Skilled Nursing Facility INTERACT Program Implementation ......Feb 06, 2017 · INTERACT PROGRAM IMPLEMENTATION TOOLKIT | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative

INTERACT PROGRAM IMPLEMENTATION TOOLKIT | SCC PROJECT MANAGEMENT OFFICE

Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788 Copyright © 2017 Suffolk Care Collaborative, All rights reserved.

Skilled Nursing Facility

INTERACT Program

Implementation Toolkit

V.2

PROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BVII

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM

SUFFOLK CARE COLLABORATIVE

SUFFOLK CARE COLLABORATIVE | PROJECT MANAGEMENT OFFICE| www.suffolkcare.org | [email protected]

http://www.suffolkcare.org/


mailto:[email protected]

INTERACT PROGRAM IMPLEMENTATION TOOLKIT | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788

Copyright © 2017 Suffolk Care Collaborative, All rights reserved.

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INTERACT PROGRAM

IMPLEMENTATION TOOLKIT

2nd Edition: February 6, 2017

Delivering The Best Care at Every Stage Of Life

PROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BVII

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM

This material was created by, and is the proprietary work of the Suffolk Care Collaborative (SCC). It may not be copied,

transmitted, or reproduced in any manner without the express permission of the SCC.

For more information, please contact us at [email protected]

SUFFOLK CARE COLLABORATIVE 1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11778

www.suffolkcare.org






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Acknowledgements We would like to acknowledge members of our program who support our ongoing efforts in health care

delivery system reform.

INTERACT Workgroup A composition of subject matter experts engaged to support the development, execution and

monitoring of project milestones.

INTERACT Committee A composition of key internal and external project stakeholders, including representation from key

community and public service and governmental agencies engaged to support the conclusions,

deliverables and monitor system impacts of the DSRIP Program.

Special thanks to our key contributors for their work on the 1st Edition Toolkit:

Organization

Affinity Skilled Living Nadege Duroseau

Apex Rehabilitation and Healthcare Diane Montagnese

Brookside Multicare Nursing Center (Avalon Gardens) Joanne Mendez

Bellhaven Center for Nursing and Rehabilitation Michele Randazzo

Broadlawn Manor Nursing and Rehabilitation Center Donna Kube

Brookhaven Rehabilitation & Health Care Center Kellie Burridge

Carillon Nursing and Rehab Center LLC Claudia Schreck

Central Island Lisa Dowd

Daleview Care Center Kim Deschamps

East Neck Nursing and Rehab Center Denise MacDonald

Good Samaritan Nursing Home Diane Guidone

Gurwin Jewish Nursing & Rehabilitation Center Julieann Yerkes

Hamptons Center for Rehabilitation and Nursing Diane Siegel

Hilaire Rehab and Nursing Stana Mosie

Huntington Hills Center for Health and Rehabilitation Teri O'Driscoll

Island Nursing and Rehab Center Hyacinth Hendrickson

Long Island State Veterans Home Sandra K. Sharp-Hayes

Maria Regina Residence Anna Moyette

Mills Pond Nursing and Rehabilitation Center Dolores Cruz

Momentum at South Bay: Rehabilitation and Nursing Regina Harrington

Nesconset Center for Nursing and Rehabilitation Crystal Thomas

Oak Hollow Nursing Center Denise Cagno

Our Lady of Consolation Nursing & Rehabilitative Care Center Theresa Rosenthal

Peconic Bay Anna Law

Peconic Landing at Southhold Lee Cole

Riverhead Care Center DBA Acadia Center for Nursing and Rehabilitation Mary Greco




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Ross Center for Health and Rehabilitation Jackyln Lyn

San Simeon by the Sound Center for Nursing and Rehabilitation Kelly Moteiro

Sayville Nursing and Rehabilitation Center Kathleen Diheenedetto

Smithtown Center for Rehabilitation and Nursing Nancy Ciaffone

St. Catherine of Siena Nursing and Rehabilitation Care Center Cindy LePage

St. James Rehabilitation and Health Care Center KellyAnn Lunghi

St. Johnland Nursing Center Sherri Elliott

Suffolk Center for Rehabilitation and Nursing Laura Schauder

Sunrise Manor Center for Nursing Eileen Fasulo

Water's Edge at Port Jefferson for Rehabilitation and Nursing Ronald D'Anna

Westhampton Care Center Deborah Schafmayer

Woodhaven Santa Espinal

Recognition to the following organizations and coalitions for their collaboration and support:

Affinity Skilled Living

Apex Rehabilitation and Healthcare

Brookside Multicare Nursing Center (Avalon Gardens)

Bellhaven Center for Nursing and Rehabilitation

Berkshire Nursing Center

Broadlawn Manor Nursing and Rehabilitation Center

Brookhaven Rehabilitation & Health Care Center

Carillon Nursing and Rehab Center LLC

Central Island

Daleview Care Center

East Neck Nursing and Rehab Center

Good Samaritan Nursing Home

Gurwin Jewish Nursing & Rehabilitation Center

Hilaire Rehab and Nursing

Huntington Hills Center for Health and Rehabilitation

Island Nursing and Rehab Center

Lakeview Rehabilitation and Care Center

Long Island State Veterans Home

Maria Regina Residence

Mills Pond Nursing and Rehabilitation Center

Momentum at South Bay: Rehabilitation and Nursing

Nesconset Center for Nursing and Rehabilitation

Oak Hollow Nursing Center

Oasis Rehabilitation and Nursing

Our Lady of Consolation Nursing & Rehabilitative Care Center

Peconic Bay

Peconic Landing at Southhold




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Riverhead Care Center DBA Acadia Center for Nursing and Rehabilitation

Ross Center for Health and Rehabilitation

San Simeon by the Sound Center for Nursing and Rehabilitation

Sayville Nursing and Rehabilitation Center

Smithtown Center for Rehabilitation and Nursing

St. Catherine of Siena Nursing and Rehabilitation Care Center

St. James Rehabilitation and Health Care Center

St. Johnland Nursing Center

Suffolk Center for Rehabilitation and Nursing

Sunrise Manor Center for Nursing

The Hamptons Center for Rehabilitation and Nursing

Vincent Bove Health Center at Jefferson's Ferry

Water's Edge at Port Jefferson for Rehabilitation and Nursing

Westhampton Care Center

White Oaks Nursing Home

Woodhaven




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Table of Contents Acknowledgements ....................................................................................................................................... 2

INTERACT Workgroup ........................................................................................................................... 2

INTERACT Committee ........................................................................................................................... 2

Overview ....................................................................................................................................................... 8

Background ............................................................................................................................................... 8

State-wide Effort: Delivery System Reform Incentive Payment Program ................................................ 8

Local Leadership: Suffolk Care Collaborative ............................................................................................ 8

INTERACT .................................................................................................................................................. 8

Program Goals ........................................................................................................................................... 9

Purpose of the Implementation Toolkit .................................................................................................... 9

Returning Required Documents ............................................................................................................... 9

Program Resources ................................................................................................................................... 9

INTERACT Program Charter ........................................................................................................................ 10

Suffolk Care Collaborative INTERACT Program Contacts ........................................................................ 14

Skilled Nursing Facility Directories .............................................................................................................. 15

Facility Champion Directory .................................................................................................................... 15

Facility Co-Champion Directory .............................................................................................................. 17

SNF Administrator Directory ................................................................................................................... 19

Performance Logic User Directory .......................................................................................................... 21

Beginning INTERACT Program Implementation .......................................................................................... 23

Identify an INTERACT Program Facility Champion .................................................................................. 23

Facility Champion Role Description .................................................................................................... 23

Submit Facility Champion Form .......................................................................................................... 24

Identify an INTERACT Implementation Team ......................................................................................... 26

Implementation Team Composition & Role Description .................................................................... 26

Submitting an Implementation Team Composition Roster Template ................................................ 20

INTERACT Implementation Kick-Off Recommendations ........................................................................ 21

INTERACT Training Minimum Guidelines & Curriculum ............................................................................. 22

Certified INTERACT™ Champion 4.0 Training Program ........................................................................... 22

INTERACT Program Staff Training & Learning Modules .......................................................................... 23

Required Training Modules (4) ............................................................................................................... 23

Module 1: INTERACT Principles & Coaching Program ........................................................................ 23

Module 2: Care Pathways & Clinical Tools .......................................................................................... 23




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Module 3: Advance Care Planning ...................................................................................................... 23

Module 4: INTERACT Quality Improvement & Assurance Program.................................................... 24

INTERACT Training Methodology ............................................................................................................ 24

Submitting an INTERACT Program Training Inventory Form .............................................................. 25

INTERACT Training Sign-In Sheet Template ........................................................................................ 25

INTERACT Coaching Program ...................................................................................................................... 26

INTERACT Regional SNF Cohort Workgroups.............................................................................................. 30

INTERACT Patient, Family & Caregiver Education Methodology ................................................................ 32

Methodology for Family & Caregiver Education ..................................................................................... 32

Methodology for Patient Education ....................................................................................................... 32

Patient, Family & Caregiver Education Tools .............................................................................................. 33

Interventions to Reduce Acute Care Transfer Program .......................................................................... 33

Advanced Care Planning ......................................................................................................................... 33

Atrial Fibrillation ..................................................................................................................................... 34

Alzheimer’s.............................................................................................................................................. 34

Cardiovascular Disease Health Wellness & Self-Management Program ................................................ 35

Tobacco Control ...................................................................................................................................... 35

Diabetes Wellness & Self-Management Program .................................................................................. 36

Advanced Care Planning ............................................................................................................................. 39

Medical Orders for Life-Sustaining Treatment (MOLST) ......................................................................... 39

What is the MOLST Program? ................................................................................................................. 39

What is the MOLST form? ....................................................................................................................... 40

INTERACT Program Partnerships for MOLST & eMOLST ........................................................................ 40

Program Contacts................................................................................................................................ 41

Quick Links & Resources ......................................................................................................................... 41

Archived Advanced Care Planning Learning Collaboratives ................................................................... 42

SCC INTERACT Quality Improvement & Assurance Plan ......................................................................... 43

Quality Improvement & Assurance Plan Resources ............................................................................... 43

Implementation Resources ................................................................................................................. 43

INTERACT Program Reporting Protocol ...................................................................................................... 45

Project Documents to submit to the Suffolk Care Collaborative ............................................................ 47

Quarterly Reporting Schedule & Data Requests ..................................................................................... 48

Domain 1 Patient Engagement Data Request......................................................................................... 49

INTERACT Clinical Tools, Care Pathways & Resources ................................................................................ 50




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INTERACT Clinical Tools and Care Pathways ........................................................................................... 50

Advanced Care Planning Tools ................................................................................................................ 50

Quality Assurance & Improvement Activities ......................................................................................... 51

Additional Resources .............................................................................................................................. 51

DSRIP GLOSSARY ......................................................................................................................................... 52




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Overview

Background In response to rising healthcare costs, Medicaid spending and concerns of health care quality, Governor

Andrew M. Cuomo created the Medicaid Redesign Team (MRT). The MRT initiatives accounted for

approximately $17.1 billion in federal savings. On April 14, 2014, Governor Andrew M. Cuomo

announced New York finalized terms and conditions with the federal government for a groundbreaking

waiver that will allow the state to reinvest $8 billion of federal savings generated by the MRT reforms.

The MRT waiver amendment goal is to transform the state’s health care system, bend the Medicaid cost

curve, and ensure access to quality care for all Medicaid members. NYS Department of Health’s charter

under this waiver to fully implement an action plan to allow for comprehensive reform through a

Delivery System Reform Incentive Payment (DSRIP) Program.

State-wide Effort: Delivery System Reform Incentive Payment Program Through the Delivery System Reform Incentive Payment Program, a grant waiver administered by the

NYS Department of Health (NYS DOH), $6.42 billion Medicaid dollars were allocated to fundamentally

restructure the health care delivery system to transition care delivery from a largely inpatient-focused

system to a community-facing system that addresses both medical needs and social determinants of

health. DSRIP is a 5-year, performance payment-based program with primary goal of reducing avoidable

hospital use by 25% over 5 years. At the end of the program life, the aim is for the newly-transformed

system is to be sustainable. Project efforts are focused on achieving improved overall health through

integration of behavioral health and primary care, provision of appropriate levels of care management,

and care delivery models designed to improve chronic disease prevention and outcomes.

Local Leadership: Suffolk Care Collaborative New York State is broken into 25 regional organizations called Performing Provider Systems (PPS). Each

PPS is responsible for engaging providers, designing programs, coordinating collaboration, reporting

project outcomes and allocating funds to partners.

The Suffolk Care Collaborative (SCC) is the PPS for Suffolk County under the DSRIP Program. The goal of

SCC is to meet the requirements of the Triple Aim Initiative – improving patient experience, improving

health outcomes and reducing the per capita cost of healthcare. Our vision to become a highly effective,

accountable, integrated, patient-centric delivery system has positioned us well to make an important

contribution to the DSRIP program. Some of the many goals will include the capacity to make the most

of patients' self-care abilities, improve access to community-based resources, break down care silos, and

reduce avoidable hospital admissions and emergency room visits.

