Enabling Strong Health Systems – LTPAC Partnerships

with Innovative Approaches and Technologies

LeadingAge NY 2017 Annual Meeting

May 23, 2017

• Al Kinel: President Strategic Interests

• Mark Klyczek: VP, Long Term Care Division Rochester Regional Health

• Travis Masonis: CIO Jewish Senior Life

• Elizabeth Amato: Director, Statewide Services NYeC

Agenda

IT Enablers Impacting LTPAC

Perspectives of Health Systems

Perspectives of LTPAC Partners

Enhancing Transitions of Care with RHIOs & SHIN-NY

Discussion: Enabling Health Systems & LTPAC to Partner

LTPAC IT Application Assessment

Application Module Score

Administrative ERP

Billing / Coding / MDS

HR / Staffing / Payroll

Managed Care / Analytics

Automated Admit / Doc Mgmt

Clinical Orders

Documentation

Meds Management / eRx

Interoperability In

Interoperability Out

Wellness

Disease Management

Population Health / Rounding

Application Module Score

Telehealth Behavioral Health

Post-Acute Consult/Monitor

Virtual Consultation

Facilities Safety & Security

Business Continuity

Concierge

Point of Sale

Analytics Management Dashboards

Value-Based Payment / Pricing

Readmission Management

Marketing CRM / Admissions

Donor Management

Volunteer Management

Enhancing Hospital-LTPAC Partnership with IT

4

Process Technologies

Discharge Planning Care Management Tool - Creation of Care Plan

Risk Profile Scoring Tool

Referral Admin Process Discharge-Referral Process

LTC Admit Process

Metrics Reporting

Exchange Clinical Data Key Data from Hospital EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in LTC EMR

Manage Patients at Risk Population Health

Dashboard & Rounding Tool with Alerts & Gaps

Telehealth: Surgeon, Care Team, Behavioral Health

LTC Discharge Process Key Data from LTC EMR in C-CDA

Transport Data (RHIO, DIRECT, Other)

Ability to Load Key Data in Home Health/PCP EMR

Transition

Of

Care

Transition

Of

Care

Hospital(s) Home Care / PGHD

Non-PCP Specialist

Urgent Care

CBOs / Social

Services

Labs, Rads, Geneticists

Behavioral Health

Disabilities

PT/OT

Community - PCMH

Transitions of CareWhere Information Gaps Appear & Compromise Care

SNF

Assisted Living

Inpatient Rehab

LTPAC

Health Home

PCP / FQHC

• Use Case 1:

– HOSPITAL to HOME

• Use Case 2:

– HOSPITAL to LTPAC

• Use Case 3:

– LTPAC to HOME

• Use Case 4:

– PCMH – PCP to Other

• Use Case 5:

– HOME to HOSPITAL

• Use Case 6:

– LTPAC to HOSPITAL

• Use Case 7:

– HOSPITAL to HOSPITAL

• Use Case 8:

– HOME to LTPAC

• Use Case 9:

– PROVIDER to BH/CBOs

• Use Case 10:

– Specialist to Specialist

Key Transitions

Improving LTPAC Transitions of Care (ToC)

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Hospitals & LTC partners can jointly improve ToC effectiveness by reviewing

areas on both sides to change discharge planning, admit process & HIE:

• Improve Hospital-LTC ToC: discharge/admit Screening and discharge efficiently getting patients to right facility

Process & tools to provide LTC data needed to receive patient

• Collaborate After ToC: address patients & risks together Process, tools, and alignment to identify patients at risk, gaps in care, actions to address

them and means for team to communicate

• Improve LTC-Home ToC: discharge/admit Discharge efficiently to home health agency, PCP, or both

Process and tools to provide data and alert hospital

Keys for Successful ToCs – More than HIE

Right information, right time, right format…without extra noise

Comprehensive Care Coordination, Health Coaching and PCMH Model

Medication Management

Effective Hand-offs to Providers and Social Workers

Timely Post Discharge Follow-up

Self-Management Care Plans with Patient Education and Clear Follow-up

Identify and Provide Resources for Social Determinants of Care

High Patient Satisfaction (correlated with lower 30 day readmit rates)

