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APRIL 2017 AMGA.ORG x GROUP PRACTICE JOURNAL 9

Originating as an open-staff, not-for-profit, com-munity hospital created by local physicians in 1873, UPMC Susquehanna (formerly Susquehanna Health) has grown into a system of four hospitals, a large multispecialty medical group, and an organized system of care.

Physician leadership, a hallmark of their founding principles, waned in the second half of the 20th century as non-physician administrators took the more active role. Although physicians have been employed by the system hospitals since the 1970s, it was not until 2001 that physician employment became a significant focus and recruiting tool. Subsequently, the CEO and Board (comprised of 16 community leaders and physicians) recognized the need for physician leadership to enhance physician participation in an organized system of care for the community and region. In 2008, a respected senior physician leader from the organized medical staff accepted this challenge and led the group to significant growth in size and leadership capabilities. Since 2008, the group has grown from 90 FTE physicians to 132 FTE physicians and 89 FTE advanced practice profes-sionals. Both employed physicians and independent physicians comprise the medical staff.

Collaboration Improves OutcomesIn 2013, UPMC Susquehanna embarked on a

collaborative Medicare Shared-Savings Plan (MSSP) Accountable Care Organization (ACO) that included another healthcare system, UPMC Susquehanna-employed physician groups, and six additional physician groups. This large, collaborative effort aligned goals of medical groups and healthcare orga-nizations, provided incentives for all groups to utilize agreed-upon, evidence-based medicine principles, and motivated the use of more robust information technol-ogy for monitoring patients and coordinating their care. Adopting this model resulted in a team approach to providing patients with the right service by the right providers at the right time in the right place.

In addition to the ACO’s accomplishments, the UPMC Susquehanna Medical Group’s primary care practices were all recognized as Level 3 Patient-Centered Medical Homes. Other contributions to UPMC Susquehanna’s recognition include the develop-ment of programming, education, and partnerships with regional, potentially medically-underserved communities, as well as the development of a pal-liative care program that recently received the 2016 American Hospital Association Circle of Life Award for excellence.

In September 2016, UPMC Susquehanna Medical

Group was named a 2016 Acclaim Award honoree. As part of the application process, the organization was asked to highlight two narratives describing the design and deployment of two major components—projects, phases, or tactical plans—that were part of their plan to transform the way they deliver health care in order to more fully achieve the AMGA High-Performing Health System™ attributes, improving both the qual-ity and cost of care. Following are details about one of these components focused on elder care and end-of-life care.

Regional Nursing Home Outreach InitiativeIn October 2010, in response to a growing aware-

ness of the important role of long-term care providers in care coordination and community health improve-ment, UPMC Susquehanna reached out to local nursing homes to create a Community Elder Provider Network. The director of their system-owned skilled nursing facil-ity (SNF) created a roundtable for leaders of six nursing homes in the county, along with representatives from an elder independent living facility, Office of the Aging, and the system-owned home care and hospice program. The initial objectives of the Network were:

1. To improve communication between multiple pro-viders, patients, families, and caregivers

2. To improve the transition and coordination of care for patients in the post-acute care setting

3. To prevent unnecessary readmissions to the hospital

The Network sponsored an annual Elder Care Symposium hosted by the system. This successful event became an annual program attended by many organiza-tions in the region to learn ways of improving care and fostering better communication.

Regular communication with area SNF leaders paved the way for targeted programs to enhance the effectiveness of these facilities in providing care to patients and improving life-sustaining care discussions and planning. Today, the Provider Network consists of nursing home facilities in five counties in the region and became the vehicle through which UPMC Susquehanna informed these providers of their ACO initiative and requirements. The Network enabled the system to com-municate and implement necessary standards to reduce readmissions and improve care coordination.

Due to participation in a new Medicare ACO, the Chief Nursing Officer of the regional medical center moved to a new position as Chief Transition Officer to facilitate care integration at all levels of the system. She facilitated the design and deployment of the program for SNFs that share in the care of patients to reduce


10 GROUP PRACTICE JOURNAL x AMGA.ORG APRIL 2017

unnecessary admissions and readmissions and to coor-dinate care across levels of care.

