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V.2Skilled Nursing FacilityINTERACT ProgramImplementation ToolkitPROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BVIIDELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAMSUFFOLK CARE COLLABORATIVESUFFOLK CARE COLLABORATIVE PROJECT MANAGEMENT OFFICE www.suffolkcare.org DSRIP@stonybrookmedicine.eduINTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
1INTERACT PROGRAMIMPLEMENTATION TOOLKIT2nd Edition: February 6, 2017Delivering The Best Care at Every Stage Of LifePROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 2BVIIDELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAMThis 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 DSRIP@stonybrookmedicine.eduSUFFOLK CARE COLLABORATIVE1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11778www.suffolkcare.orgINTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
2AcknowledgementsWe would like to acknowledge members of our program who support our ongoing efforts in health caredelivery system reform.INTERACT WorkgroupA composition of subject matter experts engaged to support the development, execution andmonitoring of project milestones.INTERACT CommitteeA composition of key internal and external project stakeholders, including representation from keycommunity and public service and governmental agencies engaged to support the conclusions,deliverables and monitor system impacts of the DSRIP Program.Special thanks to our key contributors for their work on the 1st Edition Toolkit:OrganizationAffinity Skilled LivingApex Rehabilitation and HealthcareBrookside Multicare Nursing Center (Avalon Gardens)Bellhaven Center for Nursing and RehabilitationBroadlawn Manor Nursing and Rehabilitation CenterBrookhaven Rehabilitation & Health Care CenterCarillon Nursing and Rehab Center LLCCentral IslandDaleview Care CenterEast Neck Nursing and Rehab CenterGood Samaritan Nursing HomeGurwin Jewish Nursing & Rehabilitation CenterHamptons Center for Rehabilitation and NursingHilaire Rehab and NursingHuntington Hills Center for Health and RehabilitationIsland Nursing and Rehab CenterLong Island State Veterans HomeMaria Regina ResidenceMills Pond Nursing and Rehabilitation CenterMomentum at South Bay: Rehabilitation and NursingNesconset Center for Nursing and RehabilitationOak Hollow Nursing CenterOur Lady of Consolation Nursing & Rehabilitative Care CenterPeconic BayPeconic Landing at SouthholdRiverhead Care Center DBA Acadia Center for Nursing andRehabilitationNadege DuroseauDiane MontagneseJoanne MendezMichele RandazzoDonna KubeKellie BurridgeClaudia SchreckLisa DowdKim DeschampsDenise MacDonaldDiane GuidoneJulieann YerkesDiane SiegelStana MosieTeri O'DriscollHyacinth HendricksonSandra K. Sharp-HayesAnna MoyetteDolores CruzRegina HarringtonCrystal ThomasDenise CagnoTheresa RosenthalAnna LawLee ColeMary GrecoINTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
3Ross Center for Health and RehabilitationJackyln LynSan Simeon by the Sound Center for Nursing and RehabilitationKelly MoteiroSayville Nursing and Rehabilitation CenterKathleen DiheenedettoSmithtown Center for Rehabilitation and NursingNancy CiaffoneSt. Catherine of Siena Nursing and Rehabilitation Care CenterCindy LePageSt. James Rehabilitation and Health Care CenterKellyAnn LunghiSt. Johnland Nursing CenterSherri ElliottSuffolk Center for Rehabilitation and NursingLaura SchauderSunrise Manor Center for NursingEileen FasuloWater's Edge at Port Jefferson for Rehabilitation and NursingRonald D'AnnaWesthampton Care CenterDeborah SchafmayerWoodhavenSanta EspinalRecognition to the following organizations and coalitions for their collaboration and support:Affinity Skilled LivingApex Rehabilitation and HealthcareBrookside Multicare Nursing Center (Avalon Gardens)Bellhaven Center for Nursing and RehabilitationBerkshire Nursing CenterBroadlawn Manor Nursing and Rehabilitation CenterBrookhaven Rehabilitation & Health Care CenterCarillon Nursing and Rehab Center LLCCentral IslandDaleview Care CenterEast Neck Nursing and Rehab CenterGood Samaritan Nursing HomeGurwin Jewish Nursing & Rehabilitation CenterHilaire Rehab and NursingHuntington Hills Center for Health and RehabilitationIsland Nursing and Rehab CenterLakeview Rehabilitation and Care CenterLong Island State Veterans HomeMaria Regina ResidenceMills Pond Nursing and Rehabilitation CenterMomentum at South Bay: Rehabilitation and NursingNesconset Center for Nursing and RehabilitationOak Hollow Nursing CenterOasis Rehabilitation and NursingOur Lady of Consolation Nursing & Rehabilitative Care CenterPeconic BayPeconic Landing at SouthholdINTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
4Riverhead Care Center DBA Acadia Center for Nursing and RehabilitationRoss Center for Health and RehabilitationSan Simeon by the Sound Center for Nursing and RehabilitationSayville Nursing and Rehabilitation CenterSmithtown Center for Rehabilitation and NursingSt. Catherine of Siena Nursing and Rehabilitation Care CenterSt. James Rehabilitation and Health Care CenterSt. Johnland Nursing CenterSuffolk Center for Rehabilitation and NursingSunrise Manor Center for NursingThe Hamptons Center for Rehabilitation and NursingVincent Bove Health Center at Jefferson's FerryWater's Edge at Port Jefferson for Rehabilitation and NursingWesthampton Care CenterWhite Oaks Nursing HomeWoodhavenINTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
