The Brooklyn Perinatal Health Information Technology (e-health link) Project Explanation of Need for Funding.

This Appeal is on behalf of our Brooklyn PHIT project partners, BPN, and our community partners of the 15 year old Brooklyn Coalition for Health Equity for Women and Children (known previously as The Brooklyn Task Force on Infant and Maternal Mortality and Family Health). They are the originators of the Perinatal HIT initiative proposal. Their recommendation was refined and expanded by the Health Disparities Work Group of the Medicaid Redesign Team (MRT) which was commissioned by the NYS Governor and legislature, to reshape Medicaid-funded health services to be more effective.

On March 31, 2015, Brooklyn Perinatal Network (BPN) and three other statewide regional project grantees funded by the DOH to participate in a perinatal health information technology (HIT) initiative were advised that funding delays are to expected (due to state budget matters) for monies needed to support the continued implementation Phase 2 of our special e-link health pilot project during FY ’16, commencing April 1, 2015. BPN will be severely challenged during this funding gap period of at least three months before receipt of the monies expected to fund project continuation operations of the e-link health pilot project are received by the New York State Department of Health (NYS DOH).

During the Phase 2 implementation period the focus will be on testing and refining the HIT tools through active partner utilization, collecting use data to demonstrate the utility, and to scale up utilization in order to achieve the intended impact. The goal is to improve service coordination and enhanced quality of care provision, leading to improved perinatal health outcomes for our vulnerable women and babies in order to reduce costs for Medicaid and health service providers.

Description of Brooklyn PHIT Program
This Brooklyn Perinatal Health Information Technology (e-link health) project seeks to intervene to help break the cycle of poor health by enhanced screening and quick treatment for high risks; and thus to get better outcomes for babies and moms. The project focuses on medically underserved communities in North Central Brooklyn, a Downstate NY epicenter for health disparities, plagued with high rates of perinatal health challenges including prematurity, low birth weight, maternal and infant death. Several high need zip codes are selected for priority focus by this PHIT project including the following zip codes: 11207, 11208, 11211, 11212, 11216, 11221, 11233, and 11237. Within these zip codes the PHIT project targets women who are pregnant or postpartum; parenting infants; and have been identified based on medical and social risk of poor perinatal health outcomes, including chronic health conditions including overweight/obesity.

An added factor is that many hospitals and other health service providers experiencing financial crises often result in service withdrawal and institution closures. These HIT solutions will also eventually help reduce health care delivery costs due to improved health outcomes. Poor perinatal health is known as a major cost driver for our health service delivery system - Medicaid and hospitals etc.

This project work is aimed at developing innovative perinatal HIT tools for utilization by the provider partners, aiming to provide an enhanced quality of service in order to achieve improved health and birth outcomes; and thus, saving the lives of babies and of pregnant women with high risks. The web-enabled program enhancement system has now been developed with the FY ’15 DOH funding and is available for utilization. There are 8 Brooklyn based medical and social service providers participating in this program, and actively engaged for the implementation utilization phase 2, starting April 1, 2015.

The State Department of health (DOH) Perinatal Health Information Technology (PHIT) initiative PROGRAM GOALS

  1. Expand Community Based Service Navigation (CBSN) Functionality
  2. Expand Number of Network Partners and Use of BPN/CBSN-PeerPlace
  3. The Upgraded and expanded CBSN- PeerPlace Care Coordination Program
  4. Link and Integrate the BPN/CBSN-PeerPlace system with the Healthix RHIO


The PHIT Project has 3 types of project partners, some of whom will experience overlapping participation. The categories and roles are:

1. Project Development Partners
These partners share the grant funding to develop technology project components and assist BPN with implementation, per sub-contract, these are:
a. BPN – Lead Agency
b. Healthix - HIT Technology
1. The Healthix team targets its health information exchange (HIE) services to health care providers throughout the borough of Brooklyn in which over 2.5 million people reside. They bring a great deal of expertise in delivering access to clinical data and the tools to support care coordination for over 10 million patients combined and over 100 participant organizations serving over 400 locations in New York City, including Brooklyn, as well as Long Island.
c. PeerPlace - HIT Technology

2. Key Project Partners/Users
Eight (8) key partners/ Users have been identified and are currently participating in the program. These agencies directly benefit from the use of the Medicaid Redesign Team Department of Health grant funding as they engage with the project demonstration activity, utilizing the HIT solutions related to the PeerPlace-Community Based Service Navigation (CBSN) system, the Prenatal Risk Assessment (PRA) screening criteria, Healthix and others.
These key partners/users also participate in a CBSN User work group.
The Key project Partners/Users are:
a. Brooklyn Perinatal Network
b. The Brooklyn DPHO –Healthy Start Brooklyn (HSB) Program/By My Side Birth Support Program
c. SCO Family of Services/Family Nurse Partnership Home Visiting (SCO/FNPHV) Program
d. Brownsville Multi-Service Family Health Center (BMS)
g. New Dimensions In Care/Abundant Life Agency
h. New Directions Alcohol and Substance Abuse Treatment

Participating Providers and Services Include:

