Md; Chafian David Jonathan Md; Chan Chun-Kit; Chan Hang; Chan Sheung-Kwun Samuel Md; Chang Jung Mi Md; Charlotten Kevin Alexander Md; Chasan Rachel; Chase Jennifer C; Chatterjee Lolita Md; Chattooo Premetesh Do; Chaudhry Naeem Akhter Md; Chavez Silvia; Chen Abigail; Chen Chao Do; Chennareddy Swaminathan; Cherian Siby Vengal Md; Chery Roselyne Md; Cheung Barbara A; Cheung William Md; Chhipa Mohammad Haroon Md; Chitu Carmen Elena; Chiu Gregorio E Md; Cho Hyung; Choe Josefina Luna Md; Chopra Ashok Chanparkash; Chow Desiree; Chow Rita Md; Chu Carolyn Md; Chu Jaime; Chuey John Md; Chun Eunmee H; Chung Andrew; Chung Bruce K Md; Chung Derek G Md; Chung Sung Lan Md; Ciechorska Maria Md; Cieloszyk Kinga Marta Md; Clark Cheryl L Md; Clemens Christopher Md; Coghill Alice Victoria Md; Cohen Alan J Md; Cohen Randy Edward; Cohen Roy A Md; Cohen Sandra; Cohrssen Andreas Md; Collins Megan Elizabeth Md; Conde Wright Marie France Md; Contreras Johanna Paola; Cook Heather Tiffany Md; Cook-Mack Jessica Phylis; Corrigan Kathleen; Cortes Jose Alberto Md; Cortijo Amarilys R Md; Cosmatos Andreas Md; Cosme-Thormann Braulio Federico; Coupet Nadege Marie Md; Cox Katherine Anne; Croft Lori Bray Md; Cruz Christina; Cunningham-Rundles C Md; D Oleo Vargas Maximo Jose; D'Souza David J Md; Da Rosso Robert Cian Md; Dadarwala Aashish Dhansukhlal; Daniele Rosemary Ann; Danik Jacqueline Suk; Danik Stephan B; Dantchenko Victoria Md; Daskalakis Demetre Costas; Davidson Morton I; Davis Yonette Md; Decherrie Linda Vandaele Md; Defabritus Albert M Md; Delaet David Edward Md; Dematteo Robert Enrico Md; Dennis Tian-Shu Chang; Depetris Gustavo Raul Md; Descartes-Walker Ingrid Md; Desikan Sonia; Desir Mergie X Md; Desrosiers Jean Claude; Devons Cathryn A Md; Dharapak Patricia Md; Di Scala Reno Gennaro Md; Diaz Michael Md; Dick Jeffrey M Md; Dickerson Lauren; Dilmanian Rossana; Disla Eddys Md; Doan-Schultz Yvette Chi; Docu Theodore Costa Md; Domek Maciej Md; Donovan Edmund J; Doshi Dhvani; Douglas Orin Albert; Dove Arthur Renner Md; Drake Victoria; Drazenovic Ivo; Drukman Liliya Md; Drullinsky Alexix Cesar Md; Dubey Sudha; Duddempudi Nagamma; Dumas Marie; Dunn Andrew S Md; Dunner Ricardo Orlando Md; Dvorkina Anzhela Md; Dwarka Regev Ragbardial; Dy-Guillaume Marie Eve Md; Edano Albert E Md; Edelman Laurie Beth Md; Eden Alvin N Md; Edgecomb Paul Steven; Edwards Ayisha Tene; Edwards Donna; Edwards Sharon M Md; Ehrlich Martin H Md; Eidgah Mahyar Md; Eisenson Arlene; Eisner Yvonne; Elbirt Paula M Md; Eliot P Schuster Md Pc; Ellis Earl Anthony Md; Eloi-Stiven Marie L; Emily Otis Taylor Md; Emmer Louis Mark Md; English Cary Md; Enschede Elizabeth; Enu Christopher Chukwuemeka; Eric S Barna; Erlikh Irina; Escalera Elsa Md; Escher Jeffrey Ethan Md; Escobar Christian; Esposito Amy; Esposito Stephen P Md; Etkin Alexandra; Factor Stephanie Hope Md; Faculty Practice Associates; Fafalak Robert G Md; Fakhruddin Dilshad Md; Farhat Hassan Ail Md; Farhat Samir Ali Md; Farrell Cristina; Fatica Nunzia Md; Feder Erica; Federman Alex David Md; Fefer Jose Jacobo Md; Feingold Leonard N Md; Felsen Michael R Md; Fenyves Andras Md; Fernaine George Md; Ferris David Craig Md; Field Jonathan Md; Fields Jessie Alfreda Md; Fierer Daniel Seth Md; Fievre Garnes Marie Ft Md; Finkelstein Donna Michal Md; Finkielstein Dennis Md; Fiorentino Thomas C Md; Fishman Donald R Md; Fisk Rebecca Saslow Md; Fisse Richard D Md; Fogel Joyce Frances Nahum Md; Fonfeder William; Ford Miriam; Forman Joel Alexander Md; Forman Lisa Diane Md; Forsyth Beverly Alison Md; Fox Kelita Louise; Frankel Etta Md; Frederic Bakhchi Md; Fresneda Caridad; Friedman Samuel; Friedman Scott L Md; Fteha Elie Md; Fuchs Thomas Md; Galal Nehal; Galvez Maida P Md; Ganatra Anjna Nain; Gandhi Vani Pragnesh Md; Ganea Gheorghe Romeo Md; Garankina Olga; Garber Julia; Garcia Quinones Saribel; Gardenier Donald; Gati Allison; Gault Allison Tamara Md; Gayle Eric George Md; Gazali Radfan M; Geraldine Yasmine Joseph; Gerdis Michael Md; Gerner Jenny; Gerolemou Louis N Do; Gershengorina Sofya Md; Gervais Carole E; Gharpure Anil Md; Ghooi Ashok Md; Ghosh Anita; Gibbons Olga; Gidfar Niloufar Md; Gidwani Sonia Md; Giegel Melanie Joy; Gilgoff Hugh L Md; Gillespie Ginger Md; Ginde Ranjan; Glasser Lynne Ann Md; Gliatto Peter Matthew Md; Goetz Celine; Goforth Thomas; Goldblum Louis M Do; Goldman Adam Y Md; Goldstein Lissa Kary; Goldstein Zil; Goldstone Elaine Brown; Gomez Gomez Veronica Del Carmen; Gomez Tessa S Md; Goodman Eric; Goodman Karl Richard Md; Goodman Stephanie Michelle; Gorny Mark A Md; Gottlock Robbins L; Gould Sanford Md; Gounder Celine Rani; Goyal Ravindra Kumar Md; Grabscheid Erica Md; Grand Mark Alan Md; Graney John Md; Grant Jessica J Md; Graziano Michelle; Greely John Stephen Md; Green Stuart Md; Gressel Irina Md; Gribetz Irwin X; Grimm Katherine Teets Md; Grossman Howard Alan Md; Gruber Steven Jeffrey Md; Guevara Elizabeth D L A Md; Guillen Rafael A Md; Gulrajani Ramesh S Md; Gupta Ashita; Gupte Amrita K Md; Guy Judath Philip; Hackenburg Emily; Hailu Mekdes Md; Hak Virender Md; Halberstam Meyer S Md; Hana Ehab Joseph; Hanna Emad; Haque Sayera Md; Harbord Nikolas B Md; Hariri E; Hashemian Nezhat Md; Hassan Yasmin Akbar Md; Hawkins Katherine A Md; Hazel Edovard Joseph Md; Hefferon Susan; Hernandez Cameron Roland Md; Hewitt Ross G Md; Hill Keran; Ho Wesley Hok Man; Ho Wing Wah Md; Hobson Steven; Hodjati Ramin; Hoffman Judith; Hofmeister Stephen Frank Md; Hollman Dominic; Horn Ansell Np; Horowitz Carol Rose Md; Hsiung Ahmed Leslie; Hudesman David Philip; Hui Yiqun; Hupriker Shirish S Md; Husain Syed S Md; Hussaini Batool M Md; Hussaini Syed Zabeehullah Md; Hwang Andrew; Housing Works; Iglesias Alejandro D Md; Inada Victor Katsuji Md; Indio Lillian R; Institute For Family Hlth; Iocolano Carolyn F; Iqbal Muhammad Z Md; Irani Dinaz; Ismailova Kyamalya A; Israel Ezra Ceasar; Issa Ricardo Fabian Md; Issack Joshua; Itzkovitz Ina S Md; J Barbazan-Silva M D P C; Jaber Nadim; Jacobson Robin; Jagger Samantha Jane; Jahan Mumtaz Md; Jan Ren Bang Md; Janice Prime Care Medical Pc; Jao Jennifer; Jaradeh Issa E; Jasti Harish Md; Jasty Babu N Md; Jawaid Mohammad Md; Jennifer B Cerasoli Md; Jennifer Kar Yee Hui; Jervis Ramiro Md; Jhagroo Omesh; Jhagroo Vishnudatt Md; Jimenez Mariela; Jimenez Roxanna; Jimmy R Sitt; John Bertha; Johnson Livette S Md; Johnson Timothy Curtiss Md; Jones Elizabeth Mary; Jones Michael Abou Md; Jones Vivian Lynn; Joseph Marjorie Md; Joseph Myriam; Judeh Hani; Jung Tiffany Maysu; Kale Minal Sharatkumar Md; Kannry Joseph L Md; Kaplan-Weisman Laura; Karakas Serife Eti Md; Karp Sara; Kashan Glenn Lawrence Md; Katz Cynthia J Md; Kensaint Pascale Md; Kent Jennifer Ames Md; Kerr Leslie Dubin Md; Khabyeh Shaya; Khaim Rafael Np-C; Khalid Nazneen Md; Khan Shumaila; Khorets Boris A Md; Kilinski Benjamin; Kim Julie; Kim Kyu-Han Md; Kim Sarah K; Kim Tonia K. Md; Kimble Christine Md; Kirkham Elizabeth; Kirschner Eric Md; Kitson Kwame A Md; Klein Daniel P Md; Klein Oscar Md; Kletsman Igor Md; Klimenko Elena A Md; Ko Fred Chau-Yang; Koicke Betsy C; Kondamudi Vasantha Kumari Md; Kondaveeti Harika; Kopke Mary; Koshy Sanjana Cherian; Kothari Vipul Chandrakant; Kozlov Natalya; Krausz Robert B Md; Kulina Georgia; Kuwama Yuichiro; Lai Anne; Lai Joanne Md; Lalia Madeline R Md; Lamb Angela; Landerer David; Lane Matthew John Md; Lantz Howard Md; Latt Ko Ko; Law Singwu David; Lawrence Donald P Md; Lawrence Donna Anthea; Lazala Polanco Carmen Md; Lazarin Margaux Helene; Leasy Menachem Jeremy; Leber Robert J Md; Leder Marvin A Md; Lee Hanna; Lee Jeong Ran Oh; Lee Marjorie Pc Md; Lee Namhi; Lefevre Lionel Md; Lefevre Marie Edith Faublas; Leinbach Lindsey; Lekht Vladimir; Lempel Herbert Sheldon Md; Lerner Gary; Lesnewski Ruth F Md; Levin Marc William Md; Levine Steven Barry Md; Levine-Tanco Karen; Li Ka Md; Liang Elizabeth; Liao Emilia Pauline Md; Liberman Dina Md; Lin Elaine Patricia; Lin Jenny Jen-Yi Md; Lin Lee Yulee;

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Linetskaya Irina; Lombardi Paul Md; Lopez Clark Faafp Md; Lopez-Santini Jaime; Lovenvirth Wendi Jennifer Md; Lowe Rajani; Lu Haiyan; Lurio Joseph Glen Messner Md; Luz Amarilis Lugo Md; Lwin Yinphyu Win; Ly Rose Vay Luong Md; Lynch Colleen; Lynch Gina Adriana Md; Mack Theresa Adele Md; Mackay Richard E Md; Madhava Valsa S Md; Madrid Tanya M Md; Maggio Johanna Medodie; Malachovsky Martin; Malieckal Jubil Md; Mamoon Nahreen Md; Manasia Anthony Robert Md; Mantia Augustus G Md; Mantia Philip Anthony Md; Manvar Buddhadev Nathabhai Md; Mararenko Larisa Md; Marcantonio Colomba A Md; March Anika Jolene; Maritato Andrea F Md; Markoff Brian A Md; Marseille Beatrice; Marsh Franklin Jr Md; Martin Monica A; Martinez Ofelia Md; Masson Ella; Mathews Premila Maria; Mathieu Claudine; Matthew S Cohen Md Pc; Mattoo Uijay Kumar Md; Maw Myo Md; Maybody Shideh; Mayer Amir Md; Mayer Victoria Lee; Mazza Michael Anthony Md; Mccormick Elizabeth T; Mcdonagh Mary Valentine; Mcgoldrick Patricia Engel; Mclaughlin Mary Ann Md; Mclendon Lucia Cogswell; Meacher Peter; Meah Yasmin Sultana Md; Medder Nia; Medina Leonel Delos Reyes; Meed Steven D Md; Meer John Fredric Md; Mehandru Saurabh; Mehta Davendra Md; Mehta Viplov K Md; Melis James Mark; Meltzer Elyse Michele; Menon Rakesh; Menon Rekha; Mensah Doreen Akosua Md; Merchant Yuko Md; Meredith Wepner Grossman; Merkler Richard G Md; Messinger Meridith L Md; Mettu Sudhakar Reddy Md; Mezheritsky Eleonora Md; Michael M Gaisa; Mikhail Imad Md; Mikkola Eeva Johanna; Milani Haleh Md; Miller Elizabeth; Miller Marc Andrew Md; Miller Sarah; Milman Alisa Md; Min Insung; Mino Rosa Elena Md; Mir Mohammad Arshad Md; Mirlohi Hooshang Pc Md; Misra Deepika Md; Mitchell Harrison Md; Moarefi Mehran-Reza Md; Moberg Kenneth A; Mocombe Lucien D Md P C; Modern East West Medical Pc; Moe Khaing Md; Mogilner Leora Naomi Md; Mohammad Sajjad; Mohanraj Edwardine Mirnalini; Moise Wesner Md; Motiram Savitri Ramdass Md; Mozayan Mahboobeh; Mullen Michael Patrick Md; Muller David; Mumford James M Md; Murayama-Greenbaum Robert Md; Murphy Barbara Therese Md; Murray Carolina; Muse Jessica Md; Myint Moe Moe; Myint Richard Md; Mountsianihealthsystem; Mountsianihealthsystem; Nae Edison Llc Dba Edison Home Health Care; Naing Zaw Md; Nandi Anukul C Md; Nasr Sherif; Nasreen Tahera; Nassif Neven Ibrahim; Natarajan Rupa Narayani; Naughten James Kevin Do; Nautiyal Preeti Md; Navid Kathy Farima Md; Neretin Nicole; Nghi Phuong M Md; Nguyen Henry Van; Nguyen James K; Nguyen Thomas Thang Md; Nichols Andrea Marisa Md; Niforos Fotis; Nisanian Anahid Jaquelline Md; Nissim Julie Md; Nosal Sarah Catherine; Novak Bethany Randi; Nowak-Wegrzyn Anna Halina Md; Nucci-Sack Anne Terese; Nweke-Chukumerije Obiageli Md; New York Legal Assistance Group; Obonaga Sheila; Ofosu-Amaah Sophia Md; Ogbovoh Daniel Obaroakpor Md; Oji Ngozi Afiazu Md; Okhravi Siavash Steve; Okpaleke Ifeoma Brenda; Olajide Bolanle A Md; Oliver Kristin; Orbe Jessica Md; Orin Gary Bruce Md; Orris Maxine Md; Osher Annette; Osoba Olumide Obafunmilayo Md; Osorio Georgina; Ostrager Jill Beth Md; Ostrowska Aneta; Ostrowski Roman M Md; Othoniel Marlene; Ottaviano Lawrence John Md; Paa Remedios Caparas; Pachman Jason Lee Md; Paddu Upadhyaya Padmanabh; Pagan Diane Elizabeth; Page Cameron Stuart; Pandya Amy Arun Md; Paredes Tessie Timitiman Md; Parikh Rita Md; Parkas Valerie Md; Parnes Eliezer L Md; Patel Deepti Dev; Patel Dipal Md; Patel Girishkumar Md; Patel Shamit P Md; Patel Sunil Md; Patel Truptiben; Patel Vidya; Patel Vinisha Md; Patrick Dalton Md Pc; Peccoralo Lauren Alise Md; Peimer Marta Silvee; Pena Armando Juan; Pennant Ainsley Md; Perry Andrea; Persaud Indrani; Perumareddi Krishna; Petelin Andrew Patrick Md; Peterson Monte Harold Md; Petilla-Onorato Jessica Isabel Md; Petrov Manana Md; Phillip Sohn; Photangtham Punyatech Md; Pierce Carolyn Marie; Pierre Louisdon Md; Pierro Hugo Md; Pileta Lourdes X; Pinkas Adina Md; Plokamakis Michael Md; Poff John Edward; Poitevien Vaty; Polavarapu Hari Kishan Md; Ponieman Diego Andres Md; Poomkudy Liz; Posada Roberto Md; Pressler James Md; Prigollini Alejandro Md; Prine Linda Whisler; Pristoupa Olga Md; Psevdos George Jr Md; Puente-Guzman Soledad Elvira; Pumarol Alba; Purohit Amar Lal Md; Parker Jewish Institute For Health Care And Rehabilitation; Premier Home Health Care Services, Inc.; Quick Melissa Kaufman; Quinn Carrie; Racanelli Joseph A Md; Radix Anita Eileen; Rafailov Danil Isakovich; Rafatjah Soyona; Rahman Rummana Md; Rahman Shafiqur Mohammed Md; Raifman Leonard I Md; Rajda Geetanjali Md; Ramkeesoon Rosemarie Np; Ramnarine Jotir; Ramos Tapia Alberto M Md; Rana Shital; Rathi Dwarka P Md; Raufman Joshua; Ray Roona; Ray-Schoenfeld Naomi; Read Dalan Md; Reckrey Margaret Jennifer; Reddy Chenna B Md; Reddy Lalitha Mary Md Pc; Rehman Abdul Md; Reich Danya; Reister Robin; Remde Alan Hugh; Reminick Marshal Md; Renaud Jean Leopold Edwrin Md; Reuben Stephen W; Reyes-Arcangel Fe T; Rezvani Mitra Md; Rice Laurie A Cochran Md; Rios Carlos Md; Ripp Jonathan A Md; Rivera Graciano Md; Rivera Veronica; Rizk Dahlia Md; Robert Joyce Folashade; Robie Kristin; Robinson Roberto H Quinonez Md; Rodgers Stephen L; Rodriguez German; Rodriguez Navarra; Rodriguez-Caprio Gabriela Md; Rodriguez-Jaquez Carlos R; Roedan Socrates; Rogers Linda Md; Roman Jasmin; Rosch Elliott C Md; Rosen Carolyn Michelle Md; Rosenberg Rachel; Rosenbloom Sylvie; Roshchina Yelena; Roth Rachel; Ruhe Jorg Joachim; Rule Erin Eileen Mdf; Russak Lisa; Ridgewood Bushwick Senior Citizen Homecare Council; Sacco Joseph P Md; Sacher Mandy Lauren; Sacolick Benzion Md; Sacolick Daniel; Saftchick Stuart L Md; Sagalovich Boris Md; Saha Prantik Md; Saigh Orit Md; Saint-Laurent Mario; Saint-Louis Frantz Fils Md; Salinas Jean-Louis Md; Salomon Nadim Md; Sam Tanyka; Samaniego Robert Md; Samra Faraj; San Myat Md; Santiago Allan Realin Md; Saporito Anna Gabriella Md; Sara Danielle Lorenz Md; Sarin Aparna; Satsky Mindy B Md; Savransky Alla Md; Saw Thazin Md; Sazan Inga; Schiller Robert M Md; Schirripa John Piero Md; Schneebaum Cary Md; Schwartz William J Md; Sco Family Of Services; Scrimmager Leon Md; Seidler Afet Md; Seigel Rebecca Rae Md; Semanision Kristen; Senzamici Camille Md; Sessions Jessica; Setaruddin Sazia Loqman Md; Setia Deepak K Md; Shah Harshida R Md; Shah Jilan Md; Shah Kumarpal A Md; Shah Sumatilal C Md; Shahkoohi Afshin Md; Shaikh Aftabahmed F Md; Shalhoub Robert Francis Md; Shein Ruvan Md; Sheinfeld Joanna; Shen Kuan Hung Md; Shenko Christina Angela; Sherman Frederic M; Shieh Jong-Chuan Md; Shimonov Josef Md; Shirwaikar Anil B Md; Shukla Mayank Arun Md; Shust Gail; Siddiqui Ayesha; Siegel Howard Md; Siegel Stephen D Md; Sierros Vasilios Md; Sigel L Keith Md; Sigrest Barbara Md; Sikder Subhash Chandra; Simpao Jose Rodriguez Jr Md P; Sindhwani Rajeev Md Pllc; Singal Anita; Singh Jagjit Md Pc; Siroya Pushplata B Md; Sisser Rachel; Sloan Barry; Small Katherine Morgan; Smith Alford Alexander Md; Smith Sharon Ellen Md; Smith Verta I Md; Sokolova Ekaterina; Solomon Rachel; Soriano Theresa A Md; Sosinsky Jeffrey H Md; Sotnik Regina Md; Sourial Lucy A Md; Spieler Leah Matisse; Spitzer Matthew; Spivak Dana Md; St Louis Emmanuel Lesly G Md; Sta Ana Victor; Stallings Shavonn; Starpoli Anthony A; Stauber Stuart L Md; Steever John B Md; Stein Alan J Md; Stein Janet Laurie Md; Steklova Olga Md; Stivala Alicia Christina; Straus Emily L Md; Strauss Michael Leopold Md; Strong Jennifer Elizabeth; Suden Stacy Allisa Md; Sugandhi Nandita; Suja Vinod; Suma Dasari; Suprin Gregory Md; Suter Maureen Natalie; Syed Ahmad Physician Pc; SyedNaqvi Samina Altaf Md; Szalyga John Md; Taha Hesham Mohamed Md; Talavera Wilfredo Md; Talcott James; Talerico Amanda Rae; Tam Cynthia J Md; Tamdji Natacha; Tan Wu; Tang David J Md; Tang Ian Tsai-Leu Md; Tao Chenguang Tony; Teets Raymond; Teich Marvin L Md; Tenney Nancy Lee; Tesler Peter Jon Md; Theodore Ginette Np; Thomas David Charles Md; Tikhonova Elizaveta; Tikko Suraj K Md; Tio Ruy Chen Md; Tkachenko Natalya Md; Tolbert Jerome V Md; Trager Abigail Hope; Trenton Brooke; Truglio Joseph; Truong Tuyettrinh Nguyen; Tsai Tien-Tsai; Tso Alan Ying Yeung; Tun-Chiong Yolanda Do; Tung Keith; Turetsky Risa Ross; Turner Stephen B Md; Udesky Robert A Md; Uleis Keith Harris Md; Urbina Antonio E Md; Uribarri Jaime V Md; Uribe Alejandra Maria Md; Vail Rona; Valasareddi Lalasa Reddy Md; Vamadevan Nallasivam Md; Van Gilder Max F Md; Vanegas Edgar Z Md; Vangeepuram Nita Md; Varghese Betsy; Varma Sudha Md; Vasa Chiroq V Md; Vasiliadis Athanasia S Md; Vavasis Anthony P Md; Veeramachaneni Saimamba Md; Vega Aida; Velazquez Belinda Melissa Md; Veluswamy Rajwanth; Vero Erica; Vicencio Alfin G Md; Villani Gina M Md; Vilnits Anatoliy Md; Vinas Sonia Miliza Md; Vindhya Rajesh Kumar Chand Md; Virani Zahra; Vizel-Schwartz Monique; Voddi Madhu D Md; Volokh Vladimir Md; Waite Eva Ann Md; Wajnberg Ania Md; Waldron Mary Violet Md; Walker Jenny; Wallach Frances Robin Md; Walsh Margaret Mary; Wang Emily H; Wang Jing Wa; Wang Stephanie Chih-I; Wang Zhong; Warman Jacob I Md; Waseem Faisal Md; Watkins Isheka S; Weintraub Jennifer; Weir David C; Wen-Ray Thomas Hsu; Whipple Clare; White Camele; White Elizabeth Stuyvesant Md; Wiener Joseph M Md; Wilder Venis Tiarra; Wong Chun Tung Md; Wong Hok; Woodley Walter Md; Xu Tao Shiwei; Yanagisawa Robert Takahiro Md; Yancovitz Stanley R Md; Yap Marcelo Janette Md; Yen Vincent Md; Young Edwin Reynolds Md; Yousaf Ali; Yudelman Ian M Md; Yuen Jacqueline; Zalavadia Deepti; Zaremski Benjamin Md; Zelenetz Michael Ivan Md; Zewde Mulubrhan; Zhang Jian Wei; Zhang Meng; Zheng Hanbin Md; Zilberman Alla; Zinger Yevgeniya Oskarovna Md; Zoubtsova Minzalia Md; Zuger Abigail Dell Md; Zylbert Susan Lynn Md Task

Evidence-based guidelines for chronic-condition management implemented.

Project

Completed

NYS Confidentiality – High

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 1: Standardize risk stratification across PPS and implement evidence-based guidelines for each risk level leveraging Hierarchical Conditions Category (HCC) score, and other appropriate measures

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/01/2016

12/31/2016

03/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

06/30/2016

03/31/2017

06/30/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 2: Determine information transfer from hospital to home care to assure accurate stratifications Task

Step 3: Develop care models for rehospitalized patients Task

Step 4: Establish procedures to perform initial and continuing staff competency testing Task

Step 5: Establish policies/procedures to monitor patient outcomes of care and/or hospital readmissions and share with staff Task

Step 6: Educate/Orient physicians and other care givers on evidence based practices Task

Step 7: Collect current evidence-based practices from partnering providers Task

Step 8: Evaluate and determine evidence-based practices to be used PPS-wide in collaboration with disease specific project workgroups Task

Step 9: Create implementation plan of evidence-based practices and submit to PPS (each provider completes this) Task

Step 10: Monitor use of evidence-based practices across providers Task

Step 11: Establish continuous evaluation of new evidence-based practices for implementation Milestone #3

Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer. Task

Care pathways and clinical tool(s) created to monitor chronically-

DY2 Q4

Project

Project

N/A

NYS Confidentiality – High

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Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

ill patients. Task

PPS has developed and implemented interventions aimed at avoiding eventual hospital transfer and has trained staff on use of interventions in alignment with the PPS strategic plan to monitor critically ill patients and avoid hospital readmission.

