skilled nursing facility interact program implementation ......feb 06, 2017 · interact program...
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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]
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.
1
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
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.
2
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
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.
3
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
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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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
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.
5
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
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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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
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 Clinical Tools and Care Pathways ........................................................................................... 50
Advanced Care Planning Tools ................................................................................................................ 50
Quality Assurance & Improvement Activities ......................................................................................... 51
Additional Resources .............................................................................................................................. 51
DSRIP GLOSSARY ......................................................................................................................................... 52
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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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.
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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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
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.
10
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.
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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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.
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.
12
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
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.
13
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
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.
14
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
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
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.
15
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
(631) 218-5900 [email protected]
Apex Rehabilitation and Healthcare Diane Montagnese
(631) 423-3200 [email protected]
Bellhaven Center for Nursing and Rehabilitation Michele Randazzo
(631) 286-8100 [email protected]
Broadlawn Manor Nursing and Rehabilitation Center Donna Kube
(631) 264-0222 [email protected]
Brookhaven Rehabilitation & Health Care Center Kellie Burridge
(631) 447-8800 [email protected]
Brookside Multicare Nursing Center (Avalon Gardens) Joanne Mendez
(631) 724-2200 [email protected]
Carillon Nursing and Rehab Center LLC Claudia Schreck
(631) 271-5800 [email protected]
Central Island Lisa Dowd
(516) 433-0600 [email protected]
Daleview Care Center Kim Deschamps (516) 694-9800 [email protected]
East Neck Nursing and Rehab Center Denise MacDonald
(631) 422-4800 [email protected]
Good Samaritan Nursing Home Diane Guidone
(631) 244-2400 [email protected]
Gurwin Jewish Nursing & Rehabilitation Center Julieann Yerkes
(631) 715-2602 [email protected]
Hamptons Center for Rehabilitation and Nursing Diane Siegel
(631) 702-1000 [email protected]
Hilaire Rehab and Nursing Stana Mosie
(631) 427-0254 [email protected]
Huntington Hills Center for Health and Rehabilitation Teri O'Driscoll
(631) 439-3000 [email protected]
Island Nursing and Rehab Center
Hyacinth Hendrickson
(631) 439-3000 [email protected]
Long Island State Veterans Home
Sandra K. Sharp-Hayes
(631) 444-8606 [email protected]
Maria Regina Residence Anna Moyette
(631) 273-4500 [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.
16
Mills Pond Nursing and Rehabilitation Center Dolores Cruz
(631) 862-8990 [email protected]
Momentum at South Bay: Rehabilitation and Nursing Regina Harrington
(631) 581-6400 [email protected]
Nesconset Center for Nursing and Rehabilitation Crystal Thomas
(631) 361-8800 [email protected]
Our Lady of Consolation Nursing & Rehabilitative Care Center Theresa Rosenthal
(631) 587-1600 [email protected]
Peconic Bay Anna Law
(631) 548-6071 [email protected]
Peconic Landing at Southhold Lee Cole
(631) 477-4217 [email protected]
Ross Center for Health and Rehabilitation Jackyln Lyn
