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New York Department of HealthDelivery System Reform IncentivePayment (DSRIP) ProgramDomain 1 DSRIP Project RequirementsMilestones and Metrics:Project Requirements Milestones and Metrics: Domain 2Project Requirements Milestones and Metrics: Domain 3

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDSRIP Project Requirements Milestones and MetricsTable of ContentsDomain 1 DSRIP Project Requirements Milestones and Metrics2.a.i Create an Integrated Delivery System focused on Evidence-Based Medicine and Population HealthManagement . 12.a.ii Increase Certification of Primary Care Practitioners with PCMH Certification and/or AdvancedPrimary Care Models (as developed under the NYS Health Innovation Plan (SHIP)) 62.a.iii Health Home At-Risk Intervention Program: Proactive Management of Higher Risk Patients NotCurrently Eligible for Health Homes through Access to High Quality Primary Care and SupportServices .102.a.iv Create a Medical Village Using Existing Hospital Infrastructure . 152.a.v Create a Medical Village/Alternative Housing Using Existing Nursing Home Infrastructure . 182.b.i Ambulatory ICUs . 222.b.ii Development of Co-Located Primary Care Services in the Emergency Department (ED) . .252.b.iii ED Care Triage for At-Risk Populations . 292.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic HealthConditions .322.b.v Care Transitions Intervention for Skilled Nursing Facility (SNF) Residents .352.b.vi Transitional Supportive Housing Services . 382.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) . 412.b.viii Hospital-Home Care Collaboration Solutions . . 452.b.ix Implementation of Observational Programs in Hospitals . .512.c.i To Develop a Community Based Health Navigation Service to Assist Patients to Access HealthcareServices Efficiently 532.c.ii Expand Usage of Telemedicine in Underserved Areas to Provide Access to Otherwise ScarceServices . 552.d.i Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured andlow/non-utilizing Medicaid populations into Community Based Care . . .58Domain 3 DSRIP Project Plan Applications3.a.i Integration of Primary Care and Behavioral Health Services . . .663.a.i. Model 1 663.a.i Model 2 . 683.a.i. Model 3 713.a.ii Behavioral Health Community Crisis Stabilization Services . .743.a.iii Implementation of Evidence-Based Medication Adherence Program in Community Based Sites forBehavioral Health Medication Compliance .793.a.iv Development of Withdrawal Management (e.g., ambulatory detoxification, ancillary withdrawalservices) Capabilities and Appropriate Enhanced Abstinence Services within Community-Based AddictionTreatment Programs. . . 823.a.v Behavioral Interventions Paradigm (BIP) in Nursing Homes . . . 86November 13, 2014

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDSRIP Project Requirements Milestones and Metrics3.b.i Evidence-Based Strategies for Disease Management in High Risk/Affected Populations (AdultsOnly) . . 913.b.ii Implementation of Evidence-Based Strategies in the Community to Address Chronic Disease—Primary and Secondary Prevention Projects (Adults Only) . . . .1013.c.i Implementation of Evidence-Based Strategies in the Community to Address Chronic Disease—Primary and Secondary Prevention Projects (Adults Only) . 1033.c.ii Implementation of Evidence-Based Strategies in the Community to Address Chronic Disease—Primary and Secondary Prevention Projects (Adults Only) . . 1083.d.i Development of Evidence Based Medication Adherence Programs (MAP) in Community Settings –Asthma Medication . .1113.d.ii Expansion of Asthma Home-Based Self-Management Program . .1143.d.iii Implementation of Evidence Based Medicine Guidelines for Asthma Management .1173.e.i Comprehensive Strategy to Decrease HIV/AIDS Transmission to Reduce Avoidable Hospitalizations—Development of Center of Excellence for Management of HIV/AIDS . . . .1203.e.i. Model 1 . 1203.e.i Model 2 .1243.f.i Increase Support Programs for Maternal and Child Health (Including High Risk Pregnancies) .1293.f.i. Model 1 . 1293.f.i Model 2 . 1323.f.i. Model 3 . 1363.g.i Integration of Palliative Care into the PCMH Model . . .1393.g.ii Integration of Palliative Care into Nursing Homes . . 1413.h.i Specialized Medical Home(s) for Chronic Renal Failure . . 143November 13, 2014

