No. 11 – Spring 2016
  In This Issue   NY–RAH Attends Annual ECCP Meeting

On May 2 and 3, NY–RAH project management team members joined officials from the Centers for Medicare & Medicaid Services (CMS) for the annual meeting of the seven enhanced care coordination providers (ECCPs) participating in the CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility residents (also known as the Nursing Facility Initiative, or NFI). The University of Pittsburgh Medical Center, one of the seven ECCPs, hosted the meeting in Pittsburgh, Pennsylvania. The meeting provided an opportunity for the ECCPs to discuss successes, share challenges, and hear from CMS and its contractors on NFI. Meeting attendees included Deloitte Consulting, the NFI operations support contractor; Research Triangle Institute (RTI), the NFI evaluation contractor; and staff from the Medicare Payment Advisory Commission (MedPAC), who attended to understand the issues facing nursing facilities caring for long-stay residents.

RTI staff provided an analysis of the independent 2014 evaluation that was released this year, which showed promising signs of success for NFI. Melvin Ingber, PhD, the lead evaluation scientist, said NFI has exceeded expectations as all seven ECCPs made progress on certain key metrics when comparing their results to each state's comparison group of nursing facilities. The comparison group's facility characteristics (e.g., number of occupied beds, case-mix acuity index, and quality rating) are similar to each project's facility characteristics as a whole. The method used to select the comparison group facilities reduces any confounding effect that facility characteristics may have on measuring the intervention's impact. Dr. Ingber cited potentially avoidable hospitalizations and total Medicare expenditures per resident as two areas in which NFI has demonstrated a stronger improvement than facilities in each state's comparison group.
  CMS and Deloitte staff also discussed best practices in physician engagement and implementing processes that promote regular reviews of transfers. While five of the seven ECCPs use advance practice nurses, some in combination with registered nurses also providing hands-on care, New York and Alabama both adopted hands-off nurse educator and consultant models to achieve sustainability and build facility capacity for quality improvement. Each ECCP discussed a unique focus of its project in detail, including Direct Messaging for NY–RAH, telehealth for Pennsylvania, and facility leadership training for Alabama. ECCPs also discussed the early work to launch Phase Two, including facility recruitment, data collection, and practitioner eligibility.

Please contact Ashley Hammarth, Deputy Project Director, (212) 506-5421 or, with any questions about the meeting.
  NHDD Events Promote Advance Care Planning  
In honor of National Healthcare Decisions Day (NHDD), several NY–RAH nursing facilities held events in early April to promote the completion of advance directives. NHDD occurs annually on April 16 and is part of an initiative to promote the completion of advance directives and advance care planning. NY–RAH Registered Nurse Care Coordinators (RNCCs) supported events at Schervier Nursing Care Center; Harlem Center for Nursing and Rehabilitation; Highfield Gardens Care Center of Great Neck; Highland Care Center; The Silvercrest Center for Rehabilitation and Nursing; The Hebrew Home for the Aged at Riverdale; and Palisade Nursing Home. With support from the facilities' leadership, the events drew nearly 300 participants, including residents, family members, and facility staff. Participants discussed the importance of making health care decisions for themselves and their loved ones.

National Healthcare Decisions Day photos

RNCCs and facility staff offered a variety of materials, including the Medical Orders for Life-Sustaining Treatment (MOLST) forms and brochures; Health Care Proxy forms (regular form and the wallet size version); NY–RAH Palliative Care Brochures; and The Conversation Project Starter Kit. The NY–RAH project management team greatly appreciates RNCCs' role in organizing many of these events, as well as the active participation in the events from the facility Directors of Nursing, Directors of Social Work, Administrators, Social Workers, and Palliative Care Champions.
  More NY–RAH Residents Complete MOLST Form  
In 2014, NY–RAH Medical and Palliative Care Director Joseph Sacco, MD, created a NY–RAH Palliative Care Policy Guideline that outlines a facility approach to palliative care and a NY–RAH Care Plan Policy Guideline that outlines care planning meetings as a venue for addressing palliative care and advance directives. The NY–RAH project has emphasized the importance of strong facility-wide policies and procedures, which can lead to better documentation, improved communication, and implementation of effective quality improvement interventions. The NY–RAH Palliative Care and Care Plan Policy Guidelines were provided to the RNCCs, who worked with facility leaders to improve existing policies that addressed palliative care and care planning meetings, and to garner support for adopting new policies if none were in place. The RNCCs submitted existing policies to Dr. Sacco, who compared each facility's palliative care and care plan policy to the NY–RAH policy guidelines. He subsequently signed off on policies that were in accordance with NY–RAH criteria or provided feedback on what was needed to make a policy align with the criteria. Since Quarter 3 2014, NY–RAH has reported the palliative care and care plan policy approvals on the quarterly Palliative Care Report. As of Quarter 1 2016, 21 of the 29 facilities have a NY–RAH-approved palliative care policy and 14 of 29 have a NY–RAH-approved care plan policy.

The NY–RAH facilities' effort to adjust and expand the scope of these policies has been a driving force in NY–RAH's success with advance directive metrics. Specifically, as outlined in the guidelines, "Advance directives, such as MOLST, including discussion of DNR/DNI/DNH and PEG placement, and the Health Care Proxy, will be a priority during palliative care counseling." Many facilities have implemented the MOLST form since July 2014 when NY–RAH introduced it as a means of uniformly documenting advance directives during palliative care counseling or care planning meetings. The percent of NY–RAH residents with a MOLST form has increased from 11% in Quarter 3 2014 to 37% in Quarter 1 2016. The MOLST rate exemplifies NY–RAH facilities' progress with documenting advance directives and implementing a valuable advance directive intervention. Dr. Sacco continues to review policies and provide feedback, and the NY–RAH project management team hopes to see the number of facilities that have adopted approved policies increase before Phase One concludes in September 2016.

To resubmit palliative care or care plan policies for review, please contact Megan Burns, Assistant Project Director, at (212) 554-7243 or
  RTI Plans Site Visits, Phone Calls

In June, RTI staff will visit four NY–RAH-participating facilities to interview staff at all levels about the project. As in previous years, CMS contracted with RTI to evaluate the ECCPs participating in the NFI.

The four facility visits have already been scheduled, and for those facilities not being visited, RTI will schedule calls with the Directors of Nursing for early June. Discussions with RTI are confidential and the NY–RAH project management team encourages all participants to be candid about their experiences with the project. Administrators will receive a survey in August on their experiences with the NY–RAH project over the past year. This round of evaluations is only focused on Phase One of the project and will not include information about Phase Two.

RTI is using quantitative and qualitative research methods to identify features of the ECCPs that are positively associated with improved outcomes and to identify implementation barriers and barriers to achieving positive outcomes. Ultimately, the evaluation results from the ECCPs will be used to identify and characterize the most promising models to inform future policy making for improving resident care, improving resident health, and reducing costs.

Please contact Megan Burns, Assistant Project Director, at (212) 554-7243 or, with any questions.
CMS Outstanding Nursing Facility Recognition
Spring 2016: Diane Guidone, Director of Nursing, Good Samaritan Nursing Home
CMS Outstanding ECCP Staff Recognition
Spring 2016: Megan Burns, Assistant Project Director, Greater New York Hospital Foundation
  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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