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TOC Program for Inpatient & Observation Units Implementation Toolkit | SCC PROJECT MANAGEMENT OFFICE

SCC │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788 Copyright © 2016 Suffolk Care Collaborative, All rights reserved.

V.2

Transitions of Care Program for Inpatient & Observation Units -

Implementation Toolkit

PROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BIV & 2BIX

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM

SUFFOLK CARE COLLABORATIVE

http://www.suffolkcare.org/

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Transitions of Care Program for Inpatient & Observation Units -

Implementation Toolkit

2nd Edition:

October 20th, 2016

“Building a Healthier Population, One Patient at a Time”

PROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BIV & 2BIX

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


mailto:[email protected]


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

delivery system reform.

Transition of Care for Inpatient & Observation Units Workgroup A composition of subject matter experts engaged to support the development, execution and

monitoring of project milestones.

Transition of Care for Inpatient & Observation Units 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 the Transition of Care Workgroup for their work on the Toolkit:

Hallie Bleau Northwell Health Jean McCarrick John T. Mather Hospital

Zena Brown, MD Northwell Health Gloria Mooney Catholic Health Services

Robert Chaloner Southampton Hospital Eric Niegelberg Stony Brook University Hospital

Denise Davis, St. Charles Hospital Jeanne Nissen John T. Mather Hospital

Sunil Dhuper, MD St. Charles Hospital Kathy O’Keefe Sagamore Children’s Psychiatric Center

Mary Dicostanzo Northwell Health Karol Olsen Good Samaritan Hospital

Sharon DiSunno Southampton Hospital Alyeah Ramjit Suffolk Care Collaborative

Karen Eckert CHS Physician Partners Brad Richman Sagamore Children’s Psychiatric Center

Linda Efferen, MD Suffolk Care Collaborative Brianne Rizzo Brookhaven Memorial Hospital

Lorraine Farell John T. Mather Hospital Robert Ross Southampton Hospital

Joan Faro John T. Mather Hospital George Ruggiero, MD Northwell Health

Brenda Farrell Brookhaven Memorial Hospital Maureen Ruga Northwell Health

Steven Feldman, MD Stony Brook University Hospital Alyssa Scully Suffolk Care Collaborative

Nick Fitterman, MD Northwell Health Karen Shaughness Brookhaven Memorial Hospital

Jason Golbin, DO St. Catherine of Siena Joel Shu, MD Catholic Health Services

Kristie Golden, PhD Stony Brook University Hospital Lloyd Simon, MD Eastern Long Island Hospital

Michelle Goldfarb St. Catherine of Siena Doreen Tansi CHS Physician Partners

Keith Harris John T. Mather Hospital Anna ten Napel Catholic Health Services

Ariel Hayes Northwell Health Donald Teplitz Good Samaritan Hospital

Bonnie Kamen St. Catherine of Siena Mathew Tharakan, MD Stony Brook University Hospital

Christine Kippley Northwell Health Fredric Weinbaum Southampton Hospital

Tara Kraemer Eastern Long Island Hospital Sung Whang St. Charles Hospital

Joseph Loiacono Good Samaritan Hospital Joseph Wisnoski John T. Mather Hospital

Joseph Lamantia Suffolk Care Collaborative Adam Wos John T. Mather Hospital

Karen Lange Good Samaritan Hospital Jessica Wyman Catholic Health Services

Christine Livreri John T. Mather Hospital Dianne Zambori Northwell Health

Phyllis Macchio John T. Mather Hospital Nejat Zeyneloglu Brookhaven Memorial Hospital

Special thanks to Subject Matter Expert Dr. Amy Boutwell, MD, MPP, Collaborative Healthcare Strategies, for expert-guidance, direction and facilitation of our program.


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

Suffolk County DOH Response Hotline

Family Residences & Essential Enterprises, Inc. (FREE) Southampton Hospital

Family Service League, Inc. Central Nassau Guidance & Counseling Services, Inc.

Brookhaven Memorial Hospital St. Charles Hospital

Northwell Health Maryhaven

Stony Brook University Hospital Federation of Organizations

Care Connection Home Care, LLC Nesconset Center for Nursing and Rehab

King Kullen Pharmacies Corp. St. Catherine of Siena

Visiting Nurse Service of NY Interim Healthcare of Greater NY, Western NY & NJ

Good Samaritan Hospital Belle Mead Pharmacy Inc.

Avalon Gardens Rehab South Shore Home Services, Inc.

Smithtown Center for Rehab & Nursing Care YMCA Family Services

St. Christopher’s Inn Brunswick Hospital Center

Sagamore Children’s Psychiatric Center Catholic Health Services


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Table of Contents Acknowledgements ....................................................................................................................................... 3

Transition of Care for Inpatient & Observation Units Workgroup ....................................................... 3

Transition of Care for Inpatient & Observation Units Committee ........................................................ 3

Overview ....................................................................................................................................................... 7

Background ............................................................................................................................................... 7

State-wide Effort: Delivery System Reform Incentive Payment Program ................................................ 7

Local Leadership: Suffolk Care Collaborative ............................................................................................ 7

Transition of Care Program for Inpatients & Observation Units .............................................................. 7

Program Goals ........................................................................................................................................... 8

Purpose of the Implementation Toolkit .................................................................................................... 8

Returning DSRIP Documents to the Suffolk Care Collaborative ............................................................... 9

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

Section 1: SCC Project Management Office ................................................................................................ 10

Project Charter ........................................................................................................................................ 11

Clinical Guidelines Summary ................................................................................................................... 15

Suffolk Care Collaborative TOC/OBS Program Contacts ......................................................................... 16

Facility Champion & Performance Logic Directory ................................................................................. 17

Section 2: TOC Program Protocols & Guidelines ........................................................................................ 18

TOC Workflow Diagram .......................................................................................................................... 19

OBS Workflow Diagram .......................................................................................................................... 20

Social Needs Screen Example ................................................................................................................. 21

TOC Program Protocols & Guidelines ..................................................................................................... 22

Care Transition Intervention (Transition of Care) Program Protocol ........ Error! Bookmark not defined.

Care Record Transition Protocol ................................................................ Error! Bookmark not defined.

Transitions of Care Program for Inpatient and Observation Units ................ Error! Bookmark not defined.

Health Home Eligibility & Navigation Protocol .......................................... Error! Bookmark not defined.

Section 3: Training Curriculum .................................................................................................................... 24

Training Guidelines for Hospital Partners ............................................................................................... 25

Training Requirements ........................................................................................................................ 25

Recommended Training Specifications ............................................................................................... 25

Transition of Care Program for Inpatient & Observation Units .............................................................. 26

Community Orientation .......................................................................................................................... 27


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Care Coordination Methodology, Protocol & Treatment Plans.............................................................. 28

Care Coordination & Transition Management Certification (CCTM) Program ....................................... 28

What is CCTM-RN? .............................................................................................................................. 29

CCTM Certification .............................................................................................................................. 29

SCC Transition of Care Train the Trainer Model ................................................................................. 30

Section 4: Implementation Plan .................................................................................................................. 31

TOC/OBS Implementation Plan ............................................................................................................... 32

BH Co-Morbidity ICD 9 Diagnosis Codes ................................................................................................. 36

BH Co-Morbidity ICD 10 Diagnosis Codes ............................................................................................... 37

Section 5: OBS Program Development Request ......................................................................................... 38

Section 6: Reporting to the SCC .................................................................................................................. 39

Patient Engagement ................................................................................................................................ 40

SCC Project 2.b.iv Patient Engagement Template - Transitions of Care ............................................. 42

SCC Project 2.b.ix Patient Engagement Template - Observation........................................................ 44

Documents to Be Returned..................................................................................................................... 45

Transition of Care Program Hospital-Partner Facility Champion ........................................................ 46

Identifying Your TOC/OBS Implementation Team .............................................................................. 48

Implementation Team Composition Roster Template ....................................................................... 49

Submitting a TOC Model Program Training Inventory Form .............................................................. 50

TOC Model Training Sign-In Sheet Template ...................................................................................... 51

Documentation Request Form Demonstrating TOC Provider Access ................................................. 52

EHR Social Needs Screening Request Form ........................................................................................ 53

DIRECT Secure Email Request Form .................................................................................................... 55

Section 7: Program Resources .................................................................................................................... 56


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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 (DSRIP) Program, a grant 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 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.