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainSystem Transformation Projects (Domain 2)Project ID2.a.iCreate an Integrated Delivery System focused on Evidence Based Medicine and PopulationHealth ManagementProject TitleIndex Score 56Project Requirement12All PPS providers must be included in theIntegrated Delivery System. The IDS shouldinclude all medical, behavioral, post-acute,long-term care, and community-based serviceproviders within the PPS network; additionally,the IDS structure must include payers andsocial service organizations, as necessary tosupport its strategy.Utilize partnering HH and ACO populationhealth management systems and capabilitiesto implement the PPS’ strategy towardsevolving into an IDS.Project ID 2.a.iMetric/Deliverable*Data Source(s)PPS includes continuum of providers in IDS,including Medical, behavioral health, postacute, long-term care, and community-basedproviders.Provider network list; Periodic reportsdemonstrating changes to network list;Contractual agreements.PPS produces a list of participating HHs andACOs.Participating HHs and ACOs demonstrate realservice integration which incorporates apopulation management strategy towardsevolving into an IDS.Updated network provider lists; writtenagreements.Periodic progress reports on implementationthat demonstrate a path to evolve HH or ACOinto IDS.Regularly scheduled formal meetings are heldMeeting schedule; Meeting agenda; Meetingto develop collaborative care practices andminutes; List of attendees.integrated service delivery.Page 1

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainSystem Transformation Projects (Domain 2)Project ID2.a.iCreate an Integrated Delivery System focused on Evidence Based Medicine and PopulationHealth ManagementProject TitleIndex Score 56Project Requirement3Ensure patients receive appropriate healthcare and community support, includingmedical and behavioral health, post-acutecare, long term care and public health services.Metric/Deliverable*Data Source(s)Clinically Interoperable System is in place forall participating providers.HIE Systems report, if applicable; Process workflows; Documentation of process andworkflow including responsible resources ateach stage of the workflow; Other sourcesdemonstrating implementation of the systemPPS has protocols in place for carecoordination and has identified process flowchanges required to successfully implementIDS.PPS has process for tracking care outside ofhospitals to ensure that all critical follow-upservices and appointment reminders arefollowed.PPS trains staff on IDS protocols and processes.Project ID 2.a.iProcess flow diagrams demonstrating IDSprocessesContract; Report; Periodic reporting ofdischarge plans uploaded into EHR; Othersources demonstrating implementation of thesystemWritten training materials; list of training datesalong with number of staff trained.Page 2

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainSystem Transformation Projects (Domain 2)Project ID2.a.iCreate an Integrated Delivery System focused on Evidence Based Medicine and PopulationHealth ManagementProject TitleIndex Score 56Project Requirement4Metric/Deliverable*Data Source(s)QE participation agreement; sample ofEHR meets connectivity to RHIO’s HIE and SHINEnsure that all PPS safety net providers aretransactions to public health registries; use ofNY requirements.actively sharing EHR systems with local healthDIRECT secure email transactionsinformation exchange/RHIO/SHIN-NY andsharing health information among clinicalEHR vendor documentation; Screenshots orpartners, including directed exchange (secureother evidence of use of alerts and securemessaging), alerts and patient record look up, PPS uses alerts and secure messagingmessaging; written training materials; list offunctionality.by the end of Demonstration Year (DY) 3.training dates along with number of stafftrained in use of alerts and secure messaging56Ensure that EHR systems used byparticipating safety net providers meetMeaningful Use and PCMH Level 3 standardsby the end of Demonstration Year 3.Perform population health management byactively using EHRs and other IT platforms,including use of targeted patient registries, forall participating safety net providers.Project ID 2.a.iEHR meets Meaningful Use stage 1/2 CMSrequirements (Note: any/all MUrequirements adjusted by CMS will beincorporated into the assessment criteria).Meaningful Use certification from CMS or NYSMedicaidPPS has achieved NCQA Level 3 PCMHstandards and/or APCM.Certification documentationPPS identifies targeted patients throughpatient registries and is able to track activelyengaged patients for project milestonereporting.Sample patient registries; EHR completenessreports (necessary data fields sufficientlyaccurate to conduct population healthmanagement)Page 3