Provider

Safety Net Hospital

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/31/2015

06/30/2016

12/31/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

12/31/2015

12/31/2016

12/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/31/2015

03/31/2017

12/31/2015

03/31/2017

03/31/2017

DY2 Q4

Providers Associated with Completion: Beth Israel Medical Ctr Act; Brooklyn Hospital Center; Mount Sinai Hospital; N Y Eye And Ear Infirmary; St Lukes Roosevelt Hsp Ctr Task

Step 1: Collect care pathways currently used by partnering providers Task

Step 2: Select care pathways to be used PPS-wide Task

Step 3: Engage physicians and other care givers on care pathways Task

Step 4: Determine standardized interventions for early identified instability Task

Step 5: Identify obstacles for implementation Task

Step 6: Monitor providers' compliance with selected care pathways Task

Step 7: Implement ongoing assessment for high risk patients Task

Step 8: Implement integrated care team to divert hospitalization working with care coordination cross functional group Task

Step 9: Conduct provider training on interventions Milestone #4

Educate all staff on care pathways and INTERACT-like principles.

DY2 Q4

Project

N/A

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Provider

Home Care Facilities

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Training program for all home care staff established, which encompasses care pathways and INTERACT-like principles. Providers Associated with Completion:

A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Zaheer Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf Elkomos Soliman; Akoto Edna; Al-

NYS Confidentiality – High

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Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Izzi Sawsan Hatim Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Ali Aleem A; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A Md; Androne Louis Cristian Md; Ankireddypalli Arvind; Annan Vivian; Anthony Antoinette Md; Antosofsky Howard Md; Arabelo Howard Anthony De La Paz; Arend Jonathan; Ares Ella; Armington Kevin John Md; Arnon Ronen Md; Aronov Margarita A Md; Arron Martin Md; Arya Vijaypal Md; Asare Vivian; Ascunce Gil Ignacio; Aseme Kamara; Aslam Ahmed Kamal Md; Assadi Mashid A; Astua Alfredo J Md; Asuen Imeutinyan Md; Auerbach Lisa Resnick Md; Austein Lance; Autz Arthur L; Ayinla Raji Mohammed Md; Azizi Efat; Babaeva Saiera Md; Babb Frank C Md; Back Sara Deborah; Badlani Sachal Md; Bailey Juan A Md; Baird Philip Lee Md; Baird Sara; Bakshi Anjali Md; Banta Erin; Baran Margaret Md; Baron Natacha Adele; Barrett Conor Dominic; Barsa Jonathan; Bassoul Nissim Moses Md; Batra Kamal Kumar Md; Beaubrun Pierre Ronald Md; Bee-Healthy Proffessional Ped; Begun Jay R Md Pc; Belilovsky Anatoly Md; Benchimol Corinne Do; Bennett Stephen J Md; Benovitz Harvey L Pc Md; Benrath Michelle; Bentsianov Marie Azer Md; Bergman Michael; Berkowitz Leonard Bruce Md; Berlin Arnold I Md; Berman Paul Jeremy; Berwald Cary M Md; Besada Inacia Perez Md; Beth Israel Medical Ctr Act; Beuria Prarthana Md; Bhandari Rekha Md; Bhat Kiran Kumar Md; Bhat Sandeep Md; Bhatia Sonica; Bhatt Anjani A Md; Bhattacharya Sarmistha Md; Bickell Nina Andrew Md; Bilik Ilya V Md; Bioh Dominick Kwasi Md; Blackett-Bonnett Terry Md; Blair Seidler Hammond; Blidnaya Lana; Boah William Ofori Md; Bogdanov Assen Petrov Md; Boguski-Filgueira Lisa F; Borrego Fernando J Md; Bourne Jeffrey Md; Bowers Daniel; Braswell Lezli; Braun James Frederick; Braun Maureen K; Braza Mary; Brescia Andrea M Md; Briggs Haydn Md; Briones Alan Paul Santos Md; Brody Erica Md; Brody Samuel A Md; Bron Yana Md; Brown Laura E; Brownlow Nathaniel Md; Brunner Steven J Md; Bryant Linda M Md; Buhion Caroline; Bukberg Phillip R Md; Burger Alfred Paul Md; Burke Gary Robert; Busta Agustin Md; Bustamante Marco Md; Butt Ahmar Aziz Md; Cadag Stefan; Calabio Rafaela Z Md; Calamia Vincent Md; Callahan Mark; Camargo Edgar Md; Camargo Marianne; Cammerman Daniel Joseph Md; Carcaterra Joann Do; Castillo-Rodriguez Raquel; Castro George A Md; Cataldo Donnalee; Ceballos Clare; Cecilia Griselda Calderon Md; Cespedes Michelle Simone; Cha Yonhee Md; Chadi Ronny M Md; Chafian David Jonathan Md; Chan Chun-Kit; Chan Hang; Chan Sheung-Kwun Samuel Md; Chang Jung Mi Md; Charlotten Kevin Alexander Md; Chasan Rachel; Chase Jennifer C; Chatterjee Lolita Md; Chattooo Premetesh Do; Chaudhry Naeem Akhter Md; Chavez Silvia; Chen Abigail; Chen Chao Do; Chennareddy Swaminathan; Cherian Siby Vengal Md; Chery Roselyne Md; Cheung Barbara A; Cheung William Md; Chhipa Mohammad Haroon Md; Chitu Carmen Elena; Chiu Gregorio E Md; Cho Hyung; Choe Josefina Luna Md; Chopra Ashok Chanparkash; Chow Desiree; Chow Rita Md; Chu Carolyn Md; Chu Jaime; Chuey John Md; Chun Eunmee H; Chung Andrew; Chung Bruce K Md; Chung Derek G Md; Chung Sung Lan Md; Ciechorska Maria Md; Cieloszyk Kinga Marta Md; Clark Cheryl L Md; Clemens Christopher Md; Coghill Alice Victoria Md; Cohen Alan J Md; Cohen Randy Edward; Cohen Roy A Md; Cohen Sandra; Cohrssen Andreas Md; Collins Megan Elizabeth Md; Conde Wright Marie France Md; Contreras Johanna Paola; Cook Heather Tiffany Md; Cook-Mack Jessica Phylis; Corrigan Kathleen; Cortes Jose Alberto Md; Cortijo Amarilys R Md; Cosmatos Andreas Md; Cosme-Thormann Braulio Federico; Coupet Nadege Marie Md; Cox Katherine Anne; Croft Lori Bray Md; Cruz Christina; Cunningham-Rundles C Md; D Oleo Vargas Maximo Jose; D'Souza David J Md; Da Rosso Robert Cian Md; Dadarwala Aashish Dhansukhlal; Daniele Rosemary Ann; Danik Jacqueline Suk; Danik Stephan B; Dantchenko Victoria Md; Daskalakis Demetre Costas; Davidson Morton I; Davis Yonette Md; Decherrie Linda Vandaele Md; Defabritus Albert M Md; Delaet David Edward Md; Dematteo Robert Enrico Md; Dennis Tian-Shu Chang; Depetris Gustavo Raul Md; Descartes-Walker Ingrid Md; Desikan Sonia; Desir Mergie X Md; Desrosiers Jean Claude; Devons Cathryn A Md; Dharapak Patricia Md; Di Scala Reno Gennaro Md; Diaz Michael Md; Dick Jeffrey M Md; Dickerson Lauren; Dilmanian Rossana; Disla Eddys Md; Doan-Schultz Yvette Chi; Docu Theodore Costa Md; Domek Maciej Md; Donovan Edmund J; Doshi Dhvani; Douglas Orin Albert; Dove Arthur Renner Md; Drake Victoria; Drazenovic Ivo; Drukman Liliya Md; Drullinsky Alexix Cesar Md; Dubey Sudha; Duddempudi Nagamma; Dumas Marie; Dunn Andrew S Md; Dunner Ricardo Orlando Md; Dvorkina Anzhela Md; Dwarka Regev Ragbardial; Dy-Guillaume Marie Eve Md; Edano Albert E Md; Edelman Laurie Beth Md; Eden Alvin N Md; Edgecomb Paul Steven; Edwards Ayisha Tene; Edwards Donna; Edwards Sharon M Md; Ehrlich Martin H Md; Eidgah Mahyar Md; Eisenson Arlene; Eisner Yvonne; Elbirt Paula M Md; Eliot P Schuster Md Pc; Ellis Earl Anthony Md; Eloi-Stiven Marie L; Emily Otis Taylor Md; Emmer Louis Mark Md; English Cary Md; Enschede Elizabeth; Enu Christopher Chukwuemeka; Eric S Barna; Erlikh Irina; Escalera Elsa Md; Escher Jeffrey Ethan Md; Escobar Christian; Esposito Amy; Esposito Stephen P Md; Etkin Alexandra; Factor Stephanie Hope Md; Faculty Practice Associates; Fafalak Robert G Md; Fakhruddin Dilshad Md; Farhat Hassan Ail Md; Farhat Samir Ali Md; Farrell Cristina; Fatica Nunzia Md; Feder Erica; Federman Alex David Md; Fefer Jose Jacobo Md; Feingold Leonard N Md; Felsen Michael R Md; Fenyves Andras Md; Fernaine George Md; Ferris David Craig Md; Field Jonathan Md; Fields Jessie Alfreda Md; Fierer Daniel Seth Md; Fievre Garnes Marie Ft Md; Finkelstein Donna Michal Md; Finkielstein Dennis Md; Fiorentino Thomas C Md; Fishman Donald R Md; Fisk Rebecca Saslow Md; Fisse Richard D Md; Fogel Joyce Frances Nahum Md; Fonfeder William; Ford Miriam; Forman Joel Alexander Md; Forman Lisa Diane Md; Forsyth Beverly Alison Md; Fox Kelita Louise; Frankel Etta Md; Frederic Bakhchi Md; Fresneda Caridad; Friedman Samuel; Friedman Scott L Md; Fteha Elie Md; Fuchs Thomas Md; Galal Nehal; Galvez Maida P Md; Ganatra Anjna Nain; Gandhi Vani Pragnesh Md; Ganea Gheorghe Romeo Md; Garankina Olga; Garber Julia; Garcia Quinones Saribel; Gardenier Donald; Gati Allison; Gault Allison Tamara Md; Gayle Eric George Md; Gazali Radfan M; Geraldine Yasmine Joseph; Gerdis Michael Md; Gerner Jenny; Gerolemou Louis N Do; Gershengorina Sofya Md; Gervais Carole E; Gharpure Anil Md; Ghooi Ashok Md; Ghosh Anita; Gibbons Olga; Gidfar Niloufar Md; Gidwani Sonia Md; Giegel Melanie Joy; Gilgoff Hugh L Md; Gillespie Ginger Md; Ginde Ranjan; Glasser Lynne Ann Md; Gliatto Peter Matthew Md; Goetz Celine; Goforth Thomas; Goldblum Louis M Do; Goldman Adam Y Md; Goldstein Lissa Kary; Goldstein Zil; Goldstone Elaine Brown; Gomez Gomez Veronica Del Carmen; Gomez Tessa S Md; Goodman Eric; Goodman Karl Richard Md; Goodman Stephanie Michelle; Gorny Mark A Md; Gottlock Robbins L; Gould Sanford Md; Gounder Celine Rani; Goyal Ravindra Kumar Md; Grabscheid Erica Md; Grand Mark Alan Md; Graney John Md; Grant Jessica J Md; Graziano Michelle; Greely John Stephen Md; Green Stuart Md; Gressel Irina Md; Gribetz Irwin X; Grimm Katherine Teets Md; Grossman Howard Alan Md; Gruber Steven Jeffrey Md; Guevara Elizabeth D L A Md; Guillen Rafael A Md; Gulrajani Ramesh S Md; Gupta Ashita; Gupte Amrita K Md; Guy Judath Philip; Hackenburg Emily; Hailu Mekdes Md; Hak Virender Md; Halberstam Meyer S Md; Hana Ehab Joseph; Hanna Emad; Haque Sayera Md; Harbord Nikolas B Md; Hariri E; Hashemian Nezhat Md; Hassan Yasmin Akbar Md; Hawkins Katherine A Md; Hazel Edovard Joseph Md; Hefferon Susan; Hernandez Cameron Roland Md; Hewitt Ross G Md; Hill Keran; Ho Wesley Hok Man; Ho Wing Wah Md; Hobson Steven; Hodjati Ramin; Hoffman Judith; Hofmeister Stephen Frank Md; Hollman Dominic; Horn Ansell Np; Horowitz Carol Rose Md; Hsiung Ahmed Leslie; Hudesman David Philip; Hui Yiqun; Hupriker Shirish S Md; Husain Syed S Md; Hussaini Batool M Md; Hussaini Syed Zabeehullah Md; Hwang Andrew; Iglesias Alejandro D Md; Inada Victor Katsuji Md; Indio Lillian R; Institute For Family Hlth; Iocolano Carolyn F; Iqbal Muhammad Z Md; Irani Dinaz; Ismailova Kyamalya A; Israel Ezra Ceasar; Issa Ricardo Fabian Md; Issack Joshua; Itzkovitz Ina S Md; J Barbazan-Silva M D P C; Jaber Nadim; Jacobson Robin; Jagger Samantha Jane; Jahan Mumtaz Md; Jan Ren Bang Md; Janice Prime Care Medical Pc; Jao Jennifer; Jaradeh Issa E; Jasti Harish Md; Jasty Babu N Md; Jawaid Mohammad Md; Jennifer B Cerasoli Md; Jennifer Kar Yee Hui; Jervis Ramiro Md; Jhagroo Omesh; Jhagroo Vishnudatt Md; Jimenez Mariela; Jimenez Roxanna; Jimmy R Sitt; John Bertha; Johnson Livette S Md; Johnson Timothy Curtiss Md; Jones Elizabeth Mary; Jones Michael Abou Md; Jones Vivian Lynn; Joseph Marjorie Md; Joseph Myriam; Judeh Hani; Jung Tiffany Maysu; Kale Minal Sharatkumar Md; Kannry Joseph L Md; Kaplan-Weisman Laura; Karakas Serife Eti Md; Karp Sara; Kashan Glenn Lawrence Md; Katz Cynthia J Md; Kensaint Pascale Md; Kent Jennifer Ames Md; Kerr Leslie Dubin Md; Khabyeh Shaya; Khaim Rafael Np-C; Khalid Nazneen Md; Khan Shumaila; Khorets Boris A Md; Kilinski Benjamin; Kim Julie; Kim Kyu-Han Md; Kim Sarah K; Kim Tonia K. Md; Kimble Christine Md; Kirkham Elizabeth; Kirschner Eric Md; Kitson Kwame A Md; Klein Daniel P Md; Klein Oscar Md; Kletsman Igor Md; Klimenko Elena A Md; Ko Fred Chau-Yang; Koicke Betsy C; Kondamudi Vasantha Kumari Md; Kondaveeti Harika; Kopke Mary; Koshy Sanjana Cherian; Kothari Vipul Chandrakant; Kozlov Natalya; Krausz Robert B Md; Kulina Georgia; Kuwama Yuichiro; Lai Anne; Lai Joanne Md; Lalia Madeline R Md; Lamb Angela; Landerer David; Lane Matthew John Md; Lantz Howard Md; Latt Ko Ko; Law Singwu David; Lawrence Donald P Md; Lawrence Donna Anthea; Lazala Polanco Carmen Md; Lazarin Margaux Helene; Leasy Menachem Jeremy; Leber Robert J Md; Leder Marvin A Md; Lee Hanna; Lee Jeong Ran Oh; Lee Marjorie Pc Md; Lee Namhi; Lefevre Lionel Md; Lefevre Marie Edith Faublas; Leinbach Lindsey; Lekht Vladimir; Lempel Herbert Sheldon Md; Lerner Gary; Lesnewski Ruth F Md; Levin Marc William Md; Levine Steven Barry Md; Levine-Tanco Karen; Li Ka Md; Liang Elizabeth; Liao Emilia Pauline Md; Liberman Dina Md; Lin Elaine Patricia; Lin Jenny Jen-Yi Md; Lin Lee Yulee; Linetskaya Irina; Lombardi Paul Md; Lopez Clark Faafp Md; Lopez-Santini Jaime; Lovenvirth Wendi

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Jennifer Md; Lowe Rajani; Lu Haiyan; Lurio Joseph Glen Messner Md; Luz Amarilis Lugo Md; Lwin Yinphyu Win; Ly Rose Vay Luong Md; Lynch Colleen; Lynch Gina Adriana Md; Mack Theresa Adele Md; Mackay Richard E Md; Madhava Valsa S Md; Madrid Tanya M Md; Maggio Johanna Medodie; Malachovsky Martin; Malieckal Jubil Md; Mamoon Nahreen Md; Manasia Anthony Robert Md; Mantia Augustus G Md; Mantia Philip Anthony Md; Manvar Buddhadev Nathabhai Md; Mararenko Larisa Md; Marcantonio Colomba A Md; March Anika Jolene; Maritato Andrea F Md; Markoff Brian A Md; Marseille Beatrice; Marsh Franklin Jr Md; Martin Monica A; Martinez Ofelia Md; Masson Ella; Mathews Premila Maria; Mathieu Claudine; Matthew S Cohen Md Pc; Mattoo Uijay Kumar Md; Maw Myo Md; Maybody Shideh; Mayer Amir Md; Mayer Victoria Lee; Mazza Michael Anthony Md; Mccormick Elizabeth T; Mcdonagh Mary Valentine; Mcgoldrick Patricia Engel; Mclaughlin Mary Ann Md; Mclendon Lucia Cogswell; Meacher Peter; Meah Yasmin Sultana Md; Medder Nia; Medina Leonel Delos Reyes; Meed Steven D Md; Meer John Fredric Md; Mehandru Saurabh; Mehta Davendra Md; Mehta Viplov K Md; Melis James Mark; Meltzer Elyse Michele; Menon Rakesh; Menon Rekha; Mensah Doreen Akosua Md; Merchant Yuko Md; Meredith Wepner Grossman; Merkler Richard G Md; Messinger Meridith L Md; Mettu Sudhakar Reddy Md; Mezheritsky Eleonora Md; Michael M Gaisa; Mikhail Imad Md; Mikkola Eeva Johanna; Milani Haleh Md; Miller Elizabeth; Miller Marc Andrew Md; Miller Sarah; Milman Alisa Md; Min Insung; Mino Rosa Elena Md; Mir Mohammad Arshad Md; Mirlohi Hooshang Pc Md; Misra Deepika Md; Mitchell Harrison Md; Moarefi Mehran-Reza Md; Moberg Kenneth A; Mocombe Lucien D Md P C; Modern East West Medical Pc; Moe Khaing Md; Mogilner Leora Naomi Md; Mohammad Sajjad; Mohanraj Edwardine Mirnalini; Moise Wesner Md; Motiram Savitri Ramdass Md; Mozayan Mahboobeh; Mullen Michael Patrick Md; Muller David; Mumford James M Md; Murayama-Greenbaum Robert Md; Murphy Barbara Therese Md; Murray Carolina; Muse Jessica Md; Myint Moe Moe; Myint Richard Md; Mountsianihealthsystem; Mountsianihealthsystem; Naing Zaw Md; Nandi Anukul C Md; Nasr Sherif; Nasreen Tahera; Nassif Neven Ibrahim; Natarajan Rupa Narayani; Naughten James Kevin Do; Nautiyal Preeti Md; Navid Kathy Farima Md; Neretin Nicole; Nghi Phuong M Md; Nguyen Henry Van; Nguyen James K; Nguyen Thomas Thang Md; Nichols Andrea Marisa Md; Niforos Fotis; Nisanian Anahid Jaquelline Md; Nissim Julie Md; Nosal Sarah Catherine; Novak Bethany Randi; Nowak-Wegrzyn Anna Halina Md; Nucci-Sack Anne Terese; Nweke-Chukumerije Obiageli Md; Obonaga Sheila; Ofosu-Amaah Sophia Md; Ogbovoh Daniel Obaroakpor Md; Oji Ngozi Afiazu Md; Okhravi Siavash Steve; Okpaleke Ifeoma Brenda; Olajide Bolanle A Md; Oliver Kristin; Orbe Jessica Md; Orin Gary Bruce Md; Orris Maxine Md; Osher Annette; Osoba Olumide Obafunmilayo Md; Osorio Georgina; Ostrager Jill Beth Md; Ostrowska Aneta; Ostrowski Roman M Md; Othoniel Marlene; Ottaviano Lawrence John Md; Paa Remedios Caparas; Pachman Jason Lee Md; Paddu Upadhyaya Padmanabh; Pagan Diane Elizabeth; Page Cameron Stuart; Pandya Amy Arun Md; Paredes Tessie Timitiman Md; Parikh Rita Md; Parkas Valerie Md; Parnes Eliezer L Md; Patel Deepti Dev; Patel Dipal Md; Patel Girishkumar Md; Patel Shamit P Md; Patel Sunil Md; Patel Truptiben; Patel Vidya; Patel Vinisha Md; Patrick Dalton Md Pc; Peccoralo Lauren Alise Md; Peimer Marta Silvee; Pena Armando Juan; Pennant Ainsley Md; Perry Andrea; Persaud Indrani; Perumareddi Krishna; Petelin Andrew Patrick Md; Peterson Monte Harold Md; Petilla-Onorato Jessica Isabel Md; Petrov Manana Md; Phillip Sohn; Photangtham Punyatech Md; Pierce Carolyn Marie; Pierre Louisdon Md; Pierro Hugo Md; Pileta Lourdes X; Pinkas Adina Md; Plokamakis Michael Md; Poff John Edward; Poitevien Vaty; Polavarapu Hari Kishan Md; Ponieman Diego Andres Md; Poomkudy Liz; Posada Roberto Md; Pressler James Md; Prigollini Alejandro Md; Prine Linda Whisler; Pristoupa Olga Md; Psevdos George Jr Md; Puente-Guzman Soledad Elvira; Pumarol Alba; Purohit Amar Lal Md; Quick Melissa Kaufman; Quinn Carrie; Racanelli Joseph A Md; Radix Anita Eileen; Rafailov Danil Isakovich; Rafatjah Soyona; Rahman Rummana Md; Rahman Shafiqur Mohammed Md; Raifman Leonard I Md; Rajda Geetanjali Md; Ramkeesoon Rosemarie Np; Ramnarine Jotir; Ramos Tapia Alberto M Md; Rana Shital; Rathi Dwarka P Md; Raufman Joshua; Ray Roona; Ray-Schoenfeld Naomi; Read Dalan Md; Reckrey Margaret Jennifer; Reddy Chenna B Md; Reddy Lalitha Mary Md Pc; Rehman Abdul Md; Reich Danya; Reister Robin; Remde Alan Hugh; Reminick Marshal Md; Renaud Jean Leopold Edwrin Md; Reuben Stephen W; Reyes-Arcangel Fe T; Rezvani Mitra Md; Rice Laurie A Cochran Md; Rios Carlos Md; Ripp Jonathan A Md; Rivera Graciano Md; Rivera Veronica; Rizk Dahlia Md; Robert Joyce Folashade; Robie Kristin; Robinson Roberto H Quinonez Md; Rodgers Stephen L; Rodriguez German; Rodriguez Navarra; Rodriguez-Caprio Gabriela Md; Rodriguez-Jaquez Carlos R; Roedan Socrates; Rogers Linda Md; Roman Jasmin; Rosch Elliott C Md; Rosen Carolyn Michelle Md; Rosenberg Rachel; Rosenbloom Sylvie; Roshchina Yelena; Roth Rachel; Ruhe Jorg Joachim; Rule Erin Eileen Mdf; Russak Lisa; Sacco Joseph P Md; Sacher Mandy Lauren; Sacolick Benzion Md; Sacolick Daniel; Saftchick Stuart L Md; Sagalovich Boris Md; Saha Prantik Md; Saigh Orit Md; Saint-Laurent Mario; Saint-Louis Frantz Fils Md; Salinas Jean-Louis Md; Salomon Nadim Md; Sam Tanyka; Samaniego Robert Md; Samra Faraj; San Myat Md; Santiago Allan Realin Md; Saporito Anna Gabriella Md; Sara Danielle Lorenz Md; Sarin Aparna; Satsky Mindy B Md; Savransky Alla Md; Saw Thazin Md; Sazan Inga; Schiller Robert M Md; Schirripa John Piero Md; Schneebaum Cary Md; Schwartz William J Md; Scrimmager Leon Md; Seidler Afet Md; Seigel Rebecca Rae Md; Semanision Kristen; Senzamici Camille Md; Sessions Jessica; Setaruddin Sazia Loqman Md; Setia Deepak K Md; Shah Harshida R Md; Shah Jilan Md; Shah Kumarpal A Md; Shah Sumatilal C Md; Shahkoohi Afshin Md; Shaikh Aftabahmed F Md; Shalhoub Robert Francis Md; Shein Ruvan Md; Sheinfeld Joanna; Shen Kuan Hung Md; Shenko Christina Angela; Sherman Frederic M; Shieh Jong-Chuan Md; Shimonov Josef Md; Shirwaikar Anil B Md; Shukla Mayank Arun Md; Shust Gail; Siddiqui Ayesha; Siegel Howard Md; Siegel Stephen D Md; Sierros Vasilios Md; Sigel L Keith Md; Sigrest Barbara Md; Sikder Subhash Chandra; Simpao Jose Rodriguez Jr Md P; Sindhwani Rajeev Md Pllc; Singal Anita; Singh Jagjit Md Pc; Siroya Pushplata B Md; Sisser Rachel; Sloan Barry; Small Katherine Morgan; Smith Alford Alexander Md; Smith Sharon Ellen Md; Smith Verta I Md; Sokolova Ekaterina; Solomon Rachel; Soriano Theresa A Md; Sosinsky Jeffrey H Md; Sotnik Regina Md; Sourial Lucy A Md; Spieler Leah Matisse; Spitzer Matthew; Spivak Dana Md; St Louis Emmanuel Lesly G Md; Sta Ana Victor; Stallings Shavonn; Starpoli Anthony A; Stauber Stuart L Md; Steever John B Md; Stein Alan J Md; Stein Janet Laurie Md; Steklova Olga Md; Stivala Alicia Christina; Straus Emily L Md; Strauss Michael Leopold Md; Strong Jennifer Elizabeth; Suden Stacy Allisa Md; Sugandhi Nandita; Suja Vinod; Suma Dasari; Suprin Gregory Md; Suter Maureen Natalie; Syed Ahmad Physician Pc; Syed-Naqvi Samina Altaf Md; Szalyga John Md; Taha Hesham Mohamed Md; Talavera Wilfredo Md; Talcott James; Talerico Amanda Rae; Tam Cynthia J Md; Tamdji Natacha; Tan Wu; Tang David J Md; Tang Ian Tsai-Leu Md; Tao Chenguang Tony; Teets Raymond; Teich Marvin L Md; Tenney Nancy Lee; Tesler Peter Jon Md; Theodore Ginette Np; Thomas David Charles Md; Tikhonova Elizaveta; Tikko Suraj K Md; Tio Ruy Chen Md; Tkachenko Natalya Md; Tolbert Jerome V Md; Trager Abigail Hope; Trenton Brooke; Truglio Joseph; Truong Tuyettrinh Nguyen; Tsai Tien-Tsai; Tso Alan Ying Yeung; Tun-Chiong Yolanda Do; Tung Keith; Turetsky Risa Ross; Turner Stephen B Md; Udesky Robert A Md; Uleis Keith Harris Md; Urbina Antonio E Md; Uribarri Jaime V Md; Uribe Alejandra Maria Md; Vail Rona; Valasareddi Lalasa Reddy Md; Vamadevan Nallasivam Md; Van Gilder Max F Md; Vanegas Edgar Z Md; Vangeepuram Nita Md; Varghese Betsy; Varma Sudha Md; Vasa Chiroq V Md; Vasiliadis Athanasia S Md; Vavasis Anthony P Md; Veeramachaneni Saimamba Md; Vega Aida; Velazquez Belinda Melissa Md; Veluswamy Rajwanth; Vero Erica; Vicencio Alfin G Md; Villani Gina M Md; Vilnits Anatoliy Md; Vinas Sonia Miliza Md; Vindhya Rajesh Kumar Chand Md; Virani Zahra; Vizel-Schwartz Monique; Voddi Madhu D Md; Volokh Vladimir Md; Waite Eva Ann Md; Wajnberg Ania Md; Waldron Mary Violet Md; Walker Jenny; Wallach Frances Robin Md; Walsh Margaret Mary; Wang Emily H; Wang Jing Wa; Wang Stephanie Chih-I; Wang Zhong; Warman Jacob I Md; Waseem Faisal Md; Watkins Isheka S; Weintraub Jennifer; Weir David C; Wen-Ray Thomas Hsu; Whipple Clare; White Camele; White Elizabeth Stuyvesant Md; Wiener Joseph M Md; Wilder Venis Tiarra; Wong Chun Tung Md; Wong Hok; Woodley Walter Md; Xu Tao Shiwei; Yanagisawa Robert Takahiro Md; Yancovitz Stanley R Md; Yap Marcelo Janette Md; Yen Vincent Md; Young Edwin Reynolds Md; Yousaf Ali; Yudelman Ian M Md; Yuen Jacqueline; Zalavadia Deepti; Zaremski Benjamin Md; Zelenetz Michael Ivan Md; Zewde Mulubrhan; Zhang Jian Wei; Zhang Meng; Zheng Hanbin Md; Zilberman Alla; Zinger Yevgeniya Oskarovna Md; Zoubtsova Minzalia Md; Zuger Abigail Dell Md; Zylbert Susan Lynn Md Task

Step 1: Research INTERACT-like training resources and cost

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 2: Identify first phase of INTERACT-like tools to implement across agencies

NYS Confidentiality – High

Page 209 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Task

Step 3: Determine agencies and number of staff requiring training Task

Step 4: Develop on-going training schedule Task

Step 5: Staff attend training and track participation

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 6: Establish procedures to perform staff competency testing, before and after training, for new staff and on an ongoing basis; evaluate trainee feedback and reaction to material, method, and topic to strengthen training outcomes. Task

Step 7: Perform continuous quality improvement in light of testing and training feedback to evaluate training efficacy Milestone #5

Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care.