Transition of Care Program for Inpatients & Observation Units The objective of these programs is to provide a 30-day supported transition period after a

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

risk of readmission and to establish appropriately sized observation units (either a dedicated unit or

scattered-bed approach) in all hospitals in the county to reduce short stay admissions, thereby

minimizing Potentially Preventable Readmissions.


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

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

https://suffolkcare.org/aboutDSRIP/projects

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Click here to access our program webpage.

Program Goals Procedures reflect implementation of a 30 day transition of care period for high risk inpatient

and observation (OBS) patients at participating Suffolk Care Collaborative (SCC) hospitals

Care Transition Plan is standardized for the SCC and includes the following minimum

requirements: follow up appointments, patient self-education, and medication reconciliation

Establish appropriately sized and staffed observation (OBS) units in close proximity to ED

services, unless the services required are better provided in another unit. When the latter

occurs, care coordination must be provided.

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 Transition of Care Program for Inpatient & Observation Units, 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.

The toolkit is divided into sections:

Section 1: SCC PMO Documents

Section 2: TOC Program Protocols & Guidelines

Section 3: Training Curriculum

Section 4: Implementation Plan

Section 5: OBS Development Request

Section 6: Reporting to the SCC

Section 7: Program Resources


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

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Returning DSRIP Documents to the Suffolk Care Collaborative 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. Program resources include the following:

Implementation Resources

Provider Resources

Patient Education Resources

Additional Reading Materials


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Section 1: SCC Project

Management Office


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Suffolk Care Collaborative Transitions of Care Project for Inpatients and Observation Units

2biv. Care transitions intervention model to reduce 30-day readmissions of

chronic health conditions & 2bix. Implementation of Observation Programs in Hospitals

Project Charter

Through the Delivery System Reform Incentive Payment (DSRIP) Program, a grant 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: To provide a 30-day supported transition period after a hospitalization to ensure discharge directions and plans are understood and implemented by and for e patients at risk of return to acute care, particularly patients with cardiac, renal, diabetes, respiratory and/or behavioral health disorders (2biv). To establish appropriately sized observation units (either dedicated beds or scattered beds) in all hospitals in the county to reduce short stay admissions, thereby minimizing Potentially Preventable Readmissions (2bix). High Level Deliverables:

Develop standardized protocols for a Care Transitions Intervention Model with all participating hospitals, partnering with a home care service or other appropriate community agency.

Engage with the Medicaid Managed Care Organizations and Health Homes to develop transition of care protocols that will ensure appropriate post-discharge protocols are followed.

Ensure required social services participate in the project.

Transition of care protocols may include early notification of planned discharges and the ability of a transition care manager to visit the patient while in the hospital to develop the transition of care services.

Establish protocols that include care record transitions with timely updates provided to the member’s providers, particularly to members’ primary care provider.

Use EHRs and other technical platforms to track all patients engaged in the project.

Establish appropriately sized and staffed OBS units in close proximity to ED services, unless the services required are better provided in another unit. When the latter occurs, care coordination must be provided.


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Implement standard 30-day care coordination methodology for safe discharge with inpatient and observation patients (short stay) protocol

Hospital EHR Meets Meaningful Use Stage 2

Hospital EHR Meets connectivity to RHIO’s HIE and SHINY-NY requirements Benefits: There were 30,678 “at risk” admissions within Suffolk County in 2012, which in turn triggered 1,580 Potentially Preventable Readmissions (PPR) chains. Implementation of an effective Transitions of Care (TOC) program could address this high level of PPRs. Assumptions:

Significant cause of avoidable readmissions is non-adherence with discharge regimens as a result of language issues, health literacy, and lack of engagement / access with the community health care system.

Constraints:

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

Lack of electronic connectivity between providers, facilities, hospitals, and SNFs within the community

Communications challenges and barriers as well as real time information

High-Level Risks: Patient Challenges: 1) Lack of transportation results in missed follow-up appointments post hospital discharge. 2) Many patients need to be discharged to a SNF, however a number of long-term care facilities are reluctant to take Medicaid patients which delays the patient’s disposition. 3) Homelessness places patients at risk of readmission due to increased difficulty of providing care management services to this population. Patient Remedies: 1) Expansion of Suffolk County Accessible Transportation (SCAT) program; the PPS will work to streamline the process to make transportation services more accessible to the patient. 2) The PPS will forge collaborative relationships with all participating SNFs and ensure that the payment model creates alignment of the SNFs with the purpose of the PPS. 3) A Multidisciplinary teaming process that includes a social worker/CHA/CHW may be engaged to address these potential issues. The social worker/CHA/CHW will work closely with PPS CBO's to reach patients in their communities in an effort to educate and engage them in their own health and monitor their progress towards adequate self-management of disease. Provider Challenges: 1) Lack of available PCP or BH appointments for post-discharge visits. 2) Coordination of handoffs between multiple entities can be difficult and the patient may receive conflicting messages. 3) Providers might be at different stages of readiness for meeting project requirements


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Provider Remedies: 1) As relevant PPS providers move towards NCQA PCMH Level 3 status, additional appointments will be available as practices become more efficient. PCP recruiting efforts will occur and the collaboration with BH providers will improve access. 2) Protocols will be established to provide early notification of discharge and avoid duplication of effort. This will be accomplished in the following ways: a) Hospital alert to PCP office, Health Homes and CM b) Discharge summaries transmitted electronically within 24 hours c) The PCP – Hospitalist communication provides requisite information to support the TOC. 3) PPS will develop provider prioritization plan to provide the appropriate training to providers and develop plan for a staged roll-out project implementation Infrastructure Challenges: 1) Difficulty redeploying or hiring the CMs required for the program 2) Lack of interconnectivity and use between existing EHRs and the RHIO. Infrastructure Remedies: 1) The PPS will leverage existing Health Homes capability/capacity and then work together as a PPS to identify sources of CM’s to redeploy and to hire. Training resources will be made available through the creation of a Provider Engagement team to engage the redeployed staff in appropriate training programs (e.g., online, in person, etc.). Additionally, the PPS may elect to is actively searching, through collaboration with a vendor or existing CMO’s partner for enough CM's to be effective in providing CM services across Suffolk County. Overarching care management structure will ensure appropriate risk stratification and effective use of CM resources. 2) Effective implementation of the PPS’s IDS IT strategy, and an emphasis on continual improvement, will enable the PPS to create this route for information sharing and communication. 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)

Overall achievement of project objective

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

Stakeholder Analysis: The Transitions of Care Project will include PPS partners from across the continuum of care including hospitals, CBOs, SNFs, Health Homes, MCOs, home care agencies, and other social service agencies. Care management and coordination of care will be key to the success of the project and preventing avoidable readmissions to the hospitals. The Suffolk Care Collaborative’s Care Management program will add additional resources to existing agencies and resources within the county. 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


