In May, each NY–RAH participating nursing facility received a report that includes information on transfers that occurred from the nursing facility to a hospital during the first quarter of 2014. This hospitalization report provides summary data on the most important metrics that NY–RAH tracks and reports to CMS on a quarterly basis. NY–RAH plans to provide this quarterly information on an ongoing basis to help nursing facilities develop a plan for targeted interventions to try to reduce potentially avoidable hospitalizations.

The report includes information on all hospital transfers for NY–RAH eligible beneficiaries (long-stay residents) during the reporting period. The NY–RAH RN Care Coordinator(s) (RNCC) working with your facility will work with facility leadership to select an area of focus that facility leadership believes has the most potential for improvement. The area of focus could be around a specific clinical condition or adverse event (e.g., residents with an initial diagnosis of pneumonia, residents who fall) or a specific shift or process (e.g., transfers that occur on the day shift, transfers where the resident is seen in the ER and sent back to the nursing facility).

The RNCC will complete a NY–RAH Quality Improvement (QI) Tool for each hospital transfer in the selected area of focus. The NY–RAH QI Tool gathers detailed information on how the initial acute change of condition was discovered, monitored, and managed in the facility. Information from these QI Tools will then be summarized and presented to the facility leadership, along with clear, actionable next steps that align with the NY–RAH Toolkit.

The NY–RAH Project Management Team developed the hospitalization reports and believes that implementing these steps will help facilities meet project goals. If you have any questions about the workplan, please contact Ashley Hammarth, NY–RAH Deputy Project Director, at 212-506-5421 or ahammarth@gnyha.org. If you have any questions about the hospitalization reports, please contact Jared Bosk, NY–RAH Project Data Manager, at 212-554-7247 or jbosk@gnyha.org.
Workmen’s Circle Multicare Center, a NY–RAH facility located in the Bronx, NY, began implementing elements of the NY–RAH Toolkit, including the INTERACT Stop And Watch form, the SBAR, the American Medical Directors Association (AMDA) Know-It-All-When-You’re-Called cards, and the AMDA Acute Change of Condition guidelines, in late 2013. With the help of RN Care Coordinators Roy Grimes and Ediri Okiti, Workmen’s Circle has made tremendous strides in reducing the number of avoidable hospitalizations.

According to data CMS provided to the NY–RAH Project Management Team, during Year 1 Quarter 4 (September 2013), the 30-day readmission rate for Workmen’s Circle was 23.5%. During Year 2 Quarter 1 (December 2013), the readmission rate had been reduced 15.7%. The Workmen’s Circle nursing department staff has been working in conjunction with physicians to treat residents in-house based on the information provided to them through the SBAR. According to Workmen’s Circle Administrator Laurence Abrams, the oversight and guidance provided by Mr. Grimes and Ms. Okiti has made a difference, as has Director of Nursing Services Cecile Yacat’s commitment to staff education.

Since these tools have been implemented, there have been situations in which residents were successfully treated in-house. In two cases, residents with PEG feeding tubes were minimally assessed, and a brief verbal explanation was relayed to the covering physicians, who initially recommended transfer to the hospital. In both cases, Ms. Okiti and Mr. Grimes guided staff through a comprehensive assessment of each situation and, using the SBAR form, a clear and concise picture of each situation was communicated to the physicians. In both cases, the covering physicians reversed their recommendations and the residents were treated successfully in-house.

In another case, the Stop and Watch tool was used by a CNA to report that a resident with a PEG feeding tube was seen vomiting. A facility nurse assessed the resident, completed an SBAR, and communicated the acute change of condition to the physician. Using this information, the physician suspended tube feeding while the resident was placed on IV for hydration, and abdominal X-Ray and labs were ordered. This resident was eventually managed in the facility without being transferred to the hospital.

The NY–RAH Project Management Team salutes the team at Workmen’s Circle for their fine work and their ongoing support of the project’s goals. For more information about the use of the Stop and Watch and SBAR tools, please contact Audrey Schmerzler, NY–RAH Clinical Director, at 212-241-5145 or audrey.schmerzler@mountsinai.org.
The NY–RAH Project Management Team is in the process of launching two new components of the NY–RAH project. NY–RAH is working with the RNCCs and nursing facilities on enhancing palliative care and fostering electronic solutions that enhance communication between the nursing facility and hospital.

The NY–RAH palliative care intervention consists of identifying two palliative care ”champions” in each facility to promote palliative care education and practices; providing enhanced training to facility nursing and social work staff on palliative care and advance care planning and the use of five INTERACT Resource Tools for these topics; establishing or enhancing a palliative care policy and protocol that meets the NY–RAH palliative care guidelines (as developed by Joseph Sacco, MD, NY–RAH Palliative Care Director); and providing training on implementing the use of the MOLST (Medical Orders for Life Sustaining Treatment) form.

The palliative care champions will work with the RNCC to develop or modify current palliative care policies and procedures. The RNCC will continue to serve as a consultant and educator on behalf of the NY–RAH project to support nursing facility efforts in these areas. The RNCC and the champions will review policies and procedures to ensure that they are being developed and/or implemented consistent with NY–RAH recommendations. The champions will be primarily responsible for implementing the MOLST form throughout the facility as their leadership is crucial to the adoption and ongoing use of the form.