Program DesignThe design of this program is based on the INTER-

ACT (Interventions to Reduce Acute Care Transfers) program. First designed in a project supported by the Centers for Medicare & Medicaid Services (CMS) involving 30 nursing homes in Florida, New York, and Massachusetts, the overall goal of this quality improve-ment program is to reduce the frequency of transfers to the acute care hospital. Such transfers can be emotion-ally and physically difficult for the residents and may result in a variety of complications of hospitalization which add to morbidity, mortality, and increased cost of care.

Utilizing the INTERACT framework and tools, UPMC Susquehanna invited area nursing homes that receive patients from their four acute care facilities to participate in review of readmissions. They succeeded in working with all facilities that send patients to and/or receive patients from their acute care facilities.

They recognized that some area facilities did not have physician medical directors or other providers who were immediately available (often because they worked or resided in locations remote to the facility) to provide assessment and management of acute changes

in a resident’s health status. They were finding that the on-call physician simply directed nursing staff by phone to send patients with status changes to the ED for evaluation. Therefore, providing more engaged physician leadership at each facility and providing spe-cialized geriatric support became an important aspect of the design.

Additionally, partnership between leaders of their SNF and their palliative care program led to the design of a dedicated program to assure that all patients (and their families) in the hospital or nursing care facility received instruction and assistance regarding life-sustaining treat-ment decisions and appropriate portable documentation accepted by all area hospitals and nursing facilities. A collaborative group of representatives of all local hospital and nursing homes developed and used a tool called Phy-sician Orders for Life-Sustaining Treatment (POLST) to assure that patient preferences were known and followed.

DeploymentThrough research and previous review of patient

care events, UPMC Susquehanna observed that commu-nications and hand-offs present high risk for negative patient outcomes. By working with the Community Elder Provider Network, they explained the goals of reducing readmissions and collaborating to improve communication and processes of care. After educating

UPMC UPMC Susquehanna Medical Group team accepting the 2016 Acclaim Award (from left to right): Melissa Davis, Chief Operating Officer/Vice President; David Lopatofsky, M.D., Chief Administrative Officer/Executive Vice President/CMO; Matthew Meeker, D.O., Division Chief; William McCauley, M.D., Past President, SHMG; Brian But-torff, Director Business Strategy; Krysta Wagner, Executive Director

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all long-term care leaders about the program, the team verified the correct use of the INTERACT tool with each nursing home. If they found ineffective use of the tool, they provided additional education and resources to support the facility in the appropriate use of the tool.

To improve communication regarding high-acuity patients at the time of transfer from the acute care setting to the SNF, acute care case managers expanded their roles to discuss care directly with nursing home care managers in addition to the “usual” RN hand-off to the nursing home caregiver. Nursing Home Admin-istrators and Directors of Nursing (DONs) review each readmission and admission using the INTERACT root cause analysis forms. The acute care transitions team also reviews the admission and readmissions, looking for areas of opportunity with hand-off communication and process. These reviews occur monthly, at which time action plans to address care or communication gaps are promulgated.

UPMC Susquehanna has agreed to work with all facilities to improve the care that shared patients are receiving. They have found that the nursing homes are acutely aware of the evolving healthcare performance metrics, including CMS readmission penalties, and were eager to participate actively in this program.

The overall success of this program also depends on keeping the patient at the center of the care planning process, regardless of where they are residing at the moment—hospital, nursing home, or home. The system tracks patients at nursing homes for length of stay, and seeks to support patients remaining in their home environments as much as possible. It coordinates nurs-ing home discharges with the home health program and nurse navigators care processes.

Finally, UPMC Susquehanna moved toward the goal of assuring that patients and families have the chance to consider, discuss, and document their end-of-life care preferences by incorporating this objective into the nursing home outreach program. The palliative care program conducted facilitator training with physicians, nurses, social workers, chaplains, and others from six regional hospitals (even beyond the system facilities), 12 nursing homes, and six assisted living facilities. Because of educational efforts and facilitator training across institutions, it is now the norm in all the nurs-ing homes in the region to offer and complete POLST conversations and to document completion for all appropriate patients in their care.