The SCC has operationalized all DSRIP requirements through a portfolio of programs.

INTERACT The objective of these programs is to provide a 30-day supported transition period after a

hospitalization to ensure discharge directions are understood and implemented by the patients

at high risk of readmission and to establish appropriately sized observation units (either a

dedicated unit or scattered-bed approach) in all hospitals in the county to reduce short stay

admissions, thereby minimizing Potentially Preventable Readmissions.


https://www.health.ny.gov/health_care/medicaid/redesign/

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

https://suffolkcare.org/aboutDSRIP/projects



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Click here to access our program webpage.

Program Goals Implement INTERACT at each participating SNF.

Identify a facility champion who will engage other staff and serve as a coach and leader of the INTERACT program.

Implement care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer.

Educate all staff on care pathways and INTERACT principles.

Purpose of the Implementation Toolkit The purpose of this toolkit is to assist all internal and external program stakeholders during the

implementation phase and throughout the life cycle of the program described herein. It provides an

overview of the INTERACT, including key directory of SCC project management office contacts, Program

Charter, tools and resources for implementation, program protocols, patient engagement requirements,

instructions on how to submit documents and maintain project documents and valuable program

resources. It is meant to act as a guide and information source in which you can refer to for all your

DSRIP needs.

Returning Required Documents This toolkit includes documents that will need to be completed and returned to the Suffolk Care

Collaborative (SCC) via Performance Logic. Electronic copies of these documents can be accessed via our

Partner Portal or you can complete the hard copies provided here and return them to SCC. If you

complete a document in hardcopy form, please scan the completed document prior to submitting. We

also recommend you keep a hardcopy of every document submitted to Suffolk Care Collaborative.

Program Resources Appended to this Implementation Toolkit is a set of Program Resources designed for our network

participating providers. Click here to access. INTERACT Clinical Tools, Pathways and Program Resources

include the following:

Implementation Resources

Provider Resources

Patient Education Resources

Additional Reading Materials


https://suffolkcare.org/aboutDSRIP/projects/2bvii



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Suffolk Care Collaborative Interventions to Reduce Acute Care Transfer Program

2bvii. Implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) project to reduce Skilled Nursing Facility (SNF) transfers to hospitals

INTERACT Program Charter Through the Delivery System Reform Incentive Payment (DSRIP) Program, a federal waiver

administered by the NYS DOH, $6.42 Billion Medicaid dollars were allocated to fundamentally

restructure the health care delivery system to transition care delivery from a largely inpatient-

focused system to a community-facing system that addresses both medical needs and social

determinants of health. DSRIP is a 5-year, performance payment-based program with primary

goal of reducing avoidable hospital use by 25% over 5 years. At the end of program life, the aim

is for the newly-transformed system to be sustainable. Project efforts are focused on achieving

improved overall health through integration of behavioral health and primary care, provision of

appropriate levels of care management, and care delivery models designed to improve chronic

disease prevention and outcomes.

Objective Statement:

Skilled Nursing Facilities within Suffolk County will implement the evidence-based INTERACT 4.0

Toolkit developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical

Care Foundation. INTERACT is a quality improvement program focusing on the management of

changes in a resident’s condition, with the goal of stabilizing the patient and avoiding transfer to

an acute care facility. Implementation of the project will begin in January 2016 and end March

31st, 2017, at which time all 42 facilities within Suffolk County will have initiated implementation

of the INTERACT Toolkit.

High Level Deliverables:

Implement INTERACT at each participating SNF.

Identify a facility champion who will engage other staff and serve as a coach and leader of the INTERACT program.

Implement care pathways and other clinical tools for monitoring chronically ill patients, with the goal of early identification of potential instability and intervention to avoid hospital transfer.

Educate all staff on care pathways and INTERACT principles.

Implement Advance Care Planning tools to assist residents and families in expression and documenting their wishes for near end of life and end of life care.

Create coaching program to facilitate and support implementation.

Educate patient and family/caretakers, to facilitate participation in planning of care.




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Measure outcomes (including quality assessment/root cause analysis of transfer) in order to identify additional interventions.

Benefits: According to a national study published in the Journal of the American Medical

Directors Association in 2014, “the INTERACT program has been associated with up to a 24%

reduction in all-cause hospitalizations of nursing home residents over a 6-month period”

(Ouslander et al., 2014). Overall goal of DSRIP is to reduce preventable hospital readmissions by

25% and INTERACT will contribute to that decrease.

Assumptions:

Evidence based strategies will be implemented at each SNF in the PPS

Stakeholder commitment and buy in to the project is strong as they feel implementation of the INTERACT Toolkit is an added benefit to their facility

Each Director of Nursing will be the facility champion and trained as a Certified INTERACT Champion by INTERACT T.E.A.M. Strategies, LLC.

Constraints:

Project budget, available workforce, and resources to contribute to implementation and the sustainability of the project

Lack of EHR and connectivity between SNFs, hospitals and the community

High-Level Risks:

Of those who currently utilize INTERACT, most do so on paper. Additionally, wide variation in

EMR systems exists among the PPS partners that have them. Among these facilities, many

different EHR platforms are utilized. The PPS will develop a simple interface (e.g., using Direct

Messaging, etc.) to link SNFs to hospital partners in the short term and this will be built upon as

full connectivity becomes more or a reality. Consistent with PPS goals, electronic connectivity

with hospital partners will be completed over the project lifetime. The SNFs will work with the

local RHIO to ensure useful electronic communication. As INTERACT tools are embedded in EHR

products, SNFs will move from paper to electronic use of these tools.

Efforts to engage the multiple staffing agencies relied upon by SNFs for weekend coverage to

ensure that weekend staff learn to properly use INTERACT tools may prove cumbersome. The

PPS will create and disseminate a Provider Engagement strategy to support facility training of

weekend staff in proper use of INTERACT tools and documentation through the PPS wide IT

infrastructure.

There has been a high level of turnover in nursing home leadership roles which may impact the

Project Schedule.




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Patients/families may be skeptical, or unaware, of the benefits from avoiding readmission. All

SNFs will provide orientation materials at facility admission outlining the policies and benefits of

transfer avoidance, as well as materials on advance care planning.

Success Criteria:

Successful completion of all Domain 1 requirements, including meeting patient engagement and project engagement commitments

Improvement throughout DSRIP Measurement Years across all Domain 2-3 outcome measurers (achievement of 10-20% gap to goal)

Engagement of PCPs, non-PCPs, and BH providers in implementation of the Million Hearts Campaign

Overall achievement of project objective

Sources that influenced the development of the program is accepted by public, community and key project stakeholders

Stakeholder Analysis:

38 Partner Skilled Nursing Facilities within Suffolk County will be implementing the INTERACT 4.0 Toolkit to reduce the number of admissions to hospitals.

Hospitals within Suffolk County will be oriented to the INTERACT principles and tools to enhance communication between facilities.

Closeout Criteria:

Close out will be managed during the monitoring phase of the project lifecycle and is tentatively scheduled for period ending March of 2020

Evaluate and ensure all Archive Data and final project records/documents are filed in a secure location and appropriate to demonstrate achievement of DSRIP metric/project commitments within Domain 1 - 4

Archive all project data in a central repository. Include best practices, lessons learned, and any other relevant project documentation.

Verifying acceptance of final project deliverables/ data sources by the NYS DOH

Completion of the post-project assessment and lessons learned

Completion of post-project review and evaluation

Project Strategy:

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program

focusing on the management of changes in a resident’s condition, with the goal of stabilizing the

patient and avoiding transfer to an acute care facility. Analyses suggest that a high percentage

of hospitalizations from SNFs are avoidable. According to a national study published in the

Journal of the American Medical Directors Association in 2014, “the INTERACT program has been




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associated with up to a 24% reduction in all-cause hospitalizations of nursing home residents

over a 6-month period” (Ouslander et al., 2014). To reduce the number of admissions from SNFs

to hospitals, the INTERACT 4.0 will be implemented at each PPS SNF. Hospitals will be oriented

to the INTERACT principles and tools to enhance communication between facilities. SNF

Directors of Nursing will be facility champions and trained by INTERACT T.E.A.M Strategies, LLC

to become Certified INTERACT Champions. Nurse Educators at each facility will also be trained

to become Certified INTERACT Champions and will assist the Directors of Nursing in

implementation, training of staff and instilling the value of the INTERACT program within their

respective facility. Facility champions will work with Medical Directors to build acceptance

among SNF and community physicians.

During implementation, SNF staff will be trained on the INTEACT Care Pathways to ensure

consistent patient monitoring, early identification of potential instability, and intervention to

avoid transfer. Each SNF will also complete the Capabilities List which will be given to partner

hospitals to ensure understanding of what conditions can be treated within SNFs to avoid

admissions. Learning collaboratives will be formed with SNF partners and hospitals to share

lessons learned, best practices, and to monitor outcomes using the Quality Improvement Tool

from the INTERACT 4.0 Toolkit. SNFs will also initiate INTERACT Advance Care Planning tools or

NYS DOH-approved MOLST forms to assist patients and families in documenting wishes for end

of life care to avoid unnecessary transfer.

References Ouslander, JG., Bonner, A., Herndon, L. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement

Program: An Overview for Medical Directors and Primary Care Clinicians in Long Term Care. JAMDA 15 (2014) 162-170.

http://www.interact2.net/docs/publications/Overview%20of%20INTERACT%20JAMDA%202014.pdf


http://www.interact2.net/docs/publications/Overview%20of%20INTERACT%20JAMDA%202014.pdf



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Suffolk Care Collaborative INTERACT Program Contacts

Contact Name Title Email Phone

Alexandra Kranidis Program

Assistant [email protected] (631) 638-1772

Ralph Thomas

Project

Manager, Care

Transitions

[email protected] (631) 638-1776

Alyssa Scully Sr. Director,

PMO [email protected] (631) 638-1369

Jennifer Kennedy

Director, Care

Transitions

Innovations

[email protected]

Cell: (516) 732-

3869

Tel: (631) 638-

1774

Dianne Zambori Project Lead [email protected] (516) 383-9920

Bob Heppenheimer Project Lead [email protected] (631) 766-2417

General Contact Information:

Suffolk Care Collaborative

1383 Veterans Highway, Suite 8, Hauppauge, NY 11788

Phone: (631) 638-2227

Fax: (631) 638-1009

Email: [email protected]

www.suffolkcare.org












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Skilled Nursing Facility Directories The Directories section of the Implementation Toolkit is a communications guide for your participation in

the program. All directories are subject to change, revised versions of the Implementation Toolkit will be

published to update our Directories. Please email Ralph Thomas, Project Manager at

[email protected] with any changes that you wish to make to contacts referenced

herein.

Facility Champion Directory Facility Name Facility Champion Phone Email

Acadia Center for Nursing and Rehabilitation Mary Greco

(631) 727-4400 [email protected]

Affinity Skilled Living Nadege Duroseau


Apex Rehabilitation and Healthcare Diane Montagnese


Bellhaven Center for Nursing and Rehabilitation Michele Randazzo


Broadlawn Manor Nursing and Rehabilitation Center Donna Kube


Brookhaven Rehabilitation & Health Care Center Kellie Burridge


Brookside Multicare Nursing Center (Avalon Gardens) Joanne Mendez


Carillon Nursing and Rehab Center LLC Claudia Schreck




Daleview Care Center Kim Deschamps (516) 694-9800 [email protected]

East Neck Nursing and Rehab Center Denise MacDonald


Good Samaritan Nursing Home Diane Guidone


Gurwin Jewish Nursing & Rehabilitation Center Julieann Yerkes


Hamptons Center for Rehabilitation and Nursing Diane Siegel


Hilaire Rehab and Nursing Stana Mosie


Huntington Hills Center for Health and Rehabilitation Teri O'Driscoll



Hyacinth Hendrickson



Sandra K. Sharp-Hayes


Maria Regina Residence Anna Moyette

























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Momentum at South Bay: Rehabilitation and Nursing Regina Harrington


Nesconset Center for Nursing and Rehabilitation Crystal Thomas


Our Lady of Consolation Nursing & Rehabilitative Care Center Theresa Rosenthal


Peconic Bay Anna Law


Peconic Landing at Southhold Lee Cole


Ross Center for Health and Rehabilitation Jackyln Lyn


San Simeon by the Sound Center for Nursing and Rehabilitation Kelly Moteiro


Sayville Nursing and Rehabilitation Center Jackie Donnelly


Smithtown Center for Rehabilitation and Nursing Nancy Ciaffone


St. Catherine of Siena Nursing and Rehabilitation Care Center Cindy LePage


St. James Rehabilitation and Health Care Center KellyAnn Lunghi




Suffolk Center for Rehabilitation and Nursing Laura Schauder


Sunrise Manor Center for Nursing Eileen Fasulo


Surge Rehabilitation and Nursing (Oak Hollow) Denise Cagno


Water's Edge at Port Jefferson for Rehabilitation and Nursing Ronald D'Anna


Westhampton Care Center Deborah Schafmayer


White Oaks Nursing Home Connie Biebauer (516) 367-3400

[email protected]