1. Brooklyn Perinatal Network
a. Infant Mortality Reduction Initiative
b. Health Insurance Enrollment
c. Doula Coordination
d. The Birthing Project: Sister Friend
2. Brownsville Multi-Service Family Health Center
a. Adult Medicine
b. Dental Services – Adult and Pediatric
d. Pediatric Medicine
e. WIC
a. Healthy Families
c. Department of Youth and Community Development (DYCD)
4. Caribbean Women’s Health Association
a. Immigration Services
b. HIV Counseling and Testing
c. Health Insurance Enrollment
d. Food Stamp Enrollment
5. NYC Department of Health DPHO –Healthy Start Brooklyn (HSB) Program/By My Side Birth Support Program
a. By My Side Birth Support Program
b. Childbirth Education Classes
c. Dancing Thru Pregnancy
d. Infant Safety Classes
6. New Dimensions In Care/Abundant Life Agency
a. Case Management
b. Youth Development
c. Health Education
d. Home Visiting – Parental and Youth
e. Nursing Services
f. Home Health Aide
7. New Directions Alcohol and Substance Abuse Treatment
a. Adolescent Art Therapy
b. Adolescent Individual Counseling
c. Adult Art Therapy
d. Adult Individual Counseling
e. Child Art Therapy
f. Mother/Child Art Therapy
g. Parent/Adolescent Art Therapy
8. SCO Family of Services/Family Nurse Partnership Home Visiting (SCO/FNPHV) Program
a. Nurse Newborn Home Visiting

3. The Professional Project Advisory Group (PAG) Partners
These include the Key Partners/ Users and other interested service providers, who support the project concept and framework. The NYC Department of Health and Mental Hygiene Assistant Commissioner/ Director of the Brooklyn District Public Health Office will serve as a Co-chair. HealthFirst managed care organization representatives will serve on the PAG - Susan Beane MD, Medical Director and Gorge Hulse Vice President. The PAG will function as a learning community and give relevant expert professional and service delivery that informs the project implementation and help to shape other related solutions for the local service delivery system. This PAG engagement is expected to increase “buy-in” for the project; and, for addressing the MRT DOH Goals and requirements.

1. Clients receive medical care from a variety of providers, including hospitals, nursing services, and home care agencies in Brooklyn’s neediest and most disadvantaged communities
2. Clients receive care from a variety of social service providers, including agencies that address mental health, immigration, health insurance and more in Brooklyn’s neediest and most disadvantaged communities
3. Better care from providers – particularly in an emergency. Providers involved in the PHIT program get a better picture of past medical history, prior treatments, and test results to help them make the most accurate diagnosis and provide the best treatment possible
4. Enhanced electronic risk assessments, referrals and speedy communication between medical and social service provider, and electronic health records that will be speedily and readily updated on the local regional health information data base (RHIO) upon a client’s visit.

1. Social Service Provider Benefits
a. Streamline referrals (decrease paperwork)
b. Increase referrals into your agency
c. Close the feedback loop on referrals to medical providers and other social service agencies
d. Get measures of how many clients served and other process/outcome measures for grant funders
e. Positioning for the future for reimbursements for social service agencies
2. Medical Provider Benefits
a. Streamline and coordinate care
b. Streamline referrals
c. Close the feedback loop on referrals
d. Be at the forefront of Medicaid Redesign and ACA Implementation
e. Positioning for the future for grant dollars, reimbursements or enhanced reimbursements for quality of prenatal care.

1. Expand CBSN Functionality
a. BPN has added additional screening questions addressing Brooklyn’s high need for preconception care
b. PHQ 2/9 and CSI forms have been added to PeerPlace for use by the Project Users
c. Case Management services for pregnant/parenting women have been added for two participating Project Users
d. Development of an External Resource Directory is underway
2. Expand Number of Network Partners and Use of BPN/CBSN-PeerPlace
a. BPN has successfully partnered with eight social service and medical providers throughout Brooklyn
i. Additional partners will be added based off feedback from current Project Users
b. BPN held two identical two days trainings for Project Users in February, with a Refresher Training in March
c. Recruited and trained seven interns from various schools
i. Interns participated in one and a half day training in January which covered diverse topics including professionalism, a maternal health presentation from the Bureau of Maternal and Infant and Reproductive Health of DOH, and HIPAA from the compliance officer of BMS Family Health Center.
ii. Interns have been placed at Project User sites to assist in the management of the PeerPlace system and education to clients
3. The Upgraded and expanded CBSN- PeerPlace Care Coordination Program
a. Participating Project Users have signed Project Participants Agreements and Business Associates Agreement with the assistance of a lawyer specializing in HIPAA compliance issues
4. Link and Integrate the BPN/CBSN-PeerPlace system with the Healthix RHIO
a. BPN, Healthix, and PeerPlace held a project kickoff in January and built connectivity between PeerPlace and Healthix in the following months.
b. PeerPlace and Healthix completed testing and validation, and the final integration occurred in March
We truly hope that we will be able to grasp the same opportunity for the needed Phase 2 work to continue in this funding gap period and to continue to progress forward in line with our other sister projects during this financially sensitive time. Hence the vital importance of this crowd funding appeal. This will help to assure that technical assistance and other support will be available to our health care provider partners, without delay, to enhance their service coordination, improve care quality, and eventually bring about better outcomes for our childbearing women, babies, and infants who may be at high risk of poor birth and health outcomes, including death.

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