Changes in CareUPMC Susquehanna provided “Stop and Watch”

INTERACT tool education to all participating nursing

homes for their implementation. This program is designed to educate the nurses’ aides about specific changes in a resident’s condition to which they should be alert and for which they should alert the RN.

Beginning in 2009, the system-owned SNF employed a Certified Nurse Practitioner (CRNP) to facilitate care of increasingly complex SNF patients. That program enabled the system SNF to start a unit for chronic mechanically ventilated patients (currently 12 beds). In an effort to improve care for increasingly sicker and complex patients, three other nursing homes in the county have adopted a model of care utilizing CRNPs at their facilities.

UPMC Susquehanna has now embarked on a geri-atric program that supplies medical directors to area nursing homes to more closely supervise care, enable the care of more complex conditions in the SNF setting, and to provide support for the CRNP. Thus far, they have enabled physicians to be medical directors at three facilities and have received requests from two other facilities where they plan to assist in a similar program. They have invested in and deployed a team of three physicians and two CRNPs led by a board-certified ger-iatrician to be available as needed in the local nursing homes to consult on the more challenging cases. They emphasize special attention to advanced care planning in the nursing home geriatrics program.

Based on trends that have been identified in the reviews of readmissions, IV access at nursing homes is being built into a paramedic process, allowing nursing homes to provide a higher level of care which may avoid the need for the resident to make a journey to the emergency room or avoid the need for a hospital read-mission. Families and patients are provided information about the nursing home’s star ratings and about the medical directors of the facilities. The medication rec-onciliations that occur at time of discharge have been revamped to assure clarity and consistency.

UPMC Susquehanna increased connectivity with the nursing homes by providing access to the hospital electronic health record (EHR) system so they could view medical information for mutual patients. All POLST orders are on file in the EHR for these patients so that they may be verified in either care setting.

MeasuresIn addition to the changes previously discussed,

UPMC Susquehanna, through its palliative and end-of-life care program, has achieved a marked improvement in assuring that patients and families have received appropriate information and have shared in deci-sion making to increase the number of patients with


APRIL 2017 AMGA.ORG x GROUP PRACTICE JOURNAL 13

completed POLST (Tables 1 and 2; Table 2 reports 2015 results as percent completed rather than number). Of note, increased use of palliative care/advanced care planning has been noted in two facilities. Although full data is available for only the first two quarters of the initiative to reduce readmissions from nursing homes, the early trend is promising (Table 3).

Obstacles Several obstacles remain in the program. Area on-

call physicians who are not familiar with a particular

patient and who are not part of the health system remain less engaged in trying to consider opportunities to support the patient in the nursing home setting and often have a low threshold to give orders to transfer the patient, even when nursing home staff are willing and capable of continuing care at the facility.

Another obstacle is lack of knowledge by the family of the level of care that can now be performed at the nursing facility, which may lead to pressure to transfer the patient to the hospital. UPMC Susque-hanna views this resistance as an area of opportunity to

TABLE 1

POLST Summary

Nursing Home A 133 25 25 43 33 32 71

Nursing Home B 152 75 65 87 71 112 52

Nursing Home C 116 31 18 31 54 70 62

Nursing Home D 123 5 18 27 33 52 76

Nursing Home E 138 68 83 108 117 115 86

Nursing Home F 129 103 125 124 122 122 122/100%

Nursing Home G 181 14 30 35 38 35 42

Facility Total # of POLST # of POLST POLST POLST POLST POLST # of June Dec. June Dec. Oct. Oct. beds 2011 2011 2012 2012 2013 2014

