MAX, workshops, training, Innovation Grants make a robust toolbox. When Alice Cronin, Chief System and Transformation Officer of Nyack Hospital, gave her team’s feedback at MHVC’s November Emergency Department (ED) Care Triage Workshop, it was clear that there was much more going on than just enthusiasm for a training session. In fact, Nyack Hospital is an example of how an organization has benefited from the many state- and MHVC-level training, funding, and learning opportunities, effectively connecting the Delivery System Reform dots.

Nyack became part of the MAX Series in October 2017 to work on reducing avoidable use of their Emergency Department by high utilizers of the department. “We have been working on this issue for so long that we felt we were ahead of the game, but we needed help to advance to the next level and to really master the data side,” said Cronin. “We are working with a much larger cohort of patients now (233 from 31), and we want to develop more real-time interventions.” Through the MAX Series Nyack will analyze real-time data. “We can now see if we are moving toward goal of a 10% decrease in our high utilizers. We can’t get avoidable-visit data for a while so this helps.  We have already had success with our small cohort.” Of about 30 high-utilizers, Nyack has successfully engaged alternatives for five, which represents some 35-40 ED visits a year.

Nyack is also taking advantage of the MAX train-the-trainer program, demonstrating its commitment to incorporating the MAX rapid-cycle improvement process to other work streams. “We have two participants who are facilitators who are currently participating in the MAX Training Program (MTP),” said Cronin. “Currently two of our ED social workers are attending, one from the main ED and one from the Psych ED.” MTP trains participants in facilitation techniques and rapid cycle improvement methods while supporting the development of a plan to scale and sustain redesign efforts.

The MHVC ED Care Triage Workshops, held in October and November 2017, and January 2018, have provided focused learning opportunities. “We met with other MAX Series partners — St. Luke’s and St. Joseph’s — who shared their challenges and results,” said Cronin. “Since we are working on complex issues without prior experience, we need to hear what others are doing and how they successfully implemented their programs.”

Dr. Jeffrey Rabrich, Nyack’s Medical Director for Emergency Medicine, is at the center of the work. “We have the same issues with high utilizers as other EDs: mostly social determinants of  health (SDH) — homelessness, alcohol issues, and the lack of a full-time shelter in the county,” said Rabrich. “We are focusing on innovative things we can do, so learning from others is vital.” Nyack is working with the county to establish more services, such as a warming center and a part-time shelter, but the biggest challenge is engaging the patient.

“When the patient is willing to engage we have had great success getting them to primary care. But they often say ‘no’ the first three, five, or ten times, so the key is to keep engaging.” Nyack has a social worker in the ED, and has developed an internal system of electronic alerts for the social worker and the ED team when a high-utilizer returns. “The system puts a flag in the chart system and generates an email to the ED team,” said Rabrich.

“We wrote our own program to follow patients with a DSRIP flag,” said Cronin. “We can see if they go for other services within our system, such as a patient with MS, and we are sending alerts to our providers. The next phase is to bring in our community-based organizations (CBOs).” Nyack will kick off this phase soon, and will introduce the CBOs to mobile health care and regular case conferences. A global care plan is on paper for now, but Nyack hopes to make it electronic in the future. “Our health homes are active partners with us,” said Cronin.

Tracking high-utilizers will now be expanded through an Innovation Fund grant from MHVC. Partnering with Rockland Paramedics, the Community Paramedicine Collaboration will provide multiple services to patients before they get to the ED — and hopefully preclude an avoidable visit or admission. The mobile units will have specially-trained paramedic personnel and the hospital will have a specially-trained nurse practitioner for follow-up. “The paramedics will be able to connect to the hospital through a mobile software link to provide treatment in the home in order to avoid preventable visits and admission — almost a ‘house-call’ program.” Rabrich continued. “They will also have access to a behavioral health team.” The team’s director teaches Motivational Interviewing (MI) and will go with the paramedics on initial intake visits. MHVC has been conducting MI training for partners throughout the DSRIP period. The next phase will look to include a telemedicine application.

The Community Paramedicine Collaboration will also use Nyack’s “Twiage” application, which emergency services use to communicate with the ED to ensure that everything is ready: bed assignments, alerts, medications, etc. The Collaboration will get an electronic health record (EHR) interface so information goes directly into the medical record.

“Drivers of utilization and SDH are our biggest issues, and that’s where DSRIP and ED care is going,” said Cronin. “We are taking advantage of every learning opportunity — from using MHVC intake forms, to trainings, to collaborations. With support from the MHVC network, we are not alone.”

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