DY2 Q4

Project

N/A

Task

Advance Care Planning tools incorporated into program (as evidenced by policies and procedures). Task

Step 1 - Inventory existing programs/agencies using advance care planning tools, compare/contrast, standardize Task

Step 2- Identify which INTERACT Advanced Care Planning tools complement existing tools Task

Step 3: Identify when in home care advanced care planning is explored Task

Step 4: Develop way for identifying patients without advanced directives and a triage plan for identfying their needs Task

Step 5: Identify teaching opportunities regarding advanced care planning and potential participants Task

Step 6: Develop training materials and schedule training Task

Step 7: Attend training and track participation Milestone #6

Create coaching program to facilitate and support

DY2 Q4

Project

N/A

NYS Confidentiality – High

Page 210 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

DY2 Q4

implementation. Task

INTERACT-like coaching program has been established for all home care and Rapid Response Team staff.

Provider

Home Care Facilities

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

Providers Associated with Completion: A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Zaheer Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf Elkomos Soliman; Akoto Edna; AlIzzi Sawsan Hatim Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Ali Aleem A; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A Md; Androne Louis Cristian Md; Ankireddypalli Arvind; Annan Vivian; Anthony Antoinette Md; Antosofsky Howard Md; Arabelo Howard Anthony De La Paz; Arend Jonathan; Ares Ella; Armington Kevin John Md; Arnon Ronen Md; Aronov Margarita A Md; Arron Martin Md; Arya Vijaypal Md; Asare Vivian; Ascunce Gil Ignacio; Aseme Kamara; Aslam Ahmed Kamal Md; Assadi Mashid A; Astua Alfredo J Md; Asuen Imeutinyan Md; Auerbach Lisa Resnick Md; Austein Lance; Autz Arthur L; Ayinla Raji Mohammed Md; Azizi Efat; Babaeva Saiera Md; Babb Frank C Md; Back Sara Deborah; Badlani Sachal Md; Bailey Juan A Md; Baird Philip Lee Md; Baird Sara; Bakshi Anjali Md; Banta Erin; Baran Margaret Md; Baron Natacha Adele; Barrett Conor Dominic; Barsa Jonathan; Bassoul Nissim Moses Md; Batra Kamal Kumar Md; Beaubrun Pierre Ronald Md; Bee-Healthy Proffessional Ped; Begun Jay R Md Pc; Belilovsky Anatoly Md; Benchimol Corinne Do; Bennett Stephen J Md; Benovitz Harvey L Pc Md; Benrath Michelle; Bentsianov Marie Azer Md; Bergman Michael; Berkowitz Leonard Bruce Md; Berlin Arnold I Md; Berman Paul Jeremy; Berwald Cary M Md; Besada Inacia Perez Md; Beth Israel Medical Ctr Act; Beuria Prarthana Md; Bhandari Rekha Md; Bhat Kiran Kumar Md; Bhat Sandeep Md; Bhatia Sonica; Bhatt Anjani A Md; Bhattacharya Sarmistha Md; Bickell Nina Andrew Md; Bilik Ilya V Md; Bioh Dominick Kwasi Md; Blackett-Bonnett Terry Md; Blair Seidler Hammond; Blidnaya Lana; Boah William Ofori Md; Bogdanov Assen Petrov Md; Boguski-Filgueira Lisa F; Borrego Fernando J Md; Bourne Jeffrey Md; Bowers Daniel; Braswell Lezli; Braun James Frederick; Braun Maureen K; Braza Mary; Brescia Andrea M Md; Briggs Haydn Md; Briones Alan Paul Santos Md; Brody Erica Md; Brody Samuel A Md; Bron Yana Md; Brown Laura E; Brownlow Nathaniel Md; Brunner Steven J Md; Bryant Linda M Md; Buhion Caroline; Bukberg Phillip R Md; Burger Alfred Paul Md; Burke Gary Robert; Busta Agustin Md; Bustamante Marco Md; Butt Ahmar Aziz Md; Cadag Stefan; Calabio Rafaela Z Md; Calamia Vincent Md; Callahan Mark; Camargo Edgar Md; Camargo Marianne; Cammerman Daniel Joseph Md; Carcaterra Joann Do; Castillo-Rodriguez Raquel; Castro George A Md; Cataldo Donnalee; Ceballos Clare; Cecilia Griselda Calderon Md; Cespedes Michelle Simone; Cha Yonhee Md; Chadi Ronny M Md; Chafian David Jonathan Md; Chan Chun-Kit; Chan Hang; Chan Sheung-Kwun Samuel Md; Chang Jung Mi Md; Charlotten Kevin Alexander Md; Chasan Rachel; Chase Jennifer C; Chatterjee Lolita Md; Chattooo Premetesh Do; Chaudhry Naeem Akhter Md; Chavez Silvia; Chen Abigail; Chen Chao Do; Chennareddy Swaminathan; Cherian Siby Vengal Md; Chery Roselyne Md; Cheung Barbara A; Cheung William Md; Chhipa Mohammad Haroon Md; Chitu Carmen Elena; Chiu Gregorio E Md; Cho Hyung; Choe Josefina Luna Md; Chopra Ashok Chanparkash; Chow Desiree; Chow Rita Md; Chu Carolyn Md; Chu Jaime; Chuey John Md; Chun Eunmee H; Chung Andrew; Chung Bruce K Md; Chung Derek G Md; Chung Sung Lan Md; Ciechorska Maria Md; Cieloszyk Kinga Marta Md; Clark Cheryl L Md; Clemens Christopher Md; Coghill Alice Victoria Md; Cohen Alan J Md; Cohen Randy Edward; Cohen Roy A Md; Cohen Sandra; Cohrssen Andreas Md; Collins Megan Elizabeth Md; Conde Wright Marie France Md; Contreras Johanna Paola; Cook Heather Tiffany Md; Cook-Mack Jessica Phylis; Corrigan Kathleen; Cortes Jose Alberto Md; Cortijo Amarilys R Md; Cosmatos Andreas Md; Cosme-Thormann Braulio Federico; Coupet Nadege Marie Md; Cox Katherine Anne; Croft Lori Bray Md; Cruz Christina; Cunningham-Rundles C Md; D Oleo Vargas Maximo Jose; D'Souza David J Md; Da Rosso Robert Cian Md; Dadarwala Aashish Dhansukhlal; Daniele Rosemary Ann; Danik Jacqueline Suk; Danik Stephan B; Dantchenko Victoria Md; Daskalakis Demetre Costas; Davidson Morton I; Davis Yonette Md; Decherrie Linda Vandaele Md; Defabritus Albert M Md; Delaet David Edward Md; Dematteo Robert Enrico Md; Dennis Tian-Shu Chang; Depetris Gustavo Raul Md; Descartes-Walker Ingrid Md; Desikan Sonia; Desir Mergie X Md; Desrosiers Jean Claude; Devons Cathryn A Md; Dharapak Patricia Md; Di Scala Reno Gennaro Md; Diaz Michael Md; Dick Jeffrey M Md; Dickerson Lauren; Dilmanian Rossana; Disla Eddys Md; Doan-Schultz Yvette Chi; Docu Theodore Costa Md; Domek Maciej Md; Donovan Edmund J; Doshi Dhvani; Douglas Orin Albert; Dove Arthur Renner Md; Drake Victoria; Drazenovic Ivo; Drukman Liliya Md; Drullinsky Alexix Cesar Md; Dubey Sudha; Duddempudi Nagamma; Dumas Marie; Dunn Andrew S Md; Dunner Ricardo Orlando Md; Dvorkina Anzhela Md; Dwarka Regev Ragbardial; Dy-Guillaume Marie Eve Md; Edano Albert E Md; Edelman Laurie Beth Md; Eden Alvin N Md; Edgecomb Paul Steven; Edwards Ayisha Tene; Edwards Donna; Edwards Sharon M Md; Ehrlich Martin H Md; Eidgah Mahyar Md; Eisenson Arlene; Eisner Yvonne; Elbirt Paula M Md; Eliot P Schuster Md Pc; Ellis Earl Anthony Md; Eloi-Stiven Marie L; Emily Otis Taylor Md; Emmer Louis Mark Md; English Cary Md; Enschede Elizabeth; Enu Christopher Chukwuemeka; Eric S Barna; Erlikh Irina; Escalera Elsa Md; Escher Jeffrey Ethan Md; Escobar Christian; Esposito Amy; Esposito Stephen P Md; Etkin Alexandra; Factor Stephanie Hope Md; Faculty Practice Associates; Fafalak Robert G Md; Fakhruddin Dilshad Md; Farhat Hassan Ail Md; Farhat Samir Ali Md; Farrell Cristina; Fatica Nunzia Md; Feder Erica; Federman Alex David Md; Fefer Jose Jacobo Md; Feingold Leonard N Md; Felsen Michael R Md; Fenyves Andras Md; Fernaine George Md; Ferris David Craig Md; Field Jonathan Md; Fields Jessie Alfreda Md; Fierer Daniel Seth Md; Fievre Garnes Marie Ft Md; Finkelstein Donna Michal Md; Finkielstein Dennis Md; Fiorentino Thomas C Md; Fishman Donald R Md; Fisk Rebecca Saslow Md; Fisse Richard D Md; Fogel Joyce Frances Nahum Md; Fonfeder William; Ford Miriam; Forman Joel Alexander Md; Forman Lisa Diane Md; Forsyth Beverly Alison Md; Fox Kelita Louise; Frankel Etta Md; Frederic Bakhchi Md; Fresneda Caridad; Friedman Samuel; Friedman Scott L Md; Fteha Elie Md; Fuchs Thomas Md; Galal Nehal; Galvez Maida P Md; Ganatra Anjna Nain; Gandhi Vani Pragnesh Md; Ganea Gheorghe Romeo Md; Garankina Olga; Garber Julia; Garcia Quinones Saribel; Gardenier Donald; Gati Allison; Gault Allison Tamara Md; Gayle Eric George Md; Gazali Radfan M; Geraldine Yasmine Joseph; Gerdis Michael Md; Gerner Jenny; Gerolemou Louis N Do; Gershengorina Sofya Md; Gervais Carole E; Gharpure Anil Md; Ghooi Ashok Md; Ghosh Anita; Gibbons Olga; Gidfar Niloufar Md; Gidwani Sonia Md; Giegel Melanie Joy; Gilgoff Hugh L Md; Gillespie Ginger Md; Ginde Ranjan; Glasser Lynne Ann Md; Gliatto Peter Matthew Md; Goetz Celine; Goforth Thomas; Goldblum Louis M Do; Goldman Adam Y Md; Goldstein Lissa Kary; Goldstein Zil; Goldstone Elaine Brown; Gomez Gomez Veronica Del Carmen; Gomez Tessa S Md; Goodman Eric; Goodman Karl Richard Md; Goodman Stephanie Michelle; Gorny Mark A Md; Gottlock Robbins L; Gould Sanford Md; Gounder Celine Rani; Goyal Ravindra Kumar Md; Grabscheid Erica Md; Grand Mark Alan Md; Graney John Md; Grant Jessica J Md; Graziano Michelle; Greely John Stephen Md; Green Stuart Md; Gressel Irina Md; Gribetz Irwin X; Grimm Katherine Teets Md; Grossman Howard Alan Md; Gruber Steven Jeffrey Md; Guevara Elizabeth D L A Md; Guillen Rafael A Md; Gulrajani Ramesh S Md; Gupta Ashita; Gupte Amrita K Md; Guy Judath Philip; Hackenburg Emily; Hailu Mekdes Md; Hak Virender Md; Halberstam Meyer S Md; Hana Ehab Joseph; Hanna Emad; Haque Sayera Md; Harbord Nikolas B Md; Hariri E; Hashemian Nezhat Md; Hassan Yasmin Akbar Md; Hawkins Katherine A Md; Hazel Edovard Joseph Md; Hefferon Susan; Hernandez Cameron Roland Md; Hewitt Ross G Md; Hill Keran; Ho Wesley Hok Man; Ho Wing Wah Md; Hobson Steven; Hodjati Ramin; Hoffman Judith; Hofmeister Stephen Frank Md; Hollman Dominic; Horn Ansell Np; Horowitz Carol Rose Md; Hsiung Ahmed Leslie; Hudesman David Philip; Hui Yiqun; Hupriker Shirish S Md; Husain Syed S Md; Hussaini Batool M Md; Hussaini Syed Zabeehullah Md; Hwang Andrew; Iglesias Alejandro D Md; Inada Victor Katsuji Md; Indio Lillian R; Institute For Family Hlth; Iocolano Carolyn F; Iqbal Muhammad Z Md; Irani Dinaz; Ismailova Kyamalya A; Israel Ezra Ceasar; Issa Ricardo Fabian Md; Issack Joshua; Itzkovitz Ina S Md; J Barbazan-Silva M D P C;

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Jaber Nadim; Jacobson Robin; Jagger Samantha Jane; Jahan Mumtaz Md; Jan Ren Bang Md; Janice Prime Care Medical Pc; Jao Jennifer; Jaradeh Issa E; Jasti Harish Md; Jasty Babu N Md; Jawaid Mohammad Md; Jennifer B Cerasoli Md; Jennifer Kar Yee Hui; Jervis Ramiro Md; Jhagroo Omesh; Jhagroo Vishnudatt Md; Jimenez Mariela; Jimenez Roxanna; Jimmy R Sitt; John Bertha; Johnson Livette S Md; Johnson Timothy Curtiss Md; Jones Elizabeth Mary; Jones Michael Abou Md; Jones Vivian Lynn; Joseph Marjorie Md; Joseph Myriam; Judeh Hani; Jung Tiffany Maysu; Kale Minal Sharatkumar Md; Kannry Joseph L Md; Kaplan-Weisman Laura; Karakas Serife Eti Md; Karp Sara; Kashan Glenn Lawrence Md; Katz Cynthia J Md; Kensaint Pascale Md; Kent Jennifer Ames Md; Kerr Leslie Dubin Md; Khabyeh Shaya; Khaim Rafael Np-C; Khalid Nazneen Md; Khan Shumaila; Khorets Boris A Md; Kilinski Benjamin; Kim Julie; Kim Kyu-Han Md; Kim Sarah K; Kim Tonia K. Md; Kimble Christine Md; Kirkham Elizabeth; Kirschner Eric Md; Kitson Kwame A Md; Klein Daniel P Md; Klein Oscar Md; Kletsman Igor Md; Klimenko Elena A Md; Ko Fred Chau-Yang; Koicke Betsy C; Kondamudi Vasantha Kumari Md; Kondaveeti Harika; Kopke Mary; Koshy Sanjana Cherian; Kothari Vipul Chandrakant; Kozlov Natalya; Krausz Robert B Md; Kulina Georgia; Kuwama Yuichiro; Lai Anne; Lai Joanne Md; Lalia Madeline R Md; Lamb Angela; Landerer David; Lane Matthew John Md; Lantz Howard Md; Latt Ko Ko; Law Singwu David; Lawrence Donald P Md; Lawrence Donna Anthea; Lazala Polanco Carmen Md; Lazarin Margaux Helene; Leasy Menachem Jeremy; Leber Robert J Md; Leder Marvin A Md; Lee Hanna; Lee Jeong Ran Oh; Lee Marjorie Pc Md; Lee Namhi; Lefevre Lionel Md; Lefevre Marie Edith Faublas; Leinbach Lindsey; Lekht Vladimir; Lempel Herbert Sheldon Md; Lerner Gary; Lesnewski Ruth F Md; Levin Marc William Md; Levine Steven Barry Md; Levine-Tanco Karen; Li Ka Md; Liang Elizabeth; Liao Emilia Pauline Md; Liberman Dina Md; Lin Elaine Patricia; Lin Jenny Jen-Yi Md; Lin Lee Yulee; Linetskaya Irina; Lombardi Paul Md; Lopez Clark Faafp Md; Lopez-Santini Jaime; Lovenvirth Wendi Jennifer Md; Lowe Rajani; Lu Haiyan; Lurio Joseph Glen Messner Md; Luz Amarilis Lugo Md; Lwin Yinphyu Win; Ly Rose Vay Luong Md; Lynch Colleen; Lynch Gina Adriana Md; Mack Theresa Adele Md; Mackay Richard E Md; Madhava Valsa S Md; Madrid Tanya M Md; Maggio Johanna Medodie; Malachovsky Martin; Malieckal Jubil Md; Mamoon Nahreen Md; Manasia Anthony Robert Md; Mantia Augustus G Md; Mantia Philip Anthony Md; Manvar Buddhadev Nathabhai Md; Mararenko Larisa Md; Marcantonio Colomba A Md; March Anika Jolene; Maritato Andrea F Md; Markoff Brian A Md; Marseille Beatrice; Marsh Franklin Jr Md; Martin Monica A; Martinez Ofelia Md; Masson Ella; Mathews Premila Maria; Mathieu Claudine; Matthew S Cohen Md Pc; Mattoo Uijay Kumar Md; Maw Myo Md; Maybody Shideh; Mayer Amir Md; Mayer Victoria Lee; Mazza Michael Anthony Md; Mccormick Elizabeth T; Mcdonagh Mary Valentine; Mcgoldrick Patricia Engel; Mclaughlin Mary Ann Md; Mclendon Lucia Cogswell; Meacher Peter; Meah Yasmin Sultana Md; Medder Nia; Medina Leonel Delos Reyes; Meed Steven D Md; Meer John Fredric Md; Mehandru Saurabh; Mehta Davendra Md; Mehta Viplov K Md; Melis James Mark; Meltzer Elyse Michele; Menon Rakesh; Menon Rekha; Mensah Doreen Akosua Md; Merchant Yuko Md; Meredith Wepner Grossman; Merkler Richard G Md; Messinger Meridith L Md; Mettu Sudhakar Reddy Md; Mezheritsky Eleonora Md; Michael M Gaisa; Mikhail Imad Md; Mikkola Eeva Johanna; Milani Haleh Md; Miller Elizabeth; Miller Marc Andrew Md; Miller Sarah; Milman Alisa Md; Min Insung; Mino Rosa Elena Md; Mir Mohammad Arshad Md; Mirlohi Hooshang Pc Md; Misra Deepika Md; Mitchell Harrison Md; Moarefi Mehran-Reza Md; Moberg Kenneth A; Mocombe Lucien D Md P C; Modern East West Medical Pc; Moe Khaing Md; Mogilner Leora Naomi Md; Mohammad Sajjad; Mohanraj Edwardine Mirnalini; Moise Wesner Md; Motiram Savitri Ramdass Md; Mozayan Mahboobeh; Mullen Michael Patrick Md; Muller David; Mumford James M Md; Murayama-Greenbaum Robert Md; Murphy Barbara Therese Md; Murray Carolina; Muse Jessica Md; Myint Moe Moe; Myint Richard Md; Mountsianihealthsystem; Mountsianihealthsystem; Naing Zaw Md; Nandi Anukul C Md; Nasr Sherif; Nasreen Tahera; Nassif Neven Ibrahim; Natarajan Rupa Narayani; Naughten James Kevin Do; Nautiyal Preeti Md; Navid Kathy Farima Md; Neretin Nicole; Nghi Phuong M Md; Nguyen Henry Van; Nguyen James K; Nguyen Thomas Thang Md; Nichols Andrea Marisa Md; Niforos Fotis; Nisanian Anahid Jaquelline Md; Nissim Julie Md; Nosal Sarah Catherine; Novak Bethany Randi; Nowak-Wegrzyn Anna Halina Md; Nucci-Sack Anne Terese; Nweke-Chukumerije Obiageli Md; Obonaga Sheila; Ofosu-Amaah Sophia Md; Ogbovoh Daniel Obaroakpor Md; Oji Ngozi Afiazu Md; Okhravi Siavash Steve; Okpaleke Ifeoma Brenda; Olajide Bolanle A Md; Oliver Kristin; Orbe Jessica Md; Orin Gary Bruce Md; Orris Maxine Md; Osher Annette; Osoba Olumide Obafunmilayo Md; Osorio Georgina; Ostrager Jill Beth Md; Ostrowska Aneta; Ostrowski Roman M Md; Othoniel Marlene; Ottaviano Lawrence John Md; Paa Remedios Caparas; Pachman Jason Lee Md; Paddu Upadhyaya Padmanabh; Pagan Diane Elizabeth; Page Cameron Stuart; Pandya Amy Arun Md; Paredes Tessie Timitiman Md; Parikh Rita Md; Parkas Valerie Md; Parnes Eliezer L Md; Patel Deepti Dev; Patel Dipal Md; Patel Girishkumar Md; Patel Shamit P Md; Patel Sunil Md; Patel Truptiben; Patel Vidya; Patel Vinisha Md; Patrick Dalton Md Pc; Peccoralo Lauren Alise Md; Peimer Marta Silvee; Pena Armando Juan; Pennant Ainsley Md; Perry Andrea; Persaud Indrani; Perumareddi Krishna; Petelin Andrew Patrick Md; Peterson Monte Harold Md; Petilla-Onorato Jessica Isabel Md; Petrov Manana Md; Phillip Sohn; Photangtham Punyatech Md; Pierce Carolyn Marie; Pierre Louisdon Md; Pierro Hugo Md; Pileta Lourdes X; Pinkas Adina Md; Plokamakis Michael Md; Poff John Edward; Poitevien Vaty; Polavarapu Hari Kishan Md; Ponieman Diego Andres Md; Poomkudy Liz; Posada Roberto Md; Pressler James Md; Prigollini Alejandro Md; Prine Linda Whisler; Pristoupa Olga Md; Psevdos George Jr Md; Puente-Guzman Soledad Elvira; Pumarol Alba; Purohit Amar Lal Md; Quick Melissa Kaufman; Quinn Carrie; Racanelli Joseph A Md; Radix Anita Eileen; Rafailov Danil Isakovich; Rafatjah Soyona; Rahman Rummana Md; Rahman Shafiqur Mohammed Md; Raifman Leonard I Md; Rajda Geetanjali Md; Ramkeesoon Rosemarie Np; Ramnarine Jotir; Ramos Tapia Alberto M Md; Rana Shital; Rathi Dwarka P Md; Raufman Joshua; Ray Roona; Ray-Schoenfeld Naomi; Read Dalan Md; Reckrey Margaret Jennifer; Reddy Chenna B Md; Reddy Lalitha Mary Md Pc; Rehman Abdul Md; Reich Danya; Reister Robin; Remde Alan Hugh; Reminick Marshal Md; Renaud Jean Leopold Edwrin Md; Reuben Stephen W; Reyes-Arcangel Fe T; Rezvani Mitra Md; Rice Laurie A Cochran Md; Rios Carlos Md; Ripp Jonathan A Md; Rivera Graciano Md; Rivera Veronica; Rizk Dahlia Md; Robert Joyce Folashade; Robie Kristin; Robinson Roberto H Quinonez Md; Rodgers Stephen L; Rodriguez German; Rodriguez Navarra; Rodriguez-Caprio Gabriela Md; Rodriguez-Jaquez Carlos R; Roedan Socrates; Rogers Linda Md; Roman Jasmin; Rosch Elliott C Md; Rosen Carolyn Michelle Md; Rosenberg Rachel; Rosenbloom Sylvie; Roshchina Yelena; Roth Rachel; Ruhe Jorg Joachim; Rule Erin Eileen Mdf; Russak Lisa; Sacco Joseph P Md; Sacher Mandy Lauren; Sacolick Benzion Md; Sacolick Daniel; Saftchick Stuart L Md; Sagalovich Boris Md; Saha Prantik Md; Saigh Orit Md; Saint-Laurent Mario; Saint-Louis Frantz Fils Md; Salinas Jean-Louis Md; Salomon Nadim Md; Sam Tanyka; Samaniego Robert Md; Samra Faraj; San Myat Md; Santiago Allan Realin Md; Saporito Anna Gabriella Md; Sara Danielle Lorenz Md; Sarin Aparna; Satsky Mindy B Md; Savransky Alla Md; Saw Thazin Md; Sazan Inga; Schiller Robert M Md; Schirripa John Piero Md; Schneebaum Cary Md; Schwartz William J Md; Scrimmager Leon Md; Seidler Afet Md; Seigel Rebecca Rae Md; Semanision Kristen; Senzamici Camille Md; Sessions Jessica; Setaruddin Sazia Loqman Md; Setia Deepak K Md; Shah Harshida R Md; Shah Jilan Md; Shah Kumarpal A Md; Shah Sumatilal C Md; Shahkoohi Afshin Md; Shaikh Aftabahmed F Md; Shalhoub Robert Francis Md; Shein Ruvan Md; Sheinfeld Joanna; Shen Kuan Hung Md; Shenko Christina Angela; Sherman Frederic M; Shieh Jong-Chuan Md; Shimonov Josef Md; Shirwaikar Anil B Md; Shukla Mayank Arun Md; Shust Gail; Siddiqui Ayesha; Siegel Howard Md; Siegel Stephen D Md; Sierros Vasilios Md; Sigel L Keith Md; Sigrest Barbara Md; Sikder Subhash Chandra; Simpao Jose Rodriguez Jr Md P; Sindhwani Rajeev Md Pllc; Singal Anita; Singh Jagjit Md Pc; Siroya Pushplata B Md; Sisser Rachel; Sloan Barry; Small Katherine Morgan; Smith Alford Alexander Md; Smith Sharon Ellen Md; Smith Verta I Md; Sokolova Ekaterina; Solomon Rachel; Soriano Theresa A Md; Sosinsky Jeffrey H Md; Sotnik Regina Md; Sourial Lucy A Md; Spieler Leah Matisse; Spitzer Matthew; Spivak Dana Md; St Louis Emmanuel Lesly G Md; Sta Ana Victor; Stallings Shavonn; Starpoli Anthony A; Stauber Stuart L Md; Steever John B Md; Stein Alan J Md; Stein Janet Laurie Md; Steklova Olga Md; Stivala Alicia Christina; Straus Emily L Md; Strauss Michael Leopold Md; Strong Jennifer Elizabeth; Suden Stacy Allisa Md; Sugandhi Nandita; Suja Vinod; Suma Dasari; Suprin Gregory Md; Suter Maureen Natalie; Syed Ahmad Physician Pc; Syed-Naqvi Samina Altaf Md; Szalyga John Md; Taha Hesham Mohamed Md; Talavera Wilfredo Md; Talcott James; Talerico Amanda Rae; Tam Cynthia J Md; Tamdji Natacha; Tan Wu; Tang David J Md; Tang Ian Tsai-Leu Md; Tao Chenguang Tony; Teets Raymond; Teich Marvin L Md; Tenney Nancy Lee; Tesler Peter Jon Md; Theodore Ginette Np; Thomas David Charles Md; Tikhonova Elizaveta; Tikko Suraj K Md; Tio Ruy Chen Md; Tkachenko Natalya Md; Tolbert Jerome V Md; Trager Abigail Hope; Trenton Brooke; Truglio Joseph; Truong Tuyettrinh Nguyen; Tsai Tien-Tsai; Tso Alan Ying Yeung; Tun-Chiong Yolanda Do; Tung Keith; Turetsky Risa Ross; Turner Stephen B Md; Udesky Robert A Md; Uleis Keith Harris Md; Urbina Antonio E Md; Uribarri Jaime V Md; Uribe Alejandra Maria Md; Vail Rona; Valasareddi Lalasa Reddy Md; Vamadevan Nallasivam Md; Van Gilder Max F Md; Vanegas Edgar Z Md; Vangeepuram Nita Md; Varghese Betsy; Varma Sudha Md; Vasa Chiroq V Md; Vasiliadis Athanasia S Md; Vavasis Anthony P Md; Veeramachaneni Saimamba Md; Vega Aida; Velazquez Belinda Melissa Md; Veluswamy Rajwanth; Vero Erica; Vicencio Alfin G Md; Villani Gina M Md; Vilnits Anatoliy Md; Vinas Sonia Miliza Md; Vindhya Rajesh Kumar Chand Md; Virani Zahra; Vizel-Schwartz Monique; Voddi Madhu D

