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No. 4 – Summer 2014 NYRAG flag
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In This Issue Silvercrest Avoidable Hospitalization Rate Drops
The Silvercrest Center for Nursing and Rehabilitation in Queens, NY, a NY–RAH participant, has experienced a drop in its rate of avoidable hospitalizations. According to Centers for Medicare & Medicaid Services (CMS) data provided to the NY–RAH Project Management Team, Silvercrest Center's 30-day readmission rate during Year 1 Quarter 4 (ending September 2013) was 53.3%, largely due to transfers of its ventilator dependent residents, which make up about 30% of NY–RAH eligible beneficiaries. During Year 2 Quarter 1 (ending December 2013), the readmission rate fell to 31%. Silvercrest Center leadership attributes the reductions to the implementation of the Stop and Watch form and the Know-It-All-Before-You-Call reference cards; expanded use of the SBAR tool for all changes of condition; and an increased focus on early recognition and treatment of symptoms by the clinical team.

Silvercrest Center 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-Call cards, and the AMDA Acute Change of Condition guidelines, in late 2013. In early 2014, Silvercrest Center staff was trained on advance directives and how to have meaningful discussions during care plan meetings. Under the direction of Denise Lawson, Performance Improvement Director, and Loretta McManus, Vice President of Nursing Services, and with the help of RN Care Coordinator Marva Skeete-Philip, Silvercrest Center has made tremendous strides in reducing its avoidable hospitalization rate.
Silvercrest Center also established two project workgroups, each with representation from all clinical departments. The Reducing Avoidable Hospitalizations workgroup focuses on conducting modified root cause analyses on all hospital transfers and determining, as a group, whether the transfers were appropriate. Findings from this analysis are shared and made part of the facility's performance improvement process. The other workgroup was created to review, revise, and enhance the current palliative care program. Since the tools were adopted and the workgroups formed, there have been situations in which residents were successfully treated in-house and completed the appropriate advance directives.

In July, Medical Director Daniel Russo, MD, met with Silvercrest Center physicians and nurse practitioners to discuss hospital transfers. At the meeting, Dr. Russo and his colleagues used the NY–RAH Quality Improvement Chart Audit tool on a transfer from the past month to determine the root cause of the transfer, and if anything could have been done to avoid it.

The NY–RAH Project Management Team salutes the Silvercrest Center team for its work and ongoing support of the project goals. For more information about the use of the Stop and Watch and SBAR tools, please contact Ashley Hammarth, NY–RAH Deputy Project Director, at (212) 506-5421 or ahammarth@gnyha.org.
Medical Directors Discuss Hospitalization Reports
On July 10, a Facility Medical Directors meeting was held in New York City at which each Medical Director received a copy of the aggregate Quarter 1 2014 hospitalization report, a facility specific hospitalization report, and a list of questions about the data in the reports before the meeting.

At the meeting, NY–RAH Project Medical Director Leonard Gelman, MD, asked each Medical Director to comment on his or her initial impressions of the hospitalization reports; if there were measure results that differed from his or her expectations; and how certain measures differed and why did they not expect it to be this way.

It was noted that the most common symptom resulting in a transfer was shortness of breath. Many of the Medical Directors reported that staff were often uncomfortable trying to manage this symptom at the facility. A few Medical Directors cited examples of clinical areas (such as pneumonia) where their facility had made progress in treating residents in the nursing facility. To help facilitate a better understanding of this, the Medical Directors recommended that transfers be disaggregated to look at the causes for certain symptoms, as some could easily be managed in the facility while others require a transfer.

The Medical Directors requested staff education on the most common signs and symptoms that lead to transfers. RN Care Coordinators (RNCCs) will work on developing education for this in Year 3. Many Medical Directors said sharing additional data on hospital transfers will help educate staff at all levels and further catalyze change. Several Medical Directors also expressed the belief that family requests were the most common reason for transfer. The NY–RAH hospitalization data does not fully align with this belief, as much of the data indicates there are often actions that could have been taken prior to family involvement to manage the change of condition.
NY-RAH Facilitates Adoption of Electronic Solutions
On July 15 and 24, NY–RAH held Clinical Intervention Advisory Committee (CIAC) meetings to discuss electronic solutions. The meetings were held at Greater New York Hospital Association's (GNYHA) offices in Manhattan, and at Stony Brook University Medical Center. GNYHA Vice President for Regulatory and Professional Affairs Zeynep Sumer-King described the policy under which hospitals in the downstate New York region and around the country are working to meet meaningful use (MU) requirements on transferring electronic information. Under these requirements, CMS expects that by September 30, 2014, hospitals will electronically communicate 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 promote nursing home participation in Direct Messaging, the primary means for meeting MU requirements, NY–RAH has contracted with the MedAllies Mail Health Information Service Provider (HISP). MedAllies is providing Direct Messaging mailboxes to facilities so they can receive a Consolidated Clinical Document Architecture (C-CDA) Summary of Care document. Twenty-one NY–RAH facilities have elected to use the MedAllies mailboxes, while the rest have chosen to work directly with their partner hospital or use the HISP with which their area Regional Health Information Organization has contracted. Several NY–RAH nursing facilities received C-CDA documents from partner hospitals prior to the CIAC meeting, which allowed for a discussion of the experiences and use of that information. The attendees noted that the C-CDA document has the potential to provide more timely and accurate information from the hospital electronic medical record than is currently possible. Guest speakers from nursing facilities and hospitals shared their experiences with the admission, discharge, and transfer process.