Woodhaven Santa Espinal
























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Facility Co-Champion Directory Facility Name Co-Champion Phone Email

Acadia Center for Nursing and Rehabilitation Kathy Kursar


Affinity Skilled Living Regina Prima


Apex Rehabilitation and Healthcare Annabelle Mazzochi


Bellhaven Center for Nursing and Rehabilitation Gina Iovino


Broadlawn Manor Nursing and Rehabilitation Center Kathleen Lista


Brookhaven Rehabilitation & Health Care Center Betty Honce


Brookside Multicare Nursing Center (Avalon Gardens) Mel Javier


Carillon Nursing and Rehab Center LLC Margaret Jablonski


Central Island

(516) 433-0600

Daleview Care Center Mary Kochaniwsky


East Neck Nursing and Rehab Center Helen Kiernan


Good Samaritan Nursing Home Chris Cardinal; Karen Keefer

(631) 244-2400 [email protected]; [email protected]

Gurwin Jewish Nursing & Rehabilitation Center Lynette Rutherford


Hamptons Center for Rehabilitation and Nursing Linda Mannoia


Hilaire Rehab and Nursing Yasin Rasheed


Huntington Hills Center for Health and Rehabilitation Susan D'Anna, Rn



Guendalina Norris Lopez


Long Island State Veterans Home Rona Schlau


Maria Regina Residence Dorothy Cappadora



Linda Kaufman; Noel Sweetser

(631) 862-8990 [email protected]; [email protected]

Momentum at South Bay: Rehabilitation and Nursing Jeff Marcus


Nesconset Center for Nursing and Rehabilitation Emalyn Laurino




















mailto:[email protected];

mailto:[email protected];






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Our Lady of Consolation Nursing & Rehabilitative Care Center Eleanor Marien


Peconic Bay Maureen Earl (631) 548-6071 [email protected]

Peconic Landing at Southhold Jennifer Ackroyd


Ross Center for Health and Rehabilitation Maggie Austrie


San Simeon by the Sound Center for Nursing and Rehabilitation Surinder Arora


Sayville Nursing and Rehabilitation Center Joyzelle Abonado

(631) 567-9300 <[email protected]

Smithtown Center for Rehabilitation and Nursing Donna Fleming


St. Catherine of Siena Nursing and Rehabilitation Care Center Michelle Mercier


St. James Rehabilitation and Health Care Center Tammy DiMartino


St. Johnland Nursing Center Ruby Parente


Suffolk Center for Rehabilitation and Nursing Debra Covello


Sunrise Manor Center for Nursing Maxine Lewis


Surge Rehabilitation and Nursing (Oak Hollow) Stephanie Dorsainvil


Water's Edge at Port Jefferson for Rehabilitation and Nursing Amy Podota


Westhampton Care Center Linda Mannoia


White Oaks Nursing Home Tracy Diamondopol (516) 367-3400

[email protected]

Woodhaven Deborah Hughes





















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SNF Administrator Directory Facility Name Administrator Phone Email

Acadia Center for Nursing and Rehabilitation

Mary Ann Mangels (631) 727-4400

[email protected]

Affinity Skilled Living Stephanie Malone (631) 218-5900 [email protected]

Apex Rehabilitation and Healthcare

David Efroymson (631) 423-3200 [email protected]


Bernadette Walker (631) 286-8100 [email protected]


Michael Scarpelli (631) 264-0222 [email protected]


Debi Gaines (631) 447-8800

[email protected]

Brookside Multicare Nursing Center (Avalon Gardens)

Steven Wieder (631) 724-2200 [email protected]

Carillon Nursing and Rehab Center LLC

Gerry Albers; Joe Carillo


Central Island Arthur Boden (516) 433-0600 [email protected]

Daleview Care Center Mary Kochaniwsky (516) 694-9800 [email protected]

East Neck Nursing and Rehab Center

Keith Powers (631) 422-4800 [email protected]

Good Samaritan Nursing Home

Frank Misiano (631) 244-2400 [email protected]


Stuart Almer (631) 715-2602 [email protected]

Hamptons Center for Rehabilitation and Nursing Vince Liaguno

(631) 702-1000

[email protected]

Hilaire Rehab and Nursing

Sherrita Alexander (631) 427-0254 [email protected]


Ken Knutsen (631) 439-3000 [email protected]


Dave Fridkin (631) 439-3000 [email protected]


Fred Sganga (631) 444-8606 [email protected]

Maria Regina Residence Ellen Bartoldus (631) 273-4500 [email protected]























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Andrew Yandoli (631) 862-8990 [email protected]


Frank Dano (631) 581-6400 [email protected]


Robert Baranello (631) 361-8800

[email protected]


James Ryan (631) 587-1600 [email protected]

Peconic Bay Ron McManus (631) 548-6071 [email protected]

Peconic Landing at Southhold

Greg Garrett (631) 477-4217 [email protected]

Ross Center for Health and Rehabilitation

Avri Szafranski (631) 273-4700 [email protected]


Steven Smyth (631) 477-2110 [email protected]

Sayville Nursing and Rehabilitation Center

Kwang Lee (631) 567-9300 [email protected]


Marsha Noren (631) 361-2020 [email protected]


John Chowske (631) 862-3905 [email protected]


William St. George (631) 862-8000 [email protected]

St. Johnland Nursing Center

Mary Jean Weber (631) 269-5800 [email protected]


Paul Konstam (631) 289-7700 [email protected]

Sunrise Manor Center for Nursing

Mordy Berman (631) 665-4960 [email protected]

Surge Rehabilitation and Nursing (Oak Hollow)

Michael Scarione (631) 924-8820 [email protected]


Adam Cooperman (631) 473-5400

[email protected]

Westhampton Care Center

Kelly Brady (631) 288-0101 [email protected]






















21

White Oaks Nursing Home

Jennifer Carpentieri (516) 367-3400

[email protected]

Woodhaven Ken Gaul (631) 473-7100 [email protected]

Performance Logic User Directory Facility Name Performance

Logic User Email

Acadia Center for Nursing and Rehabilitation Mary Greco [email protected]

Affinity Skilled Living Regina Prima

[email protected]

Apex Rehabilitation and Healthcare Diane Montagnese [email protected]


Jason Soldt [email protected]


Maureen Christophersen [email protected]


Kellie Burridge [email protected]

Brookside Multicare Nursing Center (Avalon Gardens) Mel Javier

[email protected]

Carillon Nursing and Rehab Center LLC Margaret Jablonski [email protected]


[email protected]

Daleview Care Center Mary Kochaniwsky

[email protected]

East Neck Nursing and Rehab Center Helen Kieran [email protected]

Good Samaritan Nursing Home Gloria Mooney [email protected]


Julie Yerkes [email protected]

Hamptons Center for Rehabilitation and Nursing

Patti Donofrie [email protected]

Hilaire Rehab and Nursing Stana Mosie [email protected]


Teri O'Driscoll [email protected]

Island Nursing and Rehab Center Hyacinth Hendrickson [email protected]

Long Island State Veterans Home Rona Schlau [email protected]

Maria Regina Residence Dorothy Cappadora [email protected]


[email protected]


Jeff Marcus [email protected]


Emalyn Grace C. Laurino [email protected]















22


Gloria Mooney [email protected]

Peconic Bay Maureen Earl [email protected]

Peconic Landing at Southhold Jen Ackroyd [email protected]

Ross Center for Health and Rehabilitation Maggie Austrie [email protected]


Debra Kennedy [email protected]

Sayville Nursing and Rehabilitation Center Kathleen DiBenedetto [email protected]


Elizabeth Zimmerman [email protected]


Gloria Mooney [email protected]


Kelly Ann Lunghi [email protected]


[email protected]


Lauren Shauder [email protected]

Sunrise Manor Center for Nursing Maxine Lewis [email protected]

Surge Rehabilitation and Nursing (Oak Hollow) Denise Cagno

[email protected]


Ronalad D'Anna [email protected]

Westhampton Care Center Deborah Schafmayer [email protected]

White Oaks Nursing Home Tracy Diamondopol [email protected]

Woodhaven Santa Espinal [email protected]










23

Beginning INTERACT Program Implementation Identify an INTERACT Program Facility Champion

Facility Champion Role Description The Facility Champion will oversee the implementation of the INTERACT Quality Improvement Program & 4.0 Toolkit at their Skilled Nursing Facility (SNF). They will provide leadership and assume continuing responsibility for the development, implementation, training, compliance, coordination, maintenance, and evaluation of the INTERACT QIP. This individual will also be enthusiastic about the program and its potential, respect and motivate the staff, and have the experience and skills to coordinate the program. This person is at the hub of the action, staying connected on a daily basis to every aspect of the implementation process by linking all teams in the facility. They will assist in creating and sustaining the implementation team, working with members of the team to identify and prepare for carrying out pre and post implementation plans, and assisting the team to work effectively with each unit within the facility. He or she will also work with department and management representatives to develop support and accountability systems for implementation purposes. Essential Responsibilities

Acts as a resource and coach for SNF staff of the day-to-day operations of INTERACT initiatives at their respective facility

Participates in and conducts process improvement analysis where applicable and in accordance with DSRIP requirements.

Promotes an interdisciplinary approach in patient care delivery. Trains staff on INTERACT 4.0 Toolkit using SCC Training Materials and recommendations Empower staff to engage in and move the INTERACT QIP forward Responsible for reporting data to the SCC Clinical Project Manager following the Reporting

Procedure Organize and host DSRIP INTERACT Project Kick Off Meeting at your facility Participate in Project Committee, Project Workgroup, Implementation Team, facility Quality

Committee, SNF Quality Improvement and Assurance Team, SCC INTERACT Quality Improvement & Assurance Committee and Learning Collaborative reporting best practices, lessons learned, challenges, etc.

Ensure SNF staff are trained appropriately and continually utilizing the INTERACT tools in clinical practice

Will be users in Performance Logic tool to maintain the SNF’s implementation plan for INTERACT (or designee option acceptable)




24

Submit Facility Champion Form

Instructions

The Facility Champion must complete this form or provide a copy of their resume or CV which outlines their experience with INTERACT principles. Include any INTERACT experience you have as well as the Certified INTERACT Training Program dates you attended. Please log on to your Performance Logic Account and upload the document. This is a DOH requirement and will be submitted to the DOH upon completion.

Facility Champion Information

Name

Title

Years of Experience in Current Position

Certified INTERACT Training Program Dates

Attended

Facility Name

Professional License (if applicable)

Email Address

Office Telephone Number

Fax Number




25

Past Professional Experience

Please complete the following table if the Facility Champion wishes to designate an alternative

contact to be the Performance Logic End-user.

Name

Title

Department Name

Hospital Name

Professional License (if applicable)

Email Address

Office Telephone Number

Please return the completed form electronically to Ralph Thomas, Project Manager via email at

[email protected]





26

Identify an INTERACT Implementation Team

Implementation Team Composition & Role Description

Recommended Team Members

This team should be an interdisciplinary team identified by Senior Leadership at your facility. It should

include membership from the Clinical Department Heads, employees with direct patient contact, the

Administrator, Medical Director, Assistant Director of Nursing, and Director of Nursing (Facility

Champion). An interdisciplinary team also encourages commitment to the INTERACT QIP from all

corners of the organization.

The clinical members of this team will also serve as the SNF Quality Improvement and Assurance Team

once the project is implemented at your facility. More instructions on this team and the SCC INTERACT

Quality Improvement & Assurance Committee are on subsequent pages of this manual.

Role summary

This team will oversee and champion the implementation of the INTERACT QIP at your facility. The team

will play an integral role in fostering an environment for positive change within each facility and

disseminating information about activities, plans and progress across the facility. It is recommended

that the team develop their own mission which will be important for driving the team’s charge.

Essential Responsibilities

Evaluate successes and lessons learned within clear parameters set forth by the team Solicit input outside of the team when appropriate Effectively communicate information to facility employees, residents, and other stakeholders Set a strategic plan and direction for the implementation INTERACT QIP Act as a strong resource for staff at all levels of the organization Assure clear communication of implementation vision, tasks, and progress to all staff in the

Facility Perform assessments and gather necessary data as outlined by the Suffolk Care Collaborative

and DSRIP Domain 1 Project Requirements Adhere to DSRIP requirements superficially the Domain 1 Project Requirements throughout

implementation and throughout the life of the project Participate in the Quality Committee within their organization and act as the SNF Quality

Improvement & Assurance Team using INTERACT QI Tools to produce Quality Improvement Plans, Root Cause Analysis examples and Implementation Reports & Results

On a quarterly basis, participate in the SCC INTERACT Quality Improvement & Assurance Committee




Submitting an Implementation Team Composition Roster Template

Form Instructions:

Please complete this form with the names, titles, and contact information of your Implementation Team and keep a copy for your reference.

Facility Name: _____________________________________________________

First Name Last Name Title Phone Email




INTERACT Implementation Kick-Off Recommendations Each SNF should meet with Senior Leadership/Executive Team to kick off implementation of INTERACT

at your facility. This meeting should include members from the Implementation Team/Quality

Improvement & Assurance Team. The goal of this meeting is to give them a high level overview of the

INTERACT QIP, INTERACT principles, training program goals/deadlines and DSRIP Project Requirements.