Sources:• Project BOOST (Better Outcomes by Optimizing Safe Transitions) – www.hospitalmedicine.org• Care Transitions Interventions (CTI) –www.caretransitions.org• CMS Community-Based Care Transitions Program (CCTP) – www.innovations.cms.gov/initiatives/CCTP/• Guided Care Comprehensive Primary Care for Complex Patients – www.guidedcare.org• Project RED (Re-Engineered Discharge) – www.bu.edu• State Action on Avoidable Rehospitalizations (STAAR) – www.ihi.org

LTPAC Attempting to Improve ToCs

S&I Framework - 2011

Care Coordination Tool for ToC to LTC DataData Proposed to be Provided by Hospital Discharge

DSRIP: Hospital Data that Facilitates LTPAC Care

Data Desired by LTPACRecipient Priority

Source AvailabilityEase of

ExtractionCDA Compatibility

Referrer Contact for Questions High High High Mod

02Sat High High High Mod

Detailed Pain Information High Mod Low Low

Detailed Functional and Cognitive Status High Mod Low Low

Pre-hospital admission meds High High High Mod

PT/OT care, abilities and willingness Mod High High Mod

Pressure ulcers / skin / wounds High High High Mod

Detailed Nursing Care: nutrition, hydration, devices, therapies

High High Mod Low

Advance Directives/MOLST High High Mod Low

Relative Notified of Transiton of Care? Mod Mod Mod Low

Vendor Supply / Info Mod Mod Mod Low

Notification regarding ToCs High High High N/A

FLPPS compared data requested by LTPAC to enable successful transitions vs.

ability to enable ToC to include additional data

Source: Strategic Interests, Population Health Summit; Digital Rochester 04-15-16

www.ihealthtran.com

Identifying & Managing a Population & Patient Needs

• CLINICAL

• PSYCHO

• SOCIAL

• COMPLIANCE

• BY DISEASE(S)

• BY PAYER

• BY AGE

• BY INCOME

• BY ETHNICITY

• URGENT

• HIGH

• TRENDING

• OTHER

• During Appointments

• With Outreach

• Ongoing

• PCMH

• DAILY HUDDLE

• REFERRALS

• PERFORMANCE REVIEWS

• REVISED WORKFLOWS

• BY SITE / PRACTICE /

• BY SPECIALTY

• BY PROVIDER

• BY PAYER

• BY RISK

• OTHER

• BY SOCIAL DETERMINANTS

• BY ETHNICITY

• BY TECH ADOPTION

• BY PREFERENCES

• BY ENGAGEMENT

Agenda

IT Enablers Impacting LTPAC

Perspectives of Health Systems

Perspectives of LTPAC Partners

Enhancing Transitions of Care with RHIOs & SHIN-NY

Discussion: Enabling Health Systems & LTPAC to Partner

Thank You

Al Kinel

President, Strategic Interests

5/11/2017

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Strengthening Post-Acute Partnerships with Technology

May 23, 2017

Mark F. Klyczek, FACHE

Vice President, Long Term Care Division

Rochester Regional Health

5/11/2017

2

A True Continuum Of Care

Rochester Regional Health: An Integrated Health System Committed to Caring for the Community

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Rochester Regional Health: Our Market

Composition of LTC Division

• Number of Owned Facilities: 6

• Total Beds: 936

• Annual Discharges: 2,500

• Annual Operating Budget: $100MM

• Total Employees: 1,400

• Total Bed Days: 331,000

• Employed Medical Staff in all RRH Facilities

• All Specialties Offered Throughout the Division

• Payor Mix: 10% Self Pay, 12% Medicare, 71% Medicaid, 7% Other

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Service Line Overview

Ventilator

Care

Clifton Springs Hospital

Extended Care

Unity Living Center

Park Ridge Living Center

DeMay Living Center

Edna Tina Wilson Living

Center

Hill Haven Transitional

Care

Long Term Care

Division

Neuro –

Behavioral

Care

Dialysis Wound

Care

Dementia

Care

Transitional

Care

(Rehab)

A Tale of Three Priorities

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RRH Hospital Priorities

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• Reduce Length Of Stay (LOS)

• Patient Throughput and Capacity Management (PTCM)

• Improve Quality & Reduce Readmissions

• Clinical & Cost Variation Reduction by DRG

• Manage margins for different environments:

• FFS

• Payor Contracts / Risk Sharing

• DSRIP

• Consumerism

RRH LTC Priorities

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• Effective management/improvement of: • Cost

