Implementation of the INTERACT Program in Suffolk County (DSRIP Project 2.b.vii)

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1 Implementation of the INTERACT Program in Suffolk County (DSRIP Project 2.b.vii) Ashley Meskill, Clinical Project Manager, RN, BSN Suffolk Care Collaborative Office of Population Health at Stony Brook Medicine January 21, 2016

2 PRESENTATION OBJECTIVES Introduction to the Suffolk Care Collaborative SCC Network Composition & SNF Coalition Partners SCC Speed & Scale Commitments Organization Structure of the Project Clinical Guideline Summary Milestone Timeline Facility Champion Role Description Certified INTERACT Champion Training Program Strategies for Program Implementation

3 WHO WE ARE Suffolk PPS Partners 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 enhance patients' self-care abilities, improve access to community-based resources, break down care silos and reduce avoidable hospital admissions and emergency room visits. 3

4 SCC PARTNER NETWORK COMPOSITION Primary Care Practitioner All Others Non-PCP Practitioner CBO & DDs Hospital Hospice Clinics Approximately 5,800 Pharmacy partners canvassing over Health Homes 500 organizations Enrolled to date Nursing Home Mental Health Substance Abuse 4

5 SUFFOLK PPS SKILLED NURSING FACILITIES 44 SNFs are par+cipa+ng in the DSRIP INTERACT Project 38 SNFs are Safety Net Domain 1 Project Requirements must be met by DY2, Q3 (March 31, 2017) Affinity Skilled Living Apex Rehabilitation and Care Avalon Gardens Nursing and Rehabilitation Bellhaven Center for Nursing and Rehabilitation Berkshire Nursing Center Vincent Bove Health Center at Jefferson's Ferry Broadlawn Manor Nursing and Rehabilitation Center Brookhaven Rehabilitation & Health Care Center Carillon Nursing and Rehabilitation Center LLC Central Nursing and Rehabilitation Daleview Care Center East Neck Nursing and Rehabilitation Center Good Samaritan Nursing Home Gurwin Jewish Nursing & Rehabilitation Center Hilaire Rehabilitation and Nursing Huntington Hills Center for Health and Rehabilitation Island Nursing and Rehabilitation Center Lakeview Rehabilitation and Care Center Long Island State Veterans Home Maria Regina Residence Medford Multicare Center for Living Mills Pond Nursing and Rehabilitation Center Momentum at South Bay for 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 Skilled Nursing and Rehabilitation Center Peconic Landing at Southhold Riverhead Care Center 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. Johnland Nursing Center St.James Rehabilitation and Health Care Center Suffolk Center for Rehabilitation and Nursing Sunrise Manor Center for Nursing The Hamptons Center for Rehabilitation and Nursing Water's Edge at Port Jefferson for Rehabilitation and Nursing Westhampton Care Center White Oaks Nursing Home Woodhaven Center of Care

6 SCC PATIENT ENGAGEMENT SPEED & SCALE COMMITMENTS 1,914 patients must be engaged in the INTERACT project by March 31, 2017 DY 1 DY 2 DY 3 DY 4 Q2: July 1- September 30, 2015 Q3: October 1- December 31, 2015 Q4: January 1- March 31, 2016 Q1: April 1- June 30, 2016 Q2: July 1- September 30, 2016 Q3: October 1- December 31, 2016 Q4: January 1- March 31, 2017 Q1: April 1- June 30, 2017 Q2: July 1- September 30, 2017 Q3: October 1- December 31, 2017 Q4: January 1- March 31, 2018 Q1: April 1 - June 30, 2018 Q2: July 1- September 30, 2018 Q3: October 1- December 31, 2018 Q4: January 1- March 31, % 37% 60% 20% 40% 70% 100% 25% 50% 75% 100% 25% 50% 75% 100% Pa+ent Engagement DY1 Q1 TARGET DY1 Q1 ACTUAL DY1 Q2 TARGET DY1 Q2 ACTUAL