We encourage the Facility Champion (Director of Nursing) to host and facilitate this meeting. The

Implementation Specialist will also make an effort to attend Kick-Off meetings, although his or her

schedule may not allow for attendance at every meeting. He or she will be working directly with the

facilities to coordinate these activities when available.

After the meeting with Senior Leadership/Executive Team, the Implementation Team should carry out

the plan to officially kick off INTERACT at your facility. Use this as an opportunity to peek interest,

generate buy-in and foster team work. For example, host an ongoing INTERACT Kick-Off Event where all

shifts can attend (6 AM-8 AM, 2 PM-4 PM) and provide light refreshments and some INTERACT posters

to educate staff.




22

INTERACT Training Minimum Guidelines & Curriculum Certified INTERACT™ Champion 4.0 Training Program In early November 2015 the SCC Project Management Office hosted the first Certified INTERACT™ Champion (CIC) Training Program at Stony Brook Medicine. There were 40 Skilled Nursing Facilities (SNFs) that participated. Participation provided trainees with new competencies in the INTERACT™ principals as well as prepared the participants for the INTERACT™ certification exam; established by INTERACT T.E.A.M. Strategies, LLC. Eighty staff members across forty SNFs passed the exam and are now certified. All trainees will lead the INTERACT™ implementation at their SNFs as "Facility Champions." The INTERACT TEAM Strategies LLC, and Pathway Health has designed the CIC to train clinical leaders who will serve as champions to implement and sustain the INTERACT™ 4.0 Quality Improvement Program (QIP) and gain the following insight: Strategies to improve the delivery of care changes in condition and prevent avoidable hospital transfers; In-depth description of the INTERACT™ 4.0 strategies Care processes, tools and other resources; Lessons learned for successful INTERACT™ 4.0 Program implementation and sustainability; and Steps to successfully prepare for the CIC Certification exam. Click here to learn more about the Certified INTERACT™ Champion program. CIC Certified SNF Partners:

1. Affinity Skilled Living 2. Apex Rehabilitation and Care 3. Bellhaven Center for Nursing and

Rehabilitation 4. Berkshire Nursing Center 5. Vincent Bove Health Center at Jefferson's

Ferry 6. Broadlawn Manor Nursing and

Rehabilitation Center 7. Brookhaven Rehabilitation & Health Care

Center 8. Carillon Nursing and Rehabilitation Center

LLC 9. Daleview Care Center 10. East Neck Nursing and Rehabilitation

Center 11. Good Samaritan Nursing Home 12. Gurwin Jewish Nursing & Rehabilitation

Center 13. Hilaire Rehabilitation and Nursing 14. Huntington Hills Center for Health and

Rehabilitation 15. Island Nursing and Rehabilitation Center 16. Lakeview Rehabilitation and Care Center 17. Long Island State Veterans Home 18. Maria Regina Residence 19. Mills Pond Nursing and Rehabilitation

Center 20. Momentum at South Bay for

Rehabilitation and Nursing

21. Nesconset Center for Nursing and Rehabilitation 22. Oak Hollow Nursing Center 23. Our Lady of Consolation Nursing & Rehabilitative

Care Center 24. Peconic Bay Skilled Nursing and Rehabilitation

Center 25. Peconic Landing at Southhold 26. Riverhead Care Center 27. Ross Center for Health and Rehabilitation 28. San Simeon by the Sound Center for Nursing and

Rehabilitation 29. Sayville Nursing and Rehabilitation Center 30. Smithtown Center for Rehabilitation and Nursing 31. St. Catherine of Siena Nursing and Rehabilitation

Care Center 32. St. Johnland Nursing Center 33. St.James Rehabilitation and Health Care Center 34. Suffolk Center for Rehabilitation and Nursing 35. Sunrise Manor Center for Nursing 36. The Hamptons Center for Rehabilitation and

Nursing 37. Water's Edge at Port Jefferson for Rehabilitation

and Nursing 38. Westhampton Care Center 39. White Oaks Nursing Home 40. Woodhaven Center of Care


http://www.interactteam.org/training/



23

INTERACT Program Staff Training & Learning Modules This module provides an overview of the SCC INTERACT Program. It focuses on an introduction to

INTERACT and describes implementation program and requirements. Participants will gain a better

understanding on the basics of the INTERACT Quality Improvement Program, INTERACT tools, and the

Facility Champion roles and responsibilities that will facilitate and act as the INTERACT coach for each

facility.

SCC Learning Center To access the INTERACT Program Learning Module on the SCC Learning Center, please click here. When

accessing the online Learning Module it is password protected, please use the password “sccinteract”

when logging in to view the videos.

Required Training Modules (4)

Module 1: INTERACT Principles & Coaching Program Learning Objectives:

Understand current landscape of health care reform and funding that make the INTERACT QIP an essential initiative.

Understand the INTERACT Coaching Program/Facility Champion within your facility.

Understand key strategies that form foundation of the INTERACT QIP tools & resources.

Understand how to properly utilize: Stop & Watch Early Warning Tool & SBAR Communication Tool

Understand your Facility Champion will continue training on: Care Pathways & Clinical Tools & Advanced Care Planning Tools

Module 2: Care Pathways & Clinical Tools Learning Objectives:

Educate and train all clinical/licensed LPNs, RNs, MDs, NPs, and PAs

Understand the INTERACT Stop & Watch-Early Warning Tool

Understand the INTERACT SBAR Communication Form

Understand the INTERACT Change in Condition Communication tool

Understand the INTERACT Care Pathways

Understand the INTERACT Hospital Communication Tools

Module 3: Advance Care Planning Learning Objectives:

Educate and train all facility staff members on Advanced care planning overview

Educate staff on Advance Care Planning Communication Guide & Advance Care Planning

Tracking Form

Educate and understand the MOLST tool to standardize Advance Care Planning.

Educate staff on IPRO resources of MOLST and eMOLST.


https://suffolkcare.org/forpartners/learning-center#ChildVerticalTab_15



24

Module 4: INTERACT Quality Improvement & Assurance Program Educate and train Implementation Team that will also act as your Quality Improvement & Assurance Team on the Quality Improvement Tools within the INTERACT Program such as: Acute Care Unplanned Transfer Report, Quality Improvement Tool: For Review of Acute Care Transfers and Quality Improvement: Summary Worksheets. Learning Objectives:

Understand current landscape of health care reform and funding that make the INTERACT QIP an essential initiative.

Understand the INTERACT QIP Quality Improvement tools related Re-hospitalizations and RCA’s. Understand key strategies that form foundation of the INTERACT QIP tools & resources to allow

cultural transformation Understand INTERACT QIP Advanced Care Planning tools

INTERACT Training Methodology Each SNF will establish its own process for training key stakeholders, managers and staff in the DSRIP

INTERACT Program. The SCC will support SNFs’ efforts by providing general and role-specific minimum

guidance and training materials that hospitals may use or customize to meet their needs.

Training Module Name

Roles Recommended Frequency of

Training Facilitator

Mode of Training

Training Curriculum

Module 1:

INTERACT principles & Coaching

Program

Staff with patient contact including

social work, CNAs, PT, OT, ST, recreation,

environmental, dietary and nursing

Once

Facility

Champion or SCC INTERACT Coach

Each Facility Champion may

use the SCC Online Learning

Center or facilitate their

own on-site trainings using

the Training Curricula available.

INTERACT Overview and Tool Highlights

Curricula

Adobe Acrobat

Document

Learning Center

Module 2: Care

Pathways & Clinical Tools

Clinical/licensed staff including LPNs, RNs, NPs, MDs, and PAs

Once

Facility


Module 3: Advance

Care Planning

LPNs, RNs, NPs, MDs, PAs, and social work

Once

Facility


Module 4:

INTERACT Quality Improvement &

Assurance Program

Member of your Implementation Team and QUAPI

Once

Facility


INTERACT Quality Improvement &

Assurance Program Curricula

Adobe Acrobat

Document

Learning Center


https://stonybrookuniversity.co1.qualtrics.com/jfe/form/SV_559Wc0oRUCnBXDv

https://stonybrookuniversity.co1.qualtrics.com/jfe/form/SV_3rSCunt66KjMMm1



25

Submitting an INTERACT Program Training Inventory Form

Instructions: Attestation of Training Requirements Fulfilled

Please complete this form when your staff has been trained on the “INTERACT Training Minimum Guidelines” as outlined on the previous pages of this manual. It is recommended that you keep a copy of this completed form in this manual for your reference as it will be submitted to the Department of Health as documentation your staff has been trained.

On this date, [Month]___ __[Day]__, 20_[Year]_, the staff at____________[SNF Facility Name]___________, were trained on the INTERACT Training Minimum Guidelines as outlined in this manual and the DSRIP Domain 1 Project Requirements by one of the Certified INTERACT Champions or a SNF designee trainer.

Please check completed training modules:

Module 1: INTERACT principles & Coaching Program

Module 2: Care Pathways & Clinical Tools

Module 3: Advance Care Planning

Module 4: INTERACT Quality Improvement & Assurance Program

Signature: ____________________________________ Date: _____________ Title: _________________________________________________

Please return this form when ALL 4 MODULES ARE COMPLETE with all sign in sheets from each training session, including date and number of staff trained via Performance Logic.




INTERACT Training Sign-In Sheet Template

Delivery System Reform Incentive Payment Program (DSRIP) SNF Training Template Instructions to return: Please print when completing this template, once complete please return to Ralph Thomas, Project Manager via email at [email protected]

[Organization Name] [Location]

[Training Name] [Training Facilitator Name & Title]

[Topic of Training] [Format of Training]

[Date] [Time}

First Name Last Name Medical License # Title Phone Email Address Initial





INTERACT Coaching Program An INTERACT Coaching Program has been established for all participating Skilled Nursing Facilities.

Introduction to the SCC Coaching Administration Jennifer Kennedy, Director for Care Transitions Innovation has joined the Suffolk Care Collaborative. Jennifer joins us from National Healthcare Associates, where she led clinical care redesign strategy to move her organization towards value-based payment reform, participation in bundle payment initiatives and created ACO partnerships. In addition, Jennifer led and motivated a clinical integration team to facilitate an integrated approach to care delivery with acute care providers. In her role as Director of Care Transition Innovation, Jennifer will be supporting our care transitions initiatives and innovations under the DSRIP project management office projects' TOC and INTERACT. Jennifer will be working directly with our PMs, workgroups, Hospital and post-acute care partners to implement care transitions interventions to reduce the prevalence of potentially avoidable hospital readmissions.

Program Goals:

To facilitation and support INTERACT program implementation.

Provide coaching and assistance to address the unique challenges of the skilled nursing facility (SNF) in payment and care delivery transformation, leading to the reduction of avoidable rehospitalizations.

Assure SNF Administrative and Medical Leadership has the necessary insights, clarities, tools, purposes and steps to implement and sustain the INTERACT Quality Improvement Program.

Continually troubleshoot the implementation and performance improvement processes of INTERACT and support leadership in developing next steps.

Train-the-trainers to become internal mentors to expand competencies facility-wide, leading to greater engagement, professional responsibility and accountability, resulting in improved team performance.

Provide collaborative opportunities with cross-continuum stakeholders to drive organizational change and performance improvement.

Provide access to subject matter experts to facilitate learning on important topics that influence in-place medical management at SNF level.

Coaching Program Process: Coach will work collaboratively with Project Manager and Project Leads to optimized

efficiency and delegation to meet project requirements.

Coach accurately observes and assesses SNFs level of capability to implement INTERACT, and form cohorts based on level of support and coaching needed, taking into consideration:

o Role(s)/Responsibilities of Facility Champion and Co-Champion o Prior INTERACT implementation experience o Facility’s Medical Model




27

o Facility size and safety net status o Facility’s staffing model o Vacancies of key personnel/positions o Facility’s preferred learning methods and schedules

Cohorts will be determined as: o Operational Implementation Status o Intermediate Implementation Status o Novice Implementation Status

Coach will schedule follow-up site visits with facilities as needed, prioritizing Novice Facilities.

Geographical Cohorts will be utilized for smaller workgroup sessions.

Educational Topics will be identified at monthly work group meetings or site visits

Coach will: o Deliver standardized SNF training by:

Assuring each SNF has adequately trained Facility Champion if turnover occurs. This training will be accomplished by workshops that provide overview of INTERACT QIP and detailed education on tools and implementation recommendations.

Provide round-the-clock education via live and recorded Webex series. Troubleshoot, with Facility Champion, barriers to successful implementation,

and assist in solution development. Providing educational overview on Performance Improvement via Webex. Organize and lead workshops to walk through development and execution of

Action Plan based on facility’s RCA’s for readmissions. Providing educational overview on VBP and regulatory issues impacting SNF

clinical care redesign. Assess readiness for collaborative pilots with Emergency Department,

Telemedicine, Hospital Care Management and Discharge Planning, and assist in coordination efforts.