(631) 273-4700 [email protected]
San Simeon by the Sound Center for Nursing and Rehabilitation Kelly Moteiro
(631) 477-2110 [email protected]
Sayville Nursing and Rehabilitation Center Jackie Donnelly
(631) 567-9300 [email protected]
Smithtown Center for Rehabilitation and Nursing Nancy Ciaffone
(631) 361-2020 [email protected]
St. Catherine of Siena Nursing and Rehabilitation Care Center Cindy LePage
(631) 862-3905 [email protected]
St. James Rehabilitation and Health Care Center KellyAnn Lunghi
(631) 862-8000 [email protected]
St. Johnland Nursing Center Sherri Elliott
(631) 269-5800 [email protected]
Suffolk Center for Rehabilitation and Nursing Laura Schauder
(631) 289-7700 [email protected]
Sunrise Manor Center for Nursing Eileen Fasulo
(631) 665-4960 [email protected]
Surge Rehabilitation and Nursing (Oak Hollow) Denise Cagno
(631) 924-8820 [email protected]
Water's Edge at Port Jefferson for Rehabilitation and Nursing Ronald D'Anna
(631) 473-5400 [email protected]
Westhampton Care Center Deborah Schafmayer
(631) 288-0101 [email protected]
White Oaks Nursing Home Connie Biebauer (516) 367-3400
Woodhaven Santa Espinal
(631) 473-7100 [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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Facility Co-Champion Directory Facility Name Co-Champion Phone Email
Acadia Center for Nursing and Rehabilitation Kathy Kursar
(631) 727-4400 [email protected]
Affinity Skilled Living Regina Prima
(631) 218-5900 [email protected]
Apex Rehabilitation and Healthcare Annabelle Mazzochi
(631) 423-3200 [email protected]
Bellhaven Center for Nursing and Rehabilitation Gina Iovino
(631) 286-8100 [email protected]
Broadlawn Manor Nursing and Rehabilitation Center Kathleen Lista
(631) 264-0222 [email protected]
Brookhaven Rehabilitation & Health Care Center Betty Honce
(631) 447-8800 [email protected]
Brookside Multicare Nursing Center (Avalon Gardens) Mel Javier
(631) 724-2200 [email protected]
Carillon Nursing and Rehab Center LLC Margaret Jablonski
(631) 271-5800 [email protected]
Central Island
(516) 433-0600
Daleview Care Center Mary Kochaniwsky
(516) 694-9800 [email protected]
East Neck Nursing and Rehab Center Helen Kiernan
(631) 422-4800 [email protected]
Good Samaritan Nursing Home Chris Cardinal; Karen Keefer
(631) 244-2400 [email protected]; [email protected]
Gurwin Jewish Nursing & Rehabilitation Center Lynette Rutherford
(631) 715-2602 [email protected]
Hamptons Center for Rehabilitation and Nursing Linda Mannoia
(631) 702-1000 [email protected]
Hilaire Rehab and Nursing Yasin Rasheed
(631) 427-0254 [email protected]
Huntington Hills Center for Health and Rehabilitation Susan D'Anna, Rn
(631) 439-3000 [email protected]
Island Nursing and Rehab Center
Guendalina Norris Lopez
(631) 439-3000 [email protected]
Long Island State Veterans Home Rona Schlau
(631) 444-8606 [email protected]
Maria Regina Residence Dorothy Cappadora
(631) 273-4500 [email protected]
Mills Pond Nursing and Rehabilitation Center
Linda Kaufman; Noel Sweetser
(631) 862-8990 [email protected]; [email protected]
Momentum at South Bay: Rehabilitation and Nursing Jeff Marcus
(631) 581-6400 [email protected]
Nesconset Center for Nursing and Rehabilitation Emalyn Laurino
(631) 361-8800 [email protected]
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Copyright © 2017 Suffolk Care Collaborative, All rights reserved.
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Our Lady of Consolation Nursing & Rehabilitative Care Center Eleanor Marien
(631) 587-1600 [email protected]
Peconic Bay Maureen Earl (631) 548-6071 [email protected]
Peconic Landing at Southhold Jennifer Ackroyd
(631) 477-4217 [email protected]
Ross Center for Health and Rehabilitation Maggie Austrie
(631) 273-4700 [email protected]
San Simeon by the Sound Center for Nursing and Rehabilitation Surinder Arora
(631) 477-2110 [email protected]
Sayville Nursing and Rehabilitation Center Joyzelle Abonado
(631) 567-9300 <[email protected]
Smithtown Center for Rehabilitation and Nursing Donna Fleming
(631) 361-2020 [email protected]
St. Catherine of Siena Nursing and Rehabilitation Care Center Michelle Mercier
(631) 862-3905 [email protected]
St. James Rehabilitation and Health Care Center Tammy DiMartino
(631) 862-8000 [email protected]
St. Johnland Nursing Center Ruby Parente
(631) 269-5800 [email protected]
Suffolk Center for Rehabilitation and Nursing Debra Covello
(631) 289-7700 [email protected]
Sunrise Manor Center for Nursing Maxine Lewis
(631) 665-4960 [email protected]
Surge Rehabilitation and Nursing (Oak Hollow) Stephanie Dorsainvil
(631) 924-8820 [email protected]
Water's Edge at Port Jefferson for Rehabilitation and Nursing Amy Podota
(631) 473-5400 [email protected]
Westhampton Care Center Linda Mannoia
(631) 288-0101 [email protected]
White Oaks Nursing Home Tracy Diamondopol (516) 367-3400
Woodhaven Deborah Hughes
(631) 473-7100 [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.
