Phase One

Project Structure

In Phase One, GNYHA Foundation partnered with the Icahn School of Medicine at Mount Sinai (Mount Sinai) to serve as an “enhanced care coordination provider” under the CMS Initiative. GNYHA Foundation is the contractor to CMS and is responsible for ensuring that project deliverables are met and that all administrative requirements associated with the cooperative agreement are achieved. Mount Sinai employed the NY–RAH medical and palliative care director, the clinical director, clinical nurse managers, and registered nurse care coordinators (RNCCs) who worked onsite at the 29 participating nursing facilities to ensure the achievement of NY–RAH project goals. The RNCCs, acting as coaches and quality improvement consultants, focused on increasing the capacity of the nursing facility by reviewing its processes, identifying root causes for preventable hospitalizations, and modifying protocols as necessary to achieve better outcomes.

NY–RAH Toolkit

The NY–RAH project toolkit includes a variety of tools and interventions that will serve to improve the care provided to long-stay residents, reduce the rate of hospitalizations, and improve the transition process when a hospitalization does need to occur.


NY–RAH is using interventions from Interventions to Reduce Acute Care Transfers (INTERACT), supplemented by tools from the American Medical Directors Association (AMDA), at the nursing facilities. Among the tools being used by nursing staff are the “Stop and Watch” and Situation-Background-Assessment-Recommendation (SBAR), tools that can improve communication between members of the health care team.

AMDA has provided NY–RAH with a discount for the Know-It-All Set and Clinical Practice Guidelines in the Long Term Care Setting for all participating nursing facilities by using the order form below. The INTERACT tools are free of charge and can be downloaded from the INTERACT website.

NY–RAH has also incorporated specific tools available from AMDA with the goal of providing a more systematic way for nurses and physicians to communicate about the condition of particular residents. The NY–RAH Quality Improvement Chart Audit Tool combines elements of the INTERACT QI tool with the AMDA Root Cause Analysis of an Unplanned Transfer.

Medication management is important in early recognition of acute changes of condition as well as avoiding potential drug interactions due to polypharmacy. NY–RAH has created easy reference medication management reference cards as well as medication guidelines.

Palliative Care Tools
Palliative Care

The NY–RAH palliative care intervention promotes palliative care best practices through training facility nursing and social work staff.

The palliative care champion at each facility has taken the lead role in implementing the MOLST (Medical Orders for Life Sustaining Treatment) form throughout the facility. The goal of the MOLST implementation is to ensure end-of-life wishes for residents and families will be honored across care settings. The Institute for Healthcare Improvement’s (IHI) The Conversation Project has a helpful resource, The Conversation Start Kit, which can help facility staff start the end-of-life conversation early on in the admission process before a MOLST form is even initiated.

NY–RAH created an easy to read Palliative Care Brochure for use with families and residents. It is available in English, Spanish, and Korean.

NY–RAH also created policy templates for both Palliative Care and Care Plan Meetings. Using evidence-based guidelines, the Project Medical and Palliative Care Director created these to ensure that a practitioner is involved in the care planning process to discuss goals of care and advance care planning.

Electronic Solutions
Electronic Solutions

The NY–RAH electronic solutions intervention consists of developing a means by which participating nursing facilities can utilize information to improve resident care and reduce avoidable hospitalizations. To achieve this, each facility has received “Direct Messaging” mailboxes, either from MedAllies, the contracted NY–RAH mailbox vendor, their partner hospital, or their Regional Health Information Organization (RHIO), to allow them to receive structured summaries and other messages electronically from partner hospitals.

Using Data to Drive Change
Using Data to Drive Change

To help sustain the quality assurance and quality improvement initiatives at the facilities, NY–RAH created a helpful data resource guide which facilities can use to identify sources of data that are readily available which can be used to develop metrics to track progress in different facility based performance improvement projects.