Innovation Driving Change Draft in Progress | 2/26/20 Who We Are - PDF document

Innovation Driving Change Draft in Progress | 2/26/20

Who We Are Montefjore, renowned for its long-standing commitment to community-based healthcare, is leading a group of nearly 250 healthcare providers, community-based organizations, local government offjcials and more, from across Westchester, Rockland, Orange, Sullivan, Dutchess, Ulster and Putnam counties, to form the Montefjore Hudson Valley Collaborative (MHVC). Working together, we are championing new models of providing over 200,000 Medicaid benefjciaries with higher quality care, while reducing expenditures through enhanced coordination, community-focused care and education. Our Guiding Vision • A more integrated delivery system, better able to take on risk and deliver value • A more sustainable delivery system, care delivered locally and in the right care setting • A more patient-centered delivery system, with expanded access to service s tailored to the unique needs of our patients and communities Draft in Progress | 2/26/20

MHVC DSRIP 1.0 Project Impact MHVC DSRIP 1.0 Network Development Patient Engagement, Supporting Care Strengthening Care Teams Transitions • 44 practice sites achieved PCMH Level III certifjcation • “What Matters to You” campaigns to target patient • Supported network adoption of PHQ 2/9, Brief experience implemented at Wakefjeld, Nyack and St. Action Planning, Motivational Interviewing, Social Lukes - Cornwall Hosptials Determinants of Health (SDH) screenings • Nyack saw an increase in 10/11 HCAPS PX scores • Regional BH networks (CBHS, CHN) aligned (Q4’18 – Q4’19) with HVIPA Lorraine’s WMTY Story “What Matters to You?” Provider Engagement • Multi-stakeholder workfmow redesign: upwards of 50% of ED referrals (St. Luke’s/Nyack) & 30% of • Provider Engagement community referrals enroll in Health Home “Understanding the Role of Teamwork” • Facilitated site deployment and ROI analysis of “Addressing Drivers of Burnout, Staff Resiliency technology tools: Valera (6 BH orgs) & EMMI (4 & Joy in Work” hospital sites) • Change Management Certifjcation (100+), Executive/ Management Training across Network Reduce Readmissions (PPR, PPA, PPV) • Joy In Work Learning Collaboratives • Community Paramedics (Nyack) – high risk patient • Addressing Institutional Racism (various programs) cohort w/ 49% reduction in readmissions Stopping the Revolving Door Building Network Interoperability “Stopping the Revolving Door” • MAX high utilizer cohorts across 5 Hospital ED’s – • 18 partners established HIE bidirectional connections reduce PPR by up to 52% “Community Partnerships Reduce ED-Utilization” Emerging Roles – Successfully train/integrate • Addressing Food Insecurity through Information Outposts • Nurse Practitioner Residents (9) “Healthy Food Distribution at • Community Health Worker (18) Information Outposts” • OASAS Certifjed Peer Recovery Coaches (24) • St. Luke’s/FQHC partnership to reduce PPR, PPV for high-risk patients. Estimated ROI = 3X project costs Research Roadmap w/ Einstein Improved Access to Care • Launched Research Roadmap with Einstein College of Medicine researchers and Hudson Valley community • Peer Recovery coaches improved 7/30 day follow-up partners to further innovation for individuals w/ SUD discharges from 47% to 100% “Recovery Coaches Building Bridge for “Understanding the Role of Teamwork” Care Transitions” “Evolution of the MHVC Research Roadmap” • Primary care sites adopted EBG for patients with uncontrolled HTN, improving adherence by 38% Nida Opioids Grant (Collaboration with Columbia); “Controlling Hypertension through Planned 5 Hudson Valley Counties Interventions” Official news release from Columbia • FQHC Mobile van promoted chronic disease mgmt at HHS press conference-NIDA grant announcement BH partner sites – improving adherence by 60% News 4 Feature • Living Room program served 100+ patients at risk for BH Crisis ED/hospitalization • Open Access for substance abuse intakes across Hudson Valler improved from 28-166.5 hours per week (MTM Same Day Access Initiative) Draft in Progress | 2/26/20

Innovation Driving Change 1 What Matters to You?: Background Building Relationships • Patient Experience Metrics and Employee Engagement data indicated a need for improvement, and became an organizational to Improve Patient priority Experience Metrics & Goal Employee Engagement • Demonstrate an improvement in HCAHPS and Press Ganey scores, specifjcally those questions related to relationship building Montefiore Nyack demonstrated an improvement in HCAHPS Strategy and Press Ganey key indicators, • Introduced the “What Matters to You” initiative (WMTY), creating awareness and desire to change while receiving positive feedback • Provided education on a unit by unit basis from patients, families, and team • Incorporated teachings into daily practice members. • Data collection included patient survey results, patient comments, direct observations and Nurse Leader and Patient Experience “What Matter’s to You?” Rounding Building Relationships to Improve Patient Experience Metrics & Employee Engagement • Sustain focus on WMTY, participating in National WMTY Day Background Outcomes Celebrations annually Our Patient Experience Metrics and Employee Engagement data indicated a need for improvement and became an organizational priority. Enhancing our ability to form genuine relationships with our patients, families and team members allows us to gain trust, ease anxiety and improve outcomes. This is the philosophy of the worldwide “What Matter’s to You” initiative, which was introduced by the Institute for Healthcare Improvement in 2012. Project Aim The objective of Montefiore Nyack’s “What Matters Outcomes to You” initiative is to demonstrate an improvement in HCAHPS and Press Ganey scores, specifically those questions related to relationship building. Project Design & Strategy Attention to Special and Personal Needs We introduced the “What Matters to You” initiative to Montefiore Nyack Hospital in the Fall of 2018 by creating awareness and desire to change. National “What Matters to You” Day Celebration at Montefiore Nyack We started off 2019 by providing education on an individual unit basis through the use of PowerPoint, On June 6, 2019 Montefiore Nyack hosted it’s first ever “What Matter’s to You Day”. In an effort to continue to bring video and role playing. awareness, celebrate our success and build relationships with our staff, the Senior Leadership Team met with over 600 Staff’s Effort to Reduce Anxiety employees throughout the day over breakfast and ice cream to find out what mattered to them. A stoplight report was The WMTY initiative was incorporated into our daily created highlighting the actions we took based on the feedback we heard from our staff. The WMTY Celebration was practice by including it in bedside handover, multidisciplinary rounds, leader rounding and in- very well received! room patient whiteboards. Data Collection included patient survey results, patient comments, direct observations and Nurse Staff Worked Together to Care of You Leader and Patient Experience Rounding. Staff Addressed Emotional Needs Response to Concerns & Complaints Conclusions Sustainability & Spread Montefiore Nyack demonstrated an improvement in Education and implementation throughout Montefiore HCAHPs and Press Ganey key indicators. Positive Nyack’s organization will continue to the Emergency feedback and unique stories were received from Department, Outpatient Services and Ancillary Support patients, families, and team members. Our results Staff. Reinforcement throughout the Inpatient & demonstrated the development of relationships, trust Communication with Nurses Ambulatory Surgery service lines will continue. and a reduction in anxiety improves the patient’s experience. Utilization of the “What Matters to You” National WMTY Day Celebrations will continue on an initiative with team members has enriched annual basis at Montefiore Nyack where we focus on relationships with the Senior Leadership Team. This has continuing to build trusting personal relationships with enhanced trust and transparency throughout the our team members. organization. Lorraine’s WMTY Story WMTY Wedding Anniversary • Successful outcomes have motivated spread through organizations, internationally and in collaboration with IHI View Poster View Poster Draft in Progress | 2/26/20