On January 21-22, the Centers for Medicare & Medicaid Services (CMS) hosted the first in-person meeting for the seven awardees of the CMS Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. NY–RAH was represented by Audrey Schmerzler, RN, DNP, Project Clinical Director, and Ashley Hammarth, Deputy Project Director. In addition to staff from the seven CMS Initiative projects, representatives of the CMS project evaluator, Research Triangle International (RTI), and the CMS project operations contractor, Deloitte, also participated. Melanie Bella, Director of the CMS Medicare-Medicaid Coordination Office (MMCO), attended the meeting and provided comments on CMS’ goals for the Initiative and the agency’s interest in its success. Ms. Bella noted that in addition to MMCO, other high-level officials at CMS and elsewhere in the Federal government were interested in the findings of the Initiative and the individual projects. Ms. Bella emphasized that CMS expects the pace of the Initiative to quicken and stated that she and her colleagues look forward to receiving results in the very near future from all of the projects. The CMS meeting provided an excellent opportunity for staff from the seven projects to share successes and challenges and learn from each other. Ms. Schmerzler and Ms. Hammarth shared preliminary NY–RAH data that highlighted the positive results of NY–RAH's use of the INTERACT and AMDA tools. The NY–RAH project management team will continue to share ideas with colleagues from around the country to further the project’s goals.







  On December 18, NY–RAH brought together 14 participating nursing facilities and seven affiliated hospitals at a Clinical Intervention Advisory Committee (CIAC) meeting, where NY–RAH nursing facilities met with their community hospitals to discuss how nursing facility staff and hospital staff can work together to collaboratively reduce avoidable hospitalizations and improve the transition process when a transfer occurs. The hospitals represented at the CIAC meeting were Jamaica Hospital Medical Center, Mount Sinai Beth Israel, Eastern Long Island Hospital, NewYork–Presbyterian Hospital, Mount Sinai Medical Center, New York Hospital Queens, and Bronx-Lebanon Hospital Center.

Leonard Gelman, MD, Project Medical Director, and Ms. Schmerzler led a discussion on the challenges in improving the process and how the NY–RAH RN Care Coordinators can be used to help build sustainable relationships and bridge the gap in the transfer process. Dr. Gelman reviewed preliminary results of an analysis of over 100 transfers from nursing facilities to hospitals in the latter part of 2013. The analysis was derived from information provided by RN Care Coordinators using the NY–RAH Quality Improvement Chart Audit Tool. The NY–RAH project management team will further analyze these results to determine the root causes of transfers with the goal of defining processes to reduce avoidable hospitalizations at the participating nursing facilities. The CIAC is expected to meet again in late spring or early summer of 2014.
  The Continuum of Care Improvement Through Information New York (CCITI NY) is working with the NY–RAH nursing facilities to deploy a web-based Electronic Transfer Application (ETA). CCITI NY staff are coordinating with the NY–RAH project management team and the RN Care Coordinators to ensure that the implementation of the electronic tool at the nursing facilities occurs in conjunction with the NY–RAH project’s other components.

CCITI NY is currently conducting introductory learning sessions for RN Care Coordinators and facility leadership teams. In addition to a demonstration of the technology, the sessions entail the development of an implementation plan for each facility. As a next step, CCITI NY will work with the RN Care Coordinators and facility staff to collect the necessary information to set up the system at each facility and create user accounts for the appropriate clinicians, who will use the transfer form to share critical resident information with hospital staff. To ensure the ETA’s smooth adoption, CCITI NY will provide onsite trainings, live and recorded webinars, and supplementary reference materials. Once the ETA is live at a facility, CCITI NY will provide feedback and updates on the adoption of the new system.
In the first quarter of 2014, RN Care Coordinators will begin inputting project data into a NY–RAH web-based data portal. Until the launch of the portal, RN Care Coordinators have collected project data using a Microsoft Excel data collection template designed and provided by CMS. Because the Excel format has been somewhat challenging to work with, NY–RAH decided to build this web-based portal. The new secure data portal has been developed specifically for the NY–RAH project, and will better serve the project’s needs. It has received enthusiastic response from the RN Care Coordinators, all of whom have been provided with a demonstration of its use. The portal will reduce the time the RN Care Coordinators spend on inputting data, improve data quality, and allow for easier, more expansive reporting on key project metrics.
  Beverly Currie and Eugenie Ognita, both former RN Care Coordinators, have been promoted to Clinical Nurse Managers for the NY–RAH project. Ms. Currie and Ms. Ognita bring a wealth of knowledge gained from their many years working in nursing homes and hospitals, and expertise in the NY–RAH project deliverables as RN Care Coordinators. In addition to having prior nurse management experience, the Clinical Nurse Managers are well-versed in the use of INTERACT and AMDA tools, palliative care, medication administration, and nursing facility regulations.

The Clinical Nurse Managers will serve as mentors, educators, troubleshooters, and advocates for the RN Care Coordinators. One of the primary responsibilities of the Clinical Nurse Managers is to do site visits to the RN Care Coordinators and their respective nursing facilities on a regular basis. These site visits will allow the Clinical Nurse Manager to become familiar with each participating nursing facility in order to help facilitate successful implementation of the NY–RAH project.

Ms. Currie will oversee the RN Care Coordinators and nursing facilities located in Nassau and Suffolk counties, while Ms. Ognita will oversee those in Manhattan, Brooklyn, Bronx, and Queens. If you wish to discuss your RN Care Coordinator, please continue to contact Audrey Schmerzler, who will work with the Clinical Nurse Managers directly.
In November 2013, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) issued a report, Medicare Nursing Home Resident Hospitalization Rates Merit Additional Monitoring, examining hospitalization rates in skilled nursing facilities. The report identified the most common diagnoses for these hospitalizations, Medicare reimbursements for these hospitalizations, and discussed variation in hospitalization rates among nursing homes. CMS agrees with the OIG’s recommendation that CMS develop a quality measure for nursing home hospitalization rates.

Commenting on the report, CMS Administrator Marilyn Tavenner specifically mentioned the CMS Initiative to Reduce Avoidable Hospitalizations, writing that “lessons learned from this initiative will help inform future policy decisions.” The full report can be accessed here.
  CMS Outstanding Nursing Facility Recognition
Fall 2013
Carlos Beato, Chief Executive Officer,
Bon Secours New York Health System, Schervier Nursing Care Center

CMS Outstanding ECCP Staff Recognition
Fall 2013
Teresa Conder, RN Care Coordinator,
Terence Cardinal Cooke Health Care Facility

  NY–RAH will host an upcoming meeting of facility nursing directors and nursing managers. Audrey Schmerzler will discuss the project and how medication management can be optimized with nursing staff.

The meeting is scheduled as follows:
Date: Tuesday, March 18, 2014
Time: 9:30 a.m.–12:00 noon
GNYHA Board Room
555 West 57th Street, 15th Floor
New York, NY 10019

Megan Burns
(212) 554-7243
or mburns@gnyha.org