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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: The Suffolk Care Collaborative is in the process of building a care management organization to support the TOC program goals. Under the direction of the SCC, transition care managers will provide support for a high risk patient post-discharge for 30 days. These care managers will link Health Home, primary care medical home, and community based behavioral health resources for patients post discharge. The model encompasses patient risk assessment, multi-disciplinary rounding, enhanced patient communication, and proactive care coordination, with patient centric information. In the outpatient setting, care management outreach will occur to ensure post discharge follow-up; medication reconciliation and a PCP visit post discharge, all facilitated through EHR communication links and a care management tool. The SCC will also create countywide partnerships with existing social service, home care, care management, community based organizations and align with MCOs and Health Homes to ensure that post-discharge protocols are followed. The Transition of Care Plan that will be designed will be a collective effort of all parties described herein to create a valuable program for all Suffolk County hospitals. In the acute care setting, the interdisciplinary team may include: Social Worker (SW), TOC/primary nurse, physician, rehabilitation specialist, pharmacist and others. The multidisciplinary team will help to ensure ongoing sharing of information between acute care and community settings. Discharge planning will begin at admission. Follow up will ensure communication with community-based organizations to address potential barriers to care post discharge e.g. transportation, housing, linguistic barriers. The discharge process will focus on culturally and linguistically competent person-centered care including “teach-backs” and culturally and health literacy appropriate educational materials. The TOC protocols will ensure patients more consistently keep follow-up appointments, receive medication reconciliation and care coordination. This includes protocols that engage the HH CM, home health agencies and Medicaid MCOs at time of discharge, and may include a CM visit to the hospital, home-visits, follow-up calls and urgent care services while awaiting a post-discharge appointment. If there is no existing outpatient (OP) CM, patients will have a case manager assigned to his/her case as available. Patients will be identified as being at high risk of readmission through a patient risk assessment tool. Patients at high risk include: the elderly; patients entering from/returning to a Skilled Nursing Facility (SNF); patients with surgery/procedural complications, infections, cardiovascular, gastro-intestinal, pulmonary, behavioral health conditions; and patients who already have a 30-day readmission.


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Clinical Guidelines Summary

Please click here to access the TOC/OBS Clinical Guidelines summary


http://scc.perflogic.com/document?s=PFN0cj4KMDExMC8xNjIwMy8zL3BkZgo8L1N0cj4K

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Suffolk Care Collaborative TOC/OBS Program Contacts Contact Name Title Email Address Phone Number

Kelly Donnelly Project Manager, Acute Care Transitions

[email protected] 631-638-1048

Jennifer Kennedy Director, Care Transitions Innovation

[email protected] 631-638-1774

Alyssa Scully Sr. Director, PMO [email protected] 631-638-1369

Steven Feldman Project Lead, TOC [email protected] 631-444-7471

Eric Niegelberg Project Lead, OBS [email protected] 631-444-2496

General Contact Information:

Suffolk Care Collaborative

1383 Veterans Highway, Suite 8, Hauppauge, NY 11788

Phone: (631) 638-2227

Fax: (631) 638-1009

Email: [email protected]

www.suffolkcare.org









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Facility Champion & Performance Logic Directory

Performance Logic Users:

Facility Performance Logic User

Email Address Phone Number

Stony Brook Lorie Hamilton [email protected] 631-444-3892

Mather Lorraine Farrell [email protected] 631-686-7685

Brookhaven Karen Shaughness [email protected] 631-654-7792

Southampton Janet Woo [email protected] 631-726-3171

Eastern Long Island Tara Kraemer [email protected] 631-477-5136

Peconic Bay (Northwell)

Ariel Hayes [email protected] 516-465-3141 Huntington (Northwell)

Southside (Northwell)

Good Samaritan (CHS)

Gloria Mooney [email protected] 914-589-0908 St. Charles (CHS)

St. Catherine (CHS)

Facility Champions:

Facility Facility Champion Email Address Phone Number

Stony Brook Mary Ann Lind [email protected] 631-444-2883

Mather Lorraine Farrell [email protected] 631-686-7685

Brookhaven Brianne Rizzo [email protected] 631-687-2838

Southampton Sharon DiSunno [email protected] 631-726-8330

Eastern Long Island Tara Kraemer [email protected] 631-477-5136

Peconic Bay (Northwell)

Ariel Hayes [email protected] 516-465-3141 Huntington (Northwell)

Southside (Northwell)

Good Samaritan (CHS) Joan Geagan [email protected]

St. Charles (CHS) Denise Davis [email protected] 631-474-6458

St. Catherine (CHS) Carol Piazza [email protected] 631-474-6877


















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Section 2: TOC Program

Protocols & Guidelines Please click here to access the Suffolk Care Collaborative

Transitions of Care Model


http://files.ctctcdn.com/b450ac0d401/083c0480-60e8-4f52-81b8-d2095066519a.pdf?ver=1468958920000

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TOC Workflow Diagram


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OBS Workflow Diagram


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Social Needs Screen Example Readmissions rarely result from a singular breakdown in the transition of care and post-hospital

supports. The social needs screen is an assessment that can be used to identify non-healthcare related

issues. The social needs screen is an invaluable tool for cross-setting and ongoing patient care plan

development for current and future providers. Utilizing the table below and the reference, a social

needs screen can be created as it pertains to your Medicaid population.

Access to Primary Care No regular Primary Care Practitioner

Difficulty with transportation to medical care

Work/family responsibilities that interfere with appointments

Regular use of emergency room for care

Access to a medical professional/ organization who helps with your care

Access to BH Care History of behavioral health services

Concern about emotional or mental health

Alcohol or drugs affecting health and wellness

Prescription medications affecting function

Unstable/ Inadequate

Housing

Lack of stable housing

Lack of heat or cooling

Environmental hazards affecting health (mold, etc.)

Lack of safety and security within or outside the home

Food Insecurity/ access Lacks access to adequate amounts of food

Lacks access to nutritious or medically appropriate diet

Legal Issues Barriers to access, coverage, benefits, specialty evaluations or testing, medications,

utilities, stable housing

Recent or repeated incarceration or detention

Language or Literacy Issues Low literacy, low numeracy

Low health literacy – diagnoses, medications, care plan

Low or no ability to speak English

Reference: Boutwell, A., Snow, J., Maxwell, J., Bourgoin, A., & Genetti, S. (2014). Hospital Guide to

Reducing Medicaid Readmissions Toolbox (Vol. 14-0050-1-EF, pp. 24-34) (USA, Agency for Healthcare

Research and Quality, Department of Health and Human Services).


http://www.ahrq.gov/sites/default/files/publications/files/medread-tools.pdf











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TOC Program Protocols & Guidelines Each protocol was carefully designed to speak to NYS DOH requirements in the Transitions of Care and

Observation Unit programs.

Number Program Protocol Name Protocol Document

2biv.2bix.01 Care Transition Intervention (Transition of Care) Program Protocol

- How to define the population (high risk stratification tool)

- TOC care coordination services for high risk population - Early notification of planned discharge - Establish 30-day transition of care coordination service

for safe discharge either to a community or a step down level of service

- Includes short stay protocol specifications (observation unit discharges)

- TOC care manager visitation to develop transition of care services

2biv.2bix.01 (v2)

TOC Care Transition Intervention (TOC) Program Protocol.pdf

2biv.2bix.02 Care Record Transition Protocol - Timely updates to community-based provider/primary

care physician - Including care transition plan in patient medical record - Ensuring medical record is updated in interoperable

EHR or provider record - Use of the CCDA from acute care to community care

provider Care Record Transition Workflow Diagram

- Demonstrating how interoperable systems share data across all participating providers, including responsible parties at every stage.

2biv.2bix.02 (v2)

Care Record Transition Protocol.pdf

2biv.2bix.03

Post Discharge Protocol for Transitional Care Providers - Partnership requirements for home care service or

other community agency - Coordination of care strategies with MCO and Health

Homes - Network social services, including medically tailored

home food services are provided to patients during care transitions

2biv.2bix.03

Post-Discharge Protocol.pdf

2biv.2bix.04 Health Home Eligibility & Navigation Protocol - How to link patients to health homes and eligibility as

required under the ACA 2biv.2bix.04 (v2)

Health Home Eligibility & Navigation protocol.pdf

2biv.2bix.05 Care Coordination for Transitions of Care - Members of the health care team - Coordination between facilities - Engagement of patient and families/guardians in care

coordination - Elements of care coordination, such as referrals - Tracking and management of referrals

2biv.2bix.05 (v2)

Care Coordination for Transitions of Care Protocol.pdf


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2bix.01 Post Discharge Protocol for Short Stay Situations

2bix-01. Post

Discharge Protocol For Short Stay Situations.pdf


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Section 3: Training Curriculum


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Training & Education Guidelines for Hospital Partners

All Suffolk County participating Hospitals will be required to facilitate training of staff participating in the

Hospital’s Transitions of Care Program. Training Requirements are organized into three Learning Modules:

Transition of Care Program for Inpatient & Observation Units, Community Orientation and Care Coordination

Methodology, Protocol & Treatment Plans.