Med Allies Mailbox Accounts
Of the 21 NY–RAH facilities that are working through MedAllies, 19 have received Direct Messaging mailboxes user accounts. On average, each facility has received three individual user mailboxes, in addition to the facility's shared mailbox, which each individual user can access. When user accounts are provided by MedAllies, a user packet is sent to individual users to allow them to set up their accounts and navigate the Direct Messaging system.

NY–RAH Project Manager Jeffrey Paul has been working with facilities and users to activate accounts and get started with Direct Messaging. NY–RAH will also schedule group trainings for September where further support for the MedAllies technology will be offered. For technical problems with the MedAllies mailboxes, please contact the MedAllies Support Center directly at supportcenter@medallies.com.

In addition, RNCCs are notifying the NY–RAH Project Management Team when a facility needs assistance and have been following up on technical issues submitted to MedAllies in conjunction with the NY–RAH Project Management Team. As the RNCCs work with their facilities to understand how C-CDA documents can be used effectively, the RNCCs are also recording in the NY–RAH data portal which residents have received a C-CDA document as part of their transfer information from the hospital.

Supporting Facility Relationships
To best support Direct Messaging implementation, the NY–RAH Project Management Team has worked with participating nursing facilities and their major transfer partners to establish regular communication with the 10 hospitals responsible for 90% of transfers from NY–RAH facilities. A directory with each NY–RAH facility's Direct Messaging mailbox address will soon be available to all hospitals and nursing homes. Only the facility-shared mailbox, not the addresses of individual users, will be included.

The directory will help hospitals and nursing facilities communicate more easily with one another. It will also help ensure that Direct Messaging is used for all transfers: long-stay residents, as well as short-stay patients who are beyond the scope of the NY–RAH project. While hospitals have a specific interest in meeting MU requirements and promoting Direct Messaging, many would like to improve transition issues more broadly.

In addition to the larger hospitals that receive the vast majority of NY–RAH transfers, several small community hospitals have developed relationships with the NY–RAH Project Management Team. Their experiences have provided additional perspective on the challenges inherent to implementing a new technology and improving transfers. NY–RAH is also working with MedAllies to develop reports that will be useful to all stakeholders, including CMS, nursing facilities, and hospitals, to understand the level of success being achieved in the transmission of C-CDA documents.
For more information on electronic solutions, please contact NY–RAH Project Manager Jeffrey Paul at (212) 258-5308 or jpaul@gnyha.org.
NY-RAH Data and Reporting Update
In early September, each NY–RAH participating facility will receive an updated report (including data from the second quarter of 2014) on their transfers from the nursing facility to the hospital. Each facility will also receive an updated Palliative Care report in October. The reports, which will be sent approximately two to three months after the end of each quarter, will help each facility better understand the root causes of its hospital transfers and the progress of its palliative care programs, and in turn develop actionable solutions.

The NY–RAH Project Management Team will provide additional reports over the next few months. Facilities can expect to receive a facility scorecard, which trends performance on a small number of metrics across all areas of the intervention, including hospital transfers, INTERACT tool implementation, and advance directive implementation. Additionally, the Project Management Team is working on grouping the participating nursing facilities based on certain characteristics, such as size, special populations, or geography. These groupings will be used in future reports to help each facility compare itself to the subset of NY–RAH facilities that it most resembles. The NY–RAH team is also working to reduce the lag time between the end of a quarter and the distribution of a report.

Facilities are encouraged to submit feedback on current reports, or suggestions for future reports. To submit feedback or ask questions about the reports, please contact Jared Bosk, NY–RAH Project Data Manager, (212) 554-7247 or jbosk@gnyha.org, or Scott Gaffney, NY–RAH Senior Research Analyst, (212) 258-5369 or sgaffney@gnyha.org.
CMS Outstanding Nursing Facility Recognition
Summer 2014: Mary Fran Thaler, Vice President of Administration, The Hebrew Home for the Aged at Riverdale and Palisade Nursing Home
CMS Outstanding ECCP Staff Recognition
Summer 2014: Ediri Okiti, RN Care Coordinator, Workmen's Circle Multicare Center
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