• Quality

• Satisfaction (resident/family/employee)

• Manage to an increasingly difficult budget and payor mix

• Develop an identity with the public

• Maintain 97% occupancy levels at challenging staffing levels

• Accept challenging patients (medically & behaviorally)

• I fight for the same shelf space as you

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RRH LTPAC Priorities

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Create a reliable network of post-acute facilities that can

accept all post-acute discharges from the 5 RRH hospitals:

• Accept more of the difficult to place patients

• Support length of stay initiatives

• Develop areas for clinical and operational integration

• Partner to improve services in the community

• Develop medical staff relationships

• Assist with credentialing and privileging

Realities of Different Perspectives

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Aspect Hospital LTC

Patients Accepted All Based on payer, clinical, situation

Admission Hours 24/7 Primarily Day-shift

Specialty Care Available 24/7 Contracted or unavailable

Primary Objectives

Discharge patients as soon as medically ready after providing quality care

Accept patients that match the facility’s capabilities

Reduce unnecessary readmissions/ED visits

Take “Best Patients”

If patients return, manage efficiently and effectively

•Admit & manage patients: • efficiently & effectively • at lowest cost • while maintaining satisfaction

Are they compatible?

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Improving Hospital-LTC Cooperation

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• Improve transitions of care: communicate with post-

acute facilities before, during and after transfer

• Partnerships for covered lives (hidden bundles)

• Metrics to manage partner performance

• Care Coordination - connecting silos of care:

• Team Based Care; Enhanced Discharge Planning

• Overcapacity Playbook

• Patient Centered Admission Team (PCAT)

• Central Placement Office (CPO)

• Staying in touch with discharges in key facilities

Innovative IT to Enable Effective Hospital-LTPAC Partnerships

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Required Elements for a Positive Transition

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Current Acute Care

CPO SWs

Proposed LTC

Transition Role

Complex Care Patients: Referrals from SW/

Physician Advisor/ Complex Care Team/ Care Mgmtx

All LTC Patients Transitioning to LTC Facilities x

Attend M-F 9:30am Daily Bed Count w Mark- Conf

Call x

Attend morning, afternoon Huddles: issues, pending

transfers, discharges x

Attend Central Placement Huddles- Cardiac 8:30; M-

S 10:15 x x

LTC Planning- Real-time, Ongoing communication w

SW, CMs r/t pending DCs, transfers, issues x

Resource, point person for Physician Advisor:

Reserving NH Beds; NH Capabilities, etc x x

Confirm LTC Bed Holds x x

Match NH Capabilities x x

Patient Advocate- NH Bed x x

Ensure Authorizations for all patients except LTC

(Admissions Coord) x

Ensure Authorizations for all LTC patients

(Admissions Coord) x

Ensure Insurance Verification for LTC patients

(Admissions Coord) x

Ensure Financial Counseling/ Financial Review;

Mcaid Process Initiated; Financial Barriers for LTC

patients resolved (FCM) x

Ensure Approp DC Dx for LTC patients (ICD 10

Coding) x

Ensure Admission Agreement Completed for LTC

patients (FCM) x

Ensure Intake Form Completed for LTC patients (IP,

NH Admissions) x

Ensure Appropriate Documentation- DC Summary,

Provider Orders, Plan of Care, etc for LTC patients x

Resource, Issues Resolution for LTC patients (Bed

Availability and Assignment; Equipment Acquisition;

Transportation Coordination, etc) x

Prep for Evening/ Weekend Transfers for LTC

patients x

How LTC can Partner with Hospitals

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• Own your patients

• Share your data (performance, services, etc.)

• Helpful to provide the most recent data vs CMS data

• Understand what is important to the referral source, including financial

and operational goals

• Take measureable actions that can be demonstrated over time

• Partner to improve results on as many measures as possible

• Review possibilities to move to the same EMR as your referral source, or

commit to interoperable processes leveraging RHIO or other means

• Utilize technology to improve processes and attain results

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Examples: Dashboards Used to Manage Hospital-LTPAC Relationship

• LTC Admission Data • Hospital Throughput • Wasted Days

The Electronic Referral Data Bomb

18

• Mother of Admissions Big-data

• Everyone knows it exists, will it be used?!

