Following is a summary of the progress of select DSRIP projects the Suffolk County Collaborative will be undertaking
Project 2.b.vii - Implementing the INTERACT? Project (Inpatient Transfer Avoidance Program for Skilled Nursing Facilities (SNF)
INTERACT? (Interventions to Reduce Acute Care Transfers) involves using clinical/educational tools and strategies at long-term care facilities to prevent avoidable patient transfer to hospitals. Current research shows that the use of INTERACT? tools can reduce readmission rates by 17-24%. The PPS is currently designing the plan to use INTERACT? tools at all SNFs in Suffolk. A survey was used to collect baseline data from all SNFs within the PPS to assess INTERACT? implementation readiness. At the same time, the Project Management Office (PMO) has been developing a training program and a team of potential INTERACT? trainers to facilitate INTERACT? adoption and use among the SNFs. This is being designed in conjunction with the Project Leads and Project Committee, which includes representation from the majority of SNFs within the PPS.
The SCC has been working closely with staff from the GNYHA on the launch of the INTERACT? project. In 2012, the GNYHA was awarded a four year cooperative agreement by CMS to implement New York-Reducing Avoidable Hospitalizations (NY-RAH), a demonstration project that is using INTERACT? tools at 29 SNFs within the New York City and Long Island regions to improve communication and the care transition process with hospitals. Tim Johnson, the Executive Director of the GNYHA and Project Director for NY-RAH, assisted the SCC in the development of the INTERACT? project application. The NY-RAH project management team have provided their insights and guidance throughout the planning phase of DSRIP and will continue to do so to help ensure the SCC's successful implementation of the INTERACT? project. According to Mr. Johnson, "the strong engagement and commitment of the SCC SNFs will serve these organizations and their affiliated hospitals well in meeting the goals of DSRIP."
Projects 2.b.iv and 2.b.ix - Implementation of observational programs in hospitals and establishment of a Care Transitions Intervention Model to reduce 30-day Readmissions for Chronic Health Conditions
A major cause of avoidable readmissions to acute care facilities are attributed to non-adherence with the discharge plan. The main reasons for this among the patient populations within Suffolk County include issues related to health literacy, language barriers, and lack of engagement with community resources. In addition, clear communication of the care plan needs to be given to the providers who care for patients after discharge.
The PMO recently administered a baseline survey to all hospital partners to assess their current observation program and transitions of care practices. Highlights from the survey revealed:
- 92.9% of Suffolk County Hospital respondents provide Observation Care
- During current Observation Program patient stays, Care Management and Physicians were the top two provider types that routinely assess patients for transition readiness
- 71% of Suffolk County Hospital respondents utilize the Millman Criteria for observation programs
- 80% of Suffolk County Hospital respondents have standardized protocols in place to manage transition of care practices
- 90% of Suffolk County Hospital respondents currently have a process in place to track readmissions to the hospital
The PMO continues to collaborate with the Project Leads and Project Committee, which includes representatives for all partner hospitals and providers across the care continuum, to design and standardize principles of a Care Transitions Intervention Model for all participating hospitals, home care agencies, and other appropriate community agencies within the PPS. This model focuses on providing patient education before the patient is discharged, care record transition to the receiving provider, along with care management and community-based support for the patient for a 30-day transition period after hospitalization.
Project 2.d.i - Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care
The goal of this project is focused on individuals not utilizing the health care system and works to engage and activate those individuals to utilize primary and preventive care services. Simply having health insurance is not enough to ensure improved health outcomes or appropriate use of the health system. To reduce avoidable ER visits and admissions, individuals must actively engage in managing their own health. The PPS, in collaboration with Community Based Organizations (CBOs), will train providers on the use of PAM? (Patient Activation Measures).
The PPS has identified three community-based partner organizations in target areas to pilot the project, and is working closely with them to prepare for rollout. Within their local communities, Community Health Workers (CHWs) will survey individuals who meet the project's criteria. Once the patient's level of activation has been identified and that person is engaged in the system, the goal will be to move the patient along the spectrum towards increasing activation and facilitate access to care.
Next steps include finalizing a contractual agreement with the PAM? vendor, Insignia, initiate training and begin to engage patients.
Project 3.a.i - Integration of Primary Care and Behavioral Health Services
The goal of this project is to integrate Primary and Behavioral Health (BH) Care using three models:embedding a BH Specialist in a Primary Care Site, embedding a Primary Care Practitioner in a BH Care Site, or implementing the Improving Mood-Providing Access to Collaborative Treatment (IMPACT) Model in the Primary Care setting. The latter program screens patients for depression, assigns a depression care manager, and refers patients to BH services in a stepped care model.
The steps taken so far to achieve these goals include: surveying PPS partners to determine what integration practices are currently in place, developing partner lists to explore geographical collaborations, and educating PPS partners about project requirements. Next steps include finalizing the timeline for partner engagement, contracting with partners and identifying workforce and training needs.
Project 3.b.i - Cardiovascular Disease: Evidence-based strategies for disease management in high risk/affected populations
Cardiovascular disease (CVD) is the third leading cause of avoidable admissions to the hospital and a significant issue within Suffolk County. The focus of this project is to ensure that strategies for evidence-based care are incorporated into the clinical protocols for our PPS partners. The Project Committee and Project Leads have been delineating the clinical protocol to ensure best practice, improve patient outcomes and meet project requirements utilizing elements of the Million Hearts? Initiative.
