New Protocols Enhance VNSNY Nurses Ability to Identify and Treat Behavioral Health Disorders

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3 New Protocols Enhance VNSNY Nurses Ability to Identify and Treat Behavioral Health Disorders Revised model stresses prompt diagnosis, psychoeducation, and fine-tuning medications If a home care patient is suffering from depression or anxiety, it can impact every aspect of his or her health, says Jill Goldstein, VNSNY s Vice President for Acute Care in the Bronx and Westchester. Behavioral disorders affect everything from eating and sleeping patterns to whether someone takes their medications as prescribed. Recognizing this, VNSNY recently began employing a new set of protocols that are significantly enhancing its clinicians ability to identify and treat behavioral disorders in its home care population. These include triggers to alert the home care team when behavioral health care is needed; an increased focus on the use of psychological screens; and new evidence-based clinical pathways that outline specific therapeutic plans and timelines for treating depression, anxiety, bipolar disorder, dementia and other behavioral health conditions. We have a tremendous group of behavioral health registered nurses and with these new protocols, they re now able to intervene even more effectively, says Constantine Checa. An interdisciplinary care team manager (ICTM) with VNSNY s behavioral health division, Checa helped shape the new care model. An increased focus on early diagnosis has been critical, she notes, since behavioral issues can easily be downplayed when a iues patient is struggling with heart failure, stroke or other acute conditions. Once a behavioral diagnosis is made, the patient begins receiving regular visits from a VNSNY behavioral health nurse. During these visits, the nurses employ a revised approach that stresses psychoeducation, rather than VNSNY s previous cognitive behavioral therapy-based intervention. We realized that the cognitive-behavioral therapy method isn t the best fit for all of our patients, since it requires patients to have substantial cognitive resources to reap full benefits, explains behavioral health ICTM Coleen Cox, who also helped design the new protocols. In our new model, we teach patients or caregivers to self-manage behavioral conditions, and we work with their physicians to fine-tune their psychiatric medications. If our nurses observe that an antidepressant dosage needs to be higher, for example, they ll have that conversation with the doctor. The new care delivery model is currently being used with Medicare and Medicaid patients while VNSNY collects sufficient data to engage private revamped VNSNY nurses are using a new set of psychological screens and triggers to identify patients who are suffering from behavioral health conditions like depression and anxiety. insurers around the protocols. Meanwhile, the revamped approach is already having a positive impact on patients and their families. Through these enhanced behavioral health services, together with the medical and rehabilitation care we provide, says Cox, VNSNY is now at the forefront of providing truly holistic care in a home health care setting. 3

4 Helping a Bereaved Patient Find Her Way Since losing her husband two years ago, 88-year-old Jean has struggled with depression. Suzette Santos, a behavioral health nurse with VNSNY, had cared for the Nassau resident previously, and when she was reassigned to Jean s case last August she could see that things had gotten worse. Jean had lost 20 pounds, wasn t sleeping well, and had no interest in eating, Suzette recalls. Hospitalization was a real possibility. While Suzette had made only limited progress before in treating Jean s depression, this time was different: Now, trained in VNSNY s new psychoeducation protocol, Suzette took a much more proactive approach to Jean s medications. She was on several medications, and their combined side effects were upsetting her more, says Suzette. Realizing the drug Remeron would address all of Jean s symptoms, Suzette suggested substituting this medication for the others, and Jean s primary care physician readily agreed. Following the new care model, Suzette also explained to Jean about the new medication and the importance of taking it daily, and got her buy-in. Within three weeks Jean was doing much better, reports Suzette. Today, her medication compliance is one hundred percent and she is a different person. She s regained her weight, is talking and eating more, and has started cooking again. Now, during my weekly visits, she asks what she can make for me! Without Suzette, I wouldn t be in the good condition I am, adds Jean. She s my soul mate. 4