NYS Confidentiality – High

Page 212 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Md; Volokh Vladimir Md; Waite Eva Ann Md; Wajnberg Ania Md; Waldron Mary Violet Md; Walker Jenny; Wallach Frances Robin Md; Walsh Margaret Mary; Wang Emily H; Wang Jing Wa; Wang Stephanie Chih-I; Wang Zhong; Warman Jacob I Md; Waseem Faisal Md; Watkins Isheka S; Weintraub Jennifer; Weir David C; Wen-Ray Thomas Hsu; Whipple Clare; White Camele; White Elizabeth Stuyvesant Md; Wiener Joseph M Md; Wilder Venis Tiarra; Wong Chun Tung Md; Wong Hok; Woodley Walter Md; Xu Tao Shiwei; Yanagisawa Robert Takahiro Md; Yancovitz Stanley R Md; Yap Marcelo Janette Md; Yen Vincent Md; Young Edwin Reynolds Md; Yousaf Ali; Yudelman Ian M Md; Yuen Jacqueline; Zalavadia Deepti; Zaremski Benjamin Md; Zelenetz Michael Ivan Md; Zewde Mulubrhan; Zhang Jian Wei; Zhang Meng; Zheng Hanbin Md; Zilberman Alla; Zinger Yevgeniya Oskarovna Md; Zoubtsova Minzalia Md; Zuger Abigail Dell Md; Zylbert Susan Lynn Md Task

Step 1: Identify agency representatives participating in INTERACT-like trainings who will be designated as "INTERACT Champion" Task

Step 2: Establish annual continuing education program Task

Step 3: Establish discussion groups to share best practices

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

01/01/2016

06/30/2016

01/01/2016

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

06/30/2016

01/01/2016

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

03/31/2016

03/31/2017

03/31/2016

03/31/2017

03/31/2017

DY2 Q4

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Milestone #7

Educate patient and family/caretakers, to facilitate participation in planning of care.

DY2 Q4

Project

N/A

Task

Patients and families educated and involved in planning of care using INTERACT-like principles. Task

Step 1: Create a hand over tool to next level of care which indicates the teaching initiated in hospital and what needs to be continued. Task

Step 2: Determine method for assessing patient/CG knowledge base and health literacy Task

Step 3: Develop a variation of teaching methods Task

Step 4: Create patient/CG educational & training materials that is patient-centered and includes patient's goals of care Task

Step 5: Decide on critical learning needs prior to discharge Task

Step 6: Detemine method for integrating Patient/CG education into the patient health record Milestone #8

Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management.

DY3 Q2

Project

N/A

Task

All relevant services (physical, behavioral, pharmacological) integrated into care and medication management model.

Project

NYS Confidentiality – High

Page 213 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 1: Actively participate in Care Coordination Cross Functional Workgroup sessions

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

06/01/2016

03/31/2017

06/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

06/01/2016

03/31/2017

06/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 2: Leverage Care Coordination Cross Functional Workgroup's resources Task

Step 3: Collaborate with CCCFW to develop CCCFW processes, workflows, and protocols as they relate to the CCCFW Charter. CCCFW's charter and deliverables to be found in Clinical Integration Section 09- MAPP Module 9.1 Task

Step 4: Implement a pharmacy review of medications including antibiotics, ensure antibiotics are used appropriately and discontinued when no longer needed Milestone #9

Utilize telehealth/telemedicine to enhance hospital-home care collaborations.

DY3 Q2

Project

N/A

Task

Telehealth/telemedicine program established to provide care transition services, prevent avoidable hospital use, and increase specialty expertise of PCPs and staff. Task

Step 1: Develop criteria of telehealth solutions Task

Step 2: Research telehealth solutions demo to project workgroup Task

Step 3: Demonstrate existing solutions to project workgroup Task

Step 4: Work with IT Committee to plan, test, implement selected solution Task

Step 5: Train family/caregivers to use selected technology Task

Step 6: Obtain feedback for optimization Milestone #10

Utilize interoperable EHR to enhance communication and avoid medication errors and/or duplicative services.

DY3 Q2

Project

N/A

Task

Clinical Interoperability System in place for all participating providers. Usage documented by the identified care coordinators.

Project

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 1: Work with IT/partners to assess interoperability systems are in plan for implementation

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

10/01/2015

09/30/2017

10/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 2: Work with IT/partners to identify specific medication error alerts/fields to monitor Task

Step 3: Track that care coordinators are accessing EHR to check for services provided to patients Milestone #11

Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions.

DY3 Q2

Project

N/A

Task

Membership of quality committee is representative of PPS staff involved in quality improvement processes and other stakeholders. Task

Quality committee identifies opportunities for quality improvement and use of rapid cycle improvement methodologies, develops implementation plans, and evaluates results of quality improvement initiatives. Task

PPS evaluates and creates action plans based on key quality metrics, to include applicable metrics in Attachment J. Task

Service and quality outcome measures are reported to all stakeholders. Task

Step 1: Develop champions within lead and partner organizations Task

Step 2: Develop monthly meeting schedule to assess root cause analyses of home-care to hospital transfers Task

Step 3: Work with the state/MCOs to obtain real-time data on readmissions to inform training plan and improve quality Task

Step 4: Schedule webinars to inform workgroup of performance measures/baseline data Task

Step 5: Evaluate and review avoidable readmissions; discuss

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

high cost of care patients Task

Step 6: Engage w/ MCO or MLTC to collect HEDIS measures and identify gaps in these measures

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

06/30/2016

01/01/2016

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 7: Use HCAHPS reports to monitor patient satisfaction scores across providers and identify areas of improvement Task

Step 8: Establish process to systematically and on a schedule share outcome measures Task

Step 9: Develop root cause analysis reports and review monthly Task

Step 10: Determine rapid cycle methodologies to use for quality improvement initiatives Task

Step 11: Determine quality improvement measures Milestone #12

Use EHRs and other technical platforms to track all patients engaged in the project.

DY2 Q4

Project

N/A

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

Step 1: Generate reports that are submitted quarterly to the PPS by home care agencies including number of staff trained, patients/caregivers trained and affected by staff trainings.

Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Assemble Rapid Response Teams (hospital/home care) to facilitate patient discharge to home and assure needed home care services are in place, including, if appropriate, hospice.

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Ensure home care staff have knowledge and skills to identify and respond to patient risks for readmission, as well as to support evidence-based medicine and chronic care management. Develop care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer. Educate all staff on care pathways and INTERACT-like principles. Develop Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care. Create coaching program to facilitate and support implementation. Educate patient and family/caretakers, to facilitate participation in planning of care. Integrate primary care, behavioral health, pharmacy, and other services into the model in order to enhance coordination of care and medication management. Utilize telehealth/telemedicine to enhance hospital-home care collaborations. Utilize interoperable EHR to enhance communication and avoid medication errors and/or duplicative services. Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions. Use EHRs and other technical platforms to track all patients engaged in the project.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Complete

Milestone #5

Pass & Complete

Milestone #6

Pass & Complete

Milestone #7

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 216 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone #

Review Status

Milestone #8

Pass & Ongoing

Milestone #9

Pass & Complete

Milestone #10

Pass & Complete

Milestone #11

Pass & Ongoing

Milestone #12

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 217 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.viii.4 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name Milestone

Status

Completed

Mid-Point Assessment

Original Start Date

Description

Mid-Point Assessment

06/01/2016

Original End Date 06/30/2016

Start Date

06/01/2016

End Date

06/30/2016

DSRIP Reporting Year and Quarter

Quarter End Date 06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.b.viii.5 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 219 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 2.c.i – Development of community-based health navigation services IPQR Module 2.c.i.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. Associated Risk: Workforce Development Part of the diminished capacity is the difficulty in hiring staff into a program without a standardized means of timely reimbursement. Risk Mitigation: The financial and workforce investment in this project will be clearly defined. Our path to achieving more clarity involves close collaboration with the financial and workforce development entities to understand any potential burdens that fall outside of the scope of our expectations and strategize avenues for successfully managing those burdens. Associated Risk: Minimal supervisory structure Risk Mitigation: Through this project, part of the staff will include licensed clinical SWs and RNs to provide support in a standardized manner to the community navigation staff. The hub of resources will also be helpful for consultations. Associated Risk: Lack of IT infrastructure Risk Mitigation: Use of the MAPP portal will allow for some of the tracking mentioned. Partners in this project will need to be well versed in MAPP through various roll out phases. Additionally, infrastructure will be created through collaboration with IT development entities for the project and current HH dashboards and partner care coordination platforms will be leveraged. Associated Risk: Potential duplication of services Risk Mitigation: Policies and best practices will be developed to facilitate warm handoffs to various members of a patient's care team. These policies and and best practices will be created through collaboration with other DSRIP projects and current programs (i.e. Health Homes, transitional care). Associated Risk: Low Patient Compliance

Risk Mitigation: Investment in collaboration with workforce development to ensure that patient navigators are adequately trained and equipped to ameliorate patient ambivalence and compliance barriers. Associated Risk: Inadequate Supply of Resources, i.e. Housing and Transportation

NYS Confidentiality – High

Page 220 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Risk Mitigation: The PPS will employ experts in each area of need to assist patients in navigating and accessing the resources. The resource hub and resource guide will include details re: wait times, languages spoken, and services provided to help patients better access appropriate resources that are not limited. Associated Risk: Difficulty determining the need for longitudinal vs. short-term services, caseload sizes, and patient graduation Risk Mitigation: Needs assessments, clinical pathways, and associated policies and workflows for patients will be created so that the patient is matched with the right level of care needed. Associated Risk: The assumptions for community navigators number "Table #1 - This number reflects the individual community-based navigators that we have committed to this project. This number reflects community-based navigators specific to this particular project only..." Risk Mitigation: The initial assumption is not accurate. We're also sharing resources with lead HHs and community based organizations providing HH services. We will integrate Care coordination models to include community navigators as a shared resource and will be able to include those who provide services in other projects ie 2ai etc. This will enable us to reach the 250 goal by DY4.

NYS Confidentiality – High

Page 221 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.c.i.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

53,125

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

21,250

33,203

45,156

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

10,625

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (10,625) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 223 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 2.c.i.3 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Create community-based health navigation services, with the goal of assisting patients in accessing healthcare services efficiently. Task

Community-based health navigation services established.

DY3 Q4

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

06/12/2015

12/31/2015

06/12/2015

12/31/2015

12/31/2015

DY1 Q3

Project

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/30/2015

03/31/2018

06/30/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Step 1. Finalize a plan to hire additional staff to assist in execution. Task

Step 2. Identify key elements of community-based health navigation Task

Step 3. Outline/ Diagram PPS care coordination. Actively participate in Care Coordination Cross Functional Workgroup sessions Task

Step 4. Leverage Care Coordination Cross Functional Workgroup's resources Task

Step 5. Collaborate with CCCFW to develop CCCFW processes, workflows, and protocols as they relate to the CCCFW Charter (Care Coordination documents have been uploaded to the Clinical Integration Section 09-> MAPP Module 9.1 • Prescribed Milestones #2-" Develop a Clinical Integration strategy." ; In order to achieve milestones for this project project 2ci will collaborate and has been involved in CCCFW. Page 2 of CCCFW charter, deliverables 1-9 will help project team to meet this milestone) Task

Step 6. Identify services needed using CNA Task

Step 7. Identify sites and agencies and Health Homes already doing community-based health navigation

NYS Confidentiality – High

Page 224 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Task

Step 8. Create Patient Work Flow chart

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Project

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

06/30/2015

03/31/2018

06/30/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/12/2015

06/30/2017

06/12/2015

09/30/2017

09/30/2017

DY3 Q2

Completed

06/12/2015

03/31/2017

06/12/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

06/12/2015

03/31/2017

06/12/2015

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

09/01/2015

03/31/2016

09/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

09/01/2015

03/31/2016

09/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

09/01/2015

03/31/2017

09/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/01/2015

06/30/2016

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

09/01/2015

06/30/2016

09/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

09/01/2015

03/31/2017

09/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Step 9. Create subgroups to work on developing community based services (data, workforce, patient engagement) Task

Step 10. Determine how community based health navigation services will collaborate with other clinical call centers to ease access and connect patients to resources and further community navigation services. Milestone #2

Develop a community care resource guide to assist the community resources and ensure compliance with protocols, under direction from a collaborating program oversight group of medical/behavioral health, community nursing, and social support services providers.

DY2 Q4

Project

N/A

Task

Resource guide completed, detailing medical/behavioral/social community resources and care protocols developed by program oversight committee. Task

Step 1.Finalize a staffing plan to execute project (do research, create written content, compile materials) Task

Step 2.Develop a collaborating program oversight group of med/beh health, community nursing, and social support services providers Task

Step 3.Identify key contributors within the workgroup and resources from within partner organizations. Task

Step 4.Identify and compile contents of resource guide Task

Step 5.Collaborate with other PPS projects to ensure that the content of guide will support their needs Task

Step 6.Identify / finalize resource guide mediums - web and phone-based Task

Step 7. Determine workflow to effectively use the resource guide, and how it can be leveraged for other clinical call centers.

NYS Confidentiality – High

Page 225 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 8. Distribute and track use of written resource guide,employing marketing resources through PMO and through each PPS partner agency

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

09/30/2015

12/31/2016

09/30/2015

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

In Progress

06/12/2015

03/31/2018

06/12/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

08/15/2016

03/31/2018

08/15/2016

03/31/2018

03/31/2018

DY3 Q4

Milestone #3

Recruit for community navigators, ideally spearheaded by residents in the targeted area to ensure community familiarity.

DY2 Q4

Project

N/A

Task

Navigators recruited by residents in the targeted area, where possible. Task

Step 1.Compile current job descriptions in collaboration with Workforce Committee Task

Step 2. With workforce guidance, standardize job titles (external to PPS), job descriptions, qualifications / credentials, and salary ranges Task

Step 3. Identify new hiring needs jointly with the Workforce Committee Task

Step 4. Work with Workforce to identify local recruitment resources (community job training, community newspapers / websites, libraries, job fairs) Task

Step 5.Communicate needs to PPS Workforce Committee Task

Step 6.Schedule and track community navigation recruitment activities (collaboration with Workforce and IT) Task

Step 7. Track all community navigation hires (collaboration with Workforce and IT) Task

Step 8.Assess need for temp agencies specializing in Health Care to assist in recruiting. (collaboration with Workforce) Milestone #4

Resource appropriately for the community navigators, evaluating placement and service type.

DY3 Q4

Project

N/A

Task

Navigator placement implemented based upon opportunity assessment.

Project

NYS Confidentiality – High

Page 226 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Telephonic and web-based health navigator services implemented by type.

Project

In Progress

08/15/2016

03/31/2018

08/15/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2016

06/30/2017

10/01/2016

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

08/15/2016

06/30/2017

08/15/2016

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

06/12/2015

12/31/2017

06/12/2015

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

08/15/2016

12/31/2017

08/15/2016

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

08/15/2016

12/31/2017

08/15/2016

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

08/15/2016

03/31/2018

08/15/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/31/2015

03/31/2018

07/31/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

08/15/2015

03/31/2018

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

08/15/2015

03/31/2018

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

08/15/2015

12/31/2017

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

08/15/2015

12/31/2017

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

08/15/2015

12/31/2017

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Task

Step 1.Review community needs assessment document to identify geographies of need Task

Step 2.Identify CBOs and HC organizations in those areas Task

Step 3.Identify opportunities for co-location with other projects and generally across PPS areas of need (EDs, clinics, shelters, public housing units). (2biv , 2bviii collaboration) Task

Step 4.Create co-location protocols and partnerships with other projects and generally across PPS areas of need (EDs, clinics, shelters, public housing units). (2biv, 2bviii collaboration) Task

Step 5.Identify a strategic plan template or best practices for expansion Task

Step 6.Draft strategic plan, get partner feedback and sign off Task

With 2ai, plan phased implementation of telephonic and webaccessible Command Center / Resource Hub , leveraging existing resources within PPS lead and participating partner infrastructure Task

Plan for telephonic and web-based health navigation services within "Phase 1" contact center Milestone #5

Provide community navigators with access to non-clinical resources, such as transportation and housing services.

DY3 Q4

Project

N/A

Task

Navigators have partnerships with transportation, housing, and other social services benefitting target population. Task

Step 1.Identify non-clinical partners within PPS Task

Step 2.Partner with non-clinical constituents to deliver on resources required to meet milestone #5 Task

Step 3.Create a list of partnerships for community navigators

NYS Confidentiality – High

Page 227 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 4. Develop and implement referral workflows and tracking protocols via telephonic and web-based navigation services.

Project

Completed

08/15/2015

12/31/2017

08/15/2015

06/30/2017

06/30/2017

DY3 Q1

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Milestone #6

Establish case loads and discharge processes to ensure efficiency in the system for community navigators who are following patients longitudinally.

DY2 Q4

Project

N/A

Task

Case loads and discharge processes established for health navigators following patients longitudinally. Task

Step 1. Actively participate in Care Coordination Cross Functional Workgroup sessions Task

Step 2. Leverage Care Coordination Cross Functional Workgroup's resources Task

Step 3. Refer to CCFW's processes, workflows, and protocols Task

Step 4. Collect current case load size/mix and discharge processes from partners Task

Step 5.Synthesize for key elements Task

Step 6.Create PPS case load and discharge process Task

Step 7.Ensure that partners all have key elements of caseload and discharge process in agency specific protocols Task

Step 8.Develop PPS materials for partner agency use, and ensure that training is completed for all staff dedicated to the community navigation project. Task

Step 9.Establish a quality assurance plan for the determined PPS protocol. Milestone #7

Market the availability of community-based navigation services.

DY2 Q4

Project

N/A

Task

Health navigator personnel and services marketed within designated communities. Task

Step 1. Create materials for resource guide, market and advertise

NYS Confidentiality – High

Page 228 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

resource hub, and market resources through PPS leads at each agency. Task

Step 2.Define Target Audience

Project

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2015

03/31/2017

09/30/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/15/2016

03/31/2017

08/15/2016

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Step 3. Collaborate with Workforce to finalize a marketing plan and workflow Task

Step 4. Share availability of community-based navigation services with PPS providers. Milestone #8

Use EHRs and other technical platforms to track all patients engaged in the project.

DY2 Q4

Project

N/A

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

Step 1.In collaboration with PMO and IT Committee, Identify patients who would benefit from receipt of community navigation services via 2ci using fields within current EHRs and other platforms. Task

Step 2.Identify key components of quarterly report template Task

Step 3.Identify patients receiving navigation services via specific programs Task

Step 4.Develop a system to collect required data for the tracking system Task

Step 5.Work with IT to create tracking and reporting system that is accessible to community navigators in the field and in the resource hub, and determine the linkages with other systems. Task

Step 6.Work with lead HHs to include projects in their dashboards for lead HH level reporting.

NYS Confidentiality – High

Page 229 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Current File Uploads Milestone Name Provide community navigators with access to nonclinical resources, such as transportation and housing services.

User ID

File Type

dlumbao

Other

dlumbao

Other

File Name

Description

34_DY3Q1_PROJ2ci_MDL2ci3_PRES5_OTH_2ci_Mile stone_5_Supportive_Documentation_Cover_Sheet_07. 18.17_16089.pdf 34_DY3Q1_PROJ2ci_MDL2ci3_PRES5_OTH_DY3_Q1 _2ci_Milestone_5_Submission_16088.xlsx

Upload Date

Cover Sheet

07/18/2017 05:40 PM

List of partnerships with nonclinical resources, such as transportation and housing services.

07/18/2017 05:32 PM

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Create community-based health navigation services, with the goal of assisting patients in accessing healthcare services efficiently. Develop a community care resource guide to assist the community resources and ensure compliance with protocols, under direction from a collaborating program oversight group of medical/behavioral health, community nursing, and social support services providers. Recruit for community navigators, ideally spearheaded by residents in the targeted area to ensure community familiarity. Resource appropriately for the community navigators, evaluating placement and service type. Provide community navigators with access to non-clinical resources, such as transportation and housing services. Establish case loads and discharge processes to ensure efficiency in the system for community navigators who are following patients longitudinally.

This project requirement 5: Provide community navigators with access to non-clinical resources, such as transportation and housing services has been completed with supporting documentation uploaded.