Training Requirements The following Learning Modules include a set of “Topics” further defined later in the Toolkit. Each Topic has a

set of Learning Objectives and associated/attached Training Curricula. Learning Modules 1 & 3 are required.

Hospitals may choose to include additional Learning Modules obtained through the CCTM Certification

Train the Trainer Model.

Recommended Training Specifications Mechanics Training Specifications

Audience TOC Implementation Team, Hospital Administration, Hospital IT Staff, Hospital-Based Providers, Hospital D/C Planner, Hospitals’ selected TOC Providers, Community based organizations, social service agencies, health homes, others as defined by the Hospital TOC Implementation Team.

Facilitator Hospital Defined (Recommendation to assign responsibility to the Hospital TOC Implementation Team, TOC Facility Champion and those certified CCTM staff).

Mode of Training Hospital Defined or SCC Online Learning Center

Frequency

Minimum Annually

•Transition of Care Program for Inpatient & Observation Units

Module 1

•Community Orientation

Module 2

•Care Coordination Methodology, Protocol & Treatment Plans

Module 3

When navigating through the 3 Core Curriculum Modules throughout this booklet, all required training topics are marked with

this symbol:


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

26:



Transition of Care Program for Inpatient & Observation Units

Module 1 Overview: Your hospital staff will have an increased knowledge base of DSRIP, performance

measuring, the Suffolk Care Collaborative Transitions of Care Model, which includes understanding the

care record transition protocol, post-discharge protocols for transitions of care providers and Health

Home eligibility and navigation. These modules will your staff in creating the best discharge plan for

every patient which qualifies for 30-day transitions of care services.

Topic Learning Objectives Training Curriculum

Understanding DSRIP & SCC’s Transition of Care Program

Describe the Suffolk Care Collaboratives’ Transition of Care Program Objectives

Understand the need for a Care Transition Intervention Model in Suffolk County

Identify key trends in high risk populations

Understand the key themes of an effective Care Transition Intervention Model

TOC Training

Presentation Final.pptx

SCC’s Transition of Care for Inpatient & Observation Unit Program

Understand the guidelines of the SCC’s Transition of Care Model

Understand how to define and identify patients at high risk of readmission

Understand the value of a Social Needs Screening

Understand the short stay protocol (observation unit discharges)

Understand the navigation and value of partnerships with home care services, health homes, care management agencies or other community agencies

Understanding your network of social services, including medically tailored home food services to be provided to patients during care transitions

Communication Lines & Care Record Transition

Understanding the Care Record Transition Protocol

Understanding the Care Record Transitions Workflow Diagram

Post-Discharge Protocol for Transitional Care Providers

Timely updates to community-based provider/primary care physician

Define the post-discharge protocol for Transitional Care Providers

Health Homes, Eligibility & Navigation

Understanding what is a Health Home

Understanding how a patient is eligible for Health Home enrollment as required under the ACA how to navigate a patient to a Health Home

Resources About DSRIP & National TOC Models

Understanding Performance Measurement

CMS Discharge Planning Conditions of Participation

Understanding C-CDA & Interoperability

Additional Reading References

TOC Resources PPT

Final.pptx


27:



Community Orientation

Module 2 Overview: This module provides an overview of the Suffolk County Community, its needs and

Suffolk Care Collaborative (SCC) initiatives. It explores how the SCC aims to focus multiple initiatives and

strategies for the high priority needs in Suffolk County to prevent chronic disease, promote mental health

and prevent substance abuse. Participants will gain a better understanding of the population characteristics

and demographics, understand and learn about strategies to address areas of need, and also how the Suffolk

Care Collaborative is connecting target populations and families to health and wellness services within the

community.


Community Orientation

Understand the population characteristics and demographics of Suffolk County

Identify and understand the priority areas/needs in Suffolk County community and the relationship to the chosen clinical projects through our Community Needs Assessment.

Identify areas of need in order to better target the intended recipients

Identify the individuals and communities where avoidable utilization of high-cost health care resources currently exist.

Learn about the SCC and HITE partnership

Core Curriculum-CE

presentation (v 5).pptx

Suffolk_HITE.pdf

Additional Resources:

U.S. Department of Health and Human Services

New York State Department of Health

Long Island Health Collaborative

Health Information Tool for Empowerment: My HITE

211 Long Island


http://www.hhs.gov/ash/about-ash/multiple-chronic-conditions/education-and-training/curriculum/module-2-self-management-support/index.html

https://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_faq.pdf

https://www.lihealthcollab.org/local-organizations.aspx

http://www.hitesite.org/About.aspx

https://211longisland.communityos.org/zf/taxonomy/directory

28:



Care Coordination Methodology, Protocol & Treatment Plans

Module 3 Overview: This module provides an overview of Care Coordination and its place in the health

care delivery system. Emphasis is placed on the importance of coordinated care throughout the

continuum and how social determinants of health can impact a patient’s health outcomes. Participants

will gain an understanding of who can coordinate care, how this is accomplished through transitions of

care, and the importance of providing patients with effective, efficient, patient centered care.


Understanding the Basic Principles and Core Elements of Care Coordination

Understand and define what it means to coordinate care

Describe those members of the care team that coordinate care and how they work as in interdisciplinary team

Understand the importance of coordinating care throughout the care continuum

Describe basic barriers to reaching optimal health outcomes and explain ways in which these barriers can be overcome

Understand the difference between care coordination and care management

Care Coordination

Training 11-16.pptx

Understanding the Purpose & Benefits of Successful Patient Handoffs

Understanding a warm hand-off & benefits of warm hand-offs, referrals and transfers

Understand effective and ineffective transitions in care

Describe the root causes of ineffective transitions

Describe various models of transitions of care

Warm Hand Off

Training.pptx

Integrated Delivery System (IDS) 101

Understanding the concepts of IDS, Clinical Integration, Clinical Interoperability and Population Health Management.

Understand the definition and meaning of an Integrated Delivery System

Understanding the SCC Clinical Integration Strategy

Describe the various levels of care coordination occurring throughout the care continuum

Understand how the DSRIP projects enhance the ability for care to be coordinated

Identify and differentiate between care coordination and more specialized, complex care management occurring at various levels of the integrated delivery system

IDS 101v2 - Core

Curriculum Version.pptx


29:



Care Coordination & Transition Management Certification (CCTM)

Program What is CCTM-RN? The Suffolk Care Collaborative has recognized the importance of supporting our hospital partners, not

just through providing implementation resources but in also supporting educational resources. We have

carefully selected the American Academy of Ambulatory Care Nursing (AAACN) Care Coordination &

Transition Management (CCTM) certification as a recommended educational opportunity providing 26.4

contact hours. While nurses have always had elements of care coordination and transition management

in their practice, patient acuity and health care delivery have become increasingly complex. A new role

for nurses primarily performing these activities has evolved into a CCTM role.

The Care Coordination & Transition Management course covers 13 modules as listed below:

1. Care Coordination & Transition Management Introduction

2. Advocacy

3. Education and Engagement of Patients and Families

4. Coaching and Counseling of Patients and Families

5. Patient-Centered Care Planning

6. Support for Self-Management

7. Nursing Process: Proxy for Monitoring and Evaluation

8. Teamwork and Collaboration

9. Cross Setting Communications and Care Transitions

10. Population Health Management

11. CCTM Between Acute Care and Ambulatory Care

12. Informatics Nursing Practice

13. Telehealth Nursing Practice

Supplemental resources to the online modules also include a core text and a library of online resources

provided by the AAACN.