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainSystem Transformation Projects (Domain 2)Project ID2.a.iCreate an Integrated Delivery System focused on Evidence Based Medicine and PopulationHealth ManagementProject TitleIndex Score 56Project Requirement7Achieve 2014 Level 3 PCMH primary carecertification for all participating PCPs, expandaccess to primary care providers, and meetEHR Meaningful Use standards by the end ofDY 3.Metric/Deliverable*Data Source(s)Primary care capacity increases improvedaccess for patients seeking services particularly in high-need areas.Status reporting of recruitment of PCPs,particularly in high-need areas; Demonstrationof improved access via CAHPS measurement;List of participating NCQA-certifiedAll practices meet NCQA Level 3 PCMH and/orphysicians/practitioners; CertificationAPCM standards.documentationEHR meets Meaningful Use stage 1/2 CMSrequirements (Note: any/all MU requirements Meaningful Use certification from CMS or NYSadjusted by CMS will be incorporated into the Medicaidassessment criteria.)8Contract with Medicaid Managed CareOrganizationsandotherpayers,as Medicaid Managed Care contract(s) are inappropriate, as an integrated system and place that include value-based payments.establish value-based payment arrangements.9Establish monthly meetings with MedicaidMCOs to discuss utilization trends,performance issues, and payment reform.Project ID 2.a.iPPS holds monthly meetings with MedicaidManaged Care plans to evaluate utilizationtrends and performance issues and ensurepayment reforms are instituted.Documentation of executed MedicaidManaged Care contracts; Reportdemonstrating percentage of total providerMedicaid reimbursement using value-basedpaymentsMeeting minutes; agendas; attendee lists;meeting materials; process of reportingmeeting outcomes/recommendations tostakeholders and PPS leadershipPage 4

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainSystem Transformation Projects (Domain 2)Project ID2.a.iCreate an Integrated Delivery System focused on Evidence Based Medicine and PopulationHealth ManagementProject TitleIndex Score 56Project Requirement1011Metric/Deliverable*PPS has a plan to evolve providercompensation model to incentive-basedRe-enforce the transition towards value-based compensationpayment reform by aligning providerProviders receive incentive-basedcompensation to patient outcomes.compensation consistent with DSRIP goals andobjectives.Engage patients in the integrated deliverysystem through outreach and navigationactivities, leveraging community healthworkers, peers, and culturally competentcommunity-based organizations, asappropriate.Data Source(s)Compensation model; implementation plan;consultant recommendationsContract; Report; Payment Voucher; Othersources demonstrating implementation of thecompensation and performance managementsystemDocumentation of partnerships withcommunity-based organizations; EvidenceCommunity health workers and communitycommunity health worker hiring; Co-locationbased organizations utilized in IDS for outreachagreements/job descriptions; Report on howand navigation activities.many patients are engaged with communityhealth worker*Define the specific tasks and timelines necessary to achieve these project requirement metrics. These must reconcile with the implementation timelinecertified in the project plan applicationProject ID 2.a.iPage 5