Market the availability of community-based navigation services. Use EHRs and other technical platforms to track all patients engaged in the project.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Ongoing

Milestone #5

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Milestone Review Status Milestone #

Review Status

Milestone #6

Pass & Complete

Milestone #7

Pass & Complete

Milestone #8

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 230 of 932 Run Date : 09/29/2017

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.c.i.4 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name

Status

Description

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone

Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8)

In Progress

Actively participate in Care Coordination Cross Functional Workgroup sessions

07/16/2015

03/31/2018

07/16/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

Leverage Care Coordination Cross Functional Workgroup's resources

07/16/2015

03/31/2018

07/16/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

Refer to CCFW's processes, workflows, and protocols

07/16/2015

03/31/2018

07/16/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

Needed to develop comprehensive web based resource guide

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Completed

Needed to develop comprehensive web based resource guide

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

Needed to develop comprehensive web based resource guide

08/15/2015

03/31/2017

08/15/2015

03/31/2017

03/31/2017

DY2 Q4

On Hold

Needed to develop comprehensive community navigator resource

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

On Hold

Needed to develop comprehensive community navigator resource

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

In Progress

Concurrent goal with marketing efforts and comprehensive marketing plan

08/15/2015

06/30/2017

08/15/2015

09/30/2017

09/30/2017

DY3 Q2

Completed

Need for process mapping of current state to develop future state

08/15/2015

06/30/2016

08/15/2015

06/30/2016

06/30/2016

DY2 Q1

Milestone

Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8) Milestone

Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8) Milestone

Develop resource guide training to meet State prescribed Req#2 in module 4 Milestone

Work with IT to create web based resource guide to meet State prescribed Req#2 in module 4 Milestone

Work with Clinical QA process to vet and verify resources to meet State prescribed Req#2 in module 4 Milestone

Obtain list of current community navigators to meet State prescribed Req#3 in module 4 Milestone

Create PPS database of community navigators to meet State prescribed Req#3 in module 4 Milestone

Increase Health Home Enrollment to meet State prescribed Req#7 in module 4 Milestone

Identify start-up sites and roll out timelines to meet

NYS Confidentiality – High

Page 232 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Milestone/Task Name

Status

Original Start Date

Description

Original End Date

Start Date

End Date

DSRIP Reporting Year and Quarter

Quarter End Date

State prescribed Req#8 in module 4 Milestone

MIDPOINT ASSESSMENT

Completed

MIDPOINT ASSESSMENT

06/01/2016

06/30/2016

06/01/2016

06/30/2016

06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8) Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8) Collaborate with Care Coordination Cross Functional Workgroup to meet Prescribed Milestones in module 4 (Req #'s 1-8) Develop resource guide training to meet State prescribed Req#2 in module 4 Work with IT to create web based resource guide to meet State prescribed Req#2 in module 4 Work with Clinical QA process to vet and verify resources to meet State prescribed Req#2 in module 4 Obtain list of current community navigators to meet State prescribed Req#3 in module 4 Create PPS database of community navigators to meet State prescribed Req#3 in module 4 Increase Health Home Enrollment to meet State prescribed Req#7 in module 4 Identify start-up sites and roll out timelines to meet State prescribed Req#8 in module 4 MIDPOINT ASSESSMENT

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 2.c.i.5 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 233 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 3.a.i – Integration of primary care and behavioral health services IPQR Module 3.a.i.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. A key challenge will be developing competent clinical workforce for this project. The primary risk is direct negative impact to patient engagement and care. We will address this by a multi-pronged approach: 1) In-depth and diverse methods of training which will draw from internal PPS expertise, external organizations, and utilizing "train the trainer" techniques. Focused curricula will include basic concepts of integrated and collaborative care; various roles in integrated care settings (i.e., collaborative supervising psychiatrist for IMPACT; Depression Care Managers); core clinical trainings (i.e., motivational interviewing; screening questionnaires); working with patients with behavioral health conditions (for Model B physical health practitioners). We will also work with the selected primary PPS workforce training vendor, local educational institutions, as well as nationally available training (i.e., the AIMS Center) to create comprehensive training modules for all disciplines in all three models. Trainings will occur via multiple venues, including formal in-services, hands-on workshops, grand rounds, staff meetings, web-based training modules, as well as individual supervision. 2) Ensure potential future workforce members receive training and clinical exposure to integrated care settings. We hope to include trainees from multiple clinical disciplines at sites across the PPS, and they will be included in trainings as appropriate. This will also help develop a pool of trained potential workforce members in later years of DSRIP, and ensure the foundations for this new clinical field of integrated care. A second major challenge is creating standardized operational models and workflows at each site to minimize practice variation. Risks with not implementing standardized models include significant impact on outcomes, risk of inefficiencies, and lower quality of care. We are developing standardized models and protocols of care for each clinical model, with detailed clinical and administrative workflows and implementation checklists. We will also work closely with the PPS IT to maximize automation and standardization of clinical documentation, handoffs, and notifications. The standardization will be based on available evidence and best practices, as well as allow for some flexibility due to the variety of different sites and phases of operational readiness for integrated care across sites. In addition, as one of the four PPS's involved in the KPMG Target Operating Model development for 3ai, we are using this platform to further refine models and workflows for our PPS, as well as contribute to the standardization of this level of care for other PPS's. Another related challenge is the variation in sites of not only EHR availability, but the readiness of their EHRs to incorporate both physical health and behavioral health clinical documentation. IT clinical documentation integration will be key to minimize the risks of separate or "opaque" documentation systems between physical and behavioral health, which can have significant safety and quality impact. Some CBOs have limited EHRs which may not easily be able to incorporate physical health documentation modules. We will work closely with the PPS IT to evaluate all partner IT capabilities, and implement any and all solutions with minimal workarounds. A final challenge will be adequate and appropriate clinical space for integrated care. Inadequate space and patient care room conditions may cause long wait times for appointments and patients dissatisfied with the care setting, leading to missed appointments and disengagement from treatment. Creative scheduling, room shares, modest expansions, and other innovative solutions will be employed. Privacy and confidentiality safeguards will be in place at the patient, provider, facility, and EHR levels.

NYS Confidentiality – High

Page 234 of 932 Run Date : 09/29/2017

Page 235 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.i.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

55,000

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

18,150

27,500

36,850

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

9,350

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (9,350) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 236 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 3.a.i.3 - Prescribed Milestones Models Selected Model 1

Model 2

Model 3

Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Co-locate behavioral health services at primary care practice sites. All participating eligible primary care practices must meet 2014 NCQA level 3 PCMH or Advance Primary Care Model standards by DY 3.

DY3 Q4

Model 1

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Provider

Practitioner - Primary Care Provider (PCP)

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Provider

Mental Health

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2016

03/31/2018

04/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Task

All eligible practices meet NCQA 2014 Level 3 PCMH and/or APCM standards by the end of DY3. Task

Behavioral health services are co-located within PCMH/APC practices and are available. Task

All practices meet NCQA 2014 Level 3 PCMH and/or APCM standards Step 1: Collaborate with 2ai to begin tracking PCMH/ and or APCM status. Task

All practices meet NCQA 2014 Level 3 PCMH and/or APCM standards Step 2: Collaborate with 2ai PCMH Technical Assistance Program to support participating PCPs. Task

All practices meet NCQA 2014 Level 3 PCMH and/or APCM standards Step 3: Collaborate with 2ai PCMH Technical Assistance Program to submit NCQA / APCM applications. Task

Behavioral health services are co-located within PCMH/APC practices and are available Step 1:

NYS Confidentiality – High

Page 237 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

10/31/2015

04/01/2015

10/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

In Progress

Project

Project

Provider Type

Original End Date

Identify pilot sites and staffing models. Task

Behavioral health services are co-located within PCMH/APC practices and are available Step 2: Develop standardized models/workflows for integrated behavioral health care in primary care settings across sites Task

Behavioral health services are co-located within PCMH/APC practices and are available Step 3: Create job descriptions and work with workforce committee to recruit and hire staff. Task

Behavioral health services are co-located within PCMH/APC practices and are available Step 4: Document licensure /certification and practice schedule and provide to PPS. Task

Behavioral health services are co-located within PCMH/APC practices and are available Step 5: Working with compliance, perform ongoing review of need for and submission of regulatory waivers and submissions of integrated service applications. Milestone #2

Develop collaborative evidence-based standards of care including medication management and care engagement process.

DY2 Q4

Model 1

Project

N/A

Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 1: Review existing evidence-based standards of care for integrated primary care/BH services, medication management, and care engagement process.

NYS Confidentiality – High

Page 238 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

04/01/2015

Project

Completed

Project

Provider Type

Original End Date

Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 2: Develop basic standards and protocols for medication management and care engagement for all sites. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 3: Draft preliminary PPS-wide high level standardized models/workflows/best practices. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 4: Draft site specific collaborative care protocol and implementation plan for Model 1. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 5: Create multidisciplinary team at each site. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 6: Schedule meetings to develop triage, integrated team conferences, medication management and engagement process. Task

Regularly scheduled formal meetings are held to develop collaborative care practices. Step 7: Ongoing consultation of PPS 3ai core committee for workflows, protocols and evidence based practices. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 1: Finalize initial site specific protocols for workflow, patient engagement and med management. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 2: Train all new clinics

NYS Confidentiality – High

Page 239 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

Completed

Project

Provider Type

Original End Date

and staff on collaborative care protocol. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 3: Create policies and procedures document for review and updates to care protocol. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 4: Pilot care protocol and implementation plan, review and update. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 5: Review new behavioral health standards of care guidelines and revise quarterly (or as needed) with 3ai core committee. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 6: Ongoing refinement of protocols based on continuous consultation with 3ai core committee. Task

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes. Step 7: Sites to conduct quarterly QI cycles on their programs to improve practices. Milestone #3

Conduct preventive care screenings, including behavioral health screenings (PHQ-2 or 9 for those screening positive, SBIRT) implemented for all patients to identify unmet needs.

DY3 Q4

Model 1

Project

N/A

Task

Policies and procedures are in place to facilitate and document completion of screenings.

Project

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

NYS Confidentiality – High

Page 240 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Screenings are documented in Electronic Health Record. Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT).

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

09/30/2015

04/01/2015

09/30/2015

09/30/2015

DY1 Q2

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Positive screenings result in "warm transfer" to behavioral health provider as measured by documentation in Electronic Health Record.

Provider

Practitioner - Primary Care Provider (PCP)

Task

Policies and procedures are in place to facilitate and document completion of screenings. Step 1: Review existing child, adolescent, and adult screening tools. Task

Policies and procedures are in place to facilitate and document completion of screenings. Step 2: Choose minimum set screening tools for sites (child, adolescent, and adult). Task

Policies and procedures are in place to facilitate and document completion of screenings. Step 3: Sites to develop individual screening policies and procedures based on recommendations from 3ai core committee. Task

Policies and procedures are in place to facilitate and document completion of screenings. Step 4: Quarterly review of screening activities, update policies and procedures as necessary. Task

Screenings are documented in Electronic Health Record Step 1: Identify current partner EHRs. Task

Screenings are documented in Electronic Health Record Step 2: Draft guide for recommended alerts and screening templates into collaborative care protocol. Task

Screenings are documented in Electronic Health

NYS Confidentiality – High

Page 241 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Record Step 3: Partners integrate alerts and screening templates into EHRs. Task

Screenings are documented in Electronic Health Record Step 4: Provide screenshots of screening alerts to project team.

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT) Step 1: Identify discrete screening variable in EHRs. Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT) Step 2: Work with site based or Sinai IT to create screening report. Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT) Step 3: Identify denominator of eligible patients (medicaid patients who receive primary care at that site) at each site and calculate screening rates. Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT) Step 4: Provide quarterly roster of eligible patients screened vs the total eligible to project team. Task

Positive screenings result in "warm transfer" to behavioral health provider as measured by documentation in Electronic Health Record Step1: Review existing protocols and develop "warm transfer" protocol, including documentation in EHRs (part of overall care protocol).

NYS Confidentiality – High

Page 242 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Positive screenings result in "warm transfer" to behavioral health provider as measured by documentation in Electronic Health Record Step 2: Train staff at sites in protocols and documentation.

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Milestone #4

Use EHRs or other technical platforms to track all patients engaged in this project.

DY2 Q4

Model 1

Project

N/A

Task

EHR demonstrates integration of medical and behavioral health record within individual patient records. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records Step 1: Survey partners to determine current EHR use, other technical platform use, or need for implementation. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records Step 2: Provide Technical Assistance to partners to integrate BH and EHR. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records Step 3: Document that both medical and behavioral health follow-up care are available in one EHR. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting Step 1: Create annual alerts in EHRs to identify eligible patients for screening Task

PPS identifies targeted patients and is able to track

NYS Confidentiality – High

Page 243 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Status

Original Start Date

Project

Completed

10/01/2015

Project

Completed

Project

Project

Provider Type

Original End Date

actively engaged patients for project milestone reporting Step 2: Identify discrete screening variable in EHRs. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting Step 3: Work with site based and / or Sinai IT to create screening report. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting Step 4: Sites provide quarterly roster of patients to project team. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting Step 5: Sites Identify patients who screen positive and are then diagnosed with depression, substance use or other mental illness. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting Step 6: Sites track referrals and follow ups of these patients. Milestone #5

Co-locate primary care services at behavioral health sites.

DY3 Q4

Model 2

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Provider

Practitioner - Primary Care Provider (PCP)

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Provider

Mental Health

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/01/2016

03/31/2018

06/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

06/01/2016

03/31/2018

06/01/2016

03/31/2018

03/31/2018

DY3 Q4

Task

Primary care services are co-located within behavioral Health practices and are available. Task

Primary care services are co-located within behavioral Health practices and are available. Task

PPS has achieved NCQA 2014 Level 3 PCMH or Advanced Primary Care Model Practices by the end of DY3. Step 1: Collaborate with 2ai to begin tracking PCMH/ and or APCM status. Task

PPS has achieved NCQA 2014 Level 3 PCMH or

NYS Confidentiality – High

Page 244 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Advanced Primary Care Model Practices by the end of DY3. Step 2: Collaborate with 2ai PCMH Technical Assistance Program to support participating PCPs. Task

PPS has achieved NCQA 2014 Level 3 PCMH or Advanced Primary Care Model Practices by the end of DY3. Step 3: Collaborate with 2ai PCMH Technical Assistance Program to submit NCQA / APCM applications.

Project

In Progress

06/01/2016

03/31/2018

06/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Primary care services are co-located within behavioral Health practices and are available. Step 1: Identify pilot sites and staffing models. Task

Primary care services are co-located within behavioral Health practices and are available. Step 2: Develop standardized models/workflows for primary care in Behavioral Health settings across sites. Task

Primary care services are co-located within behavioral Health practices and are available. Step 3: Create job descriptions and work with workforce committee to recruit and hire staff. Task

Primary care services are co-located within behavioral Health practices and are available. Step 4: Document licensure / certification and provide to PPS. Task

Primary care services are co-located within behavioral Health practices and are available. Step 5: Working with compliance, perform ongoing review of need for and submission of regulatory waivers, submissions of integrated service applications, and assessment and planning for physical space renovations. Milestone #6

Develop collaborative evidence-based standards of care including medication management and care engagement process. Task

Regularly scheduled formal meetings are held to

DY2 Q4

Model 2

Project

Project

N/A

NYS Confidentiality – High

Page 245 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

04/01/2015

Project

Completed

Project

Provider Type

Original End Date

develop collaborative care practices. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 1: Review existing evidence-based standards of care for integrated primary care/BH services, medication management, and care engagement process. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 2: Develop basic standards and protocols for medication management and care engagement for all sites. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 3: Draft preliminary PPS-wide high level standardized models/workflows/best practices. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 4: Draft site specific collaborative care protocol and implementation plan for Model 2. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 5: Create multidisciplinary team at each site. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 6: Schedule meetings to develop triage, integrated team conferences, medication management and engagement process. Task

Regularly scheduled formal meetings are held to develop collaborative care practices Step 7: Ongoing consultation of PPS 3a1 core committee for workflows,

NYS Confidentiality – High

Page 246 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

06/30/2016

04/01/2015

06/30/2016

06/30/2016

DY2 Q1

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

04/01/2015

Project

Completed

Project

Provider Type

Original End Date

protocols and evidence based practices. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 1: Finalize initial site specific protocols for workflow, patient engagement and med management. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 2: Train all new clinics and staff on collaborative care protocol. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 3: Create policies and procedures document for review and updates to care protocol. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 4: Pilot care protocol and implementation plan, review and update. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 5: Review new behavioral health standards of care guidelines and revise quarterly (or as needed) with 3ai core committee. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 6: Ongoing refinement of protocols based on continuous consultation with 3ai core committee. Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process. Step 7: Sites to conduct quarterly QI cycles on their programs to improve

NYS Confidentiality – High

Page 247 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

practices. Milestone #7

Conduct preventive care screenings, including physical and behavioral health screenings.

DY3 Q4

Model 2

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Screenings are conducted for all patients. Process workflows and operational protocols are in place to implement and document screenings. Task

Screenings are documented in Electronic Health Record. Task

At least 90% of patients receive primary care services, as defined by preventive care screenings at the established project sites (Screenings are defined as physical health screenings for primary care services and industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT for behavioral health). Task

Positive screenings result in "warm transfer" to behavioral health or primary care provider as indicated by screening as measured by documentation in Electronic Health Record (EHR).

Provider

Practitioner - Primary Care Provider (PCP)

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Provider

Mental Health

In Progress

09/01/2016

03/31/2018

09/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Positive screenings result in "warm transfer" to behavioral health or primary care provider as indicated by screening as measured by documentation in Electronic Health Record (EHR). Task

Screenings are conducted for all patients Step 1: Review existing child, adolescent, and adult screening tools and choose minimum set. Task

Screenings are conducted for all patients Step 2: Develop screening policies, workflows and operational procedures based on recommendations from 3ai core committee to adapt for implementation at sites. Task

Screenings are conducted for all patients Step 3:

NYS Confidentiality – High

Page 248 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

06/30/2016

07/01/2015

06/30/2016

06/30/2016

DY2 Q1

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

Completed

Project

Provider Type

Original End Date

Quarterly review of screening activities, update policies and procedures as necessary. Task

Screenings are documented in Electronic Health Record Step 1: Identify current partner EHRs. Task

Screenings are documented in Electronic Health Record Step 2: Draft guide for recommended alerts and screening templates into collaborative care protocol. Task

Screenings are documented in Electronic Health Record Step 3: Partners integrate alerts and screening templates into EHRs. Task

Screenings are documented in Electronic Health Record Step 4: Provide screenshots of screening alerts to project team. Task

At least 90% of patients receive screenings at the established project sites Step 1: Identify discrete screening variable in EHRs. Task

At least 90% of patients receive screenings at the established project sites Step 2: Work with site based or Sinai IT to create screening report. Task

At least 90% of patients receive screenings at the established project sites Step 3: Identify denominator of eligible patients (medicaid patients who receive primary care at that site) at each site and calculate screening rates. Task

At least 90% of patients receive screenings at the established project sites Step 4: Provide quarterly roster of eligible patients screened vs the total eligible to project team. Task

Positive screenings result in "warm transfer" to behavioral health provider Step 1: Review existing

NYS Confidentiality – High

Page 249 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

protocols and develop "warm transfer" protocol, including documentation in EHRs (part of overall care protocol). Task

Positive screenings result in "warm transfer" to behavioral health provider Step 2: Train staff at sites in protocols and documentation.

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

11/01/2015

03/31/2017

11/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Milestone #8

Use EHRs or other technical platforms to track all patients engaged in this project.

DY2 Q4

Model 2

Project

N/A

Task

EHR demonstrates integration of medical and behavioral health record within individual patient records. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records. Step 1: Survey partners to determine current EHR use, other technical platform use, or need for implementation. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records.Step 2: Provide Technical Assistance to partners to integrate BH and EHR. Task

EHR demonstrates integration of medical and behavioral health record within individual patient records.Step 3: Document that both medical and behavioral health follow-up care are available in one EHR. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Step 1: Create screening questions to identify eligible patients.

NYS Confidentiality – High

Page 250 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

PPS has implemented IMPACT Model at Primary Care Sites. Step 4: Develop IMPACT model training.

Project

Completed

10/01/2015

06/30/2017

10/01/2015

06/30/2017

06/30/2017

DY3 Q1

Task

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

Completed

Project

Project

Provider Type

Original End Date

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Step 2: Identify CPT codes variables in EHRs to query and track engaged patients. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Step 3: Work with site based or Sinai IT to create screening report. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Step 4: Provide quarterly roster of patients to project team. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Step 5: Sites track referrals and follow ups of these patients. Milestone #9

Implement IMPACT Model at Primary Care Sites.

DY3 Q4

Model 3

Project

N/A

Task

PPS has implemented IMPACT Model at Primary Care Sites. Task

PPS has implemented IMPACT Model at Primary Care Sites. Step 1: Draft customizable protocol template of Best Practices for IMPACT model. Task

PPS has implemented IMPACT Model at Primary Care Sites. Step 2: Identify sites with capacity to implement or currently using IMPACT. Task

PPS has implemented IMPACT Model at Primary Care Sites. Step 3: Recruit and hire staff for new sites. Task

NYS Confidentiality – High

Page 251 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

PPS has implemented IMPACT Model at Primary Care Sites. Step 5: Train Depression Care Managers, PCPs, Psychiatrists on IMPACT model. Task

PPS has implemented IMPACT Model at Primary Care Sites. Step 6: Customize patient flow and protocol at site.

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Milestone #10

Utilize IMPACT Model collaborative care standards, including developing coordinated evidence-based care standards and policies and procedures for care engagement.

DY2 Q4

Model 3

Project

N/A

Task

Coordinated evidence-based care protocols are in place, including a medication management and care engagement process to facilitate collaboration between primary care physician and care manager. Task

Policies and procedures include process for consulting with Psychiatrist. Task

Coordinated evidence-based care protocols are in place Step 1: Utilize basic protocols from 3ai workgroup to develop site specific protocols for workflow, patient engagement and med management. Pilot care protocol and implementation plan, review and update. Task

Coordinated evidence-based care protocols are in place Step 2: Create policies and procedures document for review and updates to care protocol. Task

Coordinated evidence-based care protocols are in place Step 3: Train all new clinics and staff on collaborative care protocol. Task

Coordinated evidence-based care protocols are in place Step 4: Review new behavioral health standards of care guidelines and revise quarterly (or as needed) with workgroup.

NYS Confidentiality – High

Page 252 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Completed

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Reporting Level

Status

Original Start Date

Project

Completed

01/01/2016

Project

Completed

Project

Provider Type

Original End Date

Task

Coordinated evidence-based care protocols are in place Step 5: Sites to conduct quarterly QI cycles on their programs to improve practices. Task

Policies and procedures include process for consulting with Psychiatrist Step 1: Review existing evidence based policies and procedures for psychiatry consults. Task

Policies and procedures include process for consulting with Psychiatrist Step 2: Create customizable procedure for sites (which would include weekly meetings- telephonic or in person and documentation procedures). Task

Policies and procedures include process for consulting with Psychiatrist Step 3: Sites customize and incorporate into collaborative care protocols. Task

Policies and procedures include process for consulting with Psychiatrist Step 4: Review quarterly and revise as necessary. Milestone #11

Employ a trained Depression Care Manager meeting requirements of the IMPACT model.

DY2 Q4

Model 3

Project

N/A

Task

PPS identifies qualified Depression Care Manager (can be a nurse, social worker, or psychologist) as identified in Electronic Health Records. Task

Depression care manager meets requirements of IMPACT model, including coaching patients in behavioral activation, offering course in counseling, monitoring depression symptoms for treatment response, and completing a relapse prevention plan. Task

PPS identifies qualified Depression Care Manager Step 1: PPS identifies sites with exisiting DCMs and sites needing to hire DCMs. Task

NYS Confidentiality – High

Page 253 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

11/01/2015

03/31/2017

03/31/2017

DY2 Q4

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

11/01/2015

12/31/2016

11/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

11/01/2015

12/31/2016

11/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

11/01/2015

Project

Completed

Project

Provider Type

Original End Date

PPS identifies qualified Depression Care Manager Step 2: Develop DCM job descriptions and qualifications for new DCMs. Task

PPS identifies qualified Depression Care Manager Step 3: Collaborate with Workforce Committee to recruit and hire Depression Care Managers. Task

PPS identifies qualified Depression Care Manager Step 4: DCM documents patient care in EMR. Task

Depression care manager meets requirements of IMPACT model Step 1: Create protocol for minimum training requirements and annual updates. Task

Depression care manager meets requirements of IMPACT model Step 2: Develop or identify training resources for DCM: depression care and monitoring, coaching patients in behavioral activation, consulting, and completing a relapse prevention plan. Task

Depression care manager meets requirements of IMPACT model Step 3: Develop supervision structure for training period for new DCM. Task

Depression care manager meets requirements of IMPACT model Step 4: Create or modify existing templates for behavioral activation, Motivational interviewing, relapse prevention. Task

Depression care manager meets requirements of IMPACT model Step 5: Chart audit to see if DCM had completed certain relevant templates for patients. Task

Depression care manager meets requirements of IMPACT model Step 6: Designate and provide ongoing consultative support in the PPS via the 3ai core committee. Milestone #12

Designate a Psychiatrist meeting requirements of the

DY2 Q4

Model 3

Project

N/A

NYS Confidentiality – High

Page 254 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

11/01/2015

03/31/2017

11/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

Completed

Project

Provider Type

Original End Date

IMPACT Model. Task

All IMPACT participants in PPS have a designated Psychiatrist. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 1: Develop Psychiatrist job descriptions specific to IMPACT model. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 2: Identify existing psychiatrists when possible and / or collaborate with Workforce Committee to recruit and hire psychiatrists. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 3: Train pscyhiatrists in case consultation for IMPACT model. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 4: Develop triage and referral protocols at new sites. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 5: Develop collaborative care case review customizable template specific to psychiatrist. Task

All IMPACT participants in PPS have a designated Psychiatrist Step 6: PCP or DCM identifies collaborating psychiatrist in IMPACT model patient EMR. Milestone #13

Measure outcomes as required in the IMPACT Model.

DY3 Q4

Model 3

Project

N/A

Task

At least 90% of patients receive screenings at the established project sites (Screenings are defined as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT). Task

At least 90% of patients receive screenings at the established project sites Step 1: Identify discrete

NYS Confidentiality – High

Page 255 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

screening variable in participating site EHRs to identify patients screened and not screened. Task

At least 90% of patients receive screenings at the established project sites Step 2: Identify denominator of eligible patients (medicaid patients receiving PC) at participating sites and calculate screening rates.

Project

In Progress

01/01/2016

06/30/2017

01/01/2016

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

01/01/2016

09/30/2017

01/01/2016

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

04/01/2016

03/31/2018

04/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2016

03/31/2018

04/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2016

03/31/2018

04/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2016

03/31/2018

07/01/2016

03/31/2018

03/31/2018

DY3 Q4

Completed

07/01/2015

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

Task

At least 90% of patients receive screenings at the established project sites Step 3: Work with site based (partners', including MSH) IT departments to create screening reports to be duplicated at future sites. Task

At least 90% of patients receive screenings at the established project sites Step 4: Provide quarterly roster of eligible patients screened vs the total eligible to project team. Task

At least 90% of patients receive screenings at the established project sites Step 5: Analyze screening rates and methods to bring overall PPS screening rates in participating projects to 90%. Task

At least 90% of patients receive screenings at the established project sites Step 6: Collaborate with IT Committee to perform analysis of opportunities for screening needs to be met by the PPS's IT infrastucture to create or streamline screening and depression registries and outcomes, including how changes will be synchronized with the PPS's IT needs for interoperability and clinical data sharing overall. Task

At least 90% of patients receive screenings at the established project sites Step 7: Collaborate with IT committee to determine how to plan for and implement any changes from above analysis. Milestone #14

Provide "stepped care" as required by the IMPACT Model.

