No. 10 – Winter 2016
  In This Issue   Phase Two Awards Delayed
The Centers for Medicare & Medicaid Services (CMS) has informed the NY–RAH project management team that the scheduled announcement for Phase Two award recipients has been delayed until "late February or early March." GNYHA Foundation submitted a Phase Two application to CMS for the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents—Payment Reform in October. A Phase Two award would extend the NY–RAH project to 2020 and include an additional payment reform incentive program for nursing facilities and providers. The NY–RAH project is currently scheduled to conclude in September 2016. Since receiving the delay notification from CMS, the GNYHA Foundation has been providing the agency supplementary information to assist with its review of the NY–RAH Phase Two application. After CMS announces Phase Two award recipients, nursing facilities will receive a memo from NY–RAH on the status of its application.

If you have any questions, please contact Ashley Hammarth, Deputy Project Director, at (212) 504-5421 or
  NY-RAH Data: A Year in Review  
In 2015, NY–RAH facilities made great progress and achieved project-best rates in data measures related to advance directives, acute change of condition (ACOC) tool usage, and hospital transfers.

Increasing the adoption of palliative care principles and improving the rate of residents with an advance directive were two of NY–RAH's focus areas in 2015. The percent of residents with a quarterly advance directive discussion grew by more than 10% between Q1 2015 and Q4 2015, from 56% to 67%. In Q4 2015, 30% of NY–RAH residents had completed a Medical Orders for Life-Sustaining Treatment (MOLST) form, which marks the highest rate for this measure since it was instituted in Q3 2014. NY–RAH recommends that facilities use the MOLST form to document end-of-life wishes. NY–RAH also measures the level of completeness of the MOLST forms. Increased facility focus on documenting all relevant resident wishes was illustrated by a decrease in the percent of partially completed MOLSTs to 56% in Q4 2015, a decrease of 12% from Q1 2015, when it was 68%.

NY–RAH's Registered Nurse Care Coordinators (RNCCs) continued to train participating facility staff on the INTERACT curriculum and communication tools from the American Medical Directors Association to build upon existing communication regarding ACOCs in their facilities. The use of these tools when identifying ACOCs is a key strategy for avoiding unnecessary hospitalizations. During 2015, the percent of ACOCs with a NY–RAH tool used increased to approximately 60% by Q4 2015.

Through the NY–RAH Quality Improvement Tool "deep dive" process, all NY–RAH facilities have been working with their RNCCs to identify ways to target specific areas for further focus, data collection, and potential intervention. During 2015, NY–RAH facilities achieved their lowest quarterly emergency department (ED)-only visit/observation stay rate in more than a year. During Q3 2015, the rate of transfers that resulted in an ED-only visit or observation stay was 0.54 transfers per 1000 resident days.

NY–RAH looks forward to continued success in all phases of the NY–RAH data in 2016 and anticipates greater progress on reducing unnecessary transfers, while maintaining and building upon the successes observed in measures related to ACOCs and advance directives. If you have any questions or would like assistance with interpreting your facility's specific reports, please contact Scott Gaffney, Senior Research Analyst, at (212) 258-5369 or
  Avoidable Transfers Reduced  
On February 3, CMS released the 2014 evaluation of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, the second performance year of the Initiative. The report highlighted NY–RAH's work and indicated that the strongest impact to date has been a decrease in the rate of potentially avoidable hospitalizations.

The evaluation, which was conducted by RTI International for CMS, indicated that the overall Initiative is having positive effects on nine key utilization and expenditure measures. RTI's independent evaluation compares each of the seven projects to a "blinded" comparison group of nursing facilities that was identified in the state in which each project is being conducted. According to RTI, the comparison group's facility characteristics (e.g., number of occupied beds, case-mix acuity index, quality rating) are similar to each project's facility characteristics on the whole. The method used to select the comparison group facilities reduces any confounding effect that facility characteristics may have on measuring the impact of the project's intervention. The comparison group facilities are subject to the same New York State policy programs, such as the Fully Integrated Dual Advantage program and Delivery System Reform Incentive Payment (DSRIP) program, as the NY–RAH facilities.

NY–RAH's results show mostly consistent indications of reductions for all nine measures, although almost none had reached the level of statistical significance as of the time period studied. NY–RAH's RNCCs' primary focus is to reduce the rate of potentially avoidable hospitalizations through the use of the INTERACT curriculum and the "deep dive" process (see article above), where transfers are reviewed quarterly. The NY–RAH project management team congratulates the participating nursing facilities and RNCCs on this success and thanks facility leadership for their ongoing efforts to reduce the rate of transfers for long-stay residents and improve the quality of care within their facilities.
  MOLST Refresher Trainings Update
On February 4 and 11, NY–RAH Medical and Palliative Care Director Joseph Sacco, MD, hosted two trainings on the MOLST form for nursing facility staff. The goal of these sessions was to provide additional support in navigating specific scenarios that arise for residents and families when using the form. Case studies were used to illustrate the process of completing a MOLST form for specific populations and the use of the Compassion and Support's Chart Documentation Forms, which assist staff with ensuring that they are meeting the legal requirements outlined in the Family Health Care Decisions Act, were discussed. These forms align with the New York State Department of Health's MOLST Legal Requirement Checklists as supportive documentation. Participants worked through case studies to learn how to address the needs of a resident with capacity and one without, and the differences between residents with a designated health care agent and those without. NY–RAH plans to provide more intermediate level MOLST training sessions in response to participants' interest in more advanced discussions. The NY–RAH project management team appreciates the level of engagement from the social work departments, which have been championing the MOLST form at many NY–RAH nursing facilities.

For more information on the MOLST form or to arrange a facility-specific MOLST overview, please contact Megan Burns, Assistant Project Director, at (212) 554-7243 or
  NY-RAH Highlights INTERACT for PPSs  
On January 21 and 22, NY–RAH project management team staff participated in two panel discussions with Joseph Ouslander, MD, the creator of the INTERACT program, on successfully implementing INTERACT. The panels were convened for staff from DSRIP performing provider systems (PPSs) that elected to implement INTERACT with their skilled nursing facility partners.

NY–RAH staff reviewed the project's experience with implementing the INTERACT structured communication tools and reviewed the successes, challenges, and lessons learned in using the tools. In addition to the Stop and Watch and SBAR tools, NY–RAH staff highlighted the importance of the Quality Improvement tool and the quarterly "deep dive" process that the NY–RAH project created to review transfers to the hospital. NY–RAH project staff commented on the importance of developing accountability for tools at all levels of care, and the need to focus on identifying early signs of acute changes of condition as part of a successful implementation. The sessions had a high level of audience engagement and provided an opportunity for problem solving and future collaboration.

For more information on the panel discussions, please contact Ashley Hammarth, Deputy Project Director, at (212) 504-5421 or
CMS Outstanding Nursing Facility Recognition
Fall 2015: Harrison Mitchell, MD, Medical Director, St. Mary's Center, Inc.

Winter 2016: Thomas Younghans, Administrator, Trump Pavilion for Nursing and Rehabilitation
CMS Outstanding ECCP Staff Recognition
Fall 2015: Fatim Sambou, RN Care Coordinator, Long Island State Veterans Home

Winter 2016: Edgardo Santana, RN Care Coordinator, St. Mary's Center, Inc. and Harlem Center for Nursing and Rehabilitation
  The project described was supported by Funding Opportunity Number 1E1CMS331086-04-02 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.  
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