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Data Points Being Reviewed

19

• Referral Volume

• Average Referral to Response Time

• Average Accept to Discharge

• Payor Mix of Booked Patients

• Payor Mix of Declined Patients

• Top 10 Referral Diagnoses

• Decline Reasons

• Readmissions Within 30 Days

• ED Returns Within 30 Days

• Readmissions and ED Returns within 30 Days

• Readmissions and ED Returns by Day of the Week

Individual Facility Dashboard Example

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Individual Facility Dashboard Example

21

12 13 14 15 16 17

3/19/17 3/26/17 4/2/17 4/9/17 4/16/17 4/23/17

ALOS 3.35 2.86 3.62 2.89 3.58 2.71 3.92

Discharges -- 30 41 32 42 29 38

ALOS 7.5 6.07 7.98 4.78 3.99 6.54 2.96

Discharges -- 7 2 4 10 7 5

12 13 14 15 16 17

3/19/17 3/26/17 4/2/17 4/9/17 4/16/17 4/23/17

ALOS 3.8 3.45 3.75 2.94 2.53 5.06 2.62

Discharges -- 24 19 41 31 15 21

ALOS 7.5 6.13 9.38 9.48 5.83 8.77 9.07

Discharges -- 3 5 4 6.14 5 9

12 13 14 15 16 17

3/19/17 3/26/17 4/2/17 4/9/17 4/16/17 4/23/17

ALOS 2.6 2.23 3.22 2.43 2.86 2.52 2.2

Discharges -- 36 28 31 45 44 42

ALOS 7.5 18.2 5.24 6.76 4.22 6.3 4.37

Discharges -- 10 10 8 9 8 9

2017

Goal

2017

Metric

4800

Home

4800

SNF

2017

GoalMetric

2017 2017

GoalMetric

7800

Home

7800

SNF

5800

Home

5800

SNF

2017

Data Source: ASAP0190 Admitted Patients LOS intervals

PTCM - Team Based Care Metrics

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2017 13 14 15 16 17

Metric 3/26/17 4/2/17 4/9/17 4/16/17 4/23/17

Wasted Bed Days 110 152 145 148 133 85

n - 51 51 47 48 40

2017

Goal

PTCM - Wasted Bed Days

Prior Week Running Totals:

Data Source: IP0303 Wasted Bed Days Report

2017 13 14 15 16 17

Metric 3/26/17 4/2/17 4/9/17 4/16/17 4/23/17# Visits - 64 62 72 81 77

Avg.Time Referral to Provider Accept (booked

Patient) 24 Hrs 49.75 52.78 44.55 59.03 70.64

Provider Accept to Discharge(booked patients)

36 Hrs 38.50 59.29 33.39 49.90 40.82

Avg. Accept to Discharge when Medically

Ready at Accept time - 22.30 22.90 19.76 46.20 26.59

Avg Accept to Discharge when Not medically

Ready at Accept - 47.04 76.47 41.64 55.04 55.06

Referral to Discharge booked patients 60 87.46 113.59 74.27 108.74 106.79

#Sum of Days exceeding 60 hrs Referral to

Discharge - 121.88 170.18 108.23 226.50 215.87

2017

Goal

PTCM – Curaspan Snapshot

Data Source: Curaspan

5/11/2017

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Questions We Are Asking

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• What are reasonable turnaround times at each stage to support length of

stay?

• Is there an advantage to sending referrals prior to the patient being

medically ready?

• What is the LOS for a referral sent before being medically ready?

• What is the LOS for a referral sent after being medically ready?

• Is there a correlation between response time and length of stay?

• How can areas of clinical and cost variation be reduced by DRG?

• What supports are needed for post-acute facilities to assist with our goals?

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Technology to Enable Better Partnerships for LTPAC

Travis Masonis, CIO Jewish Senior Life

Overview of Jewish Senior Life

Comprehensive Portfolio CCRC/Lifecare Community• SNF (362 Beds)

– short term rehab (68 beds, expanding to 88)

• Independent Living (90 Units)

• Assisted Living (78 Units)

• Adult Day Healthcare (85 slots)

• Outpatient Therapy Practice

• Companion Services

• Physician House Calls

• Alzheimer's Daytime Respite (Marian’s House)

1100 Employees including Therapy Department & Medical Staff

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Referral Tracking

• Internal database measures– Response time

– Acceptance rates

– Referral patterns

– Diagnosis Classes

– Reason for bed denial

– Reason for bed refusal (by patient), where possible

• Curaspan– Similar metrics noted above

Understanding, managing, and improving LTPAC performance as a partner receiving referrals

Referral Tracking

• Allows JSL to understand mathematically the shifts and trends in referral types:– Dx classes

– hard to place patients

– etc.