Review identified rehospitalization trends with Medical Director Facilitate quarterly Medical Director conference call with SCC Medical

Director and SNF Medical Directors. Facilitate and attend Hospital and SNF Collaborative meetings.

o Deliver individualized SNF training by: Attending SNF Department Head, Medical Board and QAPI meetings, at SNFs

invitation. Tailoring educational depth and methods based on SNFs capability and

progress point of implementation. Assessing, with Facility Champion, workflow and process barriers related to

use of INTERACT tools. Recommend changes, assist with education to implement and reassess efficacy.

Participate, with Facility Champion, in completion of INTERACT’s Review of Acute Transfer QI tool.




28

Assist in coordinating a collaborative chart review with SNF and hospital on patients rehospitalized within 72-hours of SNF admit.

Accountability:

Coach will: o Schedule on-site visits and education sessions in advance. o Prepare necessary items for site visit and/or education session. o Give adequate notice of need to reschedule. o Educate all staff on care pathways and INTERACT principles, found here. o Support implementation of Advance Care Planning tools to assist residents and

families in expressing and documenting their wishes for near end of life and end of life, found here.

o Training materials that have been developed for this model is located here.

SNF Leadership will: o Prepare necessary items for site visit. o Coordinate appropriate team members be present for site visits and education

sessions, and use sign-in sheet for attendance. o Give adequate notice of need to reschedule.

Resources to be utilized: Resources will be provided ongoing and will include, but are not limited to:

o In-person mentoring and topic-focused education sessions o Work groups and work shops o INTERACT Toolkit o Suffolk Care Collaborative Learning Center o Relevant articles and references to INTERACT, Quality, Performance

Improvement, VBP, Transitions of Care, Acute and Chronic Disease Management o Subject matter expert professionals o Community Events

Coach will leverage cross-continuum partners for expertise and opportunities for shared learning experiences.

o Hospital Emergency Department team members o Hospital Care Management and Discharge Planning team members o Hospital clinical champions o Home health partners

Expected Results:

SNFs will o Meet the implementation requirements outlined in the project. o Have a reduction trend in re-hospitalizations from their baseline.

SNF Leadership will o Demonstrate comprehension and ability to execute Performance Improvement

Action Plan




29

Results Measured By:

Start of program re-hospitalization rate and post-implementation re-hospitalization rate documented and tracked by SNF’s utilizing the INTERACT Hospitalization Rate Tracking Tool.

Quarterly Patient Engagement Data submissions to the SCC.

Initial baseline will be evaluated by the SCC Project Manager to determine gap toward implementation. The Nursing Home Compare public-facing webpage provided by Centers for Medicare and Medicaid Services will be utilized as the primary data source. The variables that will be used to build the baseline report is re-hospitalization rates per year. Results will be archived in the Quality Assurance & Performance Improvement section of the INTERACT Implementation Toolkit.

Communication of Best Practices & Shared Success:

Coach will identify and share best practices and progress made by individual SNFs or cohorts utilizing:

o DSRIP in Action o Synergy Newsletter o Webex o Emails o Conference calls o Project Workgroup and Committee Meetings

Feedback:

Feedback on coaching, facilitation, and training support will be obtained via discussion at site visits and in monthly work groups

Supporting Document: Document Name Description Link

SCC INTERACT Training

Schedule Template – Coaching

Documentation of INTERACT

Coaching by SCC INTERACT Coaching

Schedule.xlsx




30

INTERACT Regional SNF Cohort Workgroups For 2017 SCC has proposed an approach to the workgroup meetings, based on geographical and performance cohorts. Key themes including providing Coaching, Training Opportunities, INTERACT Implementation Assistance and Support as well as monitor and facilitate the INTERACT Quality Assurance & Improvement Activities. Engagement of workgroups will be based on Region and Performance: Regional SNF Cohort Methodology SCC developed the cohorts to provide efficiency within SNF’s by saving time, saving energy and decreasing implementation stress. We were able to identify regional trends to cater to their specific needs to be successful in the project. The feedback from the SNF’s will allow them to enhance ideas & work in collaboration and promotes identification of best practices. The following are our INTERACT Cohort names and Location description:

1. WG – Geographic Region 1 - East End 2. WG – Geographic Region 2 - Brookhaven Area 3. WG – Geographic Region 3 - Smithtown Area 4. WG – Geographic Region 4 - South Shore 5. WG – Geographic Region 5 - Huntington Area

Performance SNF Cohort Methodology While the SCC geographical cohorts are a great platform for feedback from SNF’s/ will be hosted at rotating SNFs in that cohort. SCC developed Performance cohorts within the project. The performance cohorts are formed based on where facility is with implementation process. These cohorts are fluid based on implementation progress and leadership staffing changes. The great feedback from the performance cohorts allowed for a plan intensified focus and preferred solutions from experience.




31

Participating SNF Regional Cohort Map

Supporting Documents

Document Name Description Link

INTERACT Regional Cohort Development Plan & Summary

Presentation describing the design and development of the Regional INTERACT SNF cohorts. Adobe Acrobat

Document




32

INTERACT Patient, Family & Caregiver Education Methodology

SCC provided educational resources to each SNF Facility Champion. Materials included are INTERACT

specific and chronic diseases patient education for the SNF residents, they are located here.

Methodology for Family & Caregiver Education Methodology for Family & Caregiver Education

Family Council Meetings

Frequency Quarterly

Narrative SCC conducted an assessment and with feedback from Facility Champions determined family council and resident council are the most valuable meetings to educate caregivers and family members. The INTERACT Project Workgroup has selected the Family Council Meetings to be the best venue for educating family members and caregivers on the INTERACT program within their facility. The Facility Champion and/or Co-Champion should educate caregivers and family members at these meetings on a quarterly basis, or designate another employee trained in the INTERACT QIP to lead the education at these meetings. In addition, family members and caregivers should be provided with the educational pamphlet developed by the SCC and INTERACT Project Workgroup.

Methodology for Patient Education Methodology for Patient Education

Resident Council Meetings

Frequency Monthly

Narrative

Resident Council Meetings take place once a month within Suffolk PPS SNFs. The Facility Champion and/or Co-Champion should educate patients or designate another INTERACT trained employee to provide education on the basic INTERACT principles and project overview. Residents should also receive the educational pamphlet.

Methodology for Patient Education

Patient and Family/Caregiver Engagement

Narrative

Patient, family and/or caregiver education can also be performed by members of the clinical team at the SNF one on one utilizing or resources below.




33

Patient, Family & Caregiver Education Tools The list below includes the patient engagement resources endorsed by the Suffolk Care Collaborative.

Interventions to Reduce Acute Care Transfer Program Name of Document Organization PDF

INTERACT Patient Education Flyer


INTERACT Patient

Family Education Flyer Final.pdf

INTERACT Patient Education Flyer

Spanish Version


Spanish INTERACT

Patient Family Education Flyer Final.pdf

Advanced Care Planning Name of Document Organization PDF

TCP_StarterKit_Alzheimers.pdf The Compassion Project TCP_StarterKit_Alzh

eimers.pdf

TCP-StarterKit-Guide-Vietnamese-Form.pdf The Compassion Project

TCP-StarterKit-Guid

e-Vietnamese-Form.pdf

TCP-StarterKit-Guide-Spanish.pdf The Compassion Project TCP-StarterKit-Guid

e-Spanish-v1.8.pdf

TCP-StarterKit-Guide -Mandarin.pdf The Compassion Project

TCP-Mandarin-GSKv

5.pdf

TCP-StarterKit-Guide -Korean.pdf The Compassion Project TCP-Korean-GSK_jk1

.pdf

Advance Care Planning Videos Compassion And Support CompassionAndSupport - YouTube

Advance Care Planning Brochure Compassion And Support Advance Care Planning Brochure


https://www.youtube.com/user/CompassionAndSupport?feature=mhee

https://www.youtube.com/user/CompassionAndSupport?feature=mhee

http://www.compassionandsupport.org/pdfs/patients/advanced/FINAL_ACP_Brochure_(EX)_rev_7.09_.pdf




34

Atrial Fibrillation Name of Document Organization PDF

Atrial Fibrillation Information

Sheets.pdf

American Heart Association

information-sheets.

pdf

Alzheimer’s Name of Document Organization PDF

Alzheimer's 10 Warning Signs.pdf

Alzheimer's Association

10warningsigns.pd

f




Cardiovascular Disease Health Wellness & Self-Management Program Name of Document Organization English Link Spanish Link

ABCs of Heart Health: To Reduce the Risk of Heart Attack or Stroke

National Alliance for Hispanic Health

http://millionhearts.hhs.gov/files/4_Steps_Forward_English.PDF

http://millionhearts.hhs.gov/files/4_Steps_Forward.PDF

Guide on How to Control Your Hypertension

The Centers for Disease Control and Prevention & The University of Texas

https://www.cdc.gov/bloodpressure/docs/promotora_guide.pdf

http://www.cdc.gov/bloodpressure/docs/promotora_guide_spanish.pdf

Journal to Help you Manage High Blood Pressure

Million Hearts Campaign by the Centers for Disease Control and Prevention

https://millionhearts.hhs.gov/files/BP_Journal.pdf

My Blood Pressure Wallet Card

National Institutes of Health

https://www.nhlbi.nih.gov/files/docs/public/heart/hbpwallet.pdf

Be Active Your Way-A Guide for Adults

Department of Health and Human Services

https://health.gov/paguidelines/pdf/adultguide.pdf

https://health.gov/paguidelines/pdf/PAG_Spanish_Booklet.pdf

How to Control Your Fat and Cholesterol

The Centers for Disease Control and Prevention & The University of Texas

https://www.cdc.gov/cholesterol/docs/fotonovela_cholesterol.pdf

http://www.cdc.gov/cholesterol/docs/fotonovela_cholesterol_spanish.pdf

High Blood Pressure: Medications and You

U.S. Food and Drug Administration

http://www.fda.gov/downloads/Drugs/ResourcesForYou/SpecialFeatures/UCM358489.pdf

High Blood Pressure: How to Make Control Your Goal


http://millionhearts.hhs.gov/files/TipSheet_How_to_MCYG_General.pdf

http://millionhearts.hhs.gov/files/TipSheet_Empower_Spanish.pdf

Supporting Your Loved One with High Blood Pressure


https://millionhearts.hhs.gov/files/TipSheet_LovedOne_General.pdf http://millionhearts.hhs.gov/files/TipSheet_LovedOne_AA.pdf

http://millionhearts.hhs.gov/files/TipSheet_LovedOne_Spanish.pdf

Tobacco Control Name of Document Organization Link

Welcome to the New York State Smokers’ Quitline

New York State Smoker’s Quitline

http://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2056

Staying Tobacco Free The Tobacco Control Program of Roswell Park Cancer Institute

https://rpcs.roswellpark.org/StayingTobaccoFree

You, Smoking and The Flu New York State Department of Health

https://www.health.ny.gov/publications/2461.pdf

Break Loose: Facts and Tips to help you stop smoking

New York State Smokers’ Quitline

https://www.health.ny.gov/prevention/tobacco_control/docs/break_loose.pdf

10 Things You Didn’t Know About Smoking

New York State Smokers’ Quitline


Nicotine Patch Use Instructions


https://www.nysmokefree.com/Factsheets/NicotinePatchInstructions.pdf

Tobacco: Leading Cause of Preventable Death

New York State Department of Health

https://www.health.ny.gov/prevention/tobacco_control/reports/statshots/volume8/n3_tobacco_leading_cause.pdf
































https://millionhearts.hhs.gov/files/TipSheet_LovedOne_General.pdf

https://millionhearts.hhs.gov/files/TipSheet_LovedOne_General.pdf

http://millionhearts.hhs.gov/files/TipSheet_LovedOne_AA.pdf

http://millionhearts.hhs.gov/files/TipSheet_LovedOne_AA.pdf





https://rpcs.roswellpark.org/StayingTobaccoFree

https://www.health.ny.gov/publications/2461.pdf











36

Medications Covered by Medicaid


https://www.nysmokefree.com/subpage.aspx?pn=medications

Smoking and Asthma New York State Smoker’s Quitline

https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2093

Smoking and COPD New York State Smoker’s Quitline


Smoking and Diabetes New York State Smoker’s Quitline


Smoking and Heart Disease New York State Smoker’s Quitline


Smoking and Lung Cancer New York State Smoker’s Quitline


Smoking and Bones New York State Smoker’s Quitline


Diabetes Wellness & Self-Management Program Name of Document English Link Spanish Link

Diabetes: An Introduction http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Diabetes_AnIntroduction_2Page_FLYER1.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Diabetes_AnIntroduction_SPA_2Page_FLYER.pdf

Type 1 Diabetes http://professional.diabetes.org/sites/professional.diabetes.org/files/media/type_1.pdf

http://professional2.diabetes.org/content/PML/Type_1_Spanish_1013c577-e105-417f-a13b-d488b037d482/Type_1_Spanish.pdf

Type 2 Diabetes http://professional.diabetes.org/sites/professional.diabetes.org/files/media/type_2.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Type_1_Spanish.pdf

Are You at Risk for Type 2 Diabetes?