The MOLST form is one of the principal tools in the NY–RAH Toolkit. In June and September, NY–RAH will host training sessions with Patricia Bomba, MD, a nationally recognized expert in MOLST who serves as the Vice President and Medical Director for Geriatrics at Excellus BlueCross BlueShield Health Plan in Rochester, NY. The training sessions will review the MOLST form in detail, and describe the use of both the paper form and the electronic version (eMOLST).

For more information about the palliative care intervention, please contact Ashley Hammarth at 212-506-5421 or ahammarth@gnyha.org.

The NY–RAH electronic solutions intervention consists of developing a means by which participating nursing facilities can utilize electronic transfer of information to improve resident care and reduce avoidable hospitalizations. The NY–RAH Project Management Team has been working diligently to develop a workable strategy that can support nursing facilities in meeting this goal. Concurrently, hospitals in the downstate New York region and around the country have been working to ensure that they meet CMS’ Meaningful Use (MU) requirements around the transfer of electronic information. Under these MU requirements, CMS expects that by September 30, 2014, hospitals will be communicating patient discharge summary information for 10% of all discharges to external partners, including nursing facilities. If hospitals are unable to do this, they will be financially penalized in 2016.

To build on this momentum and simultaneously begin to achieve NY–RAH project goals, GNYHA Foundation plans to contract with an organization that can provide “Direct Messaging” services and provide mailboxes for nursing facilities for messaging services. Once mailboxes are set up, NY–RAH nursing facilities will be able to receive structured summaries and other messages from partner hospitals. NY–RAH plans to work with facilities to address challenges facility staff have encountered working with this technology.

NY–RAH is working to ensure that all nursing facilities have Direct Messaging mailboxes by July 1 and are able to receive information from their partner hospitals. The expectation is that hospitals will initially focus solely on the MU requirement that information be delivered from the hospital to the external provider. Simultaneously, NY–RAH will work with its nursing facilities to facilitate the effective use of that transferred information to ensure that it can be used to improve resident care and reduce avoidable hospitalizations. NY–RAH will also be working with nursing facility electronic medical record vendors to develop a workplan for communicating information from nursing facilities to the hospitals using this same Direct Messaging technology.

For more information on electronic solutions, please contact Jeffrey Paul, NY–RAH Project Manager, at (212) 258-5308 or jpaul@gnyha.org.

The 30 NY–RAH nursing facilities are being divided into two groups, one that will focus intensely on electronic solutions from June through September, and another that will focus intensely on palliative care from June through September. NY–RAH will host two upcoming MOLST trainings with Patricia Bomba, M.D., which focus on implementation of the MOLST form for those NY–RAH nursing facilities initially focusing on palliative care.

The initial palliative care meetings are scheduled as follows:

New York City Facilities
Date: Tuesday, June 24
Time: 9:30 a.m.–5:00 p.m.
Location: GNYHA Conference Center
555 West 57th Street, 15th Floor
New York, NY 10019
Long Island Facilities
Date: Wednesday, June 25
Time: 9:30 a.m.–5:00 p.m.
Location: Long Island State Veterans Home
100 Patriots Road
Stony Brook, NY 11790

For information on the palliative care trainings, please contact Megan Burns, NY–RAH Project Manager, at (212) 554-7243 or mburns@gnyha.org.
In February, Governor Andrew Cuomo announced that an agreement had been reached between the State and Federal government on a waiver that will allow New York to reinvest $8 billion in Federal savings generated by the Medicaid Redesign Team (MRT) over five years to transform the State's health care system. The waiver provides funding beginning in 2015 for several distinct initiatives, the bulk of which ($6.42 billion) is for the Delivery System Reform Incentive Payment (DSRIP) program.

The DSRIP program presents an opportunity for nursing homes to collaborate with hospital partners on projects designed to achieve system integration, reduce avoidable hospitalizations, improve population health outcomes, and engage in payment reform. In 2014, applicants for DSRIP funding will be forming Performing Provider Systems (PPS), which are expected to be comprised of hospitals, primary care providers, nursing facilities, home care agencies, and other community organizations that serve the Medicaid population. A PPS will be awarded DSRIP funding for achieving specific performance benchmarks.

DSRIP projects must be new or significantly enhanced from existing provider initiatives and cannot duplicate initiatives already funded by CMS. Important achievements made as part of projects such as NY–RAH that are federally funded and of limited duration often dissipate when federal funding ends. Greater New York Hospital Association has therefore requested clarification from the New York State Department of Health about whether ongoing costs associated with reform initiatives such as NY–RAH that have been previously funded by CMS can be supported under DSRIP if the start date and time period associated with the proposed DSRIP project do not overlap with the previously funded project. The goal would be that NY–RAH nursing facilities that wish to continue to work on the components of the NY–RAH toolkits after October 2016 are able to do so.
CMS Outstanding Nursing Facility Recognition
Winter 2013: Laurence Abrams, Administrator, Workmen’s Circle Multicare Center

CMS Outstanding ECCP Staff Recognition
Winter 2013: Michael Johnston, Senior Director, Health Informatics, Greater New York Hospital Association
NY–RAH nursing facilities that have not already done so should order the American Medical Directors Association (AMDA) Know-It-All-Before-You-Call cards as soon as possible. Leonard Gelman, MD, NY–RAH Project Medical Director and AMDA President, has negotiated a discount with AMDA for the purchase of these tools by NY–RAH nursing facilities.

The Know-It-All-Before-You-Call and the Know-It-All-When-You’re-Called cards can now be purchased separately for $25 each (plus shipping). The order form can be found here.