NY-RAH News #1 Fall 2013 http://www.nyrah.org
  In this issue logoIn
    Welcome to all participating facilities in the New York–Reducing Avoidable Hospitalizations (NY–RAH) project! All of you have your RN Care Coordinator(s) in place and many of you have begun the initial intervention phase of this initiative. As we begin Year 2 of the project, we would like to introduce you to NY–RAH News, the quarterly newsletter that will provide you with updates on the initiative, our project, and information on upcoming events. We have enjoyed getting to know your facility and look forward to continuing our work with you.

                                     The NY–RAH Team
Background on the CMS Initiative

NY–RAH Year 1 Summary

Participating Nursing Facilities

NY–RAH Action Plan and toolkit

Introduction to CMS Evaluation Strategy


Meet the team


Ask the Project Management Team
  Background on the CMS InitiativeBackground on the CMS Initiative  
  In September 2012, Greater New York Hospital Foundation (GNYHA Foundation) was one of seven organizations from across the country to receive an award from the Centers for Medicare & Medicaid Services (CMS) under its Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The goal of the CMS initiative is to test interventions that would increase the likelihood of caring for long-stay residents in place in the nursing facility, and in those cases where a hospitalization is necessary, to minimize the disruption to the long-stay resident and ensure a return to the nursing facility as soon as possible.

Of the approximately 17,000 long-stay beneficiaries in this CMS initiative, more than one-third reside in New York facilities. As a result, our work is receiving significant attention, and the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents has garnered great interest at every level of CMS and beyond. Members of Congress have inquired about the initiative, as have the Agency for Healthcare Research and Quality (AHRQ), other researchers, and policy makers. CMS recently released a newsletter about the initiative.
  Year 1 SummaryNY–RAH Year 1 Summary  
  As of September 30, 2013, each of NY–RAH’s 30 participating facilities in New York City and Long Island has an RN Care Coordinator working in the facility. As we look back on the first year, we appreciate all of your hard work in preparing for the RN Care Coordinator(s) and welcoming them as consultants in your facilities, guiding them through your administrative structures, and making them part of your Quality Improvement teams. We also appreciate your patience during some of the challenges that impacted our project, including Hurricane Sandy, the transition from Park Avenue Medical Associates to the Icahn School of Medicine at Mount Sinai as the employer of the RN Care Coordinators, and the recruitment of 27 RN Care Coordinators to cover a large region. The Project Management Team at GNYHA Foundation has welcomed your feedback and we will continue to help make this initiative a success at each and every one of the participating facilities. As we enter Year 2 and begin to implement the NY–RAH Toolkit, which consists of evidence-based tools from the INTERACT curriculum and from the American Medical Directors Association (AMDA), as well as supplemental interventions in palliative care and electronic solutions, we look forward to reporting on NY–RAH’s impact on reducing avoidable hospitalizations at each facility.  
Participating Facilities Participating Nursing Facilities
Of the 30 participating NY–RAH nursing facilities, 17 are located in New York City (Bronx, Manhattan, Brooklyn, and Queens) and 13 are located in Long Island (Nassau and Suffolk counties). Because NY–RAH has such a diverse group of facilities—all sizes, traditional and specialty patient populations, non-profit, for-profit, government owned, city, suburban, and ex-urban—CMS believes the NY–RAH project model may have a significant chance for success if replicated around the country.
NY–RAH Facilities
  • The Amsterdam Nursing Home at Harborside
  • Buena Vida Continuing Care and Rehabilitation Center
  • Casa Promesa Residential Health Care Facility
  • Cold Spring Hills Center for Nursing and Rehabilitation
  • Daughters of Jacob Nursing Home and Rehabilitation Center
  • Dr. William O. Benenson Rehabilitation Pavilion
  • Flushing Manor Nursing & Rehabilitation
  • Good Samaritan Nursing Home
  • The Greater Harlem Nursing Home & Rehabilitation Center, Inc.
  • Gurwin-Jewish Nursing and Rehabilitation Center
  • The Hebrew Home for the Aged at Riverdale
  • Highfield Gardens Care Center of Great Neck
  • Highland Care Center
  • Island Nursing and Rehabilitation Center
  • Jewish Home Lifecare, Manhattan Campus
  • Long Island State Veterans Home
  • Palisade Nursing Home
  • Riverhead Care Center for Nursing and Rehabilitation
  • Rivington House: The Nicholas A. Rango Health Care Facility
  • St. Catherine of Siena Nursing and Rehabilitation Care Center
  • St. James Rehabilitation and Healthcare Center
  • St. Mary's Center Inc.
  • Schervier Nursing Care Center
  • The Shores at Peconic Landing
  • The Silvercrest Center for Nursing & Rehabilitation
  • Smithtown Center for Rehabilitation & Nursing
  • Suffolk Center for Rehabilitation and Nursing
  • Terence Cardinal Cooke Health Care Center
  • Trump Pavilion for Nursing and Rehabilitation
  • Workmen's Circle Multicare Center
  NY-RAH ToolkitNY–RAH Toolkit  
  Action Plan and Intervention Rollout.
The first group of RN Care Coordinators have worked hard on their facility-specific action plans and have presented their action plans to facility leadership to an overwhelmingly positive response. RN Care Coordinators at many of the facilities have rolled out the NY–RAH Toolkit, starting with the INTERACT Stop and Watch Form and the AMDA Acute Change of Condition Guidelines; followed by INTERACT SBAR and AMDA Know-It-All-Before-You-Call cards in late November.

