Silvercrest Implements VAP Bundle Checklist for Ventilator Residents

The Silvercrest Center for Nursing and Rehabilitation, a NY–RAH Group B facility, recently implemented a ventilator-associated pneumonia (VAP) bundle checklist for ventilator-dependent residents as part of its NY–RAH rapid cycle quality improvement project. NY–RAH’s Quality Improvement Specialist (QIS) Deborah Watman, and Clinical Project Specialist (CPS) Mariam Vaezi, MD, reviewed the 20 most-recent long-stay transfers (occurring during or before October) and found that most originated from ventilator units. Silvercrest has one of the largest ventilator units in the area. Because of the complexities of managing ventilator-dependent residents, the NY–RAH team worked with Denise Lawson, Director of Quality Improvement at Silvercrest, to modify the Institute for Healthcare Improvement VAP Bundle Checklist to focus on three areas: hand washing, oral hygiene, and bed positioning. The QIS created an angle indicator, a tool that staff can attach to resident beds to determine whether the bed is angled properly (at 30 degrees, except during feeding time). Unit nurses complete a daily checklist to ensure that all three items are checked during each shift. In addition, families will receive a handout on how to support the intervention by washing their hands, assisting with oral hygiene, and checking the bed’s positioning. 

The rapid cycle quality improvement project is part of NY–RAH’s Phase Two Year Four focus on facilities with higher-than-average hospitalization rates to identify potential process breakdowns that lead to transfers. The QIS and CPS used the INTERACT and NY–RAH Quality Improvement and Summary Tools to review transfers to identify trends. They then worked with the facility to create a rapid cycle quality improvement project for which they conducted four bi-weekly Plan-Do-Study-Act cycles, adjusting the intervention during each cycle based on the findings. The current VAP checklist was finalized with the facility’s support, and staff will continue to receive education on the interventions. While the project is still in its infancy and the sample size remains too low to draw any conclusions as to effectiveness, the checklist’s basic elements are evidence-based, so continued compliance with it can help to reduce instances of VAP for years to come.

National Healthcare Decisions Day Promotion & Continued Palliative Care Interventions

NY–RAH continues to emphasize the importance of palliative care interventions.

National Healthcare Decisions Day
NY‒RAH will again promote National Healthcare Decisions Day (NHDD) at Group B facilities. NHDD, a private national initiative, is held annually on April 16, the day after Tax Day, to reflect the adage that the only things in life that are certain are death and taxes. NY‒RAH will send updated NHDD promotional materials to all Group B facilities in early April and strongly encourages them to participate in this educational event, which benefits residents, their families, and the facilities. NHDD offers an effective way to increase a facility’s advance directive rate, promote palliative care, and encourage conducting end-of-life conversations early. To have your facility’s NHDD event featured in the next NY‒RAH Newsletter, please contact Faiza Haq, Senior Project Manager.

Palliative Care Screenings
Workmen’s Circle MultiCare Center, a NY–RAH Group B facility, is conducting a rapid cycle quality improvement project on palliative care (Workmen’s Circle, like Silvercrest Center [see first story], was chosen for a rapid cycle quality improvement project due to its higher-than-average hospitalization rate). The facility’s QIS and CPS reviewed 20 recent hospital transfers and found that the majority of residents who were transferred to hospitals for an acute change of condition expired shortly thereafter, generally while in the hospital. Many of these seriously ill residents had no advance directives and only limited access to palliative care. A review of the facility’s palliative care workflow revealed there was a gap in staff using a standard palliative care screening tool. NY–RAH’s Medical and Palliative Care Director Joseph Sacco, MD, addressed this by first conducting a palliative care training at the facility to ensure that all staff understood palliative care and how it helps reduce avoidable hospitalizations. The training focused on generalist-level palliative care. The facility also contracts with Metropolitan Jewish Health System (MJHS) to deliver specialist-level palliative and hospice care services to its residents. Additionally, the QIS and CPS worked with the facility to incorporate the INTERACT Palliative Care Screening Tool into the admissions process to proactively identify residents who were appropriate for palliative care and to improve the referral process to MJHS. The QIS and CPS also worked with the facility to generate a list of long-term care residents who meet the screening criteria and could benefit from a palliative care referral. 

Palliative Care Trainings
Dr. Sacco also conducted a palliative care training at Sapphire Center for Rehabilitation and Nursing of Central Queens in January. Two additional trainings will be held in March (at Terence Cardinal Cooke Health Care Center and The Hebrew Home at Riverdale) and support the current performance improvement projects being conducted at the facilities. The purpose of the trainings is to educate social work and nursing staff about palliative care tools and the benefits of timely conversations. Dr. Sacco focuses on differences between palliative and hospice care, communication challenges and strategies, and cases of how palliative care can relieve suffering and improve quality of life. To discuss hosting a palliative care training at your facility, please contact Faiza Haq.

