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  No. 7 – Spring 2015 Newsletter flag3
  In This Issue   NY-RAH Hosts CMS for Annual Site Visit
On April 16–17, NY–RAH hosted the CMS project officers overseeing the NY–RAH project for a site visit. As part of its oversight of the CMS Initiative to Reduce Avoidable Hospitalizations, CMS staff make site visits to each of the seven projects from around the country on an annual basis to meet with the project leads, visit participating facilities, and discuss implementation successes and challenges of the Initiative.

For this year's visit, the NY–RAH project management team reviewed the status of the various components of the project with the CMS project officers and discussed ways that CMS could better support the participating facilities. Following that discussion, the project management team and the CMS project officers visited Casa Promesa Residential Health Care Facility and Daughters of Jacob (DOJ) Nursing Home, both located in the Bronx. At each facility, the CMS project officers discussed the ongoing use of the INTERACT tools with the facility leadership and the approaches the facility is taking to ensure that the facility clinical staff are aware of the NY–RAH project and utilize the expertise of the NY–RAH registered nurse care coordinator (RNCC). At both facilities, the leadership provided an overview of their services and discussed their overall approach to ensuring that its residents are cared for properly in the facility. The NY–RAH project management team appreciates the willingness of both Casa Promesa and DOJ leadership to set aside time to discuss the project with the CMS project officers.
  NY-RAH Holds Director of Nursing Learning Webinar  
On May 7, NY–RAH Clinical Director Inna Popil facilitated the first Director of Nursing (DON) learning community webinar, with Denise Lawson, Director of Quality Improvement from The Silvercrest Center for Nursing and Rehabilitation. Ms. Lawson shared Silvercrest's strategies for reducing respiratory distress transfers and improving staff efficiency by reducing unnecessary transfers, thereby reducing the time spent entering MDS data. Ms. Lawson also discussed how the facility utilizes its RNCC, Marva Skeete-Philips, and how they use the NY–RAH quarterly reports to drive change. Other DONs and nursing staff discussed physician buy-in, tool usage, staff engagement and education, and effective use of the EMR. All participants agreed that a reduction in hospital transfers is achievable through interdisciplinary collaboration and teamwork.

The next DON learning community webinar will be held in July and focus on how facilities are utilizing the NY–RAH Palliative Care reports to increase the rate of advance directive discussions, completed advance directive forms, and completed MOLST forms. A notice with the time and date will be sent out in the next few weeks. If your facility is interested in discussing how it uses its Palliative Care report, please contact Inna Popil at (347) 714-4014 or
  CMS Evaluator Planning Site Visits and Phone Calls
In early June, staff from Research Triangle Institute (RTI) will visit four NY–RAH participating facilities to interview staff at all levels about the project. The Center for Medicare & Medicaid Innovation (CMMI) has contracted with RTI to do the formal evaluation for the seven projects participating in the Initiative to Reduce Avoidable Hospitalizations.

A NY–RAH participating facility that has not been contacted about a visit for this June may be visited at some point in the future. For those facilities that it is not formally visiting, RTI will reach out to schedule calls with those nursing facilities in late June. Discussions with RTI are confidential and the NY–RAH project management team encourages all participants to be candid about their experiences with the project.

RTI is using quantitative and qualitative research methods to identify features of the seven projects that are positively associated with improved outcomes and to identify implementation barriers and barriers to achieving positive outcomes. Ultimately, the evaluation results from all seven projects from around the country will be used to identify and characterize the most promising models to inform future policy making for improving resident care, improving resident health, and reducing costs.
  Reporting Highlights from Quarter 1 2015  
The NY–RAH project management team is pleased to report significant improvements in palliative care and advance directive measures across NY–RAH facilities in the aggregate. There was a 12% increase in residents with a quarterly advance directive discussion when compared with the previous quarter. The total number of eligible residents without an advance directive also decreased for the fourth consecutive quarter.

In addition, there was an increase in the number of acute change of conditions (ACOC) reported with a NY–RAH tool (SBAR, Stop And Watch, and Know-It-All Before You Call cards) used compared to previous quarters. A NY–RAH tool was used to report 45% of the project's ACOCs in Q1 2015. NY–RAH will continue to emphasize both the quantity and quality of these communication tools as participants increase the number of resident ACOCs that are managed in their facilities.

The data progress to date shows encouraging signs for the success of the NY–RAH project. Advancing in the aforementioned process measures will have a great impact on improving and enhancing the high-quality care each facility already provides. If you have any questions or would like assistance interpreting your facility's specific reports, please contact Scott Gaffney, Senior Research Analyst at (212) 258-5369 or
  NY-RAH Staff Reviews Project Successes with FIDA Plans
On May 15, Tim Johnson, NY–RAH Project Director, and Ashley Hammarth, NY–RAH Deputy Project Director, reviewed the project implementation status and successes with representatives of the Fully Integrated Dual Advantage (FIDA) plans on a conference call organized by the New York State Department of Health and the Centers for Medicare & Medicaid Services (CMS). The FIDA plans are authorized in New York to enroll dual eligibles (individuals with both Medicare and Medicaid coverage) in managed care plans under a CMS-authorized demonstration.

The NY–RAH representatives were asked to discuss the NY–RAH project so that the FIDA plans might learn from the experiences of the project and leverage successful approaches developed by the project management team. Mr. Johnson and Ms. Hammarth reviewed the structure of the NY–RAH project and the commitment of the participating facilities to avoid unnecessary hospitalizations. The FIDA plan representatives were also provided with a list of the NY–RAH participating facilities. The role of RNCCs as educators and consultants to the nursing facility was also highlighted. The work of the RNCC with facility staff to better identify acute changes of conditions, review communication processes to avoid transfers, and improve the adoption of advance directives was also described. NY–RAH's use of Direct Messaging for transmitting secure resident information from the hospital EMR to the nursing home was explained as a way of fostering electronic communication between facilities and their hospital transfer partners.

Mr. Johnson and Ms. Hammarth noted the strong position the NY–RAH participating nursing facilities are in to achieve the goals of both FIDA and the Delivery System Reform Incentive Payment (DSRIP) program. Under DSRIP, many nursing facilities are expected to implement the INTERACT program to support overall efforts to reduce avoidable hospitalizations and promote better care coordination. For more information about the call with the FIDA plans, please contact Ashley Hammarth at (212) 504-5421 or
CMS Outstanding Nursing Facility Recognition
Spring 2015: Jerry Enella, Administrator, Sapphire Center for Rehabilitation and Nursing
CMS Outstanding ECCP Staff Recognition
Spring 2015: Vernise Griffith, RN Care Coordinator, Buena Vida Continuing Care and Rehabilitation Center
  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.  
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