New York DSRIP Implementation: An Inside Look Into Clinical Project Planning and Process Flows

As we continue a series examining the implementation efforts for the New York Delivery System Reform Incentive Payment (DSRIP) Program, this piece will focus on the importance of clinical project planning and design for both short and long term clinical transformation and integration milestones. While the current structure of the DSRIP program draws down funds based on individual project implementation, for the transformation efforts of the program to be truly sustainable in the future, Preforming Provider Systems (PPSs) need to focus on the clinical integration of providers across the care continuum. Focusing more on overall workflow and patient experience and less on specific projects will allow for a more natural development of Integrated Delivery Systems (IDS) across New York.

Defining clinical project planning and process flows for an IDS will require PPSs to utilize interdisciplinary subject matter experts and facilitate a number of concentrated exercises defining current and desired state of clinical processes, documentation of clinical workflows, defining business requirements, and obtaining stakeholder buy-in. This process provides the foundation for deeper information technology planning, workforce roles definition and financial realignment strategies.

Workflow Documentation

Workflow documentation is a critical component of clinical project design that is needed to define the desired future state of clinical processes and the patient experience in the IDS. Additionally, documentation of workflows will advance the evaluation of implementation efforts required to meet state defined DSRIP project requirements. To start defining and documenting workflows across the IDS, many PPSs are starting with defining the workflows within their selected DSRIP projects; each DSRIP project is intended to improve one or more local community needs and contribute to the development of a fully integrated system by bringing providers together for implementation and care coordination.

In the context of DSRIP, each project should have a defined clinical workflow which outlines the patient flow, provider responsibilities, and system requirements necessary to fulfil project outcomes. Some PPSs are taking a multi-step approach to document clinical workflows. The first step is mapping out the patient process flow, within the specifications of a defined project to define the ways in which a patient moves through various points of care and the partners’ role at each point of care based on provider type (note that providers of all levels, county agencies and community based providers engaged in New York DSRIP are all called partners). The second step advances the patient process flow by defining which IT systems and other business requirements are used in each step in addition to identifying the data elements each step requires. This focused analysis will allow the PPS to determine what existing systems can be leveraged as well as what will be required for successful project implementation.

Once patient and data point workflows have been developed, the two workflows are merged and protocols are developed to operate within each step. Once these flows are developed, an essential next step requires feedback from stakeholders (e.g. information technology and workforce), clinical subject matter experts, and integrated delivery system partners. A closed loop feedback process assure partners buy-in to the newly defined clinical workflows. Finally, combined process flow maps should be updated based on stakeholder feedback and used in partner education, current state assessments, and implementation efforts.

Current State Assessment

Once clinical process flows have been defined and vetted through stakeholders, PPS leads are able to use the process flow maps and protocols to complete current state assessments of partners to define individual gaps to fill during implementation. They can also identify risks and opportunities for improvement that exist between the current state and the newly defined project workflow desired state. Current state assessments may be completed through survey assessments, partner submission of current workflows, key informant interviews, and on-site visits. Depending on their current state, some partners will require greater implementation efforts than others – PPS leads should analyze the results of current state assessments and segment partners based on the level of effort (high, medium, and low) required to reach desired state implementation requirements. Analysis efforts can also be utilized to identify best practices within the PPSs that, if spread to all partners, will maximize the patient experience and better position the PPS to achieve clinical outcome requirements.

To emphasize the importance of understanding current state of clinical process flows and implementation requirements needed across the IDS, some PPS’s are requiring partners to complete these assessments in order to earn incentive funds from their performance based contracts.

Business Requirements Development

Understanding and supporting implementation efforts for partners who have different business requirements will be challenging. Once partners have been segmented and gaps have been identified, PPS leads can further examine each partner’s infrastructure in order to understand from a clinical perspective what other operational business requirements are needed for successful project implementation and IDS development. A mature partner, classified as requiring low implementation effort, may operate with a highly functional electronic health record (EHR), share information to the local Health Information Exchange (HIE) or Regional Health Information Organization (RHIO), be able to communicate with partners outside of their organization, and report data into a centralized PPS data warehouse. A less mature partner requiring more implementation effort may not have an EHR or the staff required to make the transition from paper to electronic health records. In addition, they may be unable to meet other high-effort requirements such as becoming a certified patient centered medical home.

PPS leads will need to understand the varying degrees of maturity and subsequent business requirements of their partners to develop the IDS and implement DSRIP projects to structure implementation support into tiered pathways in order to ensure each partner is on the right trajectory based on current capabilities. Having clearly defined pathways into which partners are grouped by provider type enables the PPS lead to better define and operationalize centralized services and even define appropriate performance requirements for partner incentive contracts to earn funds. Within each pathway, the cross-functional teams will categorize and grade capabilities and requirements in standard clinical, operational, information technology and workforce domains, among  others. The competency and capability matrices should be updated at least annually as the partners and PPS evolve to adjust implementation and transformation activities, as well as continually re-aligning contracting performance expectations and incentive funds.

Bridging the Gap

COPE Health Solutions has deep expertise in clinical redesign and business requirements development for population health and integrated delivery systems. We understand the complex Medicaid waiver implications for health system lead agencies and partners. Our team has unparalleled experience and a proven track record of successes from planning to implementation to measurement with 1115 Medicaid Waivers in New York, Texas and California. Our subject matter experts can help your system move toward its long-term strategic goals, using the waiver as a path to success.

For more information about how COPE Health Solutions is helping clients across California, New York, Washington and Texas prepare for and improve reporting practices, please contact: dsrip@copehealthsolutions.com.