2015 OPTIMA Award: A breath for life

Skilled nursing facilities (SNFs) nationwide are grappling with higher acuity rates and the challenges that come from caring for high-risk populations in a reimbursement-driven environment that demands a reduction in unnecessary hospitalizations. But few SNFs can claim a higher acuity resident population than Silvercrest Center for Nursing and Rehabilitation, Briarwood, N.Y., Long-Term Living’s 2015 OPTIMA Award winner.

At this 320-bed nursing home, deep in the middle of Queens, an extraordinary 43 percent of the resident population is ventilator-dependent or has been tracheostomized. Feeding tubes and breathing tube maintenance are the norm here, rather than the exception.

Yet, the site has achieved a 34 percent reduction in its 30-day hospital readmissions in the past 18 months, including a whopping 54 percent reduction in 30-day readmissions among the residents in the ventilator unit.

Silvercrest’s model program for cross-discipline care uses customized documentation tools, unique staff training and innovative leadership to provide early clinical intervention and reduce hospitals transfers, despite its resident acuity. In other words, if a hospitalization reduction program can succeed here, it can succeed anywhere.

The hospitalization reduction program

Silvercrest is part of the New York Reducing Avoidable Hospitalization (NY-RAH) demonstration project group, a 20-site collaboration between New York State and the Centers for Medicare & Medicaid Services (CMS). But Silvercrest’s own initiatives within the program have resulted in a goldmine of quality care data and advanced protocols for high-acuity populations. “We started with reducing hospitalizations, but as we did our resident transfer reviews, we saw what we could do to improve our clinical practices and documentation,” explains Denise Lawson Munroe, RN, director of performance improvement and risk management.

Silvercrest’s implementation of early-assessment clinical tools, deeply customized electronic charting templates and specialized staff training have made it the top performer among the state’s hospitalization reduction group, despite the site’s unusual acuity rates. “Silvercrest is NY-RAH’s poster child now,” says Marva Skeete-Phillip, RN, RNCC, the CMS liaison for the NY-RAH program.

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The Rapid Response Tool (RRT), used by many hospitals, has been finessed to a fine process point at Silvercrest. Accurate assessment and early intervention can keep the “little emergencies” from becoming life-threatening ones that require a hospital transfer. The RRT works like a hospital emergency code, calling in all available hands when something is going wrong with a resident. “It’s not a tool you see used much in long-term care,” Lawson Munroe says. “It’s a quick catch for a resident who seems to be declining quickly. It’s about doing a thorough assessment of a resident to determine whether a hospital transfer is needed, or what can be done right now to prevent a transfer.” At many SNFs, a hospital transport can occur simply because the staff lacks the training or equipment to deal with emergencies in house, she adds.

Most SNFs use shift reports to make sure each nursing shift is aware of current resident statuses. But Silvercrest’s morning care team meetings include not only the medical director, director of nursing and the director of quality improvement initiatives, but also the directors of social services, speech/language pathology, rehabilitation, therapeutic recreation and admissions, as well as nurse managers and coordinators of clinical nutrition and MDS.

The daily discussion includes admissions, discharges, hospital transfers and any resident changes of condition or therapy in the past 24 hours. In the conference room, two flat-panel wall screens display the electronic chart of each resident being discussed, providing easy access to real-time nurse charting notes, the electronic medical record, medication administration lists and dietary/feeding notes.

The customized charting system flags all SBAR (Situation, Background, Assessment and Recommendation) notes and changes in condition as high priority, using a red flag icon. No matter which person originally entered the notes, everyone can see the same information at the same time during the morning meeting, so future therapy adjustments can be discussed as a team.

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At Silvercrest, most of the residents have extremely limited mobility, if any at all. Among this unusual population, many nurses and respiratory therapists (RTs) are trained in advanced cardiac life support (ACLS). All staffers—from nurses to housekeeping and maintenance personnel—are trained to use the “Stop and Watch” tool to recognize changes in resident habits and vital signs, and in the protocols of what to do when something is amiss.

Yet, the CMS reimbursement rates don’t always adjust for such high acuity levels, Lawson Munroe points out. “We’re basically like a long-term acute-care hospital (LTACH), but since New York State doesn’t have LTACHs, we’re not being reimbursed for that level of care.” 