CCTM Certification Upon completion of the modules listed above, the nurses may choose to sit for the CCTM-RN

certification. The certification is administered by the Medical-Surgical Nursing Certification Board

(MSNCB) and encompasses six (6) main domains:

1. Communication and Transition Throughout the Care Continuum

2. Education, Engagement, Coaching and Counseling of Patients, Caregivers and Support Network

3. Population Health Management

4. Patient-Centered Care Planning and Support for Self-Management

5. Teamwork and Inter-professional Collaboration

6. Advocacy

Recommended recertification should occur every five (5) years via exam or CME. Upon obtaining the

certification, nurses will have further developed tools to help them make evidence-based, patient-

centered decisions. These tools will improve patient outcomes, enhance access to quality care, decrease

health care costs, help patients navigate the health care system, ensure continuity and seamless


https://www.aaacn.org/cctm

https://www.aaacn.org/cctm

https://www.aaacn.org/cctm/course-details

https://msncb.org/care-coordination

30:



transitions among differing levels of care and settings and improve the ultimate overall goal, patient

experience.

SCC Transition of Care Train the Trainer Model

Opportunity Provided by the Suffolk Care Collaborative & Exam Requirements

The SCC is proud to offer this certification to two (2) registered nurses (RN) at each hospital facility

within the PPS. AAACN requires the chosen nurses to have a minimum of two (2) years in a care

coordination/transition management role and a minimum of 2,000 hours within the past three (3) years.

These hours can be fulfilled in an acute, ambulatory, sub-acute, school health or home health setting.

Examples of roles that qualify for the CCTM-RN certification are Care Coordinator, Transitions Manager,

Care or Case Manager, Discharge Planner and many more. Please see the AAACN and MSNCB websites

for further information.

Suffolk Care Collaborative Contact Information

Please feel free to reach out the Suffolk Care Collaborative with any questions you have regarding the

CCTM-RN certification.

Kelly Donnelly, MHA Project Manager, Acute Care Transitions

1383-8 Veterans Memorial Highway Hauppauge, NY 11788

Tel: (631) 638-1048 Fax: (631) 638-1009

[email protected]

Jennifer Kennedy, RN, BSN, MS Director, Clinical Transitions Innovation

1383-8 Veterans Memorial Highway Hauppauge, NY 11788

Tel: (631) 638-1774 Fax: (631) 638-1009

[email protected]


https://www.aaacn.org/cctm/course-details

https://msncb.org/care-coordination



31:



Section 4: Implementation

Plan

-




TOC/OBS Implementation Plan Suffolk Care Collaborative Transitions of Care Hospital Implementation Plan (Transitions of Care)

WBS Project Plan Est. Start Est.

Complete Status Support Role Supporting Documentation

1Transition of Care Model Implementation Plan for Hospital Complete 1/1/2016 3/31/2017 Kelly Donnelly

1.1 Hospital Initiates Program Implementation & Builds internal capacity to Implement TOC Program 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.1.1 Hospital-based Facility Champion Designated 01/01/16 09/30/16 Scheduled Kelly Donnelly Hospital-based Facility Champion Form

1.1.2 Hospital-based Performance Logic End User Designated 01/01/16 09/30/16 Scheduled Kelly Donnelly Hospital-based Facility Champion Form

1.1.3 Hospital-based Performance Logic End User Completes Performance Logic Training

01/01/16 09/30/16 Scheduled Kelly Donnelly

1.1.4 Obtain approval/endorsement of SCC TOC Model & Implementation Plan by Sr. Leadership 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.1.5 Build Hospital-based TOC Program Implementation team 01/01/16 09/30/16 Scheduled Kelly Donnelly TOC Model Implementation Team Directory Form

1.1.6 Present TOC Implementation Team the TOC Model and Project goals 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.1.7

Build and Roll-out Hospital-wide communication/awareness plan for TOC Model Implementation prior to training efforts to all roles named in TOC Model 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.1.8 TOC Implementation Team log issues and risks during implementation (including ability to collect feedback from frontline staff) 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.2 DSRIP TOC Program Quarterly Reporting Initiated 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.2.1 Hospital-based Facility Champion is informed on Quarterly Reporting expectations (as Described in TOC MODEL) 12/01/15 09/30/16 Scheduled Kelly Donnelly

1.2.2 Hospital-based Facility Champion initiates Quarterly Reporting Schedule 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.3 TOC Program Training Complete 01/01/16 01/31/17 Scheduled Kelly Donnelly

1.3.1 Organizing Training Approach based on TOC Model Training Methodology


1.3.2 Identify who is to be trained and training dates 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.3.3 Schedule and host training sessions 01/01/16 01/31/17 Scheduled Kelly Donnelly


33:



1.3.4 Keep record of training dates and number of staff trained using SCC Templates


1.3.5 Training documentation submitted to the SCC PMO through Performance Logic

01/01/16 01/31/17 Scheduled Kelly Donnelly TOC Model Training Attestation Form

1.3.6 Training documentation submitted to the SCC PMO through Performance Logic

01/01/16 01/31/17 Scheduled Kelly Donnelly TOC Model Training Sign In Sheets

1.4 TOC Model is Implemented for Inpatient & Observation Units (including PSYCH)


1.4.1 High Risk Population Identification Rolled Out (TOC MODEL STEP 1) 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.1.1 Build Social Needs screen 03/31/16 06/30/16 Scheduled Kelly Donnelly

1.4.1.2 Social Needs screens are implemented 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.2 Early Notification of Patient & Partners of Planned Discharge Rolled Out (TOC MODEL STEP 2) 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.3 Provision of a Written Transition of Care Plan Rolled Out (TOC MODEL STEP 3)


1.4.4 Timely Completion of Discharge Summary Expectations Rolled Out (TOC MODEL STEP 4) 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.5 30-TOC Service Provider Identified & Services Rolled Out (TOC MODEL STEP 5)


1.4.5.1 Hospital identify TOC provider for 30-day TOC services 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.5.2 Incorporate into hospital protocols and procedures the ability of the TOC Provider to visit the patient in the hospital 03/31/16 03/31/17 Scheduled Kelly Donnelly

Documentation demonstrating that the TOC Provider has access to visit their patients in the Hospital.

1.4.6 Communication Methodology for Care Coordination Rolled Out (as Described in TOC MODEL) 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.7

Process in place for Primary Care Practitioner assigned to High Risk patient participating in TOC Model is sent care transition plan electronically OR care transition plan updated in interoperable EMR 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.8 Community Navigation Services are Initiated 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.8.1 Hospital using HITE Tool as a resource to collect list of CBOs, social services, MCOs, and health homes for navigation 03/31/16 03/31/17 Scheduled Kelly Donnelly


34:



1.4.8.2 Primary Care Navigation rolled out 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.9 Communication & Building Community-based Partnerships Complete 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.9.1

TOC Model is communicated to Community based post-discharge partners (i.e. Medical Staff, community or step-down level of service, behavioral health or assisted living/SNF). 03/31/16 03/31/17 Scheduled Kelly Donnelly

1.4.9.2 Create TOC partnerships with Home Care Agencies 03/31/16 03/31/17 Scheduled Kelly Donnelly TOC Model Partnership Template

1.4.9.3 Create TOC partnerships with social service agencies 03/31/16 03/31/17 Scheduled Kelly Donnelly TOC Model Partnership Template

1.4.9.4 Create TOC partnerships with Health Homes to properly navigate eligible patients

03/31/16 03/31/17 Scheduled Kelly Donnelly TOC Model Partnership Template

1.5 IT/EMR Requirements are Complete 01/01/16 03/31/17 Scheduled Kelly Donnelly

1.5.1 IT/EMR is equipped to implement TOC Program Model 01/01/16 09/30/16 Scheduled Kelly Donnelly

1.5.1.1 Social Needs Screenings are available/documented in EMR 01/01/16 09/30/16 Scheduled Kelly Donnelly

Screen shot of EHR demonstrating screenings are documented

1.5.1.2 High Risk flags based on TOC Model High Risk criteria is built into Inpatient & OBS EMR


1.5.2

Hospital actively sharing EMR System with local health information exchange/RHIO/SHINNY and sharing health information among clinical partners 01/01/16 03/31/17 Scheduled Kelly Donnelly