• More information = Better partnerships

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Readmission Reduction Tools/Analytics

• PointClickCare EMR

• eINTERACT

• Telemedicine (URMC Cardiac)

• Practitioner Engagement Mobile App for providers– Providers have more information at their

fingertips from the mobile device after hours

Readmission Management Process

Quality Management Team:• Track patient/resident transfers to ED using version of

INTERACT’s Hospitalization Rate Tracking Tool

• Monthly analysis to calculate readmission rate & ID trends– Total readmission rate

– By payor, key diagnosis, hospital admitted from, etc.

– Transfer by day of week, shift, provider, etc.

• Monthly/Quarterly summary reports to management & QAPI Committee

• Quarterly update to organization’s KPI dashboard to Senior Management and Board

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Readmission Management Process

QAPI Hospital Transfer/Readmission Work Teams

• 1 for LTC & 1 for TCP

• Meet monthly to review transfer data

• Identify trends, problems, root cause of transfer– Identify contributing factors – clinical & non-clinical

• Determine/develop action items for improvement – Education/training

– Process improvement

Cost Accounting

• Measures activity based costs for the patient profiles. Includes cost information pertaining to:– Diagnoses (primary and co-morbidities)

– Demographics (age, gender, etc.)

– Payor type

– Ancillary Charges

– Therapy Minutes

– Physician Visits

– LOS

• Shows value to referring hospital partners; not only demonstrates improving quality, but also reducing and controlling costs– You can’t improve what you aren’t measuring

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Using EMR To Improve ToC

• Integration with RHIO– RHIO to PCC

• Lab

• Radiology

• CCD/CDA

– Perhaps ToC specific documents

– PCC to RHIO to make available to Hospital, Surgeon, Home Health

• ADT

• CCD/CDA

• Discrete data capture via clinical documentation enhance reporting and readmission prevention

Future Opportunities

• Telemedicine

• Advanced Data Sharing– Targeted ToC documents, CCD/CDA

consumption, global readmission risk alerting

• Predictive Analytics

• Biomedical/Telemetry Alerts for Readmission Risks

• Post-Discharge Monitoring (Wearables, Medication Compliance, etc.)

• Clinical and Operational Integration

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5/10/2017

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Statewide Health Information Network for NY (SHIN‐NY)

Elizabeth Amato

Senior Director, Statewide Services

New York eHealth Collaborative

• A secure network for sharing electronic clinical records

• The SHIN‐NY consists of the eight Regional Health 

Information Organizations (RHIOs) aka QEs

• Records are accessed and exchanged securely between healthcare providers with appropriate consent

• Patients decide which entities can access or see their records

• Efficient access to clinical records helps providers better manage patient care

• The SHIN‐NY can help reduce healthcare costs, improve healthcare coordination, and increase the quality of care for patients in New York State

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The SHIN‐NY in a Nutshell

State Department of Health 

•Oversees SHIN‐NY through contracts and funding of NYeC and QEs

•Additional regulatory oversight as part of new SHIN‐NY Regulation – adopted and released March 9, 2016

Qualified Entities (QEs) 

•8 QEs each governed by a board of up to 20 people

•Broad participation by local stakeholders, including providers, employers and community advocates

NYeC

•State Designated Entity to coordinate activities of the SHIN‐NY. Governing Board consists of 18 people from across healthcare industry and across New York State.

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Regional Health Information Organizations (RHIOs) or Qualified Entities (QEs) 

• A QE, or RHIO, is a local hub where a region’s electronic 

health information is stored and shared. 

• The eight QEs in New York State cover different areas 

from Buffalo to New York City with more overlap in the 

more densely populated downstate area. 

• These QEs are the backbone of the SHIN‐NY, providing 

the services that make secure, vital access to a 

patient’s health information possible statewide.