Cross-team cooperation

Silvercrest has integrated many aspects of the care team that other SNFs may consider “ancillary” services—such as speech therapy, dietary and social work. Here, the RTs do resident rounds, but they also change trach tubes and monitor the residents during handoffs to nurses. Each ventilator-dependent resident also is closely monitored by the site’s speech/language pathologists for any changes in swallowing status, speaking abilities or aspiration.

Secretion management is a huge issue at Silvercrest. Residents with trach tubes or mechanical ventilation may need assistance to learn how to speak, eat and drink again, says Marta Kazandjian, SLP, director of speech/language pathology. “They have to relearn how to do the things that everyone else does normally.” The speech/language team may notice things that are important to the nursing team and vice versa, Kazandjian says. “The team-based approach can catch things before they escalate to a hospital transport.”

Loretta McManus, vice president of nursing, acknowledges the daily challenge of balancing quality nursing care delivery with reimbursement. “Reimbursement is a real part of our life. The challenge is to do the right thing but still be financially efficient. But we have to try, and we can’t be afraid to fail.”

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The results

Silvercrest has reduced its overall unnecessary hospitalizations by more than one-third in the past 18 months, a milestone for any SNF, but a special accolade for a facility with such a high-acuity resident population.

Unexpected wins

Silvercrest has seen several unplanned achievements during the past few years:

  • Many CNAs have become LPNs or RNs
  • Several staffers earned palliative care certification
  • 65% RNs and 35% LPNs on staff
  • 95% of RNs have a bachelor's degree in nursing
  • 23% reduction in pharmacy costs

The site has won a safety award from New York State for the management of feeding tubes, and has gathered important data for clinicians (and tube manufacturers) on the impacts of yeast on feeding tube degradation—all of which have helped the hospitalization reduction cause. A “safety reward” is given to anyone who notices a clinical problem or potential safety issue, offers a good infection-reducing idea or suggests a new process change, Lawson Munroe says. For example, during a root-cause analysis, a nurse suggested instituting a “no interruption time” during the medication administration rounds, to decrease the risk of medication errors.

Silvercrest’s data on ventilator-dependent residents also has resulted in new clinical views on anemia. Residents on ventilators require frequent blood tests, which may result in a condition called “phlebotomy-induced anemia,” Lawson Munroe explains. Silvercrest has also applied to become a licensed blood transfusion site, which would reduce hospital visits further and allow residents to have transfusions conducted in their own environment if intravenous iron infusions prove to be ineffective.

The next initiatives

Thanks to its expertise and outcomes in ventilator therapy, Silvercrest has emerged as one of its region’s best sites for pulmonary care. “The respiratory program at New York Presbyterian\Queens started at Silvercrest because no one else was providing those services and residents needed them,” says Lawson Munroe.

The SNF is now in the process of expanding its bed space in the ventilator units, viewing it as an opportunity to grow a service line it already has the staff expertise to uphold, says Senior Vice President Michael Tretola. Silvercrest, a corporately sponsored member of the New York Presbyterian Healthcare System, already receives about 50 percent of the market share of ventilator-dependent patients in Queens, and the additional beds will allow for more, he says. Silvercrest also is breaking ground in care training, establishing educational partnerships with local nursing schools. Many of its CNAs and RNs have sought higher training already—while Silvercrest’s administration works with interested caregivers to allow for study time. The site also serves as a training site for all clincial disciplines as well as long-term care administrators, palliative care professionals and emergency medical technicians.

As for quality process changes overall: “You have to involve everyone—even the least-perceived clinical roles,” Lawson Munroe advises. “They need to know their participation is important.”

About the OPTIMA Award

Since 1996, the annual Long-Term Living OPTIMA Award has honored long-term care communities that enact proactive projects to enhance resident care and resident quality of life. The OPTIMA Award winner is selected by an independent judging panel of long-term care experts using a double-blind entry-judging process and adjudicated by a third-party award coordinator. No one from Long-Term Living or its parent company, Vendome Group, is involved in the judging process.

To learn about the program and see a list of previous winners, visit the OPTIMA page.

Read more about the 2015 OPTIMA Award-winning site:
  IT: The bridge between care and outcomes
  Reducing readmissions: The hospice factor
  [BLOG] The anatomy of a team


Topics: Articles , Clinical , Executive Leadership