DY3 Q4

Model 3

Project

N/A

NYS Confidentiality – High

Page 256 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

07/01/2015

09/30/2015

07/01/2015

09/30/2015

09/30/2015

DY1 Q2

Completed

10/01/2015

09/30/2016

10/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

01/01/2016

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Reporting Level

Status

Original Start Date

Project

Completed

07/01/2015

Project

Completed

Project

Provider Type

Original End Date

Task

In alignment with the IMPACT model, treatment is adjusted based on evidence-based algorithm that includes evaluation of patient after 10-12 weeks after start of treatment plan. Task

In alignment with the IMPACT model, treatment is adjusted based on evidence-based algorithm Step 1: Review evidence-based IMPACT care model guidelines from AIMS Center. Task

In alignment with the IMPACT model, treatment is adjusted based on evidence-based algorithm Step 2: Create standard algorithm for treatment for depression/anxiety/substance use (and/or disorders as determined by the 3ai core committee). Task

In alignment with the IMPACT model, treatment is adjusted based on evidence-based algorithm Step 3: Individual new sites adjust standard algorithm to fit their specific site, which must meet the basic requirements of the stepped care model Task

In alignment with the IMPACT model, treatment is adjusted based on evidence-based algorithm Step 4: Reassess and adjust algorithm as needed after 1-2 cycles. Milestone #15

Use EHRs or other technical platforms to track all patients engaged in this project.

DY2 Q4

Model 3

Project

N/A

Task

EHR demonstrates integration of medical and behavioral health record within individual patient records. Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

EHR demonstrates integration of medical and

NYS Confidentiality – High

Page 257 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Project Model Name

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

09/30/2016

07/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Reporting Level

Status

Original Start Date

Project

Completed

10/01/2015

Project

Completed

Project

Provider Type

Original End Date

behavioral health Step 1: Survey partners to determine current EHR use, other technical platform use, or need for implementation. Task

EHR demonstrates integration of medical and behavioral health Step 2: Provide Technical Assistance to partners to integrate BH and EHR. Task

EHR demonstrates integration of medical and behavioral health Step 3: Document that both medical and behavioral health follow-up care are available in one EHR. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 1: Create annual alerts in EHRs to identify eligible patients for screening. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 2: Identify discrete engagement variable in EHRs (ex: appointment with PC kept or medical assessment). Task

PPS identifies targeted patients and is able to track actively engaged patients Step 3: Work with site based or Sinai IT to create screening report. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 4: Provide quarterly roster of patients to project team. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 5: Sites track referrals and follow ups of these patients.

Prescribed Milestones Current File Uploads Milestone Name Provide "stepped care" as required by the IMPACT Model.

User ID nk434186

File Type Other

File Name 34_DY3Q1_PROJ3ai_MDL3ai3_PRES14_OTH_Project _3.a.i_Cover_Sheet_MS14_Task1_Steppedcare_16295

NYS Confidentiality – High

Description Stepped Care Milestone Completion Cover Sheet

Upload Date 07/21/2017 05:00 PM

Page 258 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

Upload Date

.pdf nk434186

Policies/Procedures

34_DY3Q1_PROJ3ai_MDL3ai3_PRES14_P&P_Mount_ Sinai_PPS_3ai_Manual_Models_1_and_3_DY3Q1_162 94.pdf

Stepped Care Practice Guidelines - Project 3ai Integrated Behavioral Health and Primary Care Manual Model 3

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Co-locate behavioral health services at primary care practice sites. All participating eligible primary care practices must meet 2014 NCQA level 3 PCMH or Advance Primary Care Model standards by DY 3. Develop collaborative evidence-based standards of care including medication management and care engagement process. Conduct preventive care screenings, including behavioral health screenings (PHQ-2 or 9 for those screening positive, SBIRT) implemented for all patients to identify unmet needs. Use EHRs or other technical platforms to track all patients engaged in this project. Co-locate primary care services at behavioral health sites. Develop collaborative evidence-based standards of care including medication management and care engagement process. Conduct preventive care screenings, including physical and behavioral health screenings. Use EHRs or other technical platforms to track all patients engaged in this project. Implement IMPACT Model at Primary Care Sites. Utilize IMPACT Model collaborative care standards, including developing coordinated evidence-based care standards and policies and procedures for care engagement. Employ a trained Depression Care Manager meeting requirements of the IMPACT model. Designate a Psychiatrist meeting requirements of the IMPACT Model. Measure outcomes as required in the IMPACT Model. Provide "stepped care" as required by the IMPACT Model.

Please find attached the Cover Sheet for Milestone 14 Completion: Project 3.a.i Cover Sheet_MS14_Task1_Steppedcare

NYS Confidentiality – High

07/21/2017 04:58 PM

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Prescribed Milestones Narrative Text Milestone Name

Narrative Text and the 3ai Model 1/3 Manual which is inclusive of the Stepped Care Practice Guidelines: Mount Sinai PPS 3ai Manual Models 1 and 3_DY3Q1

Use EHRs or other technical platforms to track all patients engaged in this project.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Complete

Milestone #3

Pass & Ongoing

Milestone #4

Pass & Complete

Milestone #5

Pass & Ongoing

Milestone #6

Pass & Complete

Milestone #7

Pass & Ongoing

Milestone #8

Pass & Complete

Milestone #9

Pass & Ongoing

Milestone #10

Pass & Complete

Milestone #11

Pass & Complete

Milestone #12

Pass & Complete

Milestone #13

Pass & Ongoing

Milestone #14

Pass & Complete

Milestone #15

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.i.4 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name Milestone

Status

Completed

Mid-Point Assessment

Original Start Date

Description

Mid-Point Assessment

06/01/2016

Original End Date 06/30/2016

Start Date

06/01/2016

End Date

06/30/2016

DSRIP Reporting Year and Quarter

Quarter End Date 06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.i.5 - IA Monitoring Instructions :

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Page 262 of 932 Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 3.a.iii – Implementation of evidence-based medication adherence programs (MAP) in community based sites for behavioral health medication compliance IPQR Module 3.a.iii.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. The foremost project risk pertains to the identified vulnerabilities and needs of the target population itself. Adherence to medication treatment specifically and both behavioral and physical health treatment generally comprise final common pathway problems and primary targets for project intervention. Challenge 1: Development of a scalable evidence-based adherence intervention targeting both behavioral health and physical health medications and related clinical encounters aligned with provider mandates. Strategy: Expand/adapt existing evidence based strategies for the behavioral health population, including both behavioral and physical health medications and related clinical engagement supported by tailored technologies, including a mobile platform to support extra-mural engagement and deployment, integrated into established workflows. Challenge 2: Implement a scalable standardized adherence intervention across Manhattan, Brooklyn and Queens and diverse professional and non-professional staff. Strategy: Interventions and related training will be piloted with discrete staff and patient cohorts then replicated with project partners supported by standardized training protocols. Each site will develop self-sustaining autonomy and network integration. Challenge 3: Complex impediments to the progressive engagement and activation of a culturally diverse, vulnerable population with prevalent multiple morbidities, social, financial, and housing problems, and family stressors. Engaging this population requires a highly committed culturally fluent staff familiar with population challenges. Strategy: A robust, established PPS apparatus for workforce recruitment, training and supervision, employing an assembled workforce of care coordinators, care navigators and peers will be oriented to population needs and 3aiii project interventions supported by a mobile technology platform. A major focus will be consumer education and health literacy in which peers may play an exceptional role. Education and treatment materials will be provided in multiple languages. Challenge 4: Assuring staff competency and adherence to prescribed interventions, related reporting, including measures of intervention efficacy. Strategy: Across the PPS, each practice setting and node will report ongoing assessment of staff adherence to the prescribed interventions and discrete performance metrics and outcomes using an integrated/mobile technology platform. Challenge 5: Other IT integration including data capture from pharmacy and other resource utilization both within and outside the PPS, including emergency services and hospitalization. Strategy: The project specific technology platform will integrate other data resources including regional and health information exchanges, and PSYCKES. Work related to the primary pilot, currently underway, is expected to produce viable scalable solutions to such integration then available to project partners. Challenge 6: Duplication of PPS services, which could complicate and impede the delivery of organized, efficient services. Strategy: Coordination at both the PPS and project level, through use of the MRT Innovation eXchange (MIX) idea bank as well as other direct collaborative initiatives, including sharing standardized approaches and protocols, experience and data, and collaborate on project development when possible. Challenge 7: Ensuring access to mobile technologies. Strategy: Access to mobile technologies and multiple points of access is a key project component of this project. When direct consumer access is not possible, case managers/care coordinators and peers may utilize other project funded mobile technologies (laptop/pad devices) to implement the adherence model.

NYS Confidentiality – High

Page 263 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.iii.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

45,000

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

12,000

18,000

25,000

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

6,000

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (6,000) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

Page 264 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 3.a.iii.3 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Develop a medication adherence program to improve behavioral health medication adherence through culturally-competent health literacy initiatives including methods based on the Fund for Public Health NY's Medication Adherence Project (MAP).

DY3 Q4

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

06/30/2017

04/01/2015

06/30/2017

06/30/2017

DY3 Q1

Project

In Progress

08/01/2015

09/30/2017

08/01/2015

09/30/2017

09/30/2017

DY3 Q2

Project

In Progress

08/01/2015

12/31/2017

08/01/2015

12/31/2017

12/31/2017

DY3 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

PPS has an active medication adherence program which includes initiatives reflecting the Fund for Public Health NY's MAP. Task

Project staff and participants receive training on PPS medication adherence program initiatives, either utilizing MAP materials or similar materials developed by the PPS. Task

PPS has an active medication adherence program Step 1: Review existing literature and DOHMH MAP program best practices. Task

PPS has an active medication adherence program Step 2: Develop and refine PPS self management goal intervention content and template to engage patients. Task

PPS has an active medication adherence program Step 3: Develop mobile Care4Today Mental Health Solutions (C4TMHS) intervention platform. Task

PPS has an active medication adherence program Step 4: Pilot and refine interventions. Task

PPS has an active medication adherence program Step 5: Create implementation protocol and module inclusive of IT integration for dissemination. Task

Project staff and participants receive training on PPS medication

NYS Confidentiality – High

Page 265 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

adherence program initiatives Step 1: Review literature, including: DOHMH MAP and CDC SIMPLE Protocols, Motivational Interviewing, Health Literacy, Shared Decision Making, and Wellness Self Management principles. Task

Project staff and participants receive training on PPS medication adherence program initiatives Step 2: Create draft training curriculum including introduction of self-management templates.

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

In Progress

08/01/2015

06/30/2017

08/01/2015

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

08/01/2015

06/30/2017

08/01/2015

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

08/01/2015

03/31/2018

08/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2016

03/31/2018

04/01/2016

03/31/2018

03/31/2018

DY3 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Completed

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Task

Project staff and participants receive training on PPS medication adherence program initiatives Step 3: Pilot and refine training curriculum including use of C4TMHS. Task

Project staff and participants receive training on PPS medication adherence program initiatives Step 4: Identify target training participants and initial and follow-up training schedules. Task

Project staff and participants receive training on PPS medication adherence program initiatives Step 5: Maintain training rosters and submit for quarterly reports. Task

Project staff and participants receive training on PPS medication adherence program initiatives Step 6: Ongoing assessment of training program and monitoring of incorporation into practice. Milestone #2

Form care teams including practitioners, care managers including Health Home care managers, social workers and pharmacists who are engaged with the behavioral health population.

DY2 Q4

Project

N/A

Task

PPS has assembled care teams focused on evidence-based medication adherence, including primary care and behavioral health practitioners as well as supporting practitioners, care managers, and others.

Project

Task

Regularly scheduled formal meetings are held to develop and update operational protocols based on evidence-based medication adherence standards.

Provider

Practitioner - Primary Care Provider (PCP)

Providers Associated with Completion: A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Sapphire Mann Md; Ahmed Zaheer Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf

NYS Confidentiality – High

Page 266 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Elkomos Soliman; Akoto Edna; Al-Izzi Sawsan Hatim Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Ali Aleem A; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A Md; Androne Louis Cristian Md; Ankireddypalli Arvind; Annan Vivian; Anthony Antoinette Md; Antosofsky Howard Md; Arabelo Howard Anthony De La Paz; Arend Jonathan; Ares Ella; Armington Kevin John Md; Arnon Ronen Md; Aronov Margarita A Md; Arron Martin Md; Arya Vijaypal Md; Asare Vivian; Ascunce Gil Ignacio; Aseme Kamara; Aslam Ahmed Kamal Md; Assadi Mashid A; Astua Alfredo J Md; Asuen Imeutinyan Md; Auerbach Lisa Resnick Md; Austein Lance; Autz Arthur L; Ayinla Raji Mohammed Md; Azizi Efat; Babaeva Saiera Md; Babb Frank C Md; Back Sara Deborah; Badlani Sachal Md; Bailey Juan A Md; Baird Philip Lee Md; Baird Sara; Bakshi Anjali Md; Banner Burton Md Pc; Banta Erin; Baran Margaret Md; Baron Natacha Adele; Barrett Conor Dominic; Barsa Jonathan; Bassoul Nissim Moses Md; Batra Kamal Kumar Md; Beaubrun Pierre Ronald Md; Bee-Healthy Proffessional Ped; Begun Jay R Md Pc; Belilovsky Anatoly Md; Benchimol Corinne Do; Benovitz Harvey L Pc Md; Benrath Michelle; Bentsianov Marie Azer Md; Bergman Michael; Berkowitz Leonard Bruce Md; Berlin Arnold I Md; Berman Paul Jeremy; Berwald Cary M Md; Besada Inacia Perez Md; Beth Israel Medical Ctr Act; Beuria Prarthana Md; Bhandari Rekha Md; Bhat Kiran Kumar Md; Bhat Sandeep Md; Bhatia Sonica; Bhattacharya Sarmistha Md; Bickell Nina Andrew Md; Bilik Ilya V Md; Bioh Dominick Kwasi Md; Blackett-Bonnett Terry Md; Blair Seidler Hammond; Blidnaya Lana; Boah William Ofori Md; Boguski-Filgueira Lisa F; Borrego Fernando J Md; Bourne Jeffrey Md; Bowers Daniel; Braun James Frederick; Braun Maureen K; Braza Mary; Brescia Andrea M Md; Briggs Haydn Md; Briones Alan Paul Santos Md; Brody Erica Md; Brody Samuel A Md; Bron Yana Md; Brown Laura E; Brownlow Nathaniel Md; Brunner Steven J Md; Bryant Linda M Md; Buhion Caroline; Bukberg Phillip R Md; Burger Alfred Paul Md; Burke Gary Robert; Busta Agustin Md; Bustamante Marco Md; Butt Ahmar Aziz Md; Cadag Stefan; Calabio Rafaela Z Md; Calamia Vincent Md; Callahan Mark; Camargo Edgar Md; Camargo Marianne; Cammerman Daniel Joseph Md; Carcaterra Joann Do; Castillo-Rodriguez Raquel; Castro George A Md; Cataldo Donnalee; Ceballos Clare; Cecilia Griselda Calderon Md; Cespedes Michelle Simone; Cha Yonhee Md; Chadi Ronny M Md; Chafian David Jonathan Md; Chan Chun-Kit; Chan Hang; Chan Sheung-Kwun Samuel Md; Charlotten Kevin Alexander Md; Chasan Rachel; Chase Jennifer C; Chatterjee Lolita Md; Chattooo Premetesh Do; Chaudhry Naeem Akhter Md; Chavez Silvia; Chen Abigail; Chen Chao Do; Chennareddy Swaminathan; Cherian Siby Vengal Md; Chery Roselyne Md; Cheung Barbara A; Cheung William Md; Chitu Carmen Elena; Chiu Gregorio E Md; Cho Hyung; Choe Josefina Luna Md; Chopra Ashok Chanparkash; Chow Desiree; Chow Rita Md; Chu Carolyn Md; Chu Jaime; Chuey John Md; Chun Eunmee H; Chung Andrew; Chung Bruce K Md; Chung Derek G Md; Chung Sung Lan Md; Ciechorska Maria Md; Cieloszyk Kinga Marta Md; Clark Cheryl L Md; Clemens Christopher Md; Coghill Alice Victoria Md; Cohen Alan J Md; Cohen Randy Edward; Cohen Roy A Md; Cohen Sandra; Cohrssen Andreas Md; Collins Megan Elizabeth Md; Conde Wright Marie France Md; Contreras Johanna Paola; Cook Heather Tiffany Md; Cook-Mack Jessica Phylis; Corrigan Kathleen; Cortes Jose Alberto Md; Cortijo Amarilys R Md; Cosmatos Andreas Md; Cosme-Thormann Braulio Federico; Coupet Nadege Marie Md; Cox Katherine Anne; Croft Lori Bray Md; Cruz Christina; Cunningham-Rundles C Md; D Oleo Vargas Maximo Jose; D'Souza David J Md; Da Rosso Robert Cian Md; Dadarwala Aashish Dhansukhlal; Daniele Rosemary Ann; Danik Jacqueline Suk; Danik Stephan B; Dantchenko Victoria Md; Daskalakis Demetre Costas; Davidson Morton I; Davis Yonette Md; Decherrie Linda Vandaele Md; Defabritus Albert M Md; Delaet David Edward Md; Dematteo Robert Enrico Md; Dennis Tian-Shu Chang; Depetris Gustavo Raul Md; Descartes-Walker Ingrid Md; Desikan Sonia; Desir Mergie X Md; Desrosiers Jean Claude; Devons Cathryn A Md; Dharapak Patricia Md; Di Scala Reno Gennaro Md; Diaz Michael Md; Dick Jeffrey M Md; Dickerson Lauren; Dilmanian Rossana; Disla Eddys Md; Doan-Schultz Yvette Chi; Docu Theodore Costa Md; Domek Maciej Md; Donovan Edmund J; Doshi Dhvani; Douglas Orin Albert; Dove Arthur Renner Md; Drake Victoria; Drazenovic Ivo; Drukman Liliya Md; Drullinsky Alexix Cesar Md; Dubey Sudha; Duddempudi Nagamma; Dumas Marie; Dunn Andrew S Md; Dunner Ricardo Orlando Md; Dvorkina Anzhela Md; Dwarka Regev Ragbardial; Dy-Guillaume Marie Eve Md; Edano Albert E Md; Edelman Laurie Beth Md; Eden Alvin N Md; Edgecomb Paul Steven; Edwards Ayisha Tene; Edwards Donna; Edwards Sharon M Md; Ehrlich Martin H Md; Eidgah Mahyar Md; Eisenson Arlene; Eisner Yvonne; Elbirt Paula M Md; Eliot P Schuster Md Pc; Ellis Earl Anthony Md; Eloi-Stiven Marie L; Emily Otis Taylor Md; Emmer Louis Mark Md; English Cary Md; Enschede Elizabeth; Enu Christopher Chukwuemeka; Eric S Barna; Erlikh Irina; Escalera Elsa Md; Escobar Christian; Esposito Amy; Esposito Stephen P Md; Etkin Alexandra; Factor Stephanie Hope Md; Faculty Practice Associates; Fafalak Robert G Md; Fakhruddin Dilshad Md; Farhat Hassan Ail Md; Farhat Samir Ali Md; Farrell Cristina; Feder Erica; Federman Alex David Md; Fefer Jose Jacobo Md; Feingold Leonard N Md; Felsen Michael R Md; Fenyves Andras Md; Fernaine George Md; Ferris David Craig Md; Field Jonathan Md; Fields Jessie Alfreda Md; Fierer Daniel Seth Md; Fievre Garnes Marie Ft Md; Finkelstein Donna Michal Md; Finkielstein Dennis Md; Fiorentino Thomas C Md; Fishman Donald R Md; Fisk Rebecca Saslow Md; Fisse Richard D Md; Fogel Joyce Frances Nahum Md; Fonfeder William; Ford Miriam; Forman Joel Alexander Md; Forman Lisa Diane Md; Forsyth Beverly Alison Md; Fox Kelita Louise; Frankel Etta Md; Frederic Bakhchi Md; Friedman Samuel; Friedman Scott L Md; Fteha Elie Md; Fuchs Thomas Md; Galal Nehal; Galvez Maida P Md; Ganatra Anjna Nain; Gandhi Vani Pragnesh Md; Ganea Gheorghe Romeo Md; Garber Julia; Garcia Quinones Saribel; Gardenier Donald; Gati Allison; Gault Allison Tamara Md; Gayle Eric George Md; Gazali Radfan M; Geraldine Yasmine Joseph; Gerdis Michael Md; Gerner Jenny; Gerolemou Louis N Do; Gervais Carole E; Gharpure Anil Md; Ghooi Ashok Md; Ghosh Anita; Gibbons Olga; Gidfar Niloufar Md; Gidwani Sonia Md; Giegel Melanie Joy; Gilgoff Hugh L Md; Gillespie Ginger Md; Ginde Ranjan; Glasser Lynne Ann Md; Gliatto Peter Matthew Md; Goetz Celine; Goforth Thomas; Goldblum Louis M Do; Goldman Adam Y Md; Goldstein Lissa Kary; Goldstein Zil; Gomez Gomez Veronica Del Carmen; Gomez Tessa S Md; Goodman Eric; Goodman Karl Richard Md; Goodman Stephanie Michelle; Gorny Mark A Md; Gottlock Robbins L; Gounder Celine Rani; Goyal Ravindra Kumar Md; Grabscheid Erica Md; Grand Mark Alan Md; Graney John Md; Grant Jessica J Md; Graziano Michelle; Greely John Stephen Md; Green Stuart Md; Gressel Irina Md; Gribetz Irwin X; Grimm Katherine Teets Md; Grossman Howard Alan Md; Gruber Steven Jeffrey Md; Guevara Elizabeth D L A Md; Guillen Rafael A Md; Gulrajani Ramesh S Md; Gupta Ashita; Gupte Amrita K Md; Guy Judath Philip; Hackenburg Emily; Hailu Mekdes Md; Hak Virender Md; Halberstam Meyer S Md; Hana Ehab Joseph; Hanna Emad; Haque Sayera Md; Harbord Nikolas B Md; Hariri E; Hashemian Nezhat Md; Hassan Yasmin Akbar Md; Hawkins Katherine A Md; Hefferon Susan; Hernandez Cameron Roland Md; Hewitt Ross G Md; Hill Keran; Ho Wesley Hok Man; Ho Wing Wah Md; Hobson Steven; Hodjati Ramin; Hoffman Judith; Hofmeister Stephen Frank Md; Hollman Dominic; Horn Ansell Np; Horowitz Carol Rose Md; Hsiung Ahmed Leslie; Hudesman David Philip; Hui Yiqun; Hupriker Shirish S Md; Husain Syed S Md; Hussaini Batool M Md; Hussaini Syed Zabeehullah Md; Hwang Andrew; Iglesias Alejandro D Md; Inada Victor Katsuji Md; Indio Lillian R; Institute For Family Hlth; Iocolano Carolyn F; Iqbal Muhammad Z Md; Irani Dinaz; Ismailova Kyamalya A; Israel Ezra Ceasar; Issa Ricardo Fabian Md; Issack Joshua; Itzkovitz Ina S Md; J Barbazan-Silva M D P C; Jaber Nadim; Jacobson Robin; Jagger Samantha Jane; Jahan Mumtaz Md; Jan Ren Bang Md; Janice Prime Care Medical Pc; Jao Jennifer; Jasti Harish Md; Jasty Babu N Md; Jawaid Mohammad Md; Jennifer B Cerasoli Md; Jennifer Kar Yee Hui; Jervis Ramiro Md; Jhagroo Omesh; Jhagroo Vishnudatt Md; Jimenez Mariela; Jimenez Roxanna; Jimmy R Sitt; John Bertha; Johnson Livette S Md; Johnson Timothy Curtiss Md; Jones Elizabeth Mary; Jones Michael Abou Md; Jones Vivian Lynn; Joseph Marjorie Md; Joseph Myriam; Judeh Hani; Jung Tiffany Maysu; Kale Minal Sharatkumar Md; Kannry Joseph L Md; Kaplan-Weisman Laura; Karakas Serife Eti Md; Karp Sara; Kashan Glenn Lawrence Md; Katz Cynthia J Md; Kensaint Pascale Md; Kent Jennifer Ames Md; Kerr Leslie Dubin Md; Khabyeh Shaya; Khaim Rafael Np-C; Khalid Nazneen Md; Khan Shumaila; Khorets Boris A Md; Kilinski Benjamin; Kim Julie; Kim Kyu-Han Md; Kim Sarah K; Kim Tonia K. Md; Kimble Christine Md; Kirkham Elizabeth; Kirschner Eric Md; Kitson Kwame A Md; Klein Daniel P Md; Klein Oscar Md; Kletsman Igor Md; Klimenko Elena A Md; Ko Fred Chau-Yang; Koicke Betsy C; Kondamudi Vasantha Kumari Md; Kondaveeti Harika; Kopke Mary; Koshy Sanjana Cherian; Kothari Vipul Chandrakant; Kozlov Natalya; Krausz Robert B Md; Kulina Georgia; Kuwama Yuichiro; Lai Anne; Lai Joanne Md; Lalia Madeline R Md; Lamb Angela; Landerer David; Lane Matthew John Md; Lantz Howard Md; Latt Ko Ko; Law Singwu David; Lawrence Donald P Md; Lawrence Donna Anthea; Lazala Polanco Carmen Md; Lazarin Margaux Helene; Leasy Menachem Jeremy; Leber Robert J Md; Leder Marvin A Md; Lee Hanna; Lee Jeong Ran Oh; Lee Marjorie Pc Md; Lee Namhi; Lefevre Lionel Md; Lefevre Marie Edith Faublas; Leinbach Lindsey; Lempel Herbert Sheldon Md; Lerner Gary; Lesnewski Ruth F Md; Levin Marc William Md; Levine Steven Barry Md; Levine-Tanco Karen; Li Ka Md; Liang Elizabeth; Liao Emilia Pauline Md; Liberman Dina Md; Lin Elaine Patricia; Lin Jenny Jen-Yi Md; Lin Lee Yulee; Linetskaya Irina; Lombardi Paul Md; Lopez-Santini Jaime; Lovenvirth Wendi Jennifer Md; Lu Haiyan; Lurio Joseph Glen Messner Md; Luz Amarilis Lugo Md; Lwin Yinphyu Win; Ly Rose Vay Luong Md; Lynch Colleen; Lynch Gina Adriana Md; Mack Theresa Adele Md; Mackay Richard E Md; Madhava Valsa S Md; Madrid Tanya M Md; Maggio Johanna