1.5.2.1 Hospital EMR meets connectivity to RHIO's HIE and SHIN-NY Requirement. Hospital RHIO QE Agreement submitted to the SCC PMO 01/01/16 03/31/17 Scheduled Kelly Donnelly QE Participation Agreement

1.5.2.2 Sample of transactions to public health registries submitted to SCC PMO 01/01/16 03/31/17 Scheduled Kelly Donnelly Sample of transactions to public health registries

1.5.2.3

Evidence of DIRECT secure email transactions using national standards (i.e. DIRECT) submitted to SCC PMO [Evidence should include screenshot of email between multiple parties demonstrating encryption] 01/01/16 03/31/17 Scheduled Kelly Donnelly

Sample DIRECT secure email transactions

1.5.3 Meaningful Use Certification Form CMS or NYS Medicaid or EHR Proof of Certification Submitted to the SCC PMO 01/01/16 03/31/17 Scheduled Kelly Donnelly

Meaningful Use Certification Form CMS or NYS Medicaid or EHR Proof of Certification

1.5.4 Technical on-boarding is Complete 01/01/16 03/31/17 Scheduled Kelly Donnelly


35:



Suffolk Care Collaborative Transitions of Care Hospital Implementation Plan (Observation Unit Implementation)

2 Observation Model Implementation Plan for Hospital Completed 1/1/2016 3/31/2019 Kelly Donnelly

WBS Project Plan Est. Start Est.

Complete Status Support Role

Supporting Documentation

Determine if Observation Program will function in a scattered bed or dedicated unit for implementation 01/01/16 06/30/16 Scheduled Kelly Donnelly

2.1.1 Email determination to SCC Project Manager 01/01/16 06/30/16 Scheduled Kelly Donnelly

2.2 Observation Program Opportunity Assessment Complete & Submitted 01/01/16 09/30/16 Scheduled Kelly Donnelly Observation Program Opportunity Assessment

2.2.1 Hospital-based Facility Champion is educated on the Observation Program Opportunity Assessment Request 01/01/16 09/30/16 Scheduled Kelly Donnelly

2.3 OBS Program Baseline Clinical & Financial Model Complete & Submitted 01/01/16 09/30/16 Scheduled Kelly Donnelly

Observation Program Clinical & Financial Model Assessment

2.3.1 Hospital-based Facility Champion is educated on the SCC OBS Unit Baseline Clinical & Financial Model Document Request 01/01/16 09/30/16 Scheduled Kelly Donnelly

2.3.2 1st Annual Periodic reports demonstrating gap to clinical and financial goals for OBS program Submitted 01/01/16 09/30/17 Scheduled Kelly Donnelly

2.3.3 2nd Annual Periodic reports demonstrating gap to clinical and financial goals for OBS program Submitted 01/01/16 09/30/18 Scheduled Kelly Donnelly

2.3.4 3rd Annual Periodic reports demonstrating gap to clinical and financial goals for OBS program Submitted 01/01/16 03/31/19 Scheduled Kelly Donnelly

2.3.5

Implementation Plan for Hospital Observation Unit drafted (if OBS program exists please share a copy of the implementation plan used to implement your OBS program) 01/01/16 12/31/16 Scheduled Kelly Donnelly

Hospital Observation Program Implementation Plan

2.3.6 Implementation Plan for Hospital Observation Unit initiated 01/01/16 12/31/16

3 CRFP Project Completed (Applicable to Hospitals receiving CRFP Funding Only)


Please contact Kelly Donnelly, Project Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative with any questions.



36:



BH Co-Morbidity ICD 9 Diagnosis Codes HPC Category ICD 9 Code

Behavioral Health 290-319

Exclude Dementia 290

Exclude Tobacco 305.1

Delirium 293.0

Exclude Intellectual Disabilities 317-319

Alzheimer’s Disease 331.0

Alcoholic Polyneuropathy 357.7

Alcoholic Cardiomyopathy 425.5

Alcoholic Gastritis 535.3 – 535.31

Alcoholic subsection of Chronic liver disease and cirrhosis 571.0 – 571.3

Poisoning by analgesics, antipyretics, and anti- rheumatics 965.00 – 965.09

Surface (topical) and infiltration anesthetics 968.5

Psychodysleptics 969.6

Drug Dependence 648.30 – 648.34

Heroin E850.0

Psychodysleptics E854.1

Alcoholic beverages E860.0

Heroin E935.0

Surface and infiltration anesthetics E938.5

Psychodysleptics E939.6

Counseling on substance use and abuse V65.42

Self-harm N/A

Reference: Boutwell, A., Snow, J., Maxwell, J., Bourgoin, A., & Genetti, S. (2014). Hospital Guide to Reducing Medicaid

Readmissions Toolbox (Vol. 14-0050-1-EF, pp. 24-34) (USA, Agency for Healthcare Research and Quality, Department of

Health and Human Services).














37:



BH Co-Morbidity ICD 10 Diagnosis Codes HPC Category ICD 10 Code

Behavioral Health F01-F99

Exclude Dementia F01-F03

Exclude Tobacco F17

Delirium F05 – F06

Exclude Intellectual Disabilities F70-F79

Alzheimer’s Disease G30.0 – G30.9

Alcoholic Polyneuropathy G62.1

Alcoholic Cardiomyopathy I42.6

Alcoholic Gastritis K29.2

Alcoholic subsection of Chronic liver disease and cirrhosis K70

Poisoning by analgesics, antipyretics, and anti- rheumatics T39, T40

Surface (topical) and infiltration anesthetics T41.3

Psychodysleptics T40

Drug Dependence O99.31, O99.32

Heroin Included in T40

Psychodysleptics Included in T40

Alcoholic beverages T51.91XA

Heroin Included in T40

Surface and infiltration anesthetics Included in T41.3

Psychodysleptics Included in T40

Counseling on substance use and abuse Z71.41, Z72.51

Self-harm R45.851, T14.91

Reference: Boutwell, A., Snow, J., Maxwell, J., Bourgoin, A., & Genetti, S. (2014). Hospital Guide to Reducing Medicaid

Readmissions Toolbox (Vol. 14-0050-1-EF, pp. 24-34) (USA, Agency for Healthcare Research and Quality, Department of

Health and Human Services).














38:



Section 5: OBS Program

Development Request Please click here to access the Suffolk Care Collaborative OBS

Opportunity Assessment with Clinical & Financial Template


http://files.constantcontact.com/b450ac0d401/d1f0c9b3-ae3c-4b8e-a3d4-70611f643079.docx?ver=1470400049000

39:



Section 6: Reporting to the SCC


40:



Patient Engagement

Throughout the length of DSRIP years for the TOC/OBS programs a certain number of “Actively Engaged” patients must

be met per quarter. Our goal is to always meet these goals and perhaps exceed them with partner participation.

TOC Targeted Patient Engagement OBS Targeted Patient Engagement

DSRIP Year & Quarter

Expected Patient Engagement

DY2, Q1 2,034

DY2, Q2 10,170

DY2, Q3 15,255

DY2, Q4 25,326

DY3, Q1 2,543

DY3, Q2 12,713

DY3, Q3 19,018

DY3, Q4 25,326

DY4, Q1 2,543

DY4, Q2 12,713

DY4, Q3 19,018

DY4, Q4 25,326

DY5, Q1 25,326

DY5, Q2 25,326

DY5, Q3 25,326

DY5, Q4 25,326

*Denotes 100% Active Patient Engagement

DSRIP Year & Quarter

Expected Patient Engagement

DY2, Q1 886

DY2, Q2 3,103

DY2, Q3 4,987

DY2, Q4 6,650

DY3, Q1 2,216

DY3, Q2 4,433

DY3, Q3 6,650

DY3, Q4 8,866

DY4, Q1 2,216

DY4, Q2 4,433

DY4, Q3 6,650

DY4, Q4 8,866

DY5, Q1 8,866

DY5, Q2 8,866

DY5, Q3 8,866

DY5, Q4 8,866


41:



Domain 1 Patient Engagement Data Request

Suffolk Care Collaborative Transitions of Care (TOC) Project

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

Patient Grouper: Medicaid Patient Data (Medicaid may be Primary, Secondary or Tertiary Insurance) Project 2biv: Transitions of Care Program Patient Engagement Definition: As per the definition of actively engaged, patient engagement refers to the number of participating patients who receive discharge instructions that include patient self-education, medication reconciliation, and follow-up appointments, prior to discharge. Duplicate counts of patients are allowed within 1 DSRIP measurement year, if the patient has multiple encounters, each encounter is counted. For example, if a patient receives TOC care plans on 5 discharges in a year, we count it 5 times in that DSRIP year.