7 COMMUNICATION & ORGANIZATIONAL STRUCTURE OF THE PROJECT

8 CLINICAL GUIDELINE SUMMARY

9 INTERACT ImplementaHon Binder Complete 11/30/2015 CerHfied INTERACT Champion Training Program Complete for PPS SNFs 11/30/2015 Clinical Guideline Summary Presented to Clinical CommiEee for Endorsement 11/30/2015 INTERACT ImplementaHon Binder Approval by Project CommiEee 12/31/2015 Facility Champion Role DescripHon is Completed & Approved by Project CommiEee 12/31/2015 IniHate INTERACT ImplementaHon in SNFs 1/31/2016 SNF ImplementaHon Teams Established at each SNF 3/31/2016 ParHcipaHon Agreements in Place with PPS SNFs 3/31/2016 Engaged Partners to Use EHR or Other Tech Pla\orms to Track all PaHents Engaged in Project 3/31/2017 Q1 Q1 Q Q4 Q2 Q3 Q4 Q2 Q3 Q DSRIP Project 2bvii. 3/31/2018 SNF ImplementaHon of INTERACT Complete 3/31/2017 Engaged Partners to Use EHR or Other Tech Pla\orms to Track all PaHents Engaged in Project

10 FACILITY CHAMPION ROLE DESCRIPTION Director of Nursing iden+fied as Facility Champion Oversee implementa+on of the INTERACT Quality Improvement Program within their facility Provide leadership and assume con+nuing responsibility for the development, implementa+on, training, compliance, coordina+on and success of the program Par+cipate in the Project Commi_ee and the INTERACT Quality Improvement & Assurance Commi_ee

11 CERTIFIED INTERACT TRAINING PROGRAM November 2015, 40 Skilled Nursing Facilities participated in the CIC Training Program at Stony Brook Medicine Two Master Trainers from Pathway Health facilitated the on-site training Eighty staff members passed the INTERACT certification exam established by INTERACT T.E.A.M. Strategies, LLC. Two individuals at each participating SNF became Certified INTERACT Champions Required that the Director of Nursing at each facility attend and become certified Cost of training program covered by PPS and free to two attendees from each PPS partner SNF

12 STRATEGIES FOR PROGRAM IMPLEMENTATION 1. SNF Implementation Plan 2. Implementation Manual 3. Role of Implementation Specialist 4. Project Workgroup Learning Collaboratives

13 CONCEPT OF PROVIDER IMPLEMENTATION PLAN Implementation Plan The SCC PMO has created a concise implementation plan for SNF Facility Champions to follow Used to collect necessary documents to demonstrate SNF provider engagement in project (Ex. Training Attestation Forms) Number Project Plan Est. Start Est. Complete 1 DSRIP Year and Quarter Status Assigned To 2bvii - PIP 4/1/2015 9/30/2016 DY2, Q4 Scheduled Iden+fy DSRIP facility champion for project implementa+on 4/1/2015 6/30/2016 DY2, Q4 Scheduled 1 Complete Facility Champion form 4/1/ /31/2015 DY2, Q4 Scheduled Facility Champion trained in Performance Logic; if applicable 4/1/2015 3/31/2016 DY2, Q4 Scheduled Reports baseline nursing home to hospital transfer rate 4/1/2015 3/31/2016 DY2, Q4 Scheduled SNF DNS and/or Nurse Educator a_end SCC CIC Champion Training 4/1/2015 6/30/2016 DY2, Q4 Scheduled Suppor+ng Documenta+on Facility Champion Form (include CV) Baseline Nursing Home to Hospital Transfer Rate Template SCC CIC Training Cer+fica+ons submi_ed to SCC 4/1/2015 6/30/2016 DY2, Q4 Scheduled CIC Training Cer+ficates Project Team established and roster/ directory sent to SCC PM 4/1/2015 6/30/2016 DY2, Q4 Scheduled Project Team Directory SNF INTERACT Implementa+on Kick Off Mee+ng hosted 4/1/2015 6/30/2016 DY2, Q4 Scheduled Complete INTERACT Program Implementa+on 4/1/2015 9/30/2016 DY2, Q4 Scheduled Iden+fy necessary staff for training program 4/1/2015 6/30/2016 DY2, Q4 Scheduled 2.2 Staff training on Module 1-4 Complete 4/1/2015 6/30/2016 DY2, Q4 Scheduled Module 1: INTERACT principles Implemented 4/1/2015 9/30/2016 DY2, Q4 Scheduled Module 2: Care pathways and Clinical Tools Implemented 4/1/2015 9/30/2016 DY2, Q4 Scheduled Module 3: Advance Care Planning Implemented 4/1/2015 9/30/2016 DY2, Q4 Scheduled Module 4: INTERACT Quality Improvement & Assurance Program Implemented 4/1/2015 9/30/2016 DY2, Q4 Scheduled SCC INTERACT Program Repor+ng Procedure Ini+ated 4/1/2015 5/30/2016 DY2, Q4 Scheduled SCC INTERACT Quality Commi_ee par+cipa+on ini+ated 4/1/2015 6/30/2016 DY2, Q4 Scheduled Facility Champion or designee par+cipates in SCC INTERACT Quality Commi_ee 4/1/2015 3/31/2016 DY2, Q4 Scheduled Facility Champ+on or designeee contributes with SNF data to the SCC 3.2INTERACT Quality Improvement Program 4/1/2015 6/30/2016 DY2, Q4 Scheduled SCC Training Roster Template INTERACT Training Inventory Form Notes 4 IT Project Requirements Completed 4/1/2015 9/30/2016 DY2, Q4 Scheduled 4.1 Facility champion submits Meaningful Use Cer+fica+on from CMS or NYS Medicaid or EHR Proof of Cer+fica+on 4/1/2015 9/30/2016 DY2, Q4 Scheduled Meaningful Use Cer+fica+on Facility champion submits RHIO QE Par+cipa+on Agreement to SCC Project 4.2 Manger or sample of transac+ons to public health registries, or evidence of DIRECT secure transac+ons 4/1/2015 9/30/2016 DY2, Q4 Scheduled RHIO QE 4.3 Use EHR or other technical plaiorm to track all pa+ents engaged in the project 4/1/2015 9/30/2016 DY2, Q4 Scheduled Sample data collec+on and tracking system; Electronic Health Record completeness report