Nursing Home H 0% 0% 4% 10% 5% 11% 11% 40% 21% 42% 40% 40% 41%

Nursing Home I 46% 46% 59% 83% 83% 75%

Nursing Home J 92% 89% 82% 90% 82% 85%

Nursing Home K 79% 86% 76% 80% 73% 81% 76% 77% 79% 79% 80% 79% 78% 80% 79% 79%

Nursing Home A 76% 76% 74% 75% 98% 91% 100% 96%

Nursing Home L 68% 86% 86%

Nursing Home B

Nursing Home C 60% 60% 64% 65%

Nursing Home D 91% 92% 90% 91% 92% 90% 95% 92% 93% 90% 94% 92% 91% 94% 91% 92%

Nursing Home E 71% 66% 70% 69% 66% 67% 68% 67% 68% 71% 72% 70% 71% 74% 67% 71%

Nursing Home G 65% 67% 67% 66% 73% 71% 69% 71% 73% 90% 86% 83% 83% 84% 88% 85%

Nursing Home F 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% of POLST completed on LTC residents (total number of POLST divided by number of residents)

2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015 2015Goal

January 2015 – December 2015

Jan. Feb. Mar. Q3 Apr. May June Q4 July Aug. Sept. Q1 Oct. Nov. Dec. Q2

80%(Review Quarterly)

TABLE 2

Continuum of Care Dashboard—POLST



provide education to families at the time of admission to the nursing home and during care plan review.

Lessons LearnedCommunication is paramount in obtaining ongoing

support. Having knowledgeable team members provide detailed explanations and be available for support throughout the change process (which remains ongoing for the program at this time) is necessary.

This program requires education at many levels, so having a well thought-out program in advance of meeting with nursing home facilities is important for success. The inclusion of palliative care specialists and staff sped the process of educating nursing home pro-fessionals in the difficult area of discussing end-of-life choices and preferences.

UPMC Susquehanna learned the importance of including all facilities in the process (rather than attempting to designate “preferred” SNFs), which enhanced their willingness to share information and improve their processes. They share outcomes transpar-ently, which maintains interest and competitiveness. Finally, UPMC Susquehanna recognizes that there is a range of capability among facilities and therefore, tries to view each one as a unique opportunity, requiring flexibility in the approach to change management.

Leading for ValueBeing named an honoree for the 2016 Acclaim

Award validates the work of UPMC Susquehanna in continuing to thrive as the industry moves to value-based models and to improve the health and health care of patients and their families.

“Since 2001, we have committed to investing in medical group development and physician leadership to enhance the system of care for our communities and region,” said David Lopatofsky, M.D., M.M.M., FAAFP, chief administrative officer of UPMC Susque-hanna Medical Group and executive vice president/CMO of UPMC Susquehanna. “The award is the result of years of focus and commitment to developing and implementing programs and partnerships which directly improve the quality of care provided to those we serve. In the ever-changing world of health care, we place patients and their families first.”

Adapted from UPMC Susquehanna’s Acclaim Award application, submitted by William C. McCauley, M.D., past president, UPMC Susquehanna Medical Group.

TABLE 3 Continuum of Care Dashboard

Nursing Home H 1.17 1.47 0.59 1.08 0.58 0.48 0.96 0.67

Nursing Home I 1.36 0.00 0.00 0.26 0.11 0.12

Nursing Home J 0.00 0.00 1.83 0.56 0.80

Nursing Home K 0.14 0.27 0.00 0.14 0.07 0.13 0.07 0.09

Nursing Home M 0.27 0.00 0.54 0.27

Nursing Home A 0.12 0.04 0.28 0.44 0.27 0.33

Nursing Home L 1.29 0.67 1.45 1.14 0.29 1.07 0.29 0.55

Nursing Home B 1.43 1.57 1.89 0.84

Nursing Home C 0.69 0.64 1.27

Nursing Home D 0.46 0.93 0.90 0.76 0.46 0.31 0.25 0.34

Nursing Home E 0.06 0.07 0.09 0.07 0.10 0.12 0.08 0.10

Nursing Home G 0.25 0.70 0.00 0.32 0.21 0.23 0.49 0.31

Nursing Home F 0.55 0.55 0.83 0.64 0.28 0.18 0.27 0.24

Readmissions within 30 days to Acute Care from LTC Critical benchmark (# of readmissions per 1,000 resident days)

Readmissions from Long-Term Care Facilities

July 2015 – Dec. 2015

July2015

Aug.2015

Sept.2015

Q1 Oct.2015

Nov.2015

Dec.2015

Q2GOAL

<19%(Review Quarterly)

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