QISs to Begin PIP Transition to Support Sustainability

Over the next quarter, the QISs at NY–RAH Group B facilities will transition their Quality Assurance & Performance Improvement (QAPI) Performance Improvement Projects (PIPs) to facility staff to ensure they continue beyond the NY–RAH project’s completion. During the second quarter of 2019, the QISs reviewed transfers to identify potential process gaps that may have resulted in avoidable hospital transfers. Based on the results, the QISs worked with facility leadership to create a PIP to address potentially avoidable hospital transfers (e.g., increase use of INTERACT tools, improve practitioner documentation, decrease occurrences of UTIs). The QISs followed basic QAPI principles to implement their PIPs and conducted small tests of change over a series of PDSA cycles to track different process measures. The QISs will hand off the projects to the facility staff designated in the Project Charters and will continue to offer support for the remainder of the NY–RAH project. The QISs will also work with facilities to establish concrete sustainability plans that ensure effective processes are ingrained in the facility’s culture and that a method for monitoring performance measures is established. Facilities can use these projects to fulfill the QAPI requirement under the Medicare Requirements of Participation for Long-Term Care Facilities, which facilities are required to demonstrate to State Surveyors under Phase Three of the implementation (made effective November 28). For questions about the QIS projects and the upcoming transition, please contact Megan Burns, Senior Advisor.

Billing Notices for Facilities and Practitioners

Throughout Phase Two, NY–RAH has noted that some facilities do not regularly bill (meaning at least once every three months) the enhanced facility payment incentive codes. To better inform facilities of their processes, NY–RAH began sending monthly e-mails to administrators and NY–RAH Payment Liaisons of facilities that have not billed the facility payment incentive codes in the last three months. The purpose of these e-mails is to notify facilities of this billing gap and encourage a review of their internal billing processes. Notices are sent after the facilities receive their Monthly Billing Reports that detail the month when a facility was last paid for a facility episode claim and the month the episode occurred. Notices started going out in November, with the most recent distribution sent earlier this month to 15 out of 54 facilities. The e-mails include a note if a facility has received the notice for two or more consecutive months. NY–RAH will continue sending monthly notices to encourage facilities to examine their internal processes for potential missed billing opportunities.

Additionally, in December and again this month, NY–RAH e-mailed all currently eligible practitioners (of which there are about 245) regarding their G9685 billing practices. The notices provide aggregate billing data—including G9685 claim counts to date—and include resources for those practitioners not using the G9685 code. Practitioners have been put in one of three groups regarding their billing practices: unengaged, disengaged, and engaged. Unengaged practitioners (65%) are approved to use G9685 but have not yet billed the code since they became eligible; disengaged practitioners (15%) have billed G9685 but not in the past six months; and engaged practitioners (20%) have billed G9685 at least once within the past six months. The NY–RAH team will evaluate the effectiveness of these e-mails in the coming months with the hope that more practitioners actively use the enhanced practitioner code.

For any questions regarding these billing notices, please contact Faiza Haq.

In Case You Missed It

Third Round of Telligen Onsite Visits & Chart Audits Begin in March 
Telligen, a CMS subcontractor for the Nursing Facility Initiative (NFI), will begin its next round of onsite visits and chart audits in March at NY–RAH facilities. The purpose of Telligen’s visits is to ensure that facilities and practitioners are complying with all NFI criteria and requirements, and the NY RAH team appreciates each facility’s cooperation. Twelve facilities—including nine Group A and three Group B—will receive visits. Facilities scheduled for visits have already received detailed information about them. These facilities must have staff onsite during the visit to assist with retrieving medical records, as the Telligen team will provide the list of claims to be reviewed in the morning. As in prior years, NY–RAH will share the audit results with all participating facilities following the visits. 

Practitioner Payment Projection Tool Updated with 2020 Rates
NY–RAH recently updated its Practitioner Payment Projection Tool to reflect calendar year 2020 reimbursement rates from the Medicare Physician Fee Schedule. This resource was created to help practitioners by highlighting the differences in reimbursement between typical Skilled Nursing Facility follow-up codes (99307-99310) and the enhanced G9685 practitioner code, which the NFI made available to eligible practitioners. The tool allows for geographic adjustments and enables practitioners to view potential cumulative differences in reimbursement over a year’s time. The tool can be accessed here.

      NY-RAH is supported by Funding Opportunity Number 1E1CMS331492-01-01 from the US
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.