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/risk-test-paper-version.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/risk-test-paper-spanish.pdf

A1C/eAG http://professional.diabetes.org/sites/professional.diabetes.org/files/media/a1ceag.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/A1CeAG_-_Spanish.pdf

Hypoglycemia http://professional.diabetes.org/sites/professional.diabetes.org/files/media/hypoglycemia.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Hypoglycemia_-_Spanish.pdf

Factors Affecting Blood Glucose

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/15_advisor_factors-blood-glucose_eng_final_lo-res.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Factors_Affecting_Blood_Glucose_-_Spanish.pdf

Managing Your Medications http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Managing_Your_Medicines.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Controlando_sus_medicinas.pdf
















http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Diabetes_AnIntroduction_2Page_FLYER1.pdf







http://professional.diabetes.org/sites/professional.diabetes.org/files/media/type_1.pdf


















http://professional.diabetes.org/sites/professional.diabetes.org/files/media/a1ceag.pdf





http://professional.diabetes.org/sites/professional.diabetes.org/files/media/hypoglycemia.pdf













http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Managing_Your_Medicines.pdf








37

Name of Document English Link Spanish Link

Protect Your Heart: Check Food Labels to Make Heart-Healthy Choices

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Check_Food_Labels_to_Make_Heart_Healthy_Choices.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Lea_las_etiquetas_de_las_comidas.pdf

Protect Your Heart: Making Smart Food Choices

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Make_Smart_Food_Choices.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Seleccione_sus_alimentos_en_forma_inteligente.pdf

All About Cholesterol http://professional.diabetes.org/sites/professional.diabetes.org/files/media/All_about_Cholesterol.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/All_about_Cholesterol_Spanish.pdf

Diabetes and Kidney Disease http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Kidney_Disease_and_Diabetes.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Kidney_Disease_and_Diabetes_-_Spanish.pdf

Eye Exams for People with Diabetes

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Eyes_-_Eye_Tests_for_People_with_Diabetes.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Eyes_-_Eye_Tests_for_People_with_Diabetes_-_Spanish.pdf

Nerve Damage and Diabetes http://professional.diabetes.org/sites/professional.diabetes.org/files/media/15_advisor_nerve-damage_eng_final_med-res.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Neuropathy_and_Diabetes_-_Spanish.pdf

Getting the Most Out of Health Care Visits

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Getting_the_Most_Out_of_Health_Care_Visits.pdf

http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Getting_the_Most_Out_of_Health_Care_Visits_-_Spanish.pdf

Name of Document Organization Name English PDF Spanish PDF

Blood Sugar Goals Learning About Diabetes, Inc.

BloodSugarGoalsE

N_SuffolkCare.pdf

BloodSugarGoalsSP

_SuffolkCare.pdf

Diabetes Care Schedule: Take Good Care of Yourself

Learning About Diabetes, Inc.

CareScheduleEN_Su

ffolkCare.pdf

CareScheduleSP_Su

ffolkCare.pdf

Diabetes Pills: How and Where They Work


DiabetesPillsAction

sEN_SuffolkCare.pdf

DiabetesPillsAction

sSP_SuffolkCare.pdf

Healthy Plate Eating Learning About Diabetes, Inc.

HealthyPlateFishEN

_SuffolkCare.pdf

HealthyPlateFishSP_

SuffolkCare.pdf















http://professional.diabetes.org/sites/professional.diabetes.org/files/media/All_about_Cholesterol.pdf






http://professional.diabetes.org/sites/professional.diabetes.org/files/media/Kidney_Disease_and_Diabetes.pdf















http://professional.diabetes.org/sites/professional.diabetes.org/files/media/15_advisor_nerve-damage_eng_final_med-res.pdf
















38

Name of Document Organization Name English PDF Spanish PDF

Diabetes: Know the Signs Learning About Diabetes, Inc.

KnowTheSignsEN_S

uffolkCare.pdf

KnowTheSignsSP_S

uffolkCare.pdf

Let’s Get Moving: Diabetes and Exercise


LetsGetMovingEN_S

uffolkCare.pdf

LetsGetMovingSP_S

uffolkCare.pdf

Type 1 Diabetes Learning About Diabetes, Inc.

Type1DiabetesEN_S

uffolkCare.pdf

Type1DiabetesSP_S

uffolkCare.pdf

Type 2 Diabetes Learning About Diabetes, Inc.

Type2DiabetesEN_S

uffolkCare.pdf

Type2DiabetesSP_S

uffolkCare.pdf

What’s My A1C? Learning About Diabetes, Inc.

WhatsMyA1CEN_Su

ffolkCare.pdf

WhatsMyA1CSP_Suf

folkCare.pdf

Why Do I Need Insulin? Learning About Diabetes, Inc.

WhyNeedInsulinEN

_SuffolkCare.pdf

WhyNeedInsulinSP_

SuffolkCare.pdf




39

Advanced Care Planning1 Honoring patient preferences is critical to providing quality end-of-life care consistent with the individual’s values and

beliefs, based on sound informed medical decision-making and evidence-based medicine.

The National Quality Forum Framework and Preferred Practices for Quality Hospice and Palliative Care outlines five preferred practices for advance care planning:

1. Document the designated surrogate/decision maker in accordance with state law for every patient in primary, acute, and long-term care and in palliative care and hospice care.

2. Document the patient/surrogate preferences for goals of care, treatment options, and setting of care at first assessment and at frequent intervals as conditions change.

3. Convert the patient treatment goals into medical orders and ensure that the information is transferable and applicable across care settings, including long-term care, emergency medical services, and hospital, such as, the Physician Orders for Life-Sustaining Treatment (POLST) Program.

4. Make advance directives and surrogacy designations available across care settings, while protecting patient privacy and adherence to HIPAA regulations, e.g., by Internet-based registries or electronic personal health records.

5. Develop healthcare and community collaborations to promote advance care planning and completion of advance directives for all individuals, e.g., Respecting Choices, Community Conversations on Compassionate Care.

Healthcare, legal and all community professionals have an opportunity and professional obligation to collaborate and

make these preferred practices a reality in New York State.

1. Advance Care Planning Clinical Pathway: Life Expectancy Greater Than 1 Year2 2. Advance Care Planning Clinical Pathway: Life Expectancy Less Than 1 Year3

Medical Orders for Life-Sustaining Treatment (MOLST)4 The Medical Orders for Life-Sustaining Treatment (MOLST) is designed to improve the quality of care people receive at

the end of life. MOLST is New York State's Physicians Orders for Life-Sustaining Treatment (POLST) Paradigm

Program. These programs are based on effective communication of patient wishes, documentation of medical orders on

a brightly colored form, and a promise by health care professionals to honor these wishes.

8-Step MOLST Protocol

What is the MOLST Program? The MOLST Program

Assists health care professionals in discussing and developing treatment plans that reflect patient wishes. Results in the completion of the MOLST form. Helps physicians, nurses, health care facilities and emergency personnel honor patient wishes regarding life-

sustaining treatments.

1 Compassion & Support, Excellus, Advanced Care Planning http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals 2 Bomba, JNCCN 4(8), 2006 3 Bomba, JNCCN 4(8), 2006 4 Compassion & Support, Excellus, MOLST http://www.compassionandsupport.org/index.php/for_professionals/molst


http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals/life_expectancy_greater_than_1

http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals/life_expectancy_less_than_1_year

https://www.compassionandsupport.org/pdfs/professionals/training/8_Step_MOLST_Protocol_with_MOLST_logo_in_Arial.color_._4_.08_.pdf

http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals

http://www.compassionandsupport.org/index.php/for_professionals/molst



40

MOLST is generally for patients with serious health conditions. Physicians should consider consulting with the patient about completing a MOLST form if the patient:

Wants to avoid or receive life-sustaining treatment. Resides in a long-term care facility or requires long-term care services. Might die within the next year.

What is the MOLST form?5 The MOLST form is a bright pink medical order form that tells others the patient’s wishes for life sustain in treatment. A health care professional must complete or change the MOLST form, based on the patient’s current medical condition, values, wishes and MOLST Instructions.

Printing the MOLST form on bright "pulsar" pink, heavy stock paper is strongly encouraged.

Astrobrights Pulsar Pink 24lb paper is available through Office Depot, Staples, Office Max, and other paper suppliers.

When EMS personnel respond to an emergency call in the community, they are trained to check whether the patient has a pink MOLST form before initiating life-sustaining treatment. They might not notice a MOLST form on plain white paper.

However, white MOLST forms and photocopies, faxes, or electronic representations of the original, signed MOLST are legal and valid.

New York State Department of Health MOLST Form (English)

New York State Department of Health MOLST Form (Spanish)

INTERACT Program Partnerships for MOLST & eMOLST IPRO, the Medicare Quality Improvement Organization for NYS has launched a CMS Special Innovation Project focusing

on adoption of a community based approach to Advance Care Planning in the Nassau and Suffolk county region. As you

know, the implementation of MOLST and eMOLST is not a DSRIP requirement, but the INTERACT Project Committee

recommends that SNFs participating in the DSRIP INTERACT Program implement MOLST or eMOLST as part of the

Advance Care Planning requirements of the project. IPRO can provide assistance and support in the implementation of

MOLST or eMOLST at your facility.

Project Goals:

1. Improve compliance with patient preferences for care and treatment options through well-informed end-of-life discussions regarding decisions to provide, withhold and/or withdraw life-sustaining treatment; and, as a result, reduce unwanted hospitalizations and improve patient/family and clinician satisfaction; and

2. Develop and implement a sustainable, scalable model for MOLST clinician training that meets the basic needs of current and future practicing clinicians and will provide a platform for additional courses to address the needs of vulnerable populations throughout NY at the end of the grant period.

5Compassion & Support, Excellus, Medical Orders for Life-Sustaining Treatment- Professionals http://www.compassionandsupport.org/index.php/for_professionals/molst


http://www.compassionandsupport.org/pdfs/professionals/molst/DOH-5003_06.10_.FINAL__.pdf

http://www.compassionandsupport.org/pdfs/homepage/010793_DOH-5003_SP_4_page_with_watermark.pdf

http://www.compassionandsupport.org/index.php/for_professionals/molst

http://goo.gl/tbGy5



41

The IPRO Program is dedicated to MOLST and eMOLST targeting education of New York’s Medicare beneficiaries and their families/caregivers on the importance of advance care planning, the terminology used by medical professionals, and how to communicate with healthcare professionals about their EOL wishes as well as to prepare documentation to ensure they are properly carried out. This intervention will apply the ACP programs Community Conversations on Compassionate Care and What Matters Most? to educate beneficiaries about planning for their

medical care and prepare them for the possibility of being unable to make their own care decisions prior to their entering the advance stages of chronic illness. In collaboration with Dr. Patricia Bomba, the SCC has promoted the IPRO’s technical support to hospitals, skilled nursing facilities (SNFs), home health agencies (HHAs), hospices, emergency medical services (EMS), and physician practices for adoption,

training and implementation of eMOLST. This effort will be focused on the Nassau & Suffolk County regions. Presentations have been conducted by Patricia Bomba, M.D., F.A.C.P. Vice President and Medical Director, Geriatrics. Dr. Bomba is an expert in Community-Wide End-of-Life/Palliative Care Initiative. During the workshop the overview included improving the quality of care people receive at the end of life. The MOLST program is based on the belief that individuals have the right to make their own medical decisions, including decisions about life-sustaining treatment, to describe these wishes to health care providers, and to receive comfort care while wishes are being honored. MOLST is based on effective communication of patient wishes, documentation of medical orders on a bright pink form and a promise by health care professionals to honor these wishes. For more information or assistance and support in the implementation of MOLST or eMOLST, please contact Carolyn Kazdan, Quality Improvement Specialist, who is overseeing the project for IPRO, at [email protected] or by phone at (518) 426-3300 ext. 190.