The second group of RN Care Coordinators has begun the action plan process and will be presenting to their facilities in mid-December, with the NY–RAH Toolkit implementation starting in January. We hope to have the final group of facilities up and running with these interventions in late winter 2014.

AMDA Tool Discount Code.
Dr. Leonard Gelman, Project Medical Director and President-Elect of the American Medical Directors Association (AMDA), has negotiated a discount code with AMDA for the tools that must be purchased as part of the NY–RAH project toolkit, namely the Know-It-All-Before-You-Call cards and the Clinical Practice Guidelines. Order the tools.
Introduction to CMS Evaluation StrategyIntroduction to CMS Evaluation Strategy
CMS has contracted with Research Triangle Institute (RTI) to be the formal evaluator for its Initiative to Reduce Avoidable Hospitalizations. All CMS demonstrations and initiatives include a formal evaluation by a third-party research organization. RTI is collaborating with the Long-Term Care Institute (LTCI) to evaluate this CMS initiative.

Several components of the RTI evaluation will require the participation of the nursing facilities, including phone calls, site visits, and web-based questionnaires. RTI is using quantitative and qualitative research methods to identify features of the seven initiatives that are positively associated with improved outcomes and to identify implementation barriers and barriers to achieving positive outcomes. RTI’s evaluation will assess both the effectiveness of the overall CMS initiative and the seven individual initiatives.

In early summer, staff from LTCI made site visits to several nursing facilities on behalf of RTI to interview staff at all levels about NY–RAH. If your facility hasn’t been visited, it will be at some point in the future. RTI is in the process of scheduling calls to all of the nursing facilities that did not participate in the site visits, and these calls are timed to ensure that the facilities have had a RN Care Coordinator present for at least 90 days.

Ultimately, the evaluation results from all seven projects from around the country will be reconciled to identify and characterize the most promising models to inform future policy making for improving beneficiary care, improving beneficiary health, and reducing costs.
  spotlightSpotlight   meet the teamMeet the Team
  CMS Outstanding Nursing Facility Recognition
Spring 2013
Audrey Marchand, Vice President, Nursing Services
Cold Spring Hills Center for Nursing and Rehabilitation

Summer 2013
Teriann Cronin, Administrator
Good Samaritan Nursing Home

CMS Outstanding ECCP Staff Recognition
Winter 2013
Kaitlin Smiroldo, RN Care Coordinator
Island Nursing and Rehabilitation Center/Good Samaritan Nursing Home

Spring 2013
Marva Skeete-Philip, RN Care Coordinator
Trump Pavilion for Nursing and Rehabilitation/The Silvercrest Center for Nursing & Rehabilitation

Summer 2013
Elizabeth Bailey, RN Care Coordinator
Daughters of Jacob Nursing & Rehabilitation Center
  GNYHA Foundation
Tim Johnson
Project Director

Ashley Hammarth
Deputy Project Director

Megan Burns
Project Manager

Jared Bosk
Project Data Manager

Icahn School of Medicine at Mount Sinai
Claudia Colgan
Vice President, Hospital Operations

Rob Southwick
Associate Dean for Alliance Development

Leonard Gelman, M.D.
Project Medical Director

Joseph Sacco, M.D.
Project Palliative Care Director

Audrey Schmerzler, D.N.P.
Clinical Director

Please contact Ashley Hammarth or Megan Burns at GNYHA Foundation if you have any questions or comments about the NY–RAH project. Please contact Audrey Schmerzler at Mount Sinai if you have any questions or comments relating to your RN Care Coordinator.
GNYHA Foundation has developed NY–RAH Storyboards as part of the ongoing communication and promotion about the NY–RAH project at the nursing facilities and within the community. We ask that all facilities display the NY–RAH Storyboard in the lobby. CMS expects all staff, residents, and families to have some knowledge of the NY–RAH project and to know who the RN Care Coordinators are. This Storyboard plays an important role in explaining the project. Each facility will receive an updated Storyboard with the RN Care Coordinator’s new Mount Sinai contact information in the coming weeks.

Beneficiary Notification Letters
Before an RN Care Coordinator went live at any of the nursing facilities, a Beneficiary Notification Letter had to be distributed to all current long-stay residents or their families as part of the CMS requirements for participation in the project. As a reminder, Beneficiary Notification Letters, which should be printed on facility letterhead, should be placed in the admission packets at each facility in order to alert any new long-stay resident of the project and allow for the two-week opt-out period required by CMS before the resident becomes officially enrolled in the project.
Question MarkAsk the Project Management Team
Q.Why does the CMS initiative focus solely on long-stay residents (residents who have been at the facility for 101 days or more or have no active discharge plan)?
A. CMS focused this initiative on the long-stay resident population because there are several other CMS initiatives that solely focus on the short-stay resident population. For example, the Medicare policy that penalizes hospitals for readmissions within 30 days of discharge has been implemented nationally and has incentivized both hospitals and post-acute providers to work on preventing readmissions for the short-stay nursing facility population. The benefit of the NY–RAH project, as a hands-off model with an emphasis on staff support and education, is that the skills and concepts that the nursing facility staff learn will undoubtedly extend to and benefit those patients who are on short-term units.

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