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiIncrease Certification of Primary Care Practitioners with PCMH Certification and/or AdvancedPrimary Care Models (as developed under the New York State Health Innovation Plan (SHIP))Index Score 37Project RequirementMetric/Deliverable*Ensure that all participating PCPs the PPS meetNCQA 2014 Level 3 PCMH accreditation and/orAll practices meet NCQA Level 3 PCMH and/or1meet state-determined criteria for AdvancedAPCM standards.Primary Care Models by the end of DSRIP Year3.23Data Source(s)List of participating NCQA-certifiedphysicians/practitioners; CertificationdocumentationIdentify a physician champion with knowledgePPS has identified physician champion withof PCMH implementation for each primaryexperience implementing PCMHs.care practice included in the project.Role description; CV (explicating NCQAcertification, PCMH content expert, populationhealth experience); Contract; CertificationsCare coordinators are identified for eachprimary care site.Care coordinator identified, site-specific roleestablished as well as inter-locationIdentify care coordinators at each primary carecoordination responsibilities.site who are responsible for care connectivity,internally, as well as connectivity to caremanagers at other primary care practices.Clinical Interoperability System in place for allparticipating providers and document usage bythe identified care coordinators.List of names of care coordinators at eachprimary care siteProject ID 2.a.iiRole descriptions; Written training materialsHIE Systems report, if applicable; Process workflows; Documentation of process and workflowincluding responsible resources at each stageof the workflow; Other sources demonstratingimplementation of the systemPage 6

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiIncrease Certification of Primary Care Practitioners with PCMH Certification and/or AdvancedPrimary Care Models (as developed under the New York State Health Innovation Plan (SHIP))Index Score 37Project Requirement456Data Source(s)QE participant agreements; sample ofEHR meets connectivity to RHIO’s HIE and SHINEnsure all PPS safety net providers are activelytransactions to public health registries; use ofNY requirements.sharing EHR systems with local healthDIRECT secure email transactionsinformation exchange/RHIO/SHIN-NY andEHR vendor documentation; Screenshots orsharing health information among clinicalother evidence of use of alerts and securepartners, including direct exchange (securePPS uses alerts and secure messagingmessaging; written training materials; list ofmessaging), alerts and patient record look up functionality.training dates along with number of staffby the end of Demonstration Year (DY) 3.trained in use of alerts and secure messagingEnsure that EHR systems used byparticipating safety net providers meetMeaningful Use and PCMH Level 3 standardsby the end of Demonstration Year 3.Perform population health management byactively using EHRs and other IT platforms,including use of targeted patient registries, forall participating safety net providers.Project ID 2.a.iiMetric/Deliverable*EHR meets Meaningful Use stage 1/2 CMSrequirements (Note: any/all MUrequirements adjusted by CMS will beincorporated into the assessment criteria).Meaningful Use certification from CMS or NYSMedicaidPPS has achieved NCQA Level 3 PCMHstandards and/or APCM.Certification documentationPPS identifies targeted patients throughpatient registries and is able to track activelyengaged patients for project milestonereporting.Sample patient registries; EHR completenessreports (necessary data fields sufficientlyaccurate to conduct population healthmanagement)Page 7

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiIncrease Certification of Primary Care Practitioners with PCMH Certification and/or AdvancedPrimary Care Models (as developed under the New York State Health Innovation Plan (SHIP))Index Score 37Project Requirement78Ensure that all staff are trained on PCMH orAdvanced Primary Care models, includingevidence-based preventive and chronic diseasemanagement.Metric/Deliverable*Data Source(s)Policies and procedures related tostandardized treatment protocols for chronicPractice has adopted preventative and chronicdisease management; agreements with PPScare protocols aligned with national guidelines.organizations to implement consistentstandardized treatment protocols.Project staff are trained on policies andDocumentation of training program; Writtenprocedures specific to evidence-basedtraining materials; List of training dates alongpreventative and chronic disease management. with number of staff trainedOQPS Reporting Requirements; claimsPreventive care screenings implementedreporting; number and types of screeningsamong participating PCPs, including behavioral implemented; numbers of patients screened;Implement preventive care screening protocols health screenings (PHQ-9, SBIRT).numbers of providers trained on screeningincluding behavioral health screenings (PHQ-9,protocolsSBIRT) for all patients to identify unmet needs.HIE Systems report, if applicable; Process workA process is developed for assuring referral toflows; Documentation of process and workflowappropriate care in a timely manner.Protocols and processes for referral toincluding responsible resources at each stageappropriate services are in place.of the workflow; Other sources demonstratingimplementation of the systemProject ID 2.a.iiPage 8

