Post on 30-Apr-2018
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
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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.
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 DSRIP@stonybrookmedicine.edu
SUFFOLK CARE COLLABORATIVE 1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11778
www.suffolkcare.org
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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.
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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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.
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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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.
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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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.
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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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.
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.
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SCC │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788 Copyright © 2016 Suffolk Care Collaborative, All rights reserved.
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
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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.
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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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.
Section 1: SCC Project
Management Office
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SCC │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788 Copyright © 2016 Suffolk Care Collaborative, All rights reserved.
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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TOC Program for Inpatient & Observation Units Implementation Toolkit | SCC PROJECT MANAGEMENT OFFICE
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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
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SCC │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788 Copyright © 2016 Suffolk Care Collaborative, All rights reserved.
Suffolk Care Collaborative TOC/OBS Program Contacts Contact Name Title Email Address Phone Number
Kelly Donnelly Project Manager, Acute Care Transitions
Kelly.Donnelly@stonybrookmedicine.edu 631-638-1048
Jennifer Kennedy Director, Care Transitions Innovation
Jennifer.kennedy@stonybrookmedicine.edu 631-638-1774
Alyssa Scully Sr. Director, PMO Alyssa.scully@stonybrookmedicine.edu 631-638-1369
Steven Feldman Project Lead, TOC Steven.feldman.1@stonybrookmedicine.edu 631-444-7471
Eric Niegelberg Project Lead, OBS Eric.niegelberg@stonybrookmedicine.edu 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: DSRIP@stonybrookmedicine.edu
www.suffolkcare.org
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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.
Facility Champion & Performance Logic Directory
Performance Logic Users:
Facility Performance Logic User
Email Address Phone Number
Stony Brook Lorie Hamilton Lorie.hamilton@stonybrookmedicine.edu 631-444-3892
Mather Lorraine Farrell lfarrell@matherhospital.org 631-686-7685
Brookhaven Karen Shaughness kshaughness@bmhmc.org 631-654-7792
Southampton Janet Woo janetwoo@southampton.org 631-726-3171
Eastern Long Island Tara Kraemer tkraemer@elih.org 631-477-5136
Peconic Bay (Northwell)
Ariel Hayes ahayes@northwell.edu 516-465-3141 Huntington (Northwell)
Southside (Northwell)
Good Samaritan (CHS)
Gloria Mooney Gloria.mooney@chsli.org 914-589-0908 St. Charles (CHS)
St. Catherine (CHS)
Facility Champions:
Facility Facility Champion Email Address Phone Number
Stony Brook Mary Ann Lind Maryann.lind@stonybrookmedicine.edu 631-444-2883
Mather Lorraine Farrell lfarrell@matherhospital.org 631-686-7685
Brookhaven Brianne Rizzo brizzo@bmhmc.org 631-687-2838
Southampton Sharon DiSunno sdisunno@southampton.org 631-726-8330
Eastern Long Island Tara Kraemer tkraemer@elih.org 631-477-5136
Peconic Bay (Northwell)
Ariel Hayes ahayes@northwell.edu 516-465-3141 Huntington (Northwell)
Southside (Northwell)
Good Samaritan (CHS) Joan Geagan Joan.geagan@chsli.org
St. Charles (CHS) Denise Davis Denise.davis@chsli.org 631-474-6458
St. Catherine (CHS) Carol Piazza Carol.piazza@chsli.org 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
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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).
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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:
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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
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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.
Topic Learning Objectives Training Curriculum
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
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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.
Topic Learning Objectives Training Curriculum
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
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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
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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
Kelly.Donnelly@stonybrookmedicine.edu
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
Jennifer.kennedy@stonybrookmedicine.edu
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Section 4: Implementation
Plan
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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
01/01/16 09/30/16 Scheduled Kelly Donnelly
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
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1.3.4 Keep record of training dates and number of staff trained using SCC Templates
01/01/16 01/31/17 Scheduled Kelly Donnelly
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)
03/31/16 03/31/17 Scheduled Kelly Donnelly
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)
03/31/16 03/31/17 Scheduled Kelly Donnelly
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)
03/31/16 03/31/17 Scheduled Kelly Donnelly
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
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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
01/01/16 09/30/16 Scheduled Kelly Donnelly
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
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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)
03/31/16 03/31/20 Scheduled Kelly Donnelly
Please contact Kelly Donnelly, Project Manager, Acute Care Transitions, (631) 638-1048 at the Suffolk Care Collaborative with any questions.
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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).
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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).
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Section 5: OBS Program
Development Request Please click here to access the Suffolk Care Collaborative OBS
Opportunity Assessment with Clinical & Financial Template
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Section 6: Reporting to the SCC
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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
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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, Kelly.Tamburello@stonybrookmedicine.edu
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.
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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 Kevin.Bozza@stonybrookmedicine.edu or Alyssa Scully,
Director, PMO at alyssa.scully@stonybrookmedicine.edu
Please click here to access the Patient
Engagement-TOC Excel Template
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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,
Kelly.Tamburello@stonybrookmedicine.edu
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.
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SCC Project 2.b.ix Patient Engagement Template - Observation For questions or more information, please contact Kevin Bozza, Director, Network
Development & Performance at Kevin.Bozza@stonybrookmedicine.edu or Alyssa Scully,
Director, PMO at alyssa.scully@stonybrookmedicine.edu
Please click here to access the Patient
Engagement-OBS Excel Template
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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)
9/30/16 Once Performance Logic
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
3/31/17 Once Performance Logic
6 QE Participation Agreement (RHIO) 3/31/17 Once Performance Logic
7 Sample of transactions to public health registries
3/31/17 Once Performance Logic
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
9/30/16 Once Performance Logic
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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.
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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.
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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
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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.
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: ________________________________
First Name Last Name Title Phone Email
Name (Print): ______________________________________ Title: ________________________
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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.
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.
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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
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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: ____________
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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: ____________
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Public Health Registries Request Form
Request:
Please provide a screenshot of the EHRs ability to send transactions to a public health registry.
Instructions:
Please upload this form 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.
Facility: _______________________________________ Please insert and label screenshots in the box below:
Name (Print): ______________________________________ Title: ________________________
Signature: _____________________________________ Date: ____________
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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:
Please upload this form 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.
Facility: _______________________________________ Please insert and label screenshots in the box below:
Name (Print): ______________________________________ Title: ________________________
Signature: _____________________________________ Date: ____________
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Section 7: Program Resources
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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).
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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.