2.b.iv Transition of Care Data Specs Request:

1. CIN # 2. Patient Last Name 3. Patient First Name 4. DOB 5. Zip Code 6. Arrival date 7. Discharge date 8. Primary Payor Name 9. Primary Payor Patient ID Number 10. Secondary Payor Name 11. Secondary Payor Patient ID Number 12. Tertiary Payor Name 13. Tertiary Payor Patient ID Number 14. Encounter Type (inpatient) 15. Completed CCDA and/or discharge instructions that includes patient self-education, follow-up

appointments, and medication reconciliation given prior to discharge.

Please note the patient engagement metrics and definitions are subject to change.


42:



SCC Project 2.b.iv Patient Engagement Template - Transitions of Care For questions or more information, please contact Kevin Bozza, Director, Network

Development & Performance at [email protected] or Alyssa Scully,

Director, PMO at [email protected]

Please click here to access the Patient

Engagement-TOC Excel Template




https://suffolkcare.org/forpartners/datarequest

43:



Domain 1 Patient Engagement Data Request

Suffolk Care Collaborative Observation Projects

Request: Please return the attached SCC excel template via BOX For BOX questions or access related inquiries, please contact Kelly Tamburello,

[email protected]

Patient Grouper: Medicaid Patient Data (Medicaid may be Primary, Secondary or Tertiary Insurance)

Project 2bix: Hospital Observation Program Development

Patient Engagement Definition: As per the definition of actively engaged, patient engagement refers to

the number of participating patients who are utilizing the OBS services that meet project requirements.

Duplicate counts of patients are not allowed within 1 DSRIP measurement year. Counts are not additive

across DSRIP years.

The following constitutes one utilization unit of the observation services, all patients with an APG rate

code 1402 billed with CPT/HCPCS code G0378 (without regard to units [hours] attached to the G0378). It

does not to be limited to this code, since this code will vary by hospital. Please assure in the report

specifications this was an “OBS” patient.

Patients transferred to an Inpatient Status from the Observation Status will NOT count, and should

not be reported.

In addition to Medical Observation patients, Psychology Observation patients “Psych OBS” or “POB”

may be included.

Project 2.b.ix: Hospital Observation Program Report Data Specifications:

1. CIN #

2. Patient Last Name

3. Patient First Name

4. DOB

5. Zip Code

6. Arrival date

7. Discharge date

8. Primary Payor Name

9. Primary Payor Patient ID Number

10. Secondary Payor Name

11. Secondary Payor Patient ID Number

12. Tertiary Payor Name

13. Tertiary Payor Patient ID Number

14. Encounter Type (Observation Program patients only)

Please note the patient engagement metrics and definitions are subject to change.


44:



SCC Project 2.b.ix Patient Engagement Template - Observation For questions or more information, please contact Kevin Bozza, Director, Network

Development & Performance at [email protected] or Alyssa Scully,

Director, PMO at [email protected]

Please click here to access the Patient

Engagement-OBS Excel Template




https://suffolkcare.org/forpartners/datarequest

45:



Documents to Be Returned

Note: Please be advised the OBS Opportunity Assessment & Clinical and Financial Model Template will

be completed on an annual basis through 2019.

Project Document Name Due Date

(uploaded into Performance Logic)

Frequency of

Submission Submission Mode

1 Hospital-based Facility Champion Form 9/30/16 Once Performance Logic

2 TOC Model Implementation Team

Directory Form

9/30/16 Once Performance Logic

3 Screenshot of EHR demonstrating screenings are documented (Social Needs

Screen)


3 TOC Model Training Attestation Form 1/31/17 Once Performance Logic

4 TOC Model Training Sign-In Sheets 1/31/17 Once Performance Logic

5 Documentation demonstrating that the

TOC Provider has access to visit their

patient in the hospital


6 QE Participation Agreement (RHIO) 3/31/17 Once Performance Logic

7 Sample of transactions to public health registries


8 Sample DIRECT secure email transactions 3/31/17 Once Performance Logic

9 Meaningful Use Certification Form 3/31/17 Once Performance Logic

10 Initial OBS Opportunity Assessment &

Clinical and Financial Model Template



46:



Transition of Care Program Hospital-Partner Facility Champion

Suffolk Care Collaborative (SCC) NYS Delivery System Reform Incentive Payment Program (DSRIP)

Role Description at Hospital:

Key internal stakeholder for the Hospital to support implementation of DSRIP Projects 2.b.ix and 2.b.iv, Observation and Transition of Care.

This role will provide leadership support and assume continuing responsibility for the development, implementation, training, compliance, coordination, maintenance, and evaluation of the DSRIP projects.

This individual will also be enthusiastic about the program and its potential, motivate staff, and have the experience and skills to coordinate the program.

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 tasks, and assisting the team to work effectively with each unit within the Hospital.

Work with department and management representatives to develop accountability systems for implementation purposes.

Role Description in coordination with SCC PMO:

The Facility Champion will play a key role in communication with the Suffolk Care Collaborative Project Management Office.

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

Work as a liaison from the SCC PMO to the Hospitals TOC Implementation Team

Responsible for reporting data to the SCC Project Manager following the Reporting Procedure

Escalate any questions, comments, risks and lessons learned to the SCC PMO

Empower Hospital staff to engage in and move the DSRIP initiatives forward

Communicate any TOC DSRIP related communications internally

Participate in TOC Project Committee, TOC Project Workgroup, and Learning Collaboratives reporting best practices, lessons learned, challenges, etc.


47:



Transition of Care Program Hospital-Partner Facility Champion

Project Management Office │ Suffolk Care Collaborative

Enrollment Information

Name

Title

Department Name

Hospital Name

Professional License (if applicable)

Email Address

Office Telephone Number

Fax Number

Hospital Address

Secretary Name

Secretary Email

Secretary Telephone Number

Additional Notes/Comments

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 upload this form into the Performance Logic tool by 9/30/16. Please contact Kelly Donnelly, Project Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative with any questions.



48:



Identifying Your TOC/OBS Implementation Team

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 TOC/OBS Program from all

corners of the organization.

Role Summary

This team will oversee and champion the implementation of the TOC/OBS Program 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 TOC/OBS Program 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 On a quarterly basis, participate in the SCC TOC/OBS Committee


49:



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: ________________________________

First Name Last Name Title Phone Email

Name (Print): ______________________________________ Title: ________________________



50:



Signature: _____________________________________ Date: ________________

Submitting a TOC Model Program Training Inventory Form

Instructions: Attestation of Training Requirements Fulfilled

Please complete this form when your staff has been trained on the “Training Guidelines for

Hospital Partners” as outlined on page 35 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 [Hospital Facility Name]

_________________________________, were trained on the TOC Model Training Minimum Guidelines as outlined in this manual and the DSRIP Domain 1 Project Requirements by one of the TOC/OBS Facility Champions.

Please check off completed required training modules:

Module 1: Transition of Care Program for Inpatient & Observation Units

Module 3: Care Coordination Methodology, Protocol & Treatment Plans

Name (Print): ______________________________________ Title: ________________________

Signature: _____________________________________ Date: ____________

Please return this form when ALL 2 MODULES ARE COMPLETE with all sign in sheets from each training session, including date and number of staff trained via Performance Logic.