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiIncrease Certification of Primary Care Practitioners with PCMH Certification and/or AdvancedPrimary Care Models (as developed under the New York State Health Innovation Plan (SHIP))Index Score 37Project Requirement9Metric/Deliverable*Data Source(s)PCMH 1A Access During Office Hoursscheduling to meet NCQA standardsestablished across all PPS primary care sites.Scheduling Standards Documentation; Reportshowing third next available appointment(Institute for Healthcare Improvementmeasures); Response times reporting;Materials communicating practice hours;Vendor System Documentation, if applicable;Other Sources demonstrating implementationPCMH 1B After Hours Access scheduling tomeet NCQA standards established across allPPS primary care sites.Scheduling Standards Documentation; Reportshowing third next available appointment(Institute for Healthcare Improvementmeasures); Response times reporting;Materials communicating practice hours;Vendor System Documentation, if applicable;Other Sources demonstrating implementationImplement open access scheduling in allprimary care practices.PPS monitors and decreases no-show rate by at Baseline no-show rate with periodic reportsleast 15%.demonstrating 15% no-show rate reduction*Define the specific tasks and timelines necessary to achieve these component metrics. These must reconcile with the implementation timeline certifiedin the project plan applicationProject ID 2.a.iiPage 9

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiiHealth Home At-Risk Intervention Program: Proactive management of higher risk patientsnot currently eligible for Health Homes through access to high quality primary care andsupport servicesIndex Score 46Project RequirementMetric/Deliverable*Data Source(s)A clear strategic plan is in place which includes,at a minimum:- Definition of the Health Home At-RiskIntervention Program- Development of comprehensive caremanagement plan, with definition of roles ofPCMH PCPs and HHsComplete strategic plan; Reports on progressin implementation that demonstrate a path tosuccessful implementation within thetimeframe committed to in the application1Develop a Health Home At-Risk InterventionProgram, utilizing participating HHs as well asPCMH PCPs in care coordination within theprogram.2Ensure all primary care providers participatingin the project meet NCQA (2011) accreditedPatient Centered Medical Home, Level 3All practices meet NCQA Level 3 PCMH andstandards and will achieve NCQA 2014 Level 3 APCM standardsPCMH and Advanced Primary Careaccreditation by Demonstration Year (DY) 3.3Ensure that all participating safety netproviders are actively sharing EHR systemswith local health informationexchange/RHIO/SHIN-NY and sharing healthinformation among clinical partners, includingdirect exchange (secure messaging), alerts andpatient record look up.Project ID 2.a.iiiList of participating NCQA-certifiedphysicians/practitioners; CertificationdocumentationQE participant agreements; sample ofEHR meets connectivity to RHIO’s HIE and SHINtransactions to public health registries; use ofNY requirements.DIRECT secure email transactionsPage 10

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiiHealth Home At-Risk Intervention Program: Proactive management of higher risk patientsnot currently eligible for Health Homes through access to high quality primary care andsupport servicesIndex Score 46Ensure that all participating safety netProject Requirementproviders are actively sharing EHR systemsMetric/Deliverable*with local health information3exchange/RHIO/SHIN-NY and sharing healthinformation among clinical partners, including PPS uses alerts and secure messagingdirect exchange (secure messaging), alerts and functionality.patient record look up.Project ID 2.a.iiiData Source(s)EHR vendor documentation; Screenshots orother evidence of use of alerts and securemessaging; written training materials; list oftraining dates along with number of stafftrained in use of alerts and secure messagingPage 11