5Table of ContentsAcknowledgements. 2INTERACT Workgroup . 2INTERACT Committee . 2Overview . 8Background . 8State-wide Effort: Delivery System Reform Incentive Payment Program . 8Local Leadership: Suffolk Care Collaborative. 8INTERACT . 8Program Goals. 9Purpose of the Implementation Toolkit. 9Returning Required Documents . 9Program Resources . 9INTERACT Program Charter . 10Suffolk Care Collaborative INTERACT Program Contacts . 14Skilled Nursing Facility Directories . 15Facility Champion Directory . 15Facility Co-Champion Directory . 17SNF Administrator Directory . 19Performance Logic User Directory . 21Beginning INTERACT Program Implementation. 23Identify an INTERACT Program Facility Champion . 23Facility Champion Role Description . 23Submit Facility Champion Form . 24Identify an INTERACT Implementation Team . 26Implementation Team Composition & Role Description . 26Submitting an Implementation Team Composition Roster Template . 20INTERACT Implementation Kick-Off Recommendations . 21INTERACT Training Minimum Guidelines & Curriculum . 22Certified INTERACT Champion 4.0 Training Program. 22INTERACT Program Staff Training & Learning Modules . 23Required Training Modules (4) . 23Module 1: INTERACT Principles & Coaching Program . 23Module 2: Care Pathways & Clinical Tools. 23INTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
6Module 3: Advance Care Planning . 23Module 4: INTERACT Quality Improvement & Assurance Program. 24INTERACT Training Methodology . 24Submitting an INTERACT Program Training Inventory Form . 25INTERACT Training Sign-In Sheet Template . 25INTERACT Coaching Program . 26INTERACT Regional SNF Cohort Workgroups. 30INTERACT Patient, Family & Caregiver Education Methodology . 32Methodology for Family & Caregiver Education. 32Methodology for Patient Education . 32Patient, Family & Caregiver Education Tools . 33Interventions to Reduce Acute Care Transfer Program . 33Advanced Care Planning . 33Atrial Fibrillation . 34Alzheimer’s. 34Cardiovascular Disease Health Wellness & Self-Management Program . 35Tobacco Control . 35Diabetes Wellness & Self-Management Program . 36Advanced Care Planning . 39Medical Orders for Life-Sustaining Treatment (MOLST). 39What is the MOLST Program? . 39What is the MOLST form? . 40INTERACT Program Partnerships for MOLST & eMOLST . 40Program Contacts. 41Quick Links & Resources . 41Archived Advanced Care Planning Learning Collaboratives . 42SCC INTERACT Quality Improvement & Assurance Plan . 43Quality Improvement & Assurance Plan Resources . 43Implementation Resources . 43INTERACT Program Reporting Protocol . 45Project Documents to submit to the Suffolk Care Collaborative . 47Quarterly Reporting Schedule & Data Requests . 48Domain 1 Patient Engagement Data Request. 49INTERACT Clinical Tools, Care Pathways & Resources . 50INTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
7INTERACT Clinical Tools and Care Pathways . 50Advanced Care Planning Tools . 50Quality Assurance & Improvement Activities . 51Additional Resources . 51DSRIP GLOSSARY . 52INTERACT PROGRAM IMPLEMENTATION TOOLKIT SCC PROJECT MANAGEMENT OFFICESuffolk Care Collaborative www.suffolkcare.org 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788Copyright 2017 Suffolk Care Collaborative, All rights reserved.
8OverviewBackgroundIn response to rising healthcare costs, Medicaid spending and concerns of health care quality, GovernorAndrew M. Cuomo created the Medicaid Redesign Team (MRT). The MRT initiatives accounted forapproximately 17.1 billion in federal savings. On April 14, 2014, Governor Andrew M. Cuomoannounced New York finalized terms and conditions with the federal government for a groundbreakingwaiver 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 costcurve, and ensure access to quality care for all Medicaid members. NYS Department of Health’s charterunder this waiver to fully implement an action plan to allow for comprehensive reform through aDelivery System Reform Incentive Payment (DSRIP) Program.State-wide Effort: Delivery System Reform Incentive Payment ProgramThrough the Delivery System Reform Incentive Payment Program, a grant waiver administered by theNYS Department of Health (NYS DOH), 6.42 billion Medicaid dollars were allocated to fundamentallyrestructure the health care delivery system to transition care delivery from a largely inpatient-focusedsystem to a community-facing system that addresses both medical needs and social determinants ofhealth. DSRIP is a 5-year, performance payment-based program with primary goal of reducing avoidablehospital use by 25% over 5 years. At the end of the program life, the aim is for the newly-transformedsystem is to be sustainable. Project efforts are focused on achieving improved overall health throughintegration 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 CollaborativeNew York State is broken into 25 regional organizations called Performing Provider Systems (PPS). EachPPS is responsible for engaging providers, designing programs, coordinating collaboration, reportingproject outcomes and allocating funds to partners.The Suffolk Care Collaborative (SCC) is the PPS for Suffolk County under the DSRIP Program. The goal ofSCC is to meet the requirements of the Triple Aim Initiative – improving patient experience, improvinghealth 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 importantcontribution to the DSRIP program. Some of the many goals will include the capacity to make the mostof patients' self-care abilities, improve access to community-based resources, break down care silos, andreduce avoidable hospital admissions and emergen
Feb 06, 2017 · Brookside Multicare Nursing Center (Avalon Gardens) Joanne Mendez Bellhaven Center for Nursing and Rehabilitation Michele Randazzo Broadlawn Manor Nursing and Rehabilitation Center Donna Kube Brookhaven Rehabilitation & Health Care Center Kellie Burridge Carillon Nursing and