Program Contacts

Carolyn Kazdan Quality Improvement Specialist IPRO Medicare Quality Improvement Organization for NYS 20 Corporate Woods Boulevard Albany, New York 12211-2370 Phone: (518) 426-3300 Ext 190 Direct Dial: (518) 320-3590 Fax: (518) 426-3418 [email protected]

www.atlanticquality.org

Patricia A. Bomba, MD, FACP

Vice President & Medical Director, Geriatrics Excellus BlueCross BlueShield & MedAmerica Insurance Company Chair, MOLST Statewide Implementation Team & eMOLST Program Director Chair, National Healthcare Decisions Day NYS Coalition 165 Court Street, Rochester, NY 14647 Office: 585-238-4514 Fax: 585-453-6365 CompassionAndSupportYouTubeChannel www.CompassionAndSupport.org

www.atlanticquality.org

Quick Links & Resources 1. MOLST website www.compassionandsupport.org 2. For Professionals: http://www.compassionandsupport.org/index.php/for_professionals 3. Training Center: http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center 4. Advanced Care Planning: http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals 5. Care Transition Intervention: http://www.compassionandsupport.org/index.php/for_professionals/the_care_transitions_intervention

Photo caption

(left to right) Diane Zambori, MBA, BSN, RN-BC, NE-BC, LNHA, FACHE, Associate Executive Director, Eastern Region, Quality Management Initiatives, Northwell Health; Ralph Thomas, MHA, Project Manager, Care Transitions, Suffolk Care Collaborative; Patricia Bomba, M.D., M.A.C.P, Vice President & Medical Director, Geriatrics, Excellus BlueCross BlueShield & MedAmerica Insurance Company, Chair, MOLST Statewide Implementation Team & eMOLST Program Director, & Chair, National Healthcare Decisions Day NYS Coalition; Jennifer Kennedy, RN, BSN, MS, Director,


http://www.compassionandsupport.org/index.php/resource_directory/compassion_and_support_video_library

http://www.compassionandsupport.org/index.php/resource_directory/compassion_and_support_video_library



http://www.atlanticquality.org/

http://www.compassionandsupport.org/

http://www.atlanticquality.org/

http://www.compassionandsupport.org/

http://www.compassionandsupport.org/index.php/for_professionals

http://www.compassionandsupport.org/index.php/for_professionals/molst_training_center

http://www.compassionandsupport.org/index.php/for_professionals/advanced_care_planning_-_professionals

http://www.compassionandsupport.org/index.php/for_professionals/the_care_transitions_intervention

http://cl.s4.exct.net/?qs=533a6d5a37f00dbe485b09610b25509350fe08dafe00928aa6c5b1878b7294f2da0fcebad65278de



42

Advanced Care Planning Tools can be found here. Register for the New York MOLST updates by emailing your interest to Carolyn Kazdan at [email protected]. Order Compassion and Support Online Resources in print copy for free by clicking here.

Archived Advanced Care Planning Learning Collaboratives Presentation Name Date Presenter Name Presentation Description

CMS Special Innovation Project focusing on adoption of a community based approach to Advance Care Planning within the Nassau and Suffolk county region!

January 19, 2016

Patricia Bomba, MD, F.A.C.P

The conference will address the following topics which can be effective strategies to support your DSRIP projects aimed at reducing avoidable hospital and emergency department use:

Key Strategies for Community-based Advanced Care Planning

Interactive Online demonstration of eMOLST

Community Outreach Programs Fostering Informed Decision-Making for End of Life Planning

Action Plan Steps and Resources to Ensure Success and Sustainability

IPRO Transforming End-Of-Life Care Initiative Suffolk County Care Collaborative SNF Partner Training Implementing MOLST and eMOLST across the healthcare continuum

April 14, 2016


The conference will feature keynote speaker Patricia Bomba, MD, F.A.C.P who will be presenting on implementing medical orders for life-sustaining treatment (MOLST) and eMOLST across the healthcare continuum. There will also be time for Dr. Bomba to help problem solve any obstacles you may be encountering in the implementation of MOLST or eMOLST in your facilities.

SCC Advanced Care Planning Learning Collaborative & Interactive Workshop

October 11, 2016


Having the Conversation by Palliative Care expert Patricia A. Bomba, M.D., F.A.C.P. covered Advance Care Planning. Goals of the interactive workshop included increasing the knowledge of partners on how to engage patients and families in meaningful discussions about goals for care, and how to communicate patient goals with interdisciplinary teams.


http://www.compassionandsupport.org/pdfs/professionals/molst/Current_Educational__Order_Form.pdf



43

Quality Improvement & Assurance Program

Project Requirement: Measure outcomes (including quality assessment/root -cause analysis of transfer) in order to identify additional interventions. There are 4 metrics defined below: 1. Membership of quality committee is representative of PPS staff involved in quality improvement processes and

other stakeholders. 2. Quality committee identifies opportunities for quality improvement and use of rapid cycle improvement

methodologies, develops implementation plans, and evaluates results of quality improvement initiatives. 3. PPS evaluates and creates action plans based on key quality metrics, to include applicable metrics in Attachment J. 4. Service and quality outcome measures are reported to all stakeholders.

SCC INTERACT Quality Improvement & Assurance Plan

Name of Document Version Number Link to Document

SCC INTERACT Quality Improvement & Assurance Plan

v-01

SCC INTERACT

Quality Imp. Assurance Plan v--08.pdf

SCC INTERACT Quality Improvement Framework

v-01

Quality

Improvement Framework v-01.pdf

Quality Improvement & Assurance Plan Resources

Implementation Resources

Acute Care Unplanned Transfer Report Template


SCC INTERACT Quality Acute Care Unplanned Transfer Report

Template

v-01

SCC Project 2.b.vii

Acute Unplanned Transfer Report.xlsx

Action Plan Template


SCC INTERACT Quality Action Plan Template

v-01

SCC Action Plan

Template.docx

Link to Action Plan Template in Qualtrics


SCC INTERACT Quality Action Plan Template in Qualtrics

v-01 https://stonybrookuniversity.co1.qualtrics.com/SE/?SID=SV_cRMn3YAIJlDIjXL


https://stonybrookuniversity.co1.qualtrics.com/SE/?SID=SV_cRMn3YAIJlDIjXL

https://stonybrookuniversity.co1.qualtrics.com/SE/?SID=SV_cRMn3YAIJlDIjXL



44

INTERACT RCA Template PDF


SCC INTERACT Quality RCA Template

v-01

QI_Tool for Review

Acute Care Transf_AL.pdf

INTERACT RCA Summary Worksheet Template PDF


SCC INTERACT Quality Action Plan RCA Summary

Template

v-01

QI_Tool for Review

Acute Care Transf_AL.pdf

Meeting Schedule template – INTERACT QI and Assurance Meetings Create and maintain list/inventory of the meeting minutes of the quality committee.


SCC INTERACT Quality Meeting Schedule Template

v-01

INTERACT Quality

Improvement & Assurance Plan Training Materials (v-01).xlsx

Quality Program Framework Membership Template Inventory of quality committee membership comprising of name, organization represented and staff category as it is defined in the milestone requirement.


SCC INTERACT Quality Program Framework Membership

Template

v-01

Quality Stakeholder

Group Membership (v-01).xlsx

SCC PI Plan SCC PI Plan click here


http://scc.perflogic.com/document?s=PFN0cj4KMDExMC8xNjIwNS82OC9kb2N4CjwvU3RyPgo%3d



45

INTERACT Program Reporting Protocol Project Management Office Suffolk Care Collaborative (SCC)

Protocol Title SCC INTERACT Program Reporting Protocol

DSRIP Project Number: 2.b.vii

Policy/Procedure Number: 2b7.1

Policy/Procedure Owner: DSRIP Project 2bvii, Project Manager

Date Created: 2/1/16

Effective Date: 4/1/16

Last Revised Dates: 9/28/16

Protocol Narrative

OBJECTIVE STATEMENT Skilled Nursing Facility (SNF) partners participating in the SCC DSRIP Project 2.b.vii: Interventions to Reduce Acute Transfer (INTERACT) Program Implementation in their facilities. This procedure outlines the reporting requirements for participating SNF Partners as part of this program.

PURPOSE The SNF will follow the Program Reporting Procedure and return all Program Documents to the SCC Clinical Project Manager upon completion:

SNF must identify a Performance Logic End User who will be trained to maintain an accurate implementation plan for INTERACT in the SCC Project Management Office’s project management software (Performance Logic).

SNF must designate a project Facility Champion as outlined in the SCC INTERACT Program Facility Champion Form.

SNF Facility Champion and Co-Champion must participate in the Certified INTERACT Champion Training Program offered by SCC and successfully pass and complete the CIC Exam.

Facility Champion and Co-Champion will submit Certified INTERACT Champion Training Certificates.

SNF Facility Champion and Co-Champion must coordinate, schedule, and train SNF staff as recommended by SCC.

SNF will create and submit Implementation Team Composition Roster Template.

SNF will submit Baseline Nursing Home to Hospital Transfer Rate Template.

SNF will submit Nursing Home to Hospital Transfer Rate on a quarterly basis using the Acute Care Unplanned Transfer Report

SNF will submit sign in sheets provided by SCC with number of staff trained and dates of training.

SNF shall submit list of staff trained in INTERACT using the SCC INTERACT Training Inventory Form and SCC Training Sign in Sheets.

Facility Champion will submit Meaningful Use Certification from CMS or NYS Medicaid or EHR Proof of Certification.

Facility Champion submits RHIO QE Participation Agreement or sample of transactions to public health registries, or evidence of DIRECT secure email transactions.

Facility Champion submits sample data collection and tracking system and Electronic Health Record Completeness Report.

REFERENCES SCC Coalition Partner Participation Manual

SCC Coalition Partner Participation Agreement

SCC Partner Implementation Manual for INTERACT

DEFINITIONS RESPONSIBLE PARTIES

1. Skilled Nursing Facility: SCC Coalition Partners 2. SCC Project Management Office: Staff Project Managers with full-time responsibility

for managing the DSRIP project portfolio.




46

3. Performance Logic End User: End Users are defined as SCC Coalition Partners who are assigned a project implementation plan to track their organizations participation in a DSRIP project requirement.

4. INTERACT Program Facility Champion: Key internal stakeholder for the SNF-partner to lead implementation of DSRIP Project 2.b.vii, implementation of the INTERACT Program within SNFs. This role will provide leadership support and assume continuing responsibility for the development, implementation, training, compliance, coordination, maintenance, and evaluation of the DSRIP project.

5. INTERACT Program Co-Champion: SNF will designate a co-champion who will assist the Facility Champion in overseeing the development, implementation, training, compliance, coordination, maintenance, and evaluation of the DSRIP project.

6. INTERACT Implementation Team: Interdisciplinary team that oversees and champions the implementation of the INTERACT program within their facility. This team will also act as the SNF Quality Improvement & Assurance Team for their facility.

7. SNF Quality Improvement & Assurance Team: This team will participate in the existing Quality Committee within each SNF that will use the INTERACT QI Tools to produce Quality Improvement Plans, Root Cause Analysis examples, and Implementation Reports & Results to be shared at the SCC INTERACT Quality Improvement and Assurance Committee on a quarterly basis.

8. SCC INTERACT Quality Improvement & Assurance Committee: This committee will meet on a quarterly basis at the PPS level and be facilitated by SCC staff. The Facility Champion and/or a designee are asked to attend quarterly sharing their Quality Improvement Plans, Root Cause Analysis examples, and Implementation Reports and Results created by each SNF Quality Committee.




47

Project Documents to submit to the Suffolk Care Collaborative The purpose of this table is to list the supporting documents that the Suffolk Care Collaborative will request from you to

demonstrate successful completion of the INTERACT Implementation. This table includes how to submit the document.

Please do not submit reports that include Protected Health Information (PHI) into Performance Logic. BOX should be

used for all reports that will include PHI.

Project Document Name Frequency of Submission Submission Mode

1. INTERACT Program SNF-Facility Champion Form

(include CV)

Once Performance Logic

2. Baseline Nursing Home to Hospital Transfer Rate

Template

Once Performance Logic

3. Patient Engagement Report & Acute Care Unplanned

Transfer Report*

Quarterly

(See Quarterly Reporting

Schedule)

BOX

4. Certified INTERACT Champion Certificate Once Performance Logic

5. Implementation Team Composition Roster Template Once Performance Logic

6. INTERACT Training Inventory Form Once Performance Logic

7. SCC Training Sign In Sheets* Once Performance Logic

8. RHIO QE Participation Agreement Once Performance Logic

9. EHR Sample Completeness Report Once Performance Logic




48

Quarterly Reporting Schedule & Data Requests All submissions must be true, accurate and complete in all material respects. In accordance with HIPAA and the minimum

necessary principle, do not provide more PHI than requested for the purpose of the quarterly reporting.

If you have questions about compliance or HIPAA with respect to quarterly reporting, contact: Sarah Putney, SCC

Compliance Officer at (631) 638-1393 and [email protected] or Stephanie Musso, SCC Chief

Information Privacy and Security Officer at (631) 444-5796 or [email protected]. Or visit the

SCC Compliance and HIPAA website at https://suffolkcare.org/Compliance.

Reporting Schedule by DSRIP Year and Quarter Period to be Reported Date Report Due

DY2 Q1 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 4/1/16-6/30/16

7/15/16


10/14/16


01/13/17


04/14/17


07/14/17


10/13/17


01/12/18


04/13/18


07/13/18


10/12/18


01/11/19


04/12/19


07/12/19

DY5 Q2 Patient Engagement Report Submission (upload through BOX ONLY) 7/1/19-9/30/19

10/11/19


01/17/20


04/17/20




https://suffolkcare.org/Compliance



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Domain 1 Patient Engagement Data Request Suffolk Care Collaborative INTERACT Project

Request: Please return the attached SCC excel template via BOX For BOX questions or access related inquiries, please contact Kevin Bozza, [email protected]

Patient Grouper: Medicaid Patient Data (Medicaid may be Primary, Secondary or Tertiary Insurance) Time Periods: Quarterly PART 1: Patient Engagement Report Patient Engagement Definition: As per the definition of actively engaged, patient engagement refers to the number of participating patients who avoided nursing home to hospital transfer, attributable to INTERACT principles as established within the project requirements. Duplicate counts of patients are not allowed. The count is not additive across DSRIP years. Any patient who was transferred to an acute facility (i.e. hospital even if they were not admitted to the hospital) from the nursing home would not count as actively engaged.