• While QEs are primarily established within geographical 

regions (Upstate more so than downstate), healthcare 

organizations may connect with the QE that best aligns 

with their business, operational, and service delivery 

needs, regardless of county catchment areas.

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• To continue advancing the SHIN‐NY, on March 9, 2016 NYS Department of Health codified the SHIN‐NY Regulation (Addition of Part 300 to Title 10 NYCRR (Statewide Health Information Network for New York (SHIN‐NY))

• Pursuant to the Regulation:• Article 28 Hospitals are to have begun participating in and contributing data to the SHIN‐NY by March 9, 2017

• The following entities* are to participate and contribute data to the SHIN‐NY by March 9, 2018: 

• Article 28 nursing homes and diagnostic treatment centers • Article 36 certified home health care agencies, long term home health care programs • Article 40 hospices*if using a Certified EHR

Full Text of the Regulation: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/2016‐03‐09_shin_ny.pdf

SHIN‐NY Regulation

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QE

Clinicians

How does a QE connect providers today?

KEY

= Transmission of Clinical Patient Information

Home Care AgencyCommunity Hospital

Medical Center

Reference Laboratory

Nursing Home

Primary Doctor’s Office

Since March 2015, all RHIOs must provide the following Core Services to Participants

1. Statewide Patient Record Lookup

2. Statewide Secure Messaging (Direct)

3. Notifications (Alerts / Subscribe and Notify)

4. Provider & Public Health Clinical Viewers

5. Consent Management

6. Identity Management and Security

7. Public Health Reporting Integration

8. Lab Results Delivery

The SHIN‐NY Core Services

No charge for these services beyond initial setup

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Who Is Connected and What Data Is Available?

7

Who is hooked up to the SHIN‐NY?

All data above as of March 18, 2017 …. Data continuously being updated, improved, & refined

8

97% 98%

81%

55%

47%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FQHCs Hospitals Public Health Dept LTC Facilities Home Care Agencies Physicians

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Types of information that may be available in the SHIN‐NY

Demographics Cardiology Results Diagnosis/Procedures

Encounters Pathology Results Problem List

Encounter Summaries Discrete Lab Values Immunizations

Diagnoses Microbiology Reports Social/Family History

Allergies Other Transcribed Reports OB/GYN/Resp/Card Reports

Contacts/Next of Kin Prescribed Medications Discharge Summary

Insurance Medications Advanced Directives

Radiology Reports Medication History Clinician Information

Lab Test Reports Medication Allergies Care Plan

Microbiology Results Vital Signs/Observations ACO/Health Home Status

Clinical Data Available in the SHIN‐NY

The Value of the SHIN‐NY and How to Get Connected 

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How HIE Can Support Healthcare Initiatives

Access to clinical data has widespread benefits to healthcare:• Statewide Clinical Event Notifications (Alerts)• DSRIP (collaborative care, reducing avoidable admissions)• Care Coordination initiatives• Population Health, Analytics• Care Plan Exchange• Meaningful Use (for hospitals and providers)• Patient Engagement (e.g. Patient Portals)• Patient Centered Medical Home (PCMH)• Quality Reporting (PQRS)• Payers (Quality Reporting, HEDIS, QARR, Care Management)

SHIN-NY Value Studies, Whitepapers, Videos and other Resources: http://www.nyehealth.org/shin-ny/value-of-hie/

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$13,000 per organization in funding is available for eligible LTPAC providers to connect to their QE and exchange clinical data

1. Contact your QE to understand appropriate services for your organization

2. Sign a data sharing/Participation agreement

3. Sign up for Clinical Viewer/Portal to search patients and their clinical data through the web

4. Explore the use of DIRECT secure messaging

5. Enroll in Alerts (admit, discharge, transfer for inpatient and ED settings)

6. Plan for bi‐directional exchange between your EHR and the QE a) Send clinical data to the QEb) Receive data automatically into your EHR (e.g. TOC, labs, alerts)

7. Check opportunities for funding through DSRIP, DEIP, or others

8. Work with your referral sources to determine workflow and content to improve TOCs

How to Get Connected to the SHIN‐NY – Where to Start

To find the QE in your region and obtain contact info, visit http://www.nyehealth.org/shin‐ny/qualified‐entities/

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40 Worth Street, 5th Floor  New York, New York  1001380 South Swan Street, 29th Floor  Albany, New York  12210