NYS Confidentiality – High

Page 267 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Medodie; Malachovsky Martin; Malieckal Jubil Md; Mamoon Nahreen Md; Manasia Anthony Robert Md; Mantia Augustus G Md; Mantia Philip Anthony Md; Manvar Buddhadev Nathabhai Md; Marcantonio Colomba A Md; March Anika Jolene; Maritato Andrea F Md; Markoff Brian A Md; Marseille Beatrice; Marsh Franklin Jr Md; Martin Monica A; Martinez Ofelia Md; Masson Ella; Mathews Premila Maria; Mathieu Claudine; Matthew S Cohen Md Pc; Mattoo Uijay Kumar Md; Maw Myo Md; Maybody Shideh; Mayer Amir Md; Mayer Victoria Lee; Mazza Michael Anthony Md; Mccormick Elizabeth T; Mcdonagh Mary Valentine; Mcgoldrick Patricia Engel; Mclaughlin Mary Ann Md; Mclendon Lucia Cogswell; Meacher Peter; Meah Yasmin Sultana Md; Medder Nia; Medina Leonel Delos Reyes; Meed Steven D Md; Meer John Fredric Md; Mehandru Saurabh; Mehta Davendra Md; Mehta Viplov K Md; Melis James Mark; Meltzer Elyse Michele; Menon Rakesh; Menon Rekha; Mensah Doreen Akosua Md; Merchant Yuko Md; Meredith Wepner Grossman; Merkler Richard G Md; Messinger Meridith L Md; Mettu Sudhakar Reddy Md; Mezheritsky Eleonora Md; Michael M Gaisa; Mikhail Imad Md; Mikkola Eeva Johanna; Milani Haleh Md; Miller Elizabeth; Miller Marc Andrew Md; Miller Sarah; Milman Alisa Md; Min Insung; Mino Rosa Elena Md; Mir Mohammad Arshad Md; Mirlohi Hooshang Pc Md; Misra Deepika Md; Mitchell Harrison Md; Moarefi Mehran-Reza Md; Mocombe Lucien D Md P C; Modern East West Medical Pc; Moe Khaing Md; Mogilner Leora Naomi Md; Mohammad Sajjad; Mohanraj Edwardine Mirnalini; Moise Wesner Md; Motiram Savitri Ramdass Md; Mozayan Mahboobeh; Mullen Michael Patrick Md; Muller David; Mumford James M Md; Murayama-Greenbaum Robert Md; Murphy Barbara Therese Md; Murray Carolina; Muse Jessica Md; Myint Moe Moe; Myint Richard Md; Mountsianihealthsystem; Mountsianihealthsystem; Naing Zaw Md; Nandi Anukul C Md; Nasr Sherif; Nasreen Tahera; Nassif Neven Ibrahim; Natarajan Rupa Narayani; Naughten James Kevin Do; Nautiyal Preeti Md; Navid Kathy Farima Md; Neretin Nicole; Nghi Phuong M Md; Nguyen Henry Van; Nguyen James K; Nguyen Thomas Thang Md; Niforos Fotis; Nisanian Anahid Jaquelline Md; Nissim Julie Md; Nosal Sarah Catherine; Novak Bethany Randi; Nowak-Wegrzyn Anna Halina Md; Nucci-Sack Anne Terese; Nweke-Chukumerije Obiageli Md; Obonaga Sheila; Ofosu-Amaah Sophia Md; Ogbovoh Daniel Obaroakpor Md; Oji Ngozi Afiazu Md; Okhravi Siavash Steve; Okpaleke Ifeoma Brenda; Olajide Bolanle A Md; Oliver Kristin; Orbe Jessica Md; Orin Gary Bruce Md; Orris Maxine Md; Osher Annette; Osoba Olumide Obafunmilayo Md; Osorio Georgina; Ostrager Jill Beth Md; Ostrowska Aneta; Ostrowski Roman M Md; Othoniel Marlene; Ottaviano Lawrence John Md; Paa Remedios Caparas; Pachman Jason Lee Md; Paddu Upadhyaya Padmanabh; Page Cameron Stuart; Pandya Amy Arun Md; Paredes Tessie Timitiman Md; Parikh Rita Md; Parkas Valerie Md; Parnes Eliezer L Md; Patel Deepti Dev; Patel Dipal Md; Patel Girishkumar Md; Patel Shamit P Md; Patel Sunil Md; Patel Truptiben; Patel Vidya; Patel Vinisha Md; Patrick Dalton Md Pc; Peccoralo Lauren Alise Md; Peimer Marta Silvee; Pena Armando Juan; Pennant Ainsley Md; Perry Andrea; Persaud Indrani; Perumareddi Krishna; Petelin Andrew Patrick Md; Peterson Monte Harold Md; Petilla-Onorato Jessica Isabel Md; Petrov Manana Md; Photangtham Punyatech Md; Pierce Carolyn Marie; Pierre Louisdon Md; Pierro Hugo Md; Pileta Lourdes X; Pinkas Adina Md; Plokamakis Michael Md; Poff John Edward; Poitevien Vaty; Polavarapu Hari Kishan Md; Ponieman Diego Andres Md; Poomkudy Liz; Posada Roberto Md; Pressler James Md; Prigollini Alejandro Md; Prine Linda Whisler; Pristoupa Olga Md; Psevdos George Jr Md; Puente-Guzman Soledad Elvira; Pumarol Alba; Purohit Amar Lal Md; Quick Melissa Kaufman; Quinn Carrie; Racanelli Joseph A Md; Radix Anita Eileen; Rafailov Danil Isakovich; Rafatjah Soyona; Rahman Rummana Md; Rahman Shafiqur Mohammed Md; Raifman Leonard I Md; Rajda Geetanjali Md; Ramkeesoon Rosemarie Np; Ramnarine Jotir; Ramos Tapia Alberto M Md; Rana Shital; Rathi Dwarka P Md; Raufman Joshua; Ray Roona; Ray-Schoenfeld Naomi; Read Dalan Md; Reckrey Margaret Jennifer; Reddy Chenna B Md; Reddy Lalitha Mary Md Pc; Rehman Abdul Md; Reich Danya; Reister Robin; Remde Alan Hugh; Reminick Marshal Md; Renaud Jean Leopold Edwrin Md; Reuben Stephen W; Rezvani Mitra Md; Rice Laurie A Cochran Md; Rios Carlos Md; Ripp Jonathan A Md; Rivera Graciano Md; Rivera Veronica; Rizk Dahlia Md; Robert Joyce Folashade; Rodgers Stephen L; Rodriguez German; Rodriguez Navarra; Rodriguez-Caprio Gabriela Md; Rodriguez-Jaquez Carlos R; Roedan Socrates; Rogers Linda Md; Roman Jasmin; Rosch Elliott C Md; Rosen Carolyn Michelle Md; Rosenberg Rachel; Rosenbloom Sylvie; Roshchina Yelena; Roth Rachel; Ruhe Jorg Joachim; Rule Erin Eileen Mdf; Russak Lisa; Sacher Mandy Lauren; Sacolick Benzion Md; Sacolick Daniel; Saftchick Stuart L Md; Sagalovich Boris Md; Saha Prantik Md; Saigh Orit Md; Saint-Laurent Mario; Saint-Louis Frantz Fils Md; Salinas Jean-Louis Md; Salomon Nadim Md; Sam Tanyka; Samaniego Robert Md; Samra Faraj; San Myat Md; Santiago Allan Realin Md; Saporito Anna Gabriella Md; Sara Danielle Lorenz Md; Sarin Aparna; Satsky Mindy B Md; Savransky Alla Md; Saw Thazin Md; Sazan Inga; Schiller Robert M Md; Schirripa John Piero Md; Schneebaum Cary Md; Schwartz William J Md; Scrimmager Leon Md; Seidler Afet Md; Seigel Rebecca Rae Md; Semanision Kristen; Senzamici Camille Md; Sessions Jessica; Setaruddin Sazia Loqman Md; Setia Deepak K Md; Shah Harshida R Md; Shah Jilan Md; Shah Kumarpal A Md; Shah Sumatilal C Md; Shahkoohi Afshin Md; Shaikh Aftabahmed F Md; Shalhoub Robert Francis Md; Shein Ruvan Md; Sheinfeld Joanna; Shen Kuan Hung Md; Shenko Christina Angela; Sherman Frederic M; Shieh Jong-Chuan Md; Shimonov Josef Md; Shirwaikar Anil B Md; Shukla Mayank Arun Md; Shust Gail; Siddiqui Ayesha; Siegel Howard Md; Siegel Stephen D Md; Sierros Vasilios Md; Sigel L Keith Md; Sigrest Barbara Md; Sikder Subhash Chandra; Simon Margo; Simpao Jose Rodriguez Jr Md P; Sindhwani Rajeev Md Pllc; Singal Anita; Singh Jagjit Md Pc; Siroya Pushplata B Md; Sisser Rachel; Sloan Barry; Small Katherine Morgan; Smith Alford Alexander Md; Smith Sharon Ellen Md; Smith Verta I Md; Sokolova Ekaterina; Solomon Rachel; Soriano Theresa A Md; Sosinsky Jeffrey H Md; Sotnik Regina Md; Sourial Lucy A Md; Spieler Leah Matisse; Spitzer Matthew; Spivak Dana Md; St Louis Emmanuel Lesly G Md; Sta Ana Victor; Stallings Shavonn; Starpoli Anthony A; Stauber Stuart L Md; Steever John B Md; Stein Alan J Md; Stein Janet Laurie Md; Stivala Alicia Christina; Straus Emily L Md; Strauss Michael Leopold Md; Suden Stacy Allisa Md; Sugandhi Nandita; Suja Vinod; Suma Dasari; Suprin Gregory Md; Suter Maureen Natalie; Syed Ahmad Physician Pc; Syed-Naqvi Samina Altaf Md; Szalyga John Md; Taha Hesham Mohamed Md; Talavera Wilfredo Md; Talcott James; Talerico Amanda Rae; Tam Cynthia J Md; Tamdji Natacha; Tan Wu; Tang David J Md; Tang Ian Tsai-Leu Md; Tao Chenguang Tony; Teets Raymond; Tenney Nancy Lee; Tesler Peter Jon Md; Theodore Ginette Np; Thomas David Charles Md; Tikhonova Elizaveta; Tikko Suraj K Md; Tio Ruy Chen Md; Tkachenko Natalya Md; Tolbert Jerome V Md; Trager Abigail Hope; Trenton Brooke; Truglio Joseph; Truong Tuyettrinh Nguyen; Tsai Tien-Tsai; Tso Alan Ying Yeung; Tun-Chiong Yolanda Do; Tung Keith; Turetsky Risa Ross; Turner Stephen B Md; Udesky Robert A Md; Uleis Keith Harris Md; Urbina Antonio E Md; Uribarri Jaime V Md; Uribe Alejandra Maria Md; Vail Rona; Valasareddi Lalasa Reddy Md; Van Gilder Max F Md; Vanegas Edgar Z Md; Vangeepuram Nita Md; Varghese Betsy; Varma Sudha Md; Vasa Chiroq V Md; Vasiliadis Athanasia S Md; Vavasis Anthony P Md; Veeramachaneni Saimamba Md; Vega Aida; Velazquez Belinda Melissa Md; Veluswamy Rajwanth; Vero Erica; Vicencio Alfin G Md; Villani Gina M Md; Vinas Sonia Miliza Md; Vindhya Rajesh Kumar Chand Md; Virani Zahra; Vizel-Schwartz Monique; Voddi Madhu D Md; Volokh Vladimir Md; Waite Eva Ann Md; Wajnberg Ania Md; Waldron Mary Violet Md; Walker Jenny; Wallach Frances Robin Md; Walsh Margaret Mary; Wang Emily H; Wang Jing Wa; Wang Stephanie Chih-I; Wang Zhong; Warman Jacob I Md; Waseem Faisal Md; Watkins Isheka S; Weintraub Jennifer; Weir David C; Wen-Ray Thomas Hsu; Whipple Clare; White Camele; White Elizabeth Stuyvesant Md; Wiener Joseph M Md; Wilder Venis Tiarra; Wong Chun Tung Md; Wong Hok; Woodley Walter Md; Xu Tao Shiwei; Yanagisawa Robert Takahiro Md; Yancovitz Stanley R Md; Yap Marcelo Janette Md; Yen Vincent Md; Young Edwin Reynolds Md; Yousaf Ali; Yudelman Ian M Md; Yuen Jacqueline; Zalavadia Deepti; Zaremski Benjamin Md; Zedeck Beth; Zelenetz Michael Ivan Md; Zewde Mulubrhan; Zhang Jian Wei; Zhang Meng; Zheng Hanbin Md; Zilberman Alla; Zinger Yevgeniya Oskarovna Md; Zoubtsova Minzalia Md; Zuger Abigail Dell Md; Zylbert Susan Lynn Md Task

Regularly scheduled formal meetings are held to develop and update operational protocols based on evidence-based medication adherence standards.

Provider

Mental Health

Completed

Providers Associated with Completion:

NYS Confidentiality – High

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Page 268 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Argus Community Inc; Argus Community,Inc; Assoc Rehab Cm & Housing Inc; Bailey House Ai; Beth Israel Medical Ctr Act; Goodwill Industries Act Rc; Greenwich House Inc Ai; Harlem East Life Plan; Henry St Settlement House Omh; Housing Works Ser,Inc Aadc; Institute For Family Hlth; Jewish Bd Of Fam Child Svc; Jewish Board Family Child A; Jewish Board Family Child B; Jewish Board Of Fmly&Child Sv; Long Island Consultation Ctr; Mental Hlth Prov/W Queens Mh; Mount Sinai Hospital; Puerto Rican Family Institute; Services For The Underserved; St Lukes Roosevelt Hsp; St Lukes Roosevelt Hsp Ctr; St Marks Place Institute; Weston United Comm Renewal Task

PPS conducts follow-up evaluations to determine patient outcomes and progress towards therapy goals, including evaluation of appropriateness, effectiveness, safety and drug interactions, and adherence where applicable.

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

08/01/2015

12/31/2016

08/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

08/01/2015

12/31/2016

08/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Task

PPS has assembled care teams focused on evidence-based medication adherence Step 1: Actively participate in Care Coordination Cross Functional Workgroup sessions to design a plan for engaging behavioral health population. Task

PPS has assembled care teams focused on evidence-based medication adherence Step 2: Leverage Care Coordination Cross Functional Workgroup's resources. Task

PPS has assembled care teams focused on evidence-based medication adherence Step 3: Collaborate with CCCFW to develop CCCFW processes, workflows, and protocols as they relate to the CCCFW Charter (uploaded in Clinical Integration, 9.1, Milestone 2). Task

PPS has assembled care teams focused on evidence-based medication adherence Step 4: Review best practices for care teams focused on medication adherence. Task

PPS has assembled care teams focused on evidence-based medication adherence Step 5: Create care teams at sites and submit site care team roster and updates to PPS project team. Task

PPS has assembled care teams focused on evidence-based medication adherence Step 6: Ongoing training of care teams and administrators in evidence based care team functions and project requirements. Task

Regularly scheduled formal meetings are held to develop and update operational protocols Step 1: Implement regular care team meetings, sites submit meeting schedule to PPS project team.

NYS Confidentiality – High

Page 269 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Regularly scheduled formal meetings are held to develop and update operational protocols Step 2: Project Workgroup creates customizable operational protocols for individual sites to adapt.

Project

Completed

01/01/2016

09/30/2016

01/01/2016

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

07/01/2016

12/31/2016

07/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Regularly scheduled formal meetings are held to develop and update operational protocols Step 3: Participating care teams review and adapt protocols. Task

Regularly scheduled formal meetings are held to develop and update operational protocols Step 4: Review and update operational protocol quarterly. Task

PPS conducts follow-up evaluations Step 1: Determine evaluation tools, including intervention template. Task

PPS conducts follow-up evaluations Step 2: Create reports progress towards therapy goal. Task

PPS conducts follow-up evaluations Step 3: Review representative sample of charts and / or electronic reports. Task

PPS conducts follow-up evaluations Step 4: Review prescriptive practices when applicable. Task

PPS conducts follow-up evaluations Step 5: Review issues with care teams and initiate corrective action plans. Milestone #3

Use EHRs or other technical platforms to track all patients engaged in this project.

DY2 Q4

Project

N/A

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

EHR for individual patients includes medication information, drug history, allergies and problems, and treatment plans with expected duration. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 1: Finalize patient inclusion criteria and identification.

NYS Confidentiality – High

Page 270 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

PPS identifies targeted patients and is able to track actively engaged patients Step 2: Build discrete variables into EHR/Template to identify engaged patients.

Project

Completed

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

09/01/2015

03/31/2017

09/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2016

03/31/2017

07/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2016

03/31/2017

04/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

01/01/2017

09/30/2017

01/01/2017

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

01/01/2017

09/30/2017

01/01/2017

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

01/01/2017

09/30/2017

01/01/2017

06/30/2017

06/30/2017

DY3 Q1

PPS has engaged MCO Step 2: Create draft protocols for coordination of services.

Project

Completed

01/01/2017

09/30/2017

01/01/2017

06/30/2017

06/30/2017

DY3 Q1

Task

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Task

PPS identifies targeted patients and is able to track actively engaged patients Step 3: Create tracking and reporting system with IT/ Mobile Care4Today platform. Task

PPS identifies targeted patients and is able to track actively engaged patients Step 4: Maintain ongoing monitoring of staff adherence and patient engagement reporting. Task

EHR for individual patients includes medication information, drug history, allergies and problems, and treatment plans Step 1: Build EHR checklist review tool. Task

EHR for individual patients includes medication information, drug history, allergies and problems, and treatment plans Step 2: Review EHRs for all participating partners. Task

EHR for individual patients includes medication information, drug history, allergies and problems, and treatment plans Step 3: Build templates into EHRs missing key elements. Task

EHR for individual patients includes medication information, drug history, allergies and problems, and treatment plans Step 4: Document compliance with goal with EHR screenshots. Milestone #4

Coordinate with Medicaid Managed Care Plans to improve medication adherence.

DY3 Q4

Project

N/A

Task

PPS has engaged MCO to develop protocols for coordination of services under this project. Task

PPS has engaged MCO Step 1: Identify key elements of service coordination. Task

NYS Confidentiality – High

Page 271 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

06/30/2017

DY3 Q1

PPS has engaged MCO Step 3: Identify MCOs and contacts. Task

PPS has engaged MCO Step 4: Work with Finance Committee and PPS Board of Managers to negotiate service contracts.

Project

Completed

01/01/2017

09/30/2017

01/01/2017

06/30/2017

Prescribed Milestones Current File Uploads Milestone Name Coordinate with Medicaid Managed Care Plans to improve medication adherence.

User ID nk434186

File Type Other

File Name

Description

34_DY3Q1_PROJ3aiii_MDL3aiii3_PRES4_OTH_Invent oryofAgreements_PPSPartner-MCO_16355.xlsx

Inventory of Agreements between PPS Partners and Managed Care Organizations.

Upload Date 07/24/2017 04:43 PM

Prescribed Milestones Narrative Text Milestone Name

Narrative Text

Develop a medication adherence program to improve behavioral health medication adherence through culturally-competent health literacy initiatives including methods based on the Fund for Public Health NY's Medication Adherence Project (MAP). Form care teams including practitioners, care managers including Health Home care managers, social workers and pharmacists who are engaged with the behavioral health population. Use EHRs or other technical platforms to track all patients engaged in this project. Please find attached the supporting Documentation for Milestone 4: Coordinate with Medicaid Managed Care Plans to improve medication adherence.

Inventory of MOUs or agreements between the PPS Network Providers/Partners and MCOs to substantiate project requirements pertaining to coordination, workflow and service agreements, including any quality and cost-beneficial treatment options to be provided by the MCO as part of the arrangements.

Milestone Review Status Milestone #

Review Status

Milestone #1

Pass & Ongoing

Milestone #2

Pass & Complete

Milestone #3

Pass & Complete

Milestone #4

Pass & Complete

IA Formal Comments

NYS Confidentiality – High

Page 272 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.iii.4 - PPS Defined Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for PPS-defined milestones.

Milestone/Task Name Milestone

Status

Completed

Mid-Point Assessment

Original Start Date

Description

Mid-Point Assessment

06/01/2016

Original End Date 06/30/2016

Start Date

06/01/2016

End Date

06/30/2016

DSRIP Reporting Year and Quarter

Quarter End Date 06/30/2016

DY2 Q1

PPS Defined Milestones Current File Uploads Milestone Name

User ID

File Type

File Name

Description

No Records Found

PPS Defined Milestones Narrative Text Milestone Name

Narrative Text

Mid-Point Assessment

NYS Confidentiality – High

Upload Date

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.a.iii.5 - IA Monitoring Instructions :

NYS Confidentiality – High

Page 273 of 932 Run Date : 09/29/2017

New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project 3.b.i – Evidence-based strategies for disease management in high risk/affected populations (adult only) IPQR Module 3.b.i.1 - Major Risks to Implementation and Mitigation Strategies Instructions : Please describe what the major risks are for this project, as well as the actions you plan to take to mitigate them. Many of the major risks within 3.b.i stem from a few underpinning topics: The difficulty of clinical workflow adjustments, patient engagement, and IT Integration dependencies Due to the number and complexity of Clinical workflow adjustments, we need to pay particular attention when implementing changes to the workflow. For example, in order to be successful when implementing workflow changes, the CVD working group, and in coordination with the diabetes working group, we will develop practical CV disease screening and management protocols which can be implemented across the PPS. In another example, when the PPS implements the 5 A's for Tobacco control, the CVD workgroup will work with care teams to train office staff to initiate the 5 A's during the initial work-up of the patient, with completion of the 5 A's to be left up to the provider. With this change, the burden of completing the 5 A's will no longer exclusively fall on the provider. This is a practical workflow adjustment There are several risks surrounding patient engagement and IT Integration. Typically, patients with elevated blood pressure but no formal diagnosis of hypertension will go undetected and untreated. To address this risk, the CVD Workgroup will work with IT to develop site reports of patients with elevated office blood pressure both with and without a formal diagnosis of hypertension. This strategy of leveraging IT to flag patients will be used across the project to mitigate risk. In another risk, the PPS may be unable to engage all participating providers in the 5 A's tobacco control program. To mitigate this sick, the CVD workgroup will work with IT to develop a hard-stop in EHR's to ensure the 5 A's are addressed prior to signing and locking a note. Risk: Low patient compliance with lifestyle recommendations is a real and potential risk related to the implementation of this project. Mitigation Strategy: To address these concerns, the PPS will ensure that its treatment protocols and lifestyle interventions are simple, efficacious and cost-effective. Furthermore, through the use of health coaches and care management teams, the PPS will ensure that engaged patients are actively participating and following up on recommendations for lifestyle modification. Risk: Due to the varying levels of readiness of PPS members for PCMH Level 3 recognition, there is a risk that not all providers will meet this deliverable. Mitigation Strategy: Through regular PPS meetings and monthly reports, providers not achieving PCMH level 3 will be identified and targeted for additional support to ensure adherence with DSRIP implementation plans. Additionally, the Clinical Committee is creating a task force/focus group specific to bringing providers to PCMH Level 3. These initiatives will mitigate the implementation risk. Risk: Due to the nature of organizational change, there is a risk that providers will fail to adopt new clinical protocols and guidelines that the PPS adopts.

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New York State Department Of Health Delivery System Reform Incentive Payment Project DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Mitigation Strategy: If participating providers are struggling to adopt new clinical guidelines, need assistance with implementing clinical guidelines, or simply fail to comply with clinical guidelines, the PPS will identify these providers as outliers, and ensure that adequate resources are allocated for additional support, guidance and/or oversight. Additionally, the PPS will develop templates that can be adopted to varying levels of organizational maturity. This will allow for flexible adoption.

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34)

IPQR Module 3.b.i.2 - Patient Engagement Speed Instructions : Enter the number of patients actively engaged through the current quarter. The number entered into the "Quarterly Update" area needs to reflect the cumulative method of counting within a DSRIP year. For example, the number reported in this field for Q4 should include patients previously reported in Q3 plus new patients engaged in Q4. Any explanations regarding altered or missed patient commitments must be included within the narrative box, not as text within uploaded documentation.

Benchmarks Actively Engaged Speed

Actively Engaged Scale

DY4,Q4

23,080

Year,Quarter

DY3,Q1

Baseline Commitment PPS Reported

DY3,Q4

8,078

13,200

18,464

0

0

0

0

0.00%

0.00%

0.00%

0.00%

0

0

0

0

0.00%

0.00%

0.00%

0.00%

Quarterly Update Percent(%) of Commitment

DY3,Q3

2,750

Quarterly Update Percent(%) of Commitment

IA Approved

DY3,Q2

Warning: PPS Reported - Please note that your patients engaged to date (0) does not meet your committed amount (2,750) for 'DY3,Q1'

Current File Uploads User ID

File Type

File Name

No Records Found

Narrative Text : For PPS to provide additional context regarding progress and/or updates to IA. "In step with the changes from reporting Actively Engaged quarterly to reporting twice a year (in Q2 and Q4), and following specific IA advice, the PPS is leaving the Q1 Actively Engaged entry at zero and will report the cumulative Actively Engaged patients in Q2."

Module Review Status Review Status

IA Formal Comments

Pass & Ongoing

NYS Confidentiality – High

File Description

Upload Date

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) IPQR Module 3.b.i.3 - Prescribed Milestones Instructions : Please provide updates to baseline reporting on status, target dates, and work breakdown tasks for prescribed milestones. For milestones that are due and completed within the reporting period, documentation is required to provide evidence of project requirement achievement. Any explanations regarding altered or missed provider commitments should be included within the narrative box, not as text within uploaded documentation.

Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #1

Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting.

DY3 Q4

Project

N/A

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

04/01/2015

03/31/2018

04/01/2017

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

01/01/2016

09/30/2016

01/01/2016

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Task

PPS has implemented program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. Task

Step 1. Identify evidence based best practices to improve management of cardiovascular disease in the ambulatory and community care setting. Task

Step 2. Create an evidence-based screening and management program to improve the health of patients with known (or high risk for) cardiovascular disease in the ambulatory care and community care setting. Task

Step 3. Receive approval from Clinical Committee on the use of the management program and protocols . Task

Step 4. Identify and inventory all ambulatory care practitioners and community care settings by provider type, services delivered, and geography served to identify locations to implement evidence-based strategies that improve management of cardiovascular disease. Task

Step 5. Set up monthly meetings with ambulatory care practitioners to design best practices for information management, and coordination across multiple settings to address patients with cardiovascular disease. Task

Step 6. Work with IT to develop quality measurements using new and existing HIT systems to facilitate screening at risk individuals

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

and promote the identification of patients not meeting prespecified targets for Cardiovascular disease risk reduction. (Cardiovascular disease screening and risk management protocols are based on the Million Hearts initiative.) Task

Step 7. Develop training program for improving management of cardiovascular disease.

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/31/2015

03/31/2016

10/31/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

12/01/2015

12/31/2016

12/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

12/01/2015

03/31/2017

12/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

12/01/2015

03/31/2017

12/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

In Progress

12/31/2015

03/31/2018

12/31/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

12/01/2015

03/31/2018

12/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

12/01/2015

03/31/2018

12/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

12/01/2015

03/31/2018

12/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

12/01/2015

03/31/2017

12/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

12/31/2015

10/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 8. Identify ambulatory care practitioners for participation in training program. Task

Step 9. Work with workforce to train and educate providers and other allied health professionals throughout the PPS on information management. Task

Step 10. Pilot program within the PPS prior to widespread dissemination throughout the PPS using rapid cycle evaluation to revise model. Task

Step 11. Continuous Quality Review results of pilot implementation sites against the baseline results from the PPS. Task

Step 12. Implement PPS-wide established program. Milestone #2

Ensure that all PPS safety net providers are actively connected to EHR systems with local health information exchange/RHIO/SHIN-NY and share health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up, by the end of DY 3.