Patient Engagement Data Specifications

1. CIN # 2. Patient Last Name 3. Patient First Name 4. DOB 5. Patient Resident Zip Code 6. Location/Site Name 7. Service Site Zip Code 8. Arrival Date 9. Primary Payor Name 10. Primary Payor Patient ID Number 11. Secondary Payor Name 12. Secondary Payor Patient ID Number 13. Tertiary Payor Name 14. Tertiary Payor Patient ID Number


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INERACT PROGRAM IMPLEMENTATION TOOLKIT| SCC PROJECT MANAGEMENT OFFICE


INTERACT Clinical Tools, Care Pathways & Resources SCC created a INTERACT this section as a resource for all SNF partners. Throughout your implementation

and continuation of the project you will be utilizing multiple documents. We arranged the documents by

subject for reference. Click the links to view the document below.

INTERACT Clinical Tools and Care Pathways

1. Stop and Watch Early Warning Tool

2. SBAR Communication Form

3. Acute Change in Condition File Cards

4. Care Pathways

a. Acute Mental Status Change

b. Change in Behavior: New or Worsening Behavioral Symptoms

c. Dehydration

d. Fever

e. GI Symptoms-nausea, vomiting, diarrhea

f. Shortness of Breath

g. Symptoms of CHF

h. Symptoms of Lower Respiratory Illness

i. Symptoms of UTI

j. Fall

5. Hospital Communication Tools

a. Engaging Your Hospitals-Tip Sheets

b. Nursing Home Capabilities List

c. NH-Hospital Transfer Form

d. NH-Hospital Data List

e. Acute Care Tracker Document Checklist

f. Hospital-Post Acute Transfer Form

g. Hospital-Post Acute Data List

Advanced Care Planning Tools

3. Advance Care Planning Tools

a. Advance Care Planning Tracking Tool

b. Advance Care Planning Communication Guide

c. Identifying Residents Who May be Appropriate for Hospice or Palliative/Comfort Care

Orders


http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604-Stop-and-Watch%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V4%20SBAR_Communication_Form%20Dec%2010.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V4%20SBAR_Communication_Form%20Dec%2010.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Change_in_Condition.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Change_in_Condition.pdf

http://interact2.net/tools_v4.html

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_MENTAL_STATUS_CHANGE_v10.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V4%20Care%20Path%20Behavior%20Change%20Dec%2010.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_DEHYDRATION_v8.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_FEVER_v10.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_GI_SYMPTOMS_v6.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_SHORTNESS_OF_BREATH_v9.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_SYMPTOMS_CHF_v8.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care-Path-Lower-Respiratory-Infection-v8.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Care_Path_UTI_v10.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V4%20Fall-Care-Path%20Dec%2010.pdf


http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Engaging_Your_Hospital%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/Nursing_Home_Capabilities_List%20Dec%2016%202014.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20NH_to_Hospital_Transfer_Form%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20NH_to_Hospital_Transfer_Data_List.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Acute_Care_Transfer_Checklist-v4.0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Hospital_to_Post_Acute_Care_Transfer_Form.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20Hospital_to_Post-Acute_Care_Data_List%20Dec%2016%202014.pdf

https://www.compassionandsupport.org/index.php/resource_directory/advance_care_planning

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20V4%20Advance_Care_Planning_Tracking_Form%20Dec%2010.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20ACP%20Communication%20Guide%20Dec%2016%202014.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Identifying_Residents_Appropriate_for_Hospice_Care%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Identifying_Residents_Appropriate_for_Hospice_Care%20v4_0.pdf

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d. Comfort Care Order Set

e. Deciding About Going to the Hospital

f. Education on CPR

g. Education on Tube Feeding

h. Digital Transformation of New York MOLST: An End of Life Care Transition Program

(eMOLST Application Demonstration)

i. Value Based End of Life Care: Having the Conversation Nobody Wants to Have Benefits

Everybody

j. New CPT Codes for Advance Care Planning and MOLST Discussions

k. The order form that providers can use to order multiple copies of printed resources (

Current Educational Order Form.pdf)

l. The DOH MOLST form

m. MOLST Frequently Asked Questions

n. Advance Care Planning Booklet

o. Advance Care Planning Brochure

p. Health Care Proxy Readiness Survey (pdf)

q. Advance Care Planning Booklets

i. Excellus BCBS English and Spanish (pdf)

r. "Five Easy Steps" to complete advance care planning

i. Excellus BCBS: "Five Easy Steps" (pdf)

Quality Assurance & Improvement Activities

1. Quality Improvement Tools

a. Acute Care Tracker Log-Worksheet

b. Hospitalization Rate Tracking Tool 2016-Excel Template

c. Quality Improvement Tool for Review of Acute Care Transfers

d. Quality Improvement Summary-Worksheet

Additional Resources

1. What is INTERACT™?

2. Where can I find the INTERACT™ Version 4.0 Tools for Nursing Homes?

3. Where can I learn more about the INTERACT™ Project Team?

4. Implementation of the INTERACT™ Program in Suffolk County Presentation

5. IPRO MOLST & eMOLST Program Materials


http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Comfort_Care_Interventions%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Deciding_About_Going_to_Hosptial%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20CPR_FlipChart_Vignette%20v4_0.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20Tube_Feeding_FlipChart_Vignette%20v4_0.pdf

http://atlanticquality.org/







http://www.compassionandsupport.org/pdfs/professionals/molst/DOH-5003_06.10_.FINAL__.pdf

http://www.compassionandsupport.org/pdfs/professionals/molst/Pt_Fx_MOLST_FAQs.pdf

http://www.compassionandsupport.org/pdfs/about/B-1576_Excellus_2010_Complete.pdf


http://www.compassionandsupport.org/pdfs/professionals/training/HCP_Readiness_Form_Updated_021810.pbomba_.pdf

http://www.compassionandsupport.org/pdfs/about/B-1576_Excellus_2010_Complete.pdf

http://www.compassionandsupport.org/pdfs/patients/molst/acp_spanish.pdf

http://www.compassionandsupport.org/pdfs/professionals/molst/FiveEasySteps-Excellus.pdf


http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%20Acute_Care_Transfer_Log%20Dec%2016%202014.pdf


http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20QI_Tool%20for%20Review%20Acute%20Care%20Transf_AL.pdf

http://interact2.net/docs/INTERACT%20Version%204.0%20Tools/INTERACT%204.0%20NH%20Tools%206_17_15/148604%20QI_Summany_Worksheet%20v4_0.pdf

https://interact2.net/about.html

https://interact2.net/tools.html

https://interact2.net/staff.html

http://www.suffolkcare.org/pubfiles/Implementation%20INTERACT%20Project%20Meskill_01%2021%2016.pdf

http://atlanticquality.org/initiatives/transforming-eol/

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DSRIP GLOSSARY Acronym Definition

ACC American College of Cardiology

ADA American Diabetes Association

ADT Admission, Discharge, Transfer

AHA American Heart Association

AHRQ Agency for Healthcare Research and Quality

AMA American Medical Association

APC Advanced Primary Care

AV Achievement Value

BAA Business Area Agreement

BH Behavioral Health

BIPNH Behavioral Interventions Paradigm in Nursing Homes

CAD Coronary Artery Disease

CAHPS Consumer Assessment of Healthcare Providers and Systems

CBO Community-Based Organization

CBS Community-Based Services

CCD Continuity Care Document

CCDA Consolidated Clinical Data Architecture

CCMS Care Coordination Management System

CDC Centers for Disease Control and Prevention (US Federal Agency)

CDE Certified Diabetes Educator

CEP Community Engagement Plan

CHA Community Health Associate

CHCS Center for Health Care Strategies

CHW Community Health Worker

CKD Chronic Kidney Disease

CM Care Manager

CMA Care Management Agency (for Health Homes)

CMO Chief Medical Officer

CMRU Care Management Resource Unit (Montefiore)

CMS Centers for Medicare and Medicaid Services (US Federal Agency)

CNA Community Needs Assessment

COO Chief Operating Officer

COP Clinical Operation Plan

COPD Chronic Obstructive Pulmonary Disorder

CQI Continuous Quality Improvement

CSO Central Services Organization

CT Care Transitions

CTCC Care Transitions Clinical Coordinator

CTI Critical Time Intervention


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CVD Cardiovascular Disease

DC Discharge

DCM Depression Care Manager

DEAA Data Exchange Application and Agreement

DNI Do Not Intubate

DNR Do Not Resuscitate

DOE Department of Education

DOH Department of Health

DOHMH Department of Health and Mental Hygiene (NYC-specific)

DSHP Designated State Health Programs

DSRIP Delivery System Reform Incentive Payment Program

DVT Deep Vein Thrombosis

DY Demonstration Year

EBG Evidence-Based Guidelines

EC Executive Committee

ECG Electrocardiogram

ED Emergency Department

EHR Electronic Health Record

EMR Electronic Medical Record

ENS Encounter Notification System

ESRD End Stage Renal Disease

FFP Federal Financial Participation

FQHC Federally Qualified Health Center

FTE Full Time Equivalent

GFR Glomerular Filtration Rate

GINA Global Initiative for Asthma

HCAHPS Consumer Assessment of Healthcare Providers and Systems, Hospital Survey

HCBS Home and Community Based Services

HCS Health Commerce System

HEDIS Healthcare Effectiveness Data and Information Set

HH Health Home

HIE Health Information Exchange

HIPAA Health Insurance Portability and Accountability Act

HIT Health Information Technology

HIV Human Immunodeficiency Virus

HPF High Performance Fund

HRSA Health Resources and Services Administration (US Federal agency within HHS)

HTN Hypertension

IA Independent Assessor

IAAF Interim Access Assurance Fund

ICS Inhaled Corticosteroids


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IDS Integrated Delivery System

IGT Intergovernmental Transfer

IPM Integrated Pest Management

IQI Inpatient Quality Indicator

IWG Implementation Work Group

LABA Long-Acting Beta Agonist

LCSW Licensed Clinical Social Worker

LEAP Lower Extremity Amputation Prevention

LPN Licensed Practical Nurse

MA Medical Assistant

MAPP Medicaid Analytics Performance Portal (NYS-specific)

MCO Managed Care Organization

MEB Mental Emotional Behavioral Disroders

MHSA Mental Health and Substance Use

MRT New York State Medicaid Redesign Team

MSA Master Services Agreement

MU Meaningful Use

NAEPP National Asthma Education and Prevention Program

NCQA National Committee for Quality Assurance (PCMH)

NHLBI National Heart, Lung, and Blood Institute

NIH National Institutes of Health

NQF National Quality Forum

NULU's Non Utilizers, Low Utilizers

NYS New York State

OASAS NYS Office of Alcoholism and Substance Abuse

OC Outreach Coordinator

OCS Oral Corticosteroids

OHIP NYS Office of Health Insurance Programs

OMH NYS Office of Mental Health

ONC Office of the National Coordinator for Health Information Technology

OPWDD Office for People with Developmental Disabilities

P4P Pay-for-Performance

P4R Pay-for-Reporting

PAC Project Advisory Committee

PAM Patient Activation Measure

PAV Percentage Achievement Value

PCG Public Consulting Group

PCMH Patient Centered Medical Home

PCP Primary Care Provider

PCR Plan All-Cause Readmission

PDI Prevention Quality Indicators - Pediatric


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PEF Peak Expiratory Flow

PF Peak Flow

Pharm.D Clinical Pharmacist

PHI Protected Health Information

PHQ Patient Health Questionnaire

PHS US Public Health Service

PM Project Manager

PN Patient Navigator

PPR Potentially Preventable Readmissions

PPS Performing Provider System

PP's Policies and Procedures

PPS Performing Provider System

PPV Potentially Preventable Emergency Room Visits

PQI Preventive Quality Indicator (to identify quality of care for ambulatory care, potentially preventable hospitalization)

PSI Patient Safety Indicator

QCIS Quality and Care Innovation Sub-Committee

QE Qualified Entity

RCE Rapid Cycle Evaluation

RDC Rapid Deployment Collaborative

RFI Request for Information

RHIO Regional Health Information Organization

RN Registered Nurse

RRU Relative Resource Use

RTF Residential Treatment Facility

SBIRT Screening, Brief Intervention, and Referral to Treatment (for substance Abuse Disorders)

SBPM Self-Measured Blood Pressure Monitoring

SCC Suffolk Care Collaborative

SHIN-NY Statewide Health Information Network for New York

SHIP New York State Health Innovation Plan

SMAP Self-Management Action Plan

SMI Serious Mental Illness

SNF Skilled Nursing Facility

SNP Safety Net Provider

SNP (HIV) Special Needs Plan

SPARCS NY Statewide Planning and Research Cooperative System

SPMI Severely and Persistently Mentally Ill

SSIT Site-Specific Implementation Team

STG Special Terms and Conditions

SUD Substance Use Disorder

TOC Transition of Care

TWG Transitional Work Group


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USPTF US Preventive Services Task Force

VAP Vital Access Provider Program

VBP Value Based Payment Reform

VLS Viral Load Suppression