51:



TOC Model Training Sign-In Sheet Template Delivery System Reform Incentive Payment Program (DSRIP) TOC/OBS Training Template:

Instructions: Please upload this form into the Performance Logic tool by 1/31/17. Please contact Kelly Donnelly, Project Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative with any questions.

[Organization Name] [Location]

[Module Number] [Training Facilitator Name & Title]

[Module Training Topic] [Format of Training]

[Date] [Time]

Note: There should be 2 training sign-in sheets upon completion of the required 2 modules as described on page 60

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



52:



Documentation Request Form Demonstrating TOC Provider Access

Request:

Please provide documentation demonstrating that the care manager has access

to visit their patients in the hospital prior to discharge.

Eg: This could be provided via hospital protocols and procedures showing the

ability of the TOC provider to visit the patient in the hospital.

Instructions: Please upload this signed form and the supporting documentation

into the Performance Logic tool by 3/31/17. Please contact Kelly Donnelly, Project

Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative

with any questions.

Name (Print): ______________________________________ Title: ____________________________

Signature: _____________________________________ Date: ____________



53:



EHR Social Needs Screening Request Form Request:

Please provide a screenshot of the documented social needs screen availability in the EHR.

Instructions:

Please upload this form into the Performance Logic tool by 9/30/16. Please contact Kelly Donnelly,

Project Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative with any

questions.

Facility: ______________________________________________

Please insert and label screenshots in the box below:

Name (Print): ______________________________________ Title: ________________________

Signature: _____________________________________ Date: ____________



54:



Public Health Registries Request Form

Request:

Please provide a screenshot of the EHRs ability to send transactions to a public health registry.

Instructions:


Facility: _______________________________________ Please insert and label screenshots in the box below:

Name (Print): ______________________________________ Title: ________________________

Signature: _____________________________________ Date: ____________



55:



DIRECT Secure Email Request Form Request:

Please provide a screenshot of your EHRs ability to send a DIRECT secure email between multiple parties

and also provide a screenshot of encryption.

Instructions:


Facility: _______________________________________ Please insert and label screenshots in the box below:

Name (Print): ______________________________________ Title: ________________________

Signature: _____________________________________ Date: ____________



56:



Section 7: Program Resources


57:



The resources listed below may be utilized for further reference:

1. CMS Readmissions Reduction Program (HRRP)

The link above will provide you with information as it relates to the CMS Readmissions

Reduction Program. Information at this site will provide background to the program, CMS

Readmission Measures and how to calculate the Readmission Adjustment Factor.

2. Hospital Readmissions Reduction Program: Keys to Success

Written by Bobbi Brown, VP of Financial Engagement at HealthCatalyst, this article speaks to the

Hospital Readmission Reduction Program and the benefit of using an Enterprise Data

Warehouse and Analytics Applications on reducing readmissions.

3. Hospital Guide to Reducing Medicaid Readmissions Toolbox

Written by Dr. Amy Boutwell, this guide published in conjunction with the Agency for Healthcare

Quality and Research (AHRQ) is a toll that can be utilized for reducing overall readmissions

specific to the Medicaid population.

4. Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations

Written by Rutherford et al. this guide published from the Institute for Healthcare Improvement is evidence based and provides strategies, key recommendations for effective transitions of care, case studies from several hospital organizations as well as suggested measures, resources and references.

5. Project Red

This guide was created by the researchers at the Boston University Medical Center (BUMC) who

developed and tested the Re-Engineered Discharge (RED). Research showed that the RED was

effective at reducing readmissions and post hospital emergency department (ED) visits. The

Agency for Healthcare Research and Quality contracted with BUMC to develop this toolkit to

assist hospitals, particularly those that serve diverse populations, to replicate the RED.

6. Post-Acute Care Transitions Toolkit

The Society Hospital Medicine provides a wealth of resources to help optimize the transitions of

care processed between short-term acute care hospital stays and Skilled Nursing Facilities.

7. The National Transitions of Care Coalition

This resource has a Compendium which is a collection of resources, papers, journals and website

links for professionals interested in improving transitions of care.

8. Implementing Consolidated Clinical Document Architecture (C-CDA)

A resource from the Office of the National Coordinator for Health Information Technology

discussing Meaningful Use Stage 2 and Clinical Document Architecture (CDA).


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

https://www.healthcatalyst.com/healthcare-data-warehouse-hospital-readmissions-reductionhttps:/www.healthcatalyst.com/healthcare-data-warehouse-hospital-readmissions-reduction


http://www.ihi.org/resources/pages/tools/howtoguideimprovingtransitionstoreduceavoidablerehospitalizations.aspx

http://www.ihi.org/resources/pages/tools/howtoguideimprovingtransitionstoreduceavoidablerehospitalizations.aspx

http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/pact/Overview_PACT.aspx

http://www.ntocc.org/

https://www.healthit.gov/sites/default/files/c-cda_and_meaningfulusecertification.pdf

https://innovation.cms.gov/initiatives/CCTP/

58:



9. Community-based Care Transitions Program (CCTP)

Provided by the Centers for Medicare and Medicaid Services, this link provides information on

the Community-based Care Transitions Program which aims to improves transitions of

beneficiaries from the inpatient hospital care setting to other care settings, to improve quality of

care, to reduce admissions for high-risk beneficiaries, and to document measureable savings to

the Medicare program.

10. Medical Readmission Reduction Toolkit

The Medical Readmission Reduction Toolkit by Advisory Board is a step-by-step guide to

lowering readmission rates. This toolkit is composed of four (4) stages for reference:

Stage 1: Transition Planning During the Inpatient Stay

Stage 2: Discharge Education

Stage 3: Post-acute care coordination

Stage 4: Transitional care support

11. Cleveland Clinic Readmission Patient Interview

An interview template provided by Cleveland Clinic for a readmission patient interview.

Questions are geared towards last admission and events following discharge from last hospital

visit.

12. Collaborative Health Strategies: 8-Step Review Process & Care Plan Templates

Provided by Dr. Amy Boutwell, a presentation identifying the 8 steps to review your strategy

13. Collaborative Health Strategies: Reducing Avoidable Hospital Utilization

Provided by Dr. Amy Boutwell, best practices and promising strategies for reducing avoidable

hospital utilization

14. Eligibility Criteria for Health Home Services: Chronic Conditions

Provided by the NYS DOH this site provides information as it relates to Health Home policy,

eligibility and coverage process.

15. Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing

Medicaid Readmissions Webinar

A webinar presented by Dr. Amy Boutwell, MD, MPP and H. Joanna Jiang, PH.D speaking to the

purpose of the AHRQ Hospital Guide to Reducing Readmissions, understanding the focus on

Medicaid as the catalyst for promoting “whole person” care for all high risk patients and

understanding the Guide’s ASPIRE framework.

16. Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing

Medicaid Readmissions Narrative

A companion narrative to the webinar presented above.


https://innovation.cms.gov/initiatives/CCTP/

https://www.advisory.com/research/cardiovascular-roundtable/studies/2014/readmissions-reduction-toolkit

https://www.advisory.com/-/media/Advisory-com/Research/CR/Research-Study/2014/Readmissions-Reduction-Toolkit/3.pdf

http://files.constantcontact.com/b450ac0d401/f45aceaf-9b09-4a0c-a366-943e10cc40bc.pptx?ver=1471435900000

http://files.constantcontact.com/b450ac0d401/d48121e3-2f5f-4693-a66b-dafdfabe4e14.pptx?ver=1471435900000

http://files.constantcontact.com/b450ac0d401/d48121e3-2f5f-4693-a66b-dafdfabe4e14.pptx?ver=1471435900000

http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/health_home_policy.htm

http://scc.perflogic.com/document?s=PFN0cj4KMDExMC8xNjIwMy82L3BkZgo8L1N0cj4K