5 An Interview with the Director of VNSNY s Center for Home Care Policy & Research Vice President Kathryn Bowles reports on how VNSNY s research projects are resulting in better home care for our customers and their patients What types of home care improvements is your research team investigating? One of our most important studies is a collaboration with an NYU School of Nursing investigator, Allison Squires, on an NIH grant involving patients with limited English. We ll be investigating whether assigning a nurse who speaks that patient s own language impacts outcomes like re-hospitalizations, functional status and number of home care visits. We also just launched another interesting collaboration between VNSNY, the University of Pennsylvania and NYU Langone Medical Center to develop and implement a home-based post-hospitalization cardiac rehabilitation program. How is VNSNY s research impacting the way VNSNY delivers care to patients? In addition to our research on which home care interventions are most effective for different types of patients, we re also engaged in projects that are helping to improve our clinical care. We just got NIH funding to study how our nurses benefit from real-time dashboards with customized patient data displays and we re now piloting a screening tool that helps intake clinicians identify which new patients need to be seen that very day, rather than within our normal 48-hour window, due to high readmission risk. We re also partnering with researchers at NYU and Columbia medical schools in a new Center for Stroke Disparities Solutions. As part of the center, we re testing a new community transitional care model that deploys nurse practitioners and specially trained home health aides as health coaches to help stroke patients manage their hypertension and prevent a recurrent stroke. And we re conducting our own study of how caregiver continuity impacts patients with various conditions. VNSNY s Research Center recently did a major study on how home care affects readmission rates for heart failure. What did you find? We re very excited about this study, which was funded by a grant from the Agency for Healthcare Research and Quality. In the study, which will be published shortly, we analyzed national home care records of 100,000 Medicare patients who had been hospitalized for congestive heart failure. We found significant reductions in hospital readmissions when these patients had several front-loaded home visits from a nurse within one week of discharge and also saw a physician that first week. That combination appears to be key to reducing readmission rates. Do you anticipate doing additional studies on this kind of nationwide scale? Absolutely. In fact, the NIH just funded us for a similar project in which we ll analyze national home care records of patients who had sepsis during their hospital stay. We will investigate the effect of early and intensive nursing and physician visits on hospital readmissions as well as which patients are at highest risk of functional decline and death over a six-month follow-up period. Very little is currently known about these patients after they leave the hospital, so I ll be quite interested to see what we find. 5

6 VNSNY Hospice Fellowship Program Increases Patients Access to Care In a step that has made a highly regarded program even stronger, VNSNY s Hospice Physician Fellowship Training Program is now embedding its Fellows in hospice care teams. This means that the Fellows comprising physicians from eight of New York City s academic medical centers who are training to become certified hospice and palliative care specialists now actively evaluate and treat hospice patients under the supervision of a VNSNY Hospice physician. In the past, our Fellows simply shadowed members of VNSNY s hospice care teams, explains Fellowship Program Director John Delfs, MD, Chief Medical Officer, VNSNY Hospice and Palliative Care. Now these already highly qualified physicians are providing hands-on care for hospice patients. Between our Fellows and our regular hospice physicians, our patients are able to be seen by physicians more often. At the same time, we re providing a richer clinical experience to physician Fellows from our educational partner institutions. This year, VNSNY Hospice and Palliative Care is providing hospice training for 38 physician Fellows and four nurse practitioners, making it the largest such program in the nation. The new clinical model, launched in July, has received widespread praise. Allowing Memorial Sloan Kettering s Fellows to function as embedded hospice physicians has encouraged more ownership and clinical responsibility during their rotation, and has enriched their hospice training, notes Dr. Stacy Stabler, program director of the Palliative Medicine Fellowship at Memorial Sloan Kettering Cancer Center. The new model is one more example, adds Dr. Stabler, of how VNSNY has been an enthusiastic and flexible training partner. I m particularly appreciative of VNSNY s responsiveness to our specific educational needs, she says. The experience that our physicians get with VNSNY Hospice is critical in order for them to become boardeligible and to develop key palliative knowledge and skills for managing patients beyond our own hospital doors. 6

7 New Outreach Initiative Spreads Hospice Awareness to African-Americans in Harlem WABC-TV s Here and Now Spotlights VNSNY Hospice and Palliative Care To help ensure that all patients of our referring partners have ready access to end-of-life care if and when it s needed, VNSNY Hospice and Palliative Care s new outreach program HOPE (Hospice Outreach Patient and Provider Education) is spreading awareness of home hospice services among the largely African-American community of Harlem. The program, one of several community outreach efforts being conducted by VNSNY Hospice, was featured recently on WABC-TV s local news show Here and Now, in a story that included video of a VNSNY hospice care team visiting a patient s bedside, and a studio interview with Rosemary Baughn, Senior Vice President of Hospice and Palliative Care, and quality manager Amealya Blake, RN. Above left: VNSNY s Amealya Blake, RN, on WABC-TV s Here and Now. Above right: The broadcast also showed a home visit by a VNSNY hospice care team. 7

8 Streamlined Authorization Process Is Speeding Patient Intake and Eliminating Gaps in Care A number of improvements to VNSNY s authorization process are underway, reports Felix Okhiria, VNSNY s Vice President for Revenue Cycle. By creating a streamlined intake process for referring partners and patients as well as fewer delays in ongoing reauthorizations of care, these changes will result in lower writeoffs, enhanced cash flow, improved relationships with payors and less workload for VNSNY s nurses. Between January and April, VNSNY will roll out an electronic verification system that uses ZirMed s online clearinghouse to conduct initial patient verifications in just a few seconds. In addition, temporary authorizations will now be electronically uploaded to VNSNY s intake system a process that, says Okhiria, should take under an hour. VNSNY is also establishing evidence-based clinical pathways to guide initial authorization asks and identify when ongoing authorizations will be needed ensuring that gaps in care are avoided and is working on a process to consolidate each patient s orders for nursing and therapy services into a single multidisciplinary request, as well. Besides making VNSNY more responsive to its referring partners, these enhancements are expected to lead to increased patient satisfaction, adds Okhiria. The bottom line is that we ll be delivering care to patients in a more timely way. With VNSNY s new system, initial patient verifications can be completed in a few seconds. 8