19
SNF Administrator Directory Facility Name Administrator Phone Email
Acadia Center for Nursing and Rehabilitation
Mary Ann Mangels (631) 727-4400
Affinity Skilled Living Stephanie Malone (631) 218-5900 [email protected]
Apex Rehabilitation and Healthcare
David Efroymson (631) 423-3200 [email protected]
Bellhaven Center for Nursing and Rehabilitation
Bernadette Walker (631) 286-8100 [email protected]
Broadlawn Manor Nursing and Rehabilitation Center
Michael Scarpelli (631) 264-0222 [email protected]
Brookhaven Rehabilitation & Health Care Center
Debi Gaines (631) 447-8800
Brookside Multicare Nursing Center (Avalon Gardens)
Steven Wieder (631) 724-2200 [email protected]
Carillon Nursing and Rehab Center LLC
Gerry Albers; Joe Carillo
(631) 271-5800 [email protected]
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]
Gurwin Jewish Nursing & Rehabilitation Center
Stuart Almer (631) 715-2602 [email protected]
Hamptons Center for Rehabilitation and Nursing Vince Liaguno
(631) 702-1000
Hilaire Rehab and Nursing
Sherrita Alexander (631) 427-0254 [email protected]
Huntington Hills Center for Health and Rehabilitation
Ken Knutsen (631) 439-3000 [email protected]
Island Nursing and Rehab Center
Dave Fridkin (631) 439-3000 [email protected]
Long Island State Veterans Home
Fred Sganga (631) 444-8606 [email protected]
Maria Regina Residence Ellen Bartoldus (631) 273-4500 [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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Mills Pond Nursing and Rehabilitation Center
Andrew Yandoli (631) 862-8990 [email protected]
Momentum at South Bay: Rehabilitation and Nursing
Frank Dano (631) 581-6400 [email protected]
Nesconset Center for Nursing and Rehabilitation
Robert Baranello (631) 361-8800
Our Lady of Consolation Nursing & Rehabilitative Care Center
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]
San Simeon by the Sound Center for Nursing and Rehabilitation
Steven Smyth (631) 477-2110 [email protected]
Sayville Nursing and Rehabilitation Center
Kwang Lee (631) 567-9300 [email protected]
Smithtown Center for Rehabilitation and Nursing
Marsha Noren (631) 361-2020 [email protected]
St. Catherine of Siena Nursing and Rehabilitation Care Center
John Chowske (631) 862-3905 [email protected]
St. James Rehabilitation and Health Care Center
William St. George (631) 862-8000 [email protected]
St. Johnland Nursing Center
Mary Jean Weber (631) 269-5800 [email protected]
Suffolk Center for Rehabilitation and Nursing
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]
Water's Edge at Port Jefferson for Rehabilitation and Nursing
Adam Cooperman (631) 473-5400
Westhampton Care Center
Kelly Brady (631) 288-0101 [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.
21
White Oaks Nursing Home
Jennifer Carpentieri (516) 367-3400
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
Apex Rehabilitation and Healthcare Diane Montagnese [email protected]
Bellhaven Center for Nursing and Rehabilitation
Jason Soldt [email protected]
Broadlawn Manor Nursing and Rehabilitation Center
Maureen Christophersen [email protected]
Brookhaven Rehabilitation & Health Care Center
Kellie Burridge [email protected]
Brookside Multicare Nursing Center (Avalon Gardens) Mel Javier
Carillon Nursing and Rehab Center LLC Margaret Jablonski [email protected]
Central Island Lisa Dowd
Daleview Care Center Mary Kochaniwsky
East Neck Nursing and Rehab Center Helen Kieran [email protected]
Good Samaritan Nursing Home Gloria Mooney [email protected]
Gurwin Jewish Nursing & Rehabilitation Center
Julie Yerkes [email protected]
Hamptons Center for Rehabilitation and Nursing
Patti Donofrie [email protected]
Hilaire Rehab and Nursing Stana Mosie [email protected]
Huntington Hills Center for Health and Rehabilitation
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]
Mills Pond Nursing and Rehabilitation Center Dolores Cruz
Momentum at South Bay: Rehabilitation and Nursing
Jeff Marcus [email protected]
Nesconset Center for Nursing and Rehabilitation
Emalyn Grace C. Laurino [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.
22
Our Lady of Consolation Nursing & Rehabilitative Care Center
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]
San Simeon by the Sound Center for Nursing and Rehabilitation
Debra Kennedy [email protected]
Sayville Nursing and Rehabilitation Center Kathleen DiBenedetto [email protected]
Smithtown Center for Rehabilitation and Nursing
Elizabeth Zimmerman [email protected]
St. Catherine of Siena Nursing and Rehabilitation Care Center
Gloria Mooney [email protected]
St. James Rehabilitation and Health Care Center
Kelly Ann Lunghi [email protected]
St. Johnland Nursing Center Sherri Elliott
Suffolk Center for Rehabilitation and Nursing
Lauren Shauder [email protected]
Sunrise Manor Center for Nursing Maxine Lewis [email protected]
Surge Rehabilitation and Nursing (Oak Hollow) Denise Cagno
Water's Edge at Port Jefferson for Rehabilitation and Nursing
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]
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.
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)
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.
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
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.
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
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.
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
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.
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 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.
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.
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.
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
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.
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.
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.
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
Champion or SCC INTERACT Coach
Module 3: Advance
Care Planning
LPNs, RNs, NPs, MDs, PAs, and social work
Once
Facility
Champion or SCC INTERACT Coach
Module 4:
INTERACT Quality Improvement &
Assurance Program
Member of your Implementation Team and QUAPI
Once
Facility
Champion or SCC INTERACT Coach
INTERACT Quality Improvement &
Assurance Program Curricula
Adobe Acrobat
Document
Learning Center
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.