This project requires developing care coordination teams, including nurses, pharmacists, dieticians and community health workers, to address medication adherence, health literacy issues, and lifestyle changes for patients. It also addresses empowering the patient to become more effective and confident in the handing of his or her own health issues. Since the project requires an interdisciplinary approach to the management and care of CVD, the Project Committee has representation from all disciplines. The following organizations have provided clinical guidance and expertise to this project: Stony Brook University Hospital, North Shore-LIJ (NSLIJ), Hudson River HealthCare (HRHCare), Eastern Long Island Hospital, King Kullen Pharmacies, Peconic Bay Medical Center, Visiting Nurse Service of New York, John T. Mather Memorial Hospital, Belle Mead Pharmacy Inc., and the Long Island Pharmacists Society.
The PPS is currently finalizing a survey that will be distributed to all Primary Care Physicians (PCPs) within our PPS to establish a baseline of current care practices and tools. HRHCare has implemented the Million Hearts? Campaign in counties outside of Suffolk with great success and plans to roll out this campaign to its Suffolk County sites in the near future.
Project 3.c.i - Diabetes: Evidence-Based Strategies for Disease Management in High Risk/Affected Populations
The number of Medicaid beneficiaries who have diabetes and related long-term complications is significantly higher in Suffolk County when compared to the rest of New York State. Unfortunately, access to diabetes education and the use of secondary screening practices in Suffolk County is limited.
The 3.c.i Project Committee is a multidisciplinary team of experts involved in diabetes education, community engagement, care management and clinical care. The project aims to identify high-risk diabetics, increase access to and use of secondary prevention, expand available education resources and support primary care clinicians with the tools needed to care for complex patients with diabetes, including care management, access to clinical guidelines, educational resources for patients and providers, and point-of-care testing.
The Project Committee has charged a team of subject matter advisors within the SCC Diabetes Education Workgroup to aggregate resources and curriculum that will undergo a literature review for the Diabetes Education Program roll-out. The goal is to identify best practices in diabetes self-management, and ultimately synthesize a unified set of materials for the SCC to use across the PPS.
Project 3.d.ii - Expansion of asthma home-based self-management program
In Suffolk County, the percentage of pediatric Medicaid patients with asthma is 13.3% compared to 4.5% in the general population. This project uses a medical home program enriched with home visits provided by trained community health workers (CHWs) and leverages the strengths of the existing pediatrics' Keeping Families Healthy (KFH) program at a current Level 3 Patient-Centered Medical Home (PCMH) site. The CHWs will be equipped with secure tablet devices and mobile phones. This will help CHWs provide appropriate services to patients and families by allowing them to communicate remotely with health care team members.
To date, the asthma project team has worked diligently to produce a detailed project design and begun to prioritize providers who will be among the first to incorporate the program into their practices. In conjunction with the Stony Brook University Hospital Information Technology (IT) Department, the team is working to develop a patient registry platform that will interface with provider practices.
Project 4.a.ii - Prevent Substance Abuse and other Mental Emotional Behavioral Disorders
This project's initiatives include putting substance abuse screening tools in place in all Suffolk Hospital Emergency Departments, implementing tobacco cessation efforts among select high-risk populations, and working to prevent/reduce underage drinking among Suffolk County residents under the age of 21 who live in the greater Bellport region (which includes Bellport, North Bellport, parts of East Patchogue, Medford and Yaphank, and Native Americans from the Shinnecock Nation).
Steps towards these goals so far have included surveying PPS partners to determine what screening practices are currently used or planned, developing a Screening, Brief Intervention, and Referral to Treatment (SBIRT) implementation team with representation from each Suffolk Hospital, and collaborating with the North Shore-LIJ SBIRT Team and Office of Alcoholism and Substance Abuse Services (OASAS) to develop an implementation webinar for partners to be used across the state.
Next steps include conducting Implementation Team meetings, finalizing the timeline for partner engagement, contracting with partners, and addressing workforce needs.
Project 4.b.ii - Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings
Initiatives under this project include lung and breast cancer screening, colorectal screening education, obesity prevention and tobacco cessation. Specific goals include providing colorectal screening education, offering access to screening for lung and breast cancer, assisting in the adoption of the electronic NYS Quitline "Opt to Quit?" protocol by all PPS providers, using Care Managers to help with Tobacco Cessation, offering Body Mass Index (BMI) screenings, and arranging for HRHCare Nutrition and/or other evidence based obesity prevention programs.
We plan to improve awareness among the community about local screening events, educational activities and health fairs via the Suffolk Care Collaborative website. The collaborative approach planned to pursue this project includes the development of committees and a number of workgroups (Obesity Prevention, Lung Cancer Screening, Breast Cancer Screening, Colorectal Screening Education, and Tobacco Cessation) and representation from HRHCare, Cornell Cooperative Extension, Peconic Bay Medical Center, Mather Hospital, the Suffolk County Department of Health, Long Island Health Collaborative (LIHC) and North Shore-LIJ.