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New York–Reducing Avoidable Hospitalizations (NY–RAH)

In September 2012, GNYHA Foundation was one of seven organizations from around the country awarded a four-year cooperative agreement by the Centers for Medicare & Medicaid Services to conduct a special project to improve the quality of care for long-stay nursing facility residents. GNYHA Foundation’s project, New York–Reducing Avoidable Hospitalizations (NY–RAH), seeks to reduce avoidable hospitalizations from nursing facilities, improve transitions between nursing facilities and hospitals, and strengthen palliative care.

GNYHA Foundation is serving as an “enhanced care and coordination provider” and placing registered nurse care coordinators (RNCCs) at 30 participating nursing facilities in New York to provide evidence-based interventions to reduce avoidable hospitalizations among long-stay residents. The cooperative agreement is being conducted in New York’s downstate region, where there are high hospital readmission rates and Medicare-Medicaid dual eligibles account for a large percentage of nursing facility residents. Several participating facilities also serve specialty populations, such as a 40-bed facility for people with HIV and AIDS and a 600-bed facility with units for renal dialysis, Huntington’s disease, and children with developmental disabilities.

As the facilities are phased into NY–RAH throughout 2013, the RNCCs, acting as coaches and quality improvement consultants, will focus on increasing the capacity of each facility to review its processes, identify root causes for preventable hospitalizations, and modify protocols as necessary by engaging staff at all levels. Tools from Interventions to Reduce Acute Care Transfers (INTERACT) will be the principal intervention, supplemented by tools from the American Medical Directors Association (AMDA). GNYHA Foundation will place a high priority on implementing advance care planning and palliative care resources available from INTERACT and other sources. The RNCCs will also help facilitate implementation of electronic solutions to improve transitions.

In March 2016, the GNYHA Foundation was awarded another four-year agreement to continue the NY-RAH project and support the interventions in currently participating facilities while also testing the impact of new Medicare incentive payment nursing facilities to cost-effectively provide appropriate treatment for certain qualifying conditions. Also referred to as "Phase Two" under the CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents - Payment Reform, two new distinct cohorts of nursing facilities are participating in the NY-RAH project across New York State.

For more information, please contact Megan Burns.

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