No. 5 – Fall 2014 Flag3
  In This Issue   NY-RAH Hires Medical and Clinical Directors
The GNYHA Foundation and Icahn School of Medicine have added a new project medical director and a new project clinical director.

Joseph Sacco, MD, ABFM, ABHPM, NY–RAH's Palliative Care Director since the project's inception, will now serve in a dual role as Project Medical and Palliative Care Director. Dr. Sacco will visit each nursing facility over the next few months to assist medical and administrative staff with implementing the American Medical Directors Association (AMDA) Clinical Practice Guidelines, determine actionable next steps to reduce avoidable hospitalizations based on the QI Summary Tool deep dives, and implement the Medical Orders for Life-Sustaining Treatment (MOLST) or electronic MOLST (eMOLST) form.

Inna Popil, RN, MSN, ACNS-BC, CCM, has been named NY–RAH's Clinical Director. Ms. Popil has decades of experience in nursing and in educating, managing, and building relationships across care teams. Most recently she worked at NYU Medical Center's Simulation Learning Center. Ms. Popil will arrange site visits to meet with each Director of Nursing over the next few months and will work with the NY–RAH Clinical Nurse Managers and the RN Care Coordinators to interpret the data from the NY–RAH QI Tools and create educational resources for nursing facility staff.

The Project Management Team looks forward to working with Dr. Sacco in his expanded capacity and with Ms. Popil in her new role over the next two years. Dr. Sacco can be reached at jsacco@bronxleb.org or (917) 327-8569. Ms. Popil can be reached at inna.popil@mountsinai.org.
  Smithtown Uses Deep Drive to Reinforce INTERACT Tools  
In June, NY–RAH distributed a Quarter 1 2014 Hospitalization Report to all NY–RAH facilities. Each RN Care Coordinator met with his or her facility to review the report and select an area for the RN Care Coordinator to do a "deep dive" to determine the root cause of the transfers.

Mary Chadda, RN Care Coordinator at Smithtown Center for Rehabilitation & Nursing Care (Smithtown Center), reviewed the report with Elizabeth Zimmermann, RN, Smithtown Center Director of Nursing, who decided to focus on night shift transfers. Ms. Chadda analyzed the data collected in the NY–RAH Quality Improvement (QI) Chart Audit tools and then synthesized the findings in the NY–RAH QI Summary Tool. The QI Summary Tool revealed that nurses on the night shift were not completing the INTERACT SBAR form before calling the physician. Ms. Zimmermann met with the night shift staff and highlighted how using the INTERACT SBAR (Situation-Background-Assessment-Request) and Stop And Watch tools can communicate a change in a resident's condition to the physician. Ms. Zimmerman noted that if the information is presented appropriately, many residents can avoid an unnecessary transfer to a hospital. She further emphasized that the nurses at the facility are capable of caring for residents who may need IVs, IV antibiotics, X-rays, vital signs/neurological checks, blood drawn, and EKG's. Smithtown Center is confident in their nursing staff's ability to monitor residents in the facility overnight in many cases before the physician assesses the resident first thing in the morning.

After that meeting, the number of Acute Changes of Condition reported with an INTERACT SBAR or Stop And Watch tool increased from 5% in June to 22% and 20% in July and August, respectively. Smithtown Center also adopted a new 24-hour report template that indicates that "All ACOCs must have an SBAR," which has led to an increase in the number of SBAR tools being completed.

The NY–RAH Project Management Team encourages each facility to look closely at the data the RN Care Coordinator collects and review processes that may help reduce avoidable hospitalizations as the team at Smithtown Center has done. For more information about using the INTERACT Stop and Watch and SBAR tools, please contact Megan Burns, NY–RAH Project Manager, at (212) 554-7243 or mburns@gnyha.org.
More Than Half of NY-RAH Facilities Already Using MOLST
On October 8 and 10, trainings were held in Long Island and New York City on implementing the MOLST form. The trainings were led by Patricia Bomba, M.D., a nationally recognized end-of-life care expert, the key leader for MOLST in New York State, and Vice President and Medical Director for Geriatrics at Excellus BlueCross BlueShield Health Plan in Rochester, NY.

Sixteen of the 29 NY–RAH nursing facilities have implemented the MOLST form. An additional five facilities have been trained on eMOLST and are establishing a workflow to encourage eligible residents to complete the form. Beginning January 1, facilities are asked to begin using the MOLST paper form for new residents and to incorporate it into quarterly care plan meetings with all current residents. For those nursing facilities that have not yet implemented the MOLST or eMOLST form, the NY–RAH Project Management Team and your RN Care Coordinator will help establish an implementation process. To support this, Dr. Bomba and Dr. Sacco are writing a model MOLST policy for facilities to use. A webinar will be scheduled with the administrators and other facility staff to review the model MOLST policy in the near future.

NY–RAH launched its palliative care intervention in June and requested that all facilities identify two palliative care "champions" to take the lead on implementing the MOLST form. The support and leadership of these individuals is crucial to the MOLST form's adoption and ongoing use. All facilities are in the process of establishing or enhancing a palliative care and care plan meeting policy and protocol that meets the NY–RAH guidelines Dr. Sacco developed. Dr. Sacco has given RN Care Coordinators feedback on the palliative care policies with the goal of having the final policies approved and adopted by each facility by December 15. The care plan meeting policies are under review, and facilities can expect feedback from Dr. Sacco in December.

For more information on the MOLST or the palliative care intervention, please contact Dr. Sacco, NY–RAH Medical and Palliative Care Director, at jsacco@bronxleb.org or (917) 327-8569.
NY-RAH Facilities Make Progress on Advance Directives
In November, each NY–RAH facility received the first iteration of the NY–RAH Facility Progress Report. The report provided six months of data on a variety of measures, including rates of hospital transfers, advance directive discussions, and NY–RAH tool use. In addition, NY–RAH has been tracking overall project performance and has seen great improvement, specifically in the area of advance directives.

Since Quarter 1 (Q1) of 2014, NY–RAH has aimed to increase the number of residents who have a documented quarterly advance directive discussion with facility staff. In Q1 2014, 16% of eligible residents had an advance directive discussion documented during that quarter. In Quarter 3 (Q3) of 2014, the percentage of residents with a documented quarterly advance directive discussion had improved to 27%. This increase is a testament to the hard work that each facility's staff has done to improve the quantity and quality of the advance directive discussions within their facility.

NY–RAH has also encouraged each facility to increase the number of eligible residents who have a documented advance directive. At the end of Q3 2014, 83% of residents eligible for NY–RAH had a documented advance directive, up from 69% at the end of Q1 2014. Furthermore, NY–RAH has observed growth of resident advance directives across all advance directive categories (Do Not Resuscitate, Do Not Intubate, Do Not Hospitalize, No Enteral Feeding) during this same time period.

The NY–RAH Project Management Team appreciates the continued efforts of your facility staff in making progress in the area of advance directives. NY–RAH will provide more information to each facility on advance directives in the updated Palliative Care Report that will be sent later this month.

For questions about the NY–RAH Progress 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
Fall 2014: Dr. Daniel Russo, MD, Medical Director; Loretta McManus, Vice President of Nursing Services; Denise Lawson, Director of Performance Improvement; and Peaches Smith-Grinion, Staff Educator, The Silvercrest Center for Nursing and Rehabilitation
CMS Outstanding ECCP Staff Recognition
Fall 2014: Kelvin Omonzane, RN Care Coordinator, Casa Promesa Residential Health Care Facility and Daughters of Jacob Nursing Home
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.
Greater New York Hospital Association
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