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 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.
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 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.
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
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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.
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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
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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
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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.
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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
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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.
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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
Suffolk Care Collaborative
INTERACT Patient
Family Education Flyer Final.pdf
INTERACT Patient Education Flyer
Spanish Version
Suffolk Care Collaborative
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
Advance Care Planning Videos Compassion And Support CompassionAndSupport - YouTube
Advance Care Planning Brochure Compassion And Support Advance Care Planning Brochure
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Atrial Fibrillation Name of Document Organization PDF
Atrial Fibrillation Information
Sheets.pdf
American Heart Association
information-sheets.
Alzheimer’s Name of Document Organization PDF
Alzheimer's 10 Warning Signs.pdf
Alzheimer's Association
10warningsigns.pd
f
INTERACT PROGRAM IMPLEMENTATION TOOLKIT | SCC PROJECT MANAGEMENT OFFICE
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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
Million Hearts Campaign by the Centers for Disease Control and Prevention
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
Million Hearts Campaign by the Centers for Disease Control and Prevention
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
http://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2052
Nicotine Patch Use Instructions
New York State Smoker’s Quitline
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
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Medications Covered by Medicaid
New York State Smoker’s Quitline
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
https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2094
Smoking and Diabetes New York State Smoker’s Quitline
https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2091
Smoking and Heart Disease New York State Smoker’s Quitline
https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2092
Smoking and Lung Cancer New York State Smoker’s Quitline
https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2101
Smoking and Bones New York State Smoker’s Quitline
https://www.nysmokefree.com/Specialpages/rViewpdf1.ashx?No=2102
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
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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
Learning About Diabetes, Inc.
DiabetesPillsAction
sEN_SuffolkCare.pdf
DiabetesPillsAction
sSP_SuffolkCare.pdf
Healthy Plate Eating Learning About Diabetes, Inc.
HealthyPlateFishEN
_SuffolkCare.pdf
HealthyPlateFishSP_
SuffolkCare.pdf
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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
Learning About Diabetes, Inc.
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
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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
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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
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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,
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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
Patricia Bomba, MD, F.A.C.P
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
Patricia Bomba, MD, F.A.C.P
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.
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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
Name of Document Version Number Link to Document
SCC INTERACT Quality Acute Care Unplanned Transfer Report
Template
v-01
SCC Project 2.b.vii
Acute Unplanned Transfer Report.xlsx
Action Plan Template
Name of Document Version Number Link to Document
SCC INTERACT Quality Action Plan Template
v-01
SCC Action Plan
Template.docx
Link to Action Plan Template in Qualtrics
Name of Document Version Number Link to Document
SCC INTERACT Quality Action Plan Template in Qualtrics
v-01 https://stonybrookuniversity.co1.qualtrics.com/SE/?SID=SV_cRMn3YAIJlDIjXL
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INTERACT RCA Template PDF
Name of Document Version Number Link to Document
SCC INTERACT Quality RCA Template
v-01
QI_Tool for Review
Acute Care Transf_AL.pdf
INTERACT RCA Summary Worksheet Template PDF
Name of Document Version Number Link to Document
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.
Name of Document Version Number Link to Document
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.
Name of Document Version Number Link to Document
SCC INTERACT Quality Program Framework Membership
Template
v-01
Quality Stakeholder
Group Membership (v-01).xlsx
SCC PI Plan SCC PI Plan click here
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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.
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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.
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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
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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
DY2 Q2 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 7/1/16-9/30/16
10/14/16
DY2 Q3 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 10/1/16-12/31/16
01/13/17
DY2 Q4 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 1/1/17-3/31/17
04/14/17
DY3 Q1 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 4/1/17-6/30/17
07/14/17
DY3 Q2 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 7/1/17-9/30/17
10/13/17
DY3 Q3 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 10/1/17-12/31/17
01/12/18
DY3 Q4 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 1/1/18-3/31/18
04/13/18
DY4 Q1 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 4/1/18-6/30/18
07/13/18
DY4 Q2 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 7/1/18-9/30/18
10/12/18
DY4 Q3 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 10/1/18-12/31/18
01/11/19
DY4 Q4 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 1/1/19-3/31/19
04/12/19
DY5 Q1 Patient Engagement Report & Acute Care Tracker Submission (upload through BOX ONLY) 4/1/19-6/30/19
07/12/19
DY5 Q2 Patient Engagement Report Submission (upload through BOX ONLY) 7/1/19-9/30/19
10/11/19
DY5 Q3 Patient Engagement Report Submission (upload through BOX ONLY) 10/1/19-12/31/19
01/17/20
DY5 Q4 Patient Engagement Report Submission (upload through BOX ONLY) 1/1/20-3/31/20
04/17/20
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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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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
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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
52
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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