DY3 Q4

Project

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements.

Provider

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements.

Provider

N/A

Safety Net Practitioner Primary Care Provider (PCP) Safety Net Practitioner Non-Primary Care Provider (PCP)

Task

EHR meets connectivity to RHIO's HIE and SHIN-NY requirements. Task

PPS uses alerts and secure messaging functionality. Task

Provider

Safety Net Mental Health

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 1. Assess partner EMRs and identify bi-directional data interface capability / gaps to EHRs and other data source systems Task

Step 2. Develop and agree on the future state and a plan to close any gaps identified in step 1

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

In Progress

10/01/2016

03/31/2018

10/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

01/01/2016

06/30/2017

01/01/2016

06/30/2017

06/30/2017

DY3 Q1

Project

In Progress

01/01/2016

12/31/2017

01/01/2016

12/31/2017

12/31/2017

DY3 Q3

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

04/01/2015

03/31/2018

04/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Task

Step 3. Provision MSPPS HIE eMPI for use with PPS data interfaces Task

Step 4. Develop, implement, and deploy CBO data entry portal and associated flat-file data collection and normalization process. Task

Step 5. Implement interfaces from EHRs including care management protocols and other data sources to partnering RHIOs, or directly to MS PPS system Task

Step 6. Develop, implement, and deploy direct messaging and referrals management tools Milestone #3

Ensure that EHR systems used by participating safety net providers meet Meaningful Use and PCMH Level 3 standards and/or APCM by the end of Demonstration Year 3.

DY3 Q4

Project

N/A

Task

EHR meets Meaningful Use Stage 2 CMS requirements (Note: any/all MU requirements adjusted by CMS will be incorporated into the assessment criteria).

Project

Task

PPS has achieved NCQA 2014 Level 3 PCMH standards and/or APCM.

Provider

Practitioner - Primary Care Provider (PCP)

Task

Step 1. Identify baseline and gaps in adoption of ONC-certified EHR technology among PPS participants as part of the current state assessment and gap analysis process Task

Step 2. Develop plan, detail around technical assistance services, and timeline for implementation of technical assistance program Task

Step 3. Provide technical assistance, including purchasing decision support, dissemination of EHR implementation best

NYS Confidentiality – High

Page 280 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

practices via the PPS Learning Management System (LMS), and other modes of implementation support to be determined through the current state assessment and gap-analysis processes to providers that need to adopt a new EHR or upgrade their existing EHR - in time for achievement of PCMH III and adoption of MU eligible EHRs in DY3 Milestone #4

Use EHRs or other technical platforms to track all patients engaged in this project.

DY2 Q4

Project

N/A

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

09/30/2016

04/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

04/01/2015

03/31/2016

04/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

08/01/2015

06/30/2016

08/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

In Progress

09/01/2015

03/31/2018

09/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

09/01/2015

03/31/2018

09/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

PPS identifies targeted patients and is able to track actively engaged patients for project milestone reporting. Task

Step 1. Finalize patient inclusion criteria and identification per NYS and PPS criteria including risk stratification criteria Task

Step 2. Select an IT platform(s) to use for the PPS Task

Step 3. Build discrete variables to track patients into EHR/Template to identify engaged patients. Task

Step 4. Create tracking and reporting system with IT platform with the support of the IT Committee. Task

Step 5. Train providers on how to input patient information and track patients in the IT Platform Task

Step 6. Develop ongoing webinars and trainings for providers to learn how to access, analyze and read the data inputted into the IT platform Task

Step 7. Maintain ongoing monitoring of staff adherence and patient engagement reporting by organization. When organizations actively engaged patient trends downward, the PPS will follow-up Milestone #5

Use the EHR to prompt providers to complete the 5 A's of tobacco control (Ask, Assess, Advise, Assist, and Arrange).

DY3 Q4

Project

N/A

Task

PPS has implemented an automated scheduling system to facilitate tobacco control protocols.

Project

NYS Confidentiality – High

Page 281 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

PPS provides periodic training to staff to incorporate the use of EHR to prompt the use of 5 A's of tobacco control.

Project

In Progress

09/01/2015

03/31/2018

09/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

09/01/2015

12/31/2016

09/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

11/01/2015

12/31/2016

11/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2016

03/31/2018

10/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

10/01/2016

03/31/2018

10/01/2016

03/31/2018

03/31/2018

DY3 Q4

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 1. Develop plan with IT to integrate prompt of 5 A's of tobacco control within EHR for patients identified as being active tobacco users. The prompts will direct providers to use the 5 A's of tobacco control to counsel, provide support and assist patients with smoking cessation. Task

Step 2. Create education plan teaching providers on how to use 5A's of tobacco control and NY Quits for at-risk patients. Task

Step 3. Work with workforce to incorporate 5 A's of tobacco control into Learning Management as a PPS wide training. Task

Step 4. Implement training in learning management for providers on how to use EHR prompt of 5 A's of tobacco control. Task

Step 5. Assess using continuous quality review of providers completing 5 A's of tobacco. Task

Step 6. Provide quarterly training to providers on how to use prompt of 5 A's of tobacco control. Milestone #6

Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol.

DY2 Q4

Project

N/A

Task

Practice has adopted treatment protocols aligned with national guidelines, such as the National Cholesterol Education Program (NCEP) or US Preventive Services Task Force (USPSTF). Task

Step 1. Identify team of providers who have treatment protocols aligned with national guidelines such as National Cholesterol Education Program (NCEP) or US Preventive Services Task Force (USPSTF). Task

Step 2. Work with designated team to create plan to integrate standardized treatment protocols for hypertension and elevated cholesterol using screening and management guidelines set forth in the NCEP/ATP-III update. For hypertension, the PPS will

NYS Confidentiality – High

Page 282 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

follow the screening and management guidelines set forth by JNC-8. Task

Step 3. Collaborate with IT to integrate standardize screening and treatment protocols into EHRs for the PPS.

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

09/01/2015

09/30/2016

09/01/2015

09/30/2016

09/30/2016

DY2 Q2

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Completed

07/01/2015

03/31/2017

07/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/01/2016

03/31/2017

03/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/01/2016

03/31/2017

03/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/01/2016

03/31/2017

03/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

07/01/2015

12/31/2015

07/01/2015

12/31/2015

12/31/2015

DY1 Q3

Task

Step 4. Create education and training plan for providers working with the Stakeholder Engagement team and Clinical committee. Task

Step 5. Work with workforce and IT to train providers on standardized treatment protocols for hypertension and elevated cholesterol. Task

Step 6. Present to PPS leadership for approval of standardized treatment protocols. Task

Step 7. Train providers on treatment protocols and procedures PPS wide. Task

Step 8. Implement hypertension and elevated cholesterol screening and management protocols to participating PPS organizations. Task

Step 9. Perform continuous quality improvement of process and improve accordingly. Milestone #7

Develop care coordination teams including use of nursing staff, pharmacists, dieticians and community health workers to address lifestyle changes, medication adherence, health literacy issues, and patient self-efficacy and confidence in self-management.

DY2 Q4

Project

N/A

Task

Clinically Interoperable System is in place for all participating providers. Task

Care coordination teams are in place and include nursing staff, pharmacists, dieticians, community health workers, and Health Home care managers where applicable. Task

Care coordination processes are in place. Task

Step 1. Perform a network analysis of provider types according to

NYS Confidentiality – High

Page 283 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

geographic area, type of service and project participation. Task

Step 2. Work with care coordination workgroup to develop care coordination teams (consisting of physicians, nurse care managers, health home care managers, registered dietitians and health coaches) to screen and manage eligible patients with known (or high risk for developing) CVD.

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

04/01/2016

12/31/2016

04/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

06/30/2016

12/31/2016

06/30/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2016

12/31/2016

09/30/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Task

Step 3. Working with care coordination workgroup to identify best practices on how to address life style changes, medication adherence, health literacy issues and patient self-efficacy and confidence in self management be standardized across the PPS Task

Step 4. Work with IT/partners and care coordination work group to assess interoperability systems are in place for implementation. Task

Step 5. Work with IT/partners to identify providers for engagement of existing care coordination teams as well as development of new care coordination teams to deliver appropriate services. Task

Step 6. Perform assessment of care coordination teams who are following protocol of assessing EHR to check for services to provide to patients. Task

Step 7. Create care coordination teams (Include nursing staff, pharmacists, dieticians, community health workers, and health home care managers) to meet the needs of patients. Task

Step 8. Work with workforce and care coordination work group to develop training materials, policies and procedures. Task

Step 9. Present to PPS leadership for approval of standardized treatment protocols and training program. Task

Step 10. With workforce and care coordination work group to train care coordination teams. Task

Step 11. Measure training program for effectiveness. Task

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 12. Pilot care coordination teams at participating sites. Task

Step 13. Performing Continuous Quality Improvement to identify effectiveness and areas of improvement for care coordination. Task

Step 14. Implement to PPS wide participating partners.

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Completed

09/01/2015

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

09/01/2015

03/31/2018

04/01/2017

06/30/2017

06/30/2017

DY3 Q1

Project

Completed

09/01/2015

03/31/2016

09/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

09/01/2015

12/31/2016

09/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/31/2015

12/31/2016

10/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/31/2015

12/31/2016

10/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

10/31/2015

12/31/2016

10/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Milestone #8

Provide opportunities for follow-up blood pressure checks without a copayment or advanced appointment.

DY3 Q4

Project

N/A

Task

All primary care practices in the PPS provide follow-up blood pressure checks without copayment or advanced appointments. Task

Step 1. Work with workforce to develop protocol for PCPs in PPS to provide follow up blood pressure checks without copayment or advanced appointments. Task

Step 2. Develop plan to train and educate primary care providers to follow-up on blood pressure checks. Task

Step 3. Work with workforce to design training of PCPs and supporting staff across the PPS on follow up blood pressure checks. Task

Step 4. Integrate training into Learning Management for all PCPs in PPS. Task

Step 5. Work with Stakeholder engagement team to socialize protocol to all primary care practices in the PPS on follow-up blood pressure checks without copayment or advanced appointments. Task

Step 6. Implement Learning Management tool for all PCPs to access. Task

Step 7. Analyze data of number of PCPs completed Learning management on blood pressure checks. Task

Step 8. Perform quality improvement to review design and implementation of process and correct accordingly. Milestone #9

DY2 Q4

Project

N/A

NYS Confidentiality – High

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DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Ensure that all staff involved in measuring and recording blood pressure are using correct measurement techniques and equipment. Task

PPS has protocols in place to ensure blood pressure measurements are taken correctly with the correct equipment.

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

11/01/2015

03/31/2016

11/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

12/31/2015

09/30/2016

12/31/2015

09/30/2016

09/30/2016

DY2 Q2

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Step 1. Design standard protocol for measuring and recording blood pressure using correct measurement techniques and equipment. Task

Step 2. Review protocol with clinical committee for approval. Task

Step 3. Work with workforce to creating training program. Task

Step 4. Execute training and education of designate staff of standardized blood pressure screening and management protocols Task

Step 5. Hire new designate staff and train current staff throughout the PPS to continue to educate and monitor sites on the proper use of the BP equipment, as well as the screening and management protocols at the partner level. Task

Step 6. Collaborate with stakeholder engagement workgroup to develop communication materials and medium to inform partners of the standard protocols PPS wide. Task

Step 7. Deliver communication to partners of standard protocol. Task

Step 8. Provide ongoing trainings through workforce, particularly for new staff that join the PPS. Task

Step 9. Perform continuous quality Improvement to identify effectiveness of training. Milestone #10

Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit. Task

PPS uses a patient stratification system to identify patients who

DY3 Q4

Project

Project

N/A

NYS Confidentiality – High

Page 286 of 932

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Run Date : 09/29/2017

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

have repeated elevated blood pressure but no diagnosis of hypertension. Task

PPS has implemented an automated scheduling system to facilitate scheduling of targeted hypertension patients.

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Step 9. Work with workforce to train and educate staff on policies and protocols of identifying patients who meet inclusion criteria.

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Task

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Task

PPS provides periodic training to staff to ensure effective patient identification and hypertension visit scheduling. Task

Step 1. Develop plan on identifying patients with repeated elevated blood pressure reading but no diagnosis of hypertension. Task

Step 2. Identify criteria for patient stratification for Cardiovascular patients (High, medium, low risk, confirmed diagnosis, etc.) Task

Step 3. Work with IT to create EMR alerts for patients with elevated blood pressure readings without the diagnosis of hypertension. Task

Step 4. Work with IT to create aggregate list of patients who fall in the inclusion criteria. Task

Step 5. Create training program for staff to learn to generate lists of patients who fall in inclusion criteria . Task

Step 6. Work with IT to create automated scheduling system that will generate frequent lists of patients with elevated blood pressure without a diagnosis of hypertension and send out ealerts and/or phone calls to these patients to scheduled follow-up visits and/or blood pressure checks. Task

Step 7. Collaborate with workforce to execute trainings as staff are onboarded. Task

Step 8. Work with IT to generate Compliance reports for monitoring compliance to protocols. Task

NYS Confidentiality – High

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Step 10. Perform continuous quality improvement of process and improve accordingly. Milestone #11

Prescribe once-daily regimens or fixed-dose combination pills when appropriate.

DY2 Q4

Project

N/A

Completed

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2015

12/31/2016

10/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

04/01/2015

12/31/2016

04/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

12/31/2015

12/31/2016

12/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

In Progress

07/01/2015

03/31/2018

07/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

07/01/2015

03/31/2016

07/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

10/31/2015

06/30/2016

10/31/2015

06/30/2016

06/30/2016

DY2 Q1

Task

PPS has protocols in place for determining preferential drugs based on ease of medication adherence where there are no other significant non-differentiating factors. Task

Step 1. Create plan using evidence-based screening and management guidelines set forth by JNC-8. Task

Step 2. Identify current PPS protocols for determining preferential drugs based on ease of medication adherence. Task

Step 3. Incorporate protocol and policy for providers through EHR reminder. Task

Step 4. Work with IT to generate reports to ensure these regimens are followed. Task

Step 5. Collaborate with workforce committee to train staff on protocols. Task

Step 6. Quality improve process and monitor participating organizations for improvement. Milestone #12

Document patient driven self-management goals in the medical record and review with patients at each visit. Task

Self-management goals are documented in the clinical record.

DY3 Q4

Project

N/A

Task

PPS provides periodic training to staff on person-centered methods that include documentation of self-management goals. Task

Step 1. Develop plan to determine the structure of selfmanagement goals (i.e. free text or structured data), identify the workflow, and strategy on self-management goals Task

Step 2. Collaborate with project work groups and PCMH

NYS Confidentiality – High

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

workgroup(s) to ensure both the PCMH and DSRIP workflows on Self-management goals align. Task

Step 3. Engage IT to build self-management goal templates into EMR. Explore hard stops, alerts, and flags to ask the clinician to complete the self-management goal. IT will also create reports to identify organizations with low rates of self-management goals

Project

Completed

10/31/2015

12/31/2016

10/31/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

03/31/2016

06/30/2016

03/31/2016

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

03/31/2016

12/31/2016

03/31/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

03/31/2016

12/31/2016

03/31/2016

12/31/2016

12/31/2016

DY2 Q3

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

11/01/2015

03/31/2018

11/01/2015

03/31/2018

03/31/2018

DY3 Q4

Task

Step 4. Create documentation for self-management goals such as a self-management checklist, which patients can complete in the waiting room. Task

Step 5. Education and train clinicians to review the patient's self management goal throughout the care of the patient. This will ensure compliance with the self-management goal. Task

Step 6. Engage Workforce to train on self-management goal documenting. This may include online trainings and leveraging PCMH trainings to incorporate the self management goal into the training. The training will also educate the providers on the importance of patient engagement in their care. Task

Step 7. Train providers on self management goal documenting. Task

Step 8. Assess training efficacy through surveys. Task

Step 9. Perform continuous quality improvement of process by using the IT data and improve accordingly. Milestone #13

Follow up with referrals to community based programs to document participation and behavioral and health status changes.

DY3 Q4

Project

N/A

Task

PPS has developed referral and follow-up process and adheres to process. Task

PPS provides periodic training to staff on warm referral and follow-up process. Task

Agreements are in place with community-based organizations and process is in place to facilitate feedback to and from

NYS Confidentiality – High

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

community organizations. Task

Step 1. Identify community based programs in the PPS to participate in design of referral program.

Project

Completed

11/01/2015

12/31/2016

11/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

11/01/2015

12/31/2016

11/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

Completed

10/01/2015

03/31/2016

10/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

In Progress

10/01/2015

03/31/2018

10/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

12/01/2015

03/31/2018

12/01/2015

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

03/31/2016

03/31/2018

03/31/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Project

In Progress

01/01/2016

03/31/2018

01/01/2016

03/31/2018

03/31/2018

DY3 Q4

Task

Step 2. Collaborate with care coordination cross functional workgroup to develop referral and follow up process with select with community based programs. Task

Step 3. Design a model to enable closed loop referrals with community based programs. Task

Step 4. Work with Finance and Legal to secure contracts agreements with participating CBOs Task

Step 5. Work with workforce in creating training program for referrals and follow up protocol Task

Step 6. Present at Clinical for approval of process. Task

Step 7. Educate and train CBOs on documenting participation and behavioral and health status changes. Task

Step 8. Work with CBO's to ensure the referral process includes non-clinical services. When patients are identified at a CBO, the CBO can refer patients seamlessly into the PPS. Task

Step 9. Work with stakeholder engagement group to communicate to providers to ensure the Care Coordination Strategy is communicated to all levels of the partner organizations Task

Step 10. Establish ongoing trainings through workforce to train new and existing staff on Care Coordination processes with community organizations. Task

Step 11. Work with IT to build in system with community organizations for interoperability. Task

Step 12. Perform continuous quality improvement for processes where applicable.

NYS Confidentiality – High

Page 290 of 932

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Run Date : 09/29/2017

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Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Milestone #14

Develop and implement protocols for home blood pressure monitoring with follow up support.

DY2 Q4

Project

N/A

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

12/31/2015

04/01/2015

12/31/2015

12/31/2015

DY1 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Task

PPS has developed and implemented protocols for home blood pressure monitoring. Task

PPS provides follow up to support to patients with ongoing blood pressure monitoring, including equipment evaluation and followup if blood pressure results are abnormal. Task

PPS provides periodic training to staff on warm referral and follow-up process. Task

Step 1. Develop specific protocols for home as well as ambulatory blood pressure monitoring. Task

Step 2. Train Nurse educators within the PPS of protocols. Task

Step 3. Nurse educators within the PPS will disseminate these protocols throughout the PPS to ensure a systematic approach to blood pressure screening and management is used. Offices within the PPS will assist patients with blood pressure monitoring, feedback , equipment checks, medication adjustments, as well as follow routine follow-up blood pressure checks without a formal appointment or copayment. Task

Step 4. IT will build fields in the EMR to collect data on Home Blood pressure monitoring Task

Step 5. Leverage community resources, such as the pharmacies, to offer Blood Pressure Monitoring Task

Step 6. Train staff involved in referral process on the developed protocols Task

Step 7. IT will create a report, which will monitor the use of home blood pressure monitoring. Task

Step 8. Educate providers of the benefits of ongoing/home blood pressure monitoring

NYS Confidentiality – High

Page 291 of 932

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Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 9. Collect data on patients who received ongoing blood pressure monitoring and follow up.

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/01/2015

03/31/2017

09/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

08/01/2015

03/31/2016

08/01/2015

03/31/2016

03/31/2016

DY1 Q4

Project

Completed

08/01/2015

03/31/2017

08/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

03/31/2017

10/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2016

03/31/2017

01/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/01/2016

03/31/2017

03/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

04/01/2015

03/31/2017

04/01/2015

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2015

06/30/2016

10/01/2015

06/30/2016

06/30/2016

DY2 Q1

Project

Completed

03/31/2016

03/31/2017

03/31/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

03/31/2016

12/31/2016

03/31/2016

12/31/2016

12/31/2016

DY2 Q3

Task

Step 10. Perform continuous quality improvement for processes where applicable. Milestone #15

Generate lists of patients with hypertension who have not had a recent visit and schedule a follow up visit.

DY2 Q4

Project

N/A

Task

PPS has implemented an automated scheduling system to facilitate scheduling of targeted hypertension patients. Task

Step 1. Define report criteria and automated alert criteria with risk stratification (outlined in above milestones) for lists of patients with hypertension who have not had a recent visit. Task

Step 2. IT develops report and automated alert within EMR to aid schedulers within practices with identifying hypertensive patients. Task

Step 3. Developing education materials to train staff on how to use list of patients with hypertension. Task

Step 4. Provide training to ensure the lists and tools IT has developed are adopted and scheduling system is adopted. Task

Step 5. Evaluate log of patients to ensure these patients are scheduled for follow-up. Milestone #16

Facilitate referrals to NYS Smoker's Quitline.

DY2 Q4

Project

N/A

Task

PPS has developed referral and follow-up process and adheres to process. Task

Step 1. Design referral and follow up process for NYS Smokers Quit Line for the PPS. Task

Step 2. Train providers and care coordinators on protocol to use NYS Smoker's Quit line. Task

Step 3. Work with workforce to provide ongoing trainings to new hires into learning management tool.

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

Task

Step 4. Develop communications material to share about NY Quits to patients.

Project

Completed

06/30/2016

12/31/2016

06/30/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2016

03/31/2017

09/30/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

09/30/2016

03/31/2017

09/30/2016

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

07/01/2015

12/31/2016

07/01/2015

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Task

Step 5. Develop a referral network by working with care coordination work group. Task

Step 6. Deploy training to providers in the PPS to complete an online smoking cessation counseling and treatment training module. Task

Step 7. Work with IT to build materials into EMR to include an after visit summary, which may be printed for patients with information on the NYS Smokers Quit Line. Task

Step 8. Perform Continuous Quality Improvement to identify effectiveness and areas of improvement for care coordination. Milestone #17

Perform additional actions including "hot spotting" strategies in high risk neighborhoods, linkages to Health Homes for the highest risk population, group visits, and implementation of the Stanford Model for chronic diseases.

DY3 Q4

Project

N/A

Task

If applicable, PPS has Implemented collection of valid and reliable REAL (Race, Ethnicity, and Language) data and uses the data to target high risk populations, develop improvement plans, and address top health disparities. Task

If applicable, PPS has established linkages to health homes for targeted patient populations. Task

If applicable, PPS has implemented Stanford Model through partnerships with community-based organizations. Task

Step 1. Collaborate with Care Coordination Cross Functional Workgroup design model for hot spotting strategy of identifying high risk neighborhoods, linkages in health homes for highest risk patients, linkages to Health Homes for the highest risk population, and group visits. Task

Step 2. Develop plan and identifying the Stanford Model (if

NYS Confidentiality – High

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New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Status

Original Start Date

Original End Date

Start Date

End Date

Quarter End Date

DSRIP Reporting Year and Quarter

applicable), including self-management approaches. These will be documented in the EMR, so the providers/care coordinators can discuss the progress with the patient on an ongoing basis. Task

Step 3. Work with IT to establish REAL data collection of high risk populations.

Project

Completed

10/01/2016

12/31/2016

10/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

Completed

01/01/2016

12/31/2016

01/01/2016

12/31/2016

12/31/2016

DY2 Q3

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

On Hold

04/01/2015

03/31/2020

04/01/2015

03/31/2020

03/31/2020

DY5 Q4

Project

Completed

01/01/2017

03/31/2017

01/01/2017

03/31/2017

03/31/2017

DY2 Q4

Task

Step 4. Create plan for group visits and programs, where a centralized PPS members can perform group visits. This may include events at churches, food pantries, etc. This will occur in conjunction with 3.c.i. Task

Step 5. Design education materials to train providers on Stanford Model. Task

Step 6. Work with workforce to design education materials to train providers on how to engage high risk populations around CV disease. Task

Step 7. Engage health homes that work with targeted patient populations. Task

Step 8. Work with workforce to train providers in using Stanford Model. Task

Step 9. Deploy Stanford Model to the PPS. Task

Step 10. Quality improve based on IT reports to aid in understanding impact in identifying highest risk regions and areas throughout the PPS. Milestone #18

Adopt strategies from the Million Hearts Campaign.

DY2 Q4

Project

N/A

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Provider

Practitioner - Primary Care Provider (PCP)

Completed

10/01/2016

03/31/2017

10/01/2016

03/31/2017

03/31/2017

DY2 Q4

Task

Provider can demonstrate implementation of policies and procedures which reflect principles and initiatives of Million Hearts Campaign. Providers Associated with Completion:

A T Adebayo Md Pc; Abankwah Akosua Sarpomaa; Aberg Judith; Abraham Sherly Md; Acenas Recientes Elizabeth S Md; Adamian Julia Md; Adams-Henry Claudeth; Adeyinka Adebayo; Adler Rhodes S Md; Afroza Farzana; Agarwal Reena Md; Agarwal Ritu; Agashiwala Rajiv; Agrawal Veevek Anand Md; Ahamed Jahid Md; Ahmad Imtiaz Md; Ahmed Farruque; Ahmed Najma A Md; Ahmed Zaheer Md; Ahmed Zia Md; Ahuja Neera Md Pc; Ainsworth Alison M; Ajl Stephen I Md; Akhnoukh Afaf Elkomos Soliman; Akoto Edna; Al-Izzi Sawsan Hatim Md; Alacha Nabil Md; Albano Rita; Albohm Kathleen C; Aleksandrovich Viktoriya Md; Alerte Serge G Md; Ali Aleem A; Ali Amanda Elizabeth; Allan Jessica Md; Almonte Maria Isabel Md; Alperin Robert B Md; Altaf Hussain Shaik; Alvarado Leslie; Alvarez Dimitri; Alzoobaee Faiz Orabi Md; Ameri Ali; Amin Prina Pandya; Amoruso Leonard D; An Jianqiang Md; Anandaraja Natasha Ruvini Md; Ancion Jean Herold Md; Andrilli John A

NYS Confidentiality – High

Page 294 of 932

New York State Department Of Health Delivery System Reform Incentive Payment Project

Run Date : 09/29/2017

DSRIP Implementation Plan Project Mount Sinai PPS, LLC (PPS ID:34) Project Requirements (Milestone/Task Name)

Prescribed Due Date

Reporting Level

Provider Type

Statu