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiiHealth Home At-Risk Intervention Program: Proactive management of higher risk patientsnot currently eligible for Health Homes through access to high quality primary care andsupport servicesIndex Score 46Project Requirement456Metric/Deliverable*Data Source(s)EHR meets Meaningful Use stage 1/2 CMSrequirements (Note: any/all MUrequirements adjusted by CMS will beincorporated into the assessment criteria).Meaningful Use certification from CMS or NYSMedicaidPPS has achieved NCQA Level 3 PCMHstandards and/or APCM.Certification documentationPerform population health management byactively using EHRs and other IT platforms,including use of targeted patient registries, forall participating safety net providers.PPS identifies targeted patients throughpatient registries and is able to track activelyengaged patients for project milestonereporting.Sample patient registries; EHR completenessreports(necessary data fields are populated inorder to track project implementation andprogress)Develop a comprehensive care managementplan for each patient to engage him/her incare and to reduce patient risk factors.Documentation of process and workflowincluding responsible resources at each stage;Written training materials; List of trainingProcedures to engage at-risk patients with caredates, including number of staff trained;management plan instituted.Sample care management plans; Samplepatient outreach; Number of patients engagedwith care management planEnsure that EHR systems used byparticipating safety net providers meetMeaningful Use and PCMH Level 3 standards.Project ID 2.a.iiiPage 12

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiiHealth Home At-Risk Intervention Program: Proactive management of higher risk patientsnot currently eligible for Health Homes through access to high quality primary care andsupport servicesIndex Score 46Project RequirementEstablish partnerships between primary careproviders and the local Health Home for care7management services. This plan should clearlydelineate roles and responsibilities for bothparties.8Establish partnerships between the primarycare providers, in concert with the HealthHome, with network resources for neededservices. Where necessary, the provider willwork with local government units (such asSPOAs and public health departments).Implement evidence-based practice guidelinesto address risk factor reduction as well as toensure appropriate management of chronic9diseases. Develop educational materialsProject IDconsistent2.a.iiiwith cultural and linguistic needs ofthe population.Metric/Deliverable*Data Source(s)Each identified PCP establish partnerships with Information-sharing policies and procedures;the local Health Home for care management Number of patients provided careservices.management servicesPPS has established partnerships to medical,behavioral health, and social services.Policies and procedures with list of activepartner providers and agencies; writtenagreements with partner providers andagencies; processes and notifications; clinicalteams processes and group decision-makingPPS uses EHRs and HIE system to facilitate and EHR vendor documentation; protocols for usedocument partnerships with needed services. of EHR vendor documentation for referralsPPS has adopted evidence-based practiceguidelines for management of chronicconditions. Chronic condition appropriateevidence-based practice guidelines developedand process implemented.Documentation of evidence-based practiceguidelines; Process and workflow includingresponsible resources at each stage; Writtentraining materials; List of training dates;Chronic condition protocols and trainingmaterialsPage 13

New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramDomain 1 DSRIP Project Requirements Milestones and MetricsProject DomainProject IDProject TitleSystem Transformation Projects (Domain 2)2.a.iiiHealth Home At-Risk Intervention Program: Proactive management of higher risk patientsnot currently eligible for Health Homes through access to high quality primary care andsupport servicesIndex Score 46Implement evidence-based practice guidelinesProject Requirementto address risk factor reduction as well as toensure appropriate management of chronic9diseases. Develop educational materialsconsistent with cultural and linguistic needs ofthe population.Metric/Deliverable*Data Source(s)Regularly scheduled formal meetings are heldMeeting schedule; Meeting agenda; Meetingto develop collaborative evidence-based careminutes; List of attendeesprac

Delivery System Reform Incentive Payment (DSRIP) Program DSRIP Project Requirements Milestones and Metrics November 13, 2014 Table of Contents Domain 1 DSRIP Project Requirements Milestones and Metrics 2.a.i Create an Integrated Delivery System