14 MANAGING IMPLEMENTATION OF DSRIP PROGRAMS SBU CHS NWH Example: Skilled Nursing Facilities (SNF) Project: Implementing INTERACT SCC CSO Project Manager Final Documentation Approval & Monitor Task Status Send required documents and status updates CA* Send required documents and TX* status updates NY* Send required documents and status updates SBU HUB Project Owner CHS HUB Project Owner NWH HUB Project Owner Island NM Hilaire Gurwin K Our Lady Good Sam St Catherine MA Broadlawn NJ Imp Plan Imp Plan Imp Plan Imp Plan Imp Plan Imp Plan Imp Plan 14

15 INTERACT IMPLEMENTATION BINDER Implementation Manual and Toolkit Instructions INTERACT Program Charter SCC INTERACT Program Contacts Build your INTERACT Implementation Team 1) Identify an INTERACT Program Facility Champion a. Facility Champion Role Description. b. Submit Facility Champion Form (including CV) 2) Identify an INTERACT Implementation team a. INTERACT Implementation Team Composition & Role Description b. Submit Implementation Team Composition Roster Template 3) SCC Coalition Partner Participation Agreement Executed INTERACT Implementation Kick-Off 1) Initiating the INTERACT Program Presentation & Agenda

16 INTERACT IMPLEMENTATION MANUAL CONTD. INTERACT Training Minimum Guidelines 1) Module 1: INTERACT principles & Coaching Program implemented 2) Module 2: Care Pathways & Clinical Tools implemented 3) Module 3: Advance Care Planning implemented a. Advance Care Planning Tools b. MOLST 4) Module 4: INTERACT Quality Improvement & Assurance Program implemented 5) Submit INTERACT Program Training Inventory Form 6) INTERACT Training Program Sign in Sheet Template INTERACT Communication & Education Tool Methodology for Patients, Families and Caregivers 1) Patient/family Education Methodology 2) Family/Caregiver Flyer & Education Tools Building your Quality Improvement & Assurance Program Description 1) Quality Improvement & Assurance Committee Composition & Role Description INTERACT Program Reporting Procedure 1)INTERACT Quarterly Reporting Schedule

17 ROLE OF IMPLEMENTATION SPECIALIST Oversees implementa+on of the INTERACT project within the PPS Content expert in the INTERACT QIP & a Cer+fied INTERACT Champion Facilitates and leads the INTERACT Quality Improvement & Assurance Commi_ee and par+cipates in Learning Collabora+ves Assists facili+es with training when necessary Presents SNF highlights to other stakeholder groups, i.e. TOC Hospital Workgroup

18 PROJECT WORKGROUP LEARNING COLLABORATIVES Methodology for assessing effec+veness of implementa+on Direct communica+on lines for all SNFs & Facility Champions Engaging other provider types to join discussion to support implementa+on. Ex. Hospitals use of Nursing Capabili+es Checklist Focus on one topic per month sharing best prac+ces and/or implementa+on challenges and risk mi+ga+on strategies Func+on as SCC INTERACT Quality Improvement & Assurance Commi_ee Discuss topics as they arise from actual work taking place at SNFs

19 Thank You Ashley Meskill, RN, BSN Clinical Project Manager, Suffolk Care Collaborative Office of Population Health at Stony Brook Medicine

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