9 VNSNY Expected to Provide $25 Million in Charitable Care and Community Benefit in 2015 VNSNY s mission of providing unreimbursed health care and other vital services to the most vulnerable New Yorkers remains as important today as it has been throughout its 120-year history. Last year VNSNY expected to provide $25 million in charitable care and community benefit both to its underfunded programs and to thousands of uninsured and underinsured adults and children across the New York metropolitan area, including many managed care patients and patients on Medicaid. In 2015, VNSNY Home Care and VNSNY Hospice and Palliative Care provided unreimbursed home care and hospice services to more than 4,000 individuals who could not otherwise have afforded it. In addition, VNSNY s grant-funded Nurse- Family Partnership, the largest such program in the New York City area, provided one-on-one counseling and nursing support to an estimated 1,100 Bronx and Nassau County first-time mothers and their children in This past fall saw the graduation of 198 mothers and their toddlers from this widely praised program. VNSNY s Community Mental Health Services also cared for about 12,000 clients in 2015 through services such as its New York Cityfunded quick-response units for children and adults in psychological crisis. As these updates show, says Marki Flannery, Executive Vice President and Chief of Provider Operations, VNSNY s mission-related activities are not only ongoing, but are having more impact than ever. In 2015, VNSNY provided unreimbursed home care and hospice services to over 4,000 New Yorkers. 9

10 VNSNY CHOICE Expands Its Upstate MLTC Presence Hello, Albany and Buffalo! VNSNY has traditionally been associated with the New York metropolitan area but for the past two years, VNSNY CHOICE, the organization s managed care arm, has also been offering its managed longterm care health plan to residents in the upstate Albany/Capital region and Erie County. The Albany/Capital-area MLTC product is being administered in conjunction with the Eddy (a home care division of St. Peter s Health Partners), while the Buffalo-area initiative is a collaboration with the Visiting Nurse Association of Western New York (a division of Kaleida Health). Today, both businesses are thriving. The upstate plan has been very well-received by our members and by the organizations we work with, reports Jim Riesel, Regional Director of Market Development for CHOICE MLTC. Total upstate enrollment for CHOICE MLTC plans is expected to reach well over 1,000 members within the next year. The goal is for VNSNY CHOICE to become the premier MLTC plan in these upstate regions, adds Riesel. The MLTC agreements call for the two local agencies to administer front-line services, including patient assessments and care management, VNSNY CHOICE provides oversight and training of the care management staff and handles all dayto-day issues related to quality, compliance, utilization management and payment of claims. The collaborations have benefited everyone involved, says Hany Abdelaal, DO, President of VNSNY CHOICE Health Plans. By teaming together, we re able to give residents in these communities access to high quality, home-based MLTC services. At the same time, these relationships are providing an opportunity for CHOICE to make important inroads in upstate New York s new and growing MLTC market. 10

11 New Health Coach Training Program is Helping VNSNY s Home Health Aides Keep Their Clients Healthy at Home As a certified home health aide (HHA) with Partners in Care, VNSNY s private care affiliate, Sashana Jones had spent months trying to get her full-time client to change his diet. At age 85, Henry is diabetic, and had recently suffered a stroke that weakened one side of his body. Because he couldn t move about easily, he d put on significant weight, which affected his blood sugar levels and put him at risk for bed sores, says Sashana. In short order, Sashana got Henry to agree to eat smaller portions, substitute water for sugared drinks, and consume more vegetables. The danger was that Henry would need expensive nursing home care if he didn t lose weight an option he wanted to avoid if at all possible. To help him slim down, Sashana urged him to forego his beloved sugared drinks and bread products but with little success. He insisted on eating whatever he wanted, she recalls. That all changed last summer, however, when Sashana took the new health coach training class that Partners in Care is offering to its HHAs. There, she learned the technique of motivational interviewing, in which the caregiver helps the patient set his or her own goals for better health, then collaborates on a plan to get there. I d been asking Henry to do what I wanted, Sashana recalls. My health coach training taught me that it s all about reaching the patient s own goals. Once we were both clear about Henry s desire to remain living at home, I was able to remind him of what he needs to do to accomplish that. In short order, Sashana got Henry to agree to eat smaller portions, substitute water for sugared drinks, and consume more vegetables. We found he really enjoys veggies topped with low-calorie Italian or French salad dressing, she says. Henry began shedding pounds and, with Sashana monitoring his medications, stabilized his blood glucose. For Sashana, her health coach training has transformed her HHA work I m so much more involved in my client s well-being, she notes and also inspired her to begin taking nursing classes. I always knew that my path lay in health care, she says. Now, my health coach skills are letting me help others in a more powerful way. VNSNY home health aide Sashana Jones caring for her patient Henry (inset photo). It s all about reaching the patient s own goals, she says. 11