© florida atlantic university 2011 the interact program this handout is intended for use by this...

© Florida Atlantic University 2011© Florida Atlantic University 2011

The INTERACT Program

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Improving Nursing Home Care and Reducing Unnecessary Hospital Transfers, Admissions, and

Readmissions

© Florida Atlantic University 2011In collaboration with participating nursing homes

The INTERACT Program:What is It and Why Does It Matter?

The INTERACT Interdisciplinary TeamJoseph Ouslander, MD Florida Atlantic UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversityJill Shutes, GNP Florida Atlantic UniversityNancy Henry, PhD, GNP Florida Atlantic UniversityMichelle Duhaney, DO Florida Atlantic UniversityMaria Rojido, MD Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityLaurie Herndon, MSN, GNP-BC Mass Senior Care FoundationJo Taylor, RN, MPH The Carolinas Center for Medical ExcellenceGerri Lamb, PhD, RN, FAAN Arizona State UniversityAnnie Rahman, PhD, MSW USC Davis School of GerontologyDan Osterweil, MD California Association of Long Term Care MedicineAmy E. Boutwell, MD, MPP Collaborative Healthcare StrategiesAdrienne Mihelic, PhD Colorado Foundation for Medical Care Mary Perloe, GNP Georgia Medical Care FoundationJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services

© Florida Atlantic University 2011

Disclosures


No members of the INTERACT Team derive any personal income from the INTERACT program except for compensation for time spent delivering educational programs

The further development and dissemination of INTERACT is supported by grants from:

NINR/NIH Centers for Medicare & Medicaid Services The Commonwealth Fund The Patient Centered Outcomes Research

Institute PointClickCare Medline Industries


1. Provide a broad overview of the INTERACT quality improvement program and how it fits with health care reform initiatives

2. Describe barriers to implementing the INTERACT program and strategies to overcome them

Objectives of this Presentation



The Affordable Care Act is focused on a “triple aim”:

• Improving care• Improving health• Making care affordable

This presents major opportunities to improve geriatric care in the U.S.

Health Care Reform




Hospitalization

At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning,

pressure ulcers

At the beauty salon

Why Does This Matter?


Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

Video Clip:

Why This Matters


Why Does This Matter?


1. Hospital transfers are common and often result in complications in older NH residents

2. Some hospital transfers are preventable3. Care can be improved, resulting in fewer

complications and reduced cost4. Cost savings to Medicare can be shared

with NHs to further improve care5. Financial and regulatory incentives are

changing

© Florida Atlantic University 2011Mor et al. Health Affairs 29: 57-64, 2010

1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion




Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012.

(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf

http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images/PreventableHospitalizations_021512_2.pdf



Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize







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Several studies suggest that a substantial percent of hospital transfers , admissions, and readmissions are unnecessary and can be prevented

Some Hospitalizations of NH Residents are Preventable

The INTERACT Program:Background and Why it Matters



Was the Hospitalization Avoidable?

Definitely/Probably YES

Definitely/Probably NO

Medicare A 69% 31%

Other 65% 35%

HIGH Hospitalization Rate Homes

75% 25%

LOWHospitalization Rate Homes

59% 41%

TOTAL 68% 32%

CMS Special Study in GeorgiaExpert Ratings of Potentially Avoidable Hospitalizations

Ouslander et al: J Amer Ger Soc 58: 627-635, 2010

Based review of 200 hospitalizations from 20 NHs



CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries



Financial incentives in the Medicare fee-for-service program incentivize overuse of diagnostic tests and procedures that do not benefit many elderly people, and can result in morbidity and costs

By far, the most costly example in the geriatric population is potentially preventable hospitalizations

Medicare Fee-for-Service

Willie SuttonFBI Ten Most Wanted Fugitives

Born/Died 1901 -1980

Charges Bank robbery

Caught February 1952

During his forty year criminal career he stole an estimated $2 million, and eventually spent more than half his adult life in prison.

http://en.wikipedia.org/wiki/File:Willie_Sutton.jpg



Pay-for-Performance (“P4P”) No payment for certain complications;

disincentives for avoidable hospitalizations

Bundling of payments for episodes of care

Accountable Care Organizations that include hospitals, physicians, home health agencies, and SNFs that are responsible for the care of a defined group of patients

Changes in Medicare Financing



$ Costs HIGHLOW

Qu

alit

y

LOW

HIGH

$

$ Incentives for Providers

Improved Quality,Reduced Costs

Reduced AvoidableHospitalizations

Opportunities for You and Your Facility

Costs Avoided



Opportunities Related to the New QAPI Requirement

The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”)

The regulation and related surveyor guidance are being written

Improving management of acute change in condition and reducing unnecessary hospital transfers is one potential focus to meet the QAPI requirement


Safe Reduction in Unnecessary Acute Care Transfers

Infrastructure

Incentives

QI Programs

Tools

Morbidity

Costs Quality

What Do Nursing Homes Need to Take Advantage of These Opportunities?




Is a quality improvement program designed to improve the care of nursing home

residents with acute changes in condition


Includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources

The basic program is located on the internet:http://interact2.net




“BOOST”(Better Outcomes for Older Adults

Through Safe Transitions)http://www.hospitalmedicine.org

“Project RED”(Re-Engineered Discharge)

https://www.bu.edu/fammed/projectred

•Enhanced hospital discharge planning

“Care Transition Program”http://www.caretransitions.org

•Transition coach•Trained volunteers•Empowered patients and caregivers

“POLST” (or “MOLST”)(Physician (or Medical) OrdersFor life Sustaining Treatment)

http://www.ohsu.edu/polst

•Advance care planning

“Bridge Model”http://www.transitionalcare.org/the-bridge-model

•Social Worker coordinating Aging Resource Center Services at hospital discharge

“Transitional Care Model”http://www.transitionalcare.info/index.html

•APN coordinates care during and after discharge•Home, SNF, and clinic visits

“INTERACT”(Interventions to Reduce

Acute Care Transfers)http://interact2.net

•Communication Tools, Care Paths, Advance Care Planning Tools, and QI tools for nursing homes and SNFs

High Quality Care Transitions for

Older Adults &Caregivers

High Quality Care Transitions for

Older Adults &Caregivers

INTERACT is One of Several Evidence-Based Care Transitions Interventions

http://www.hospitalmedicine.org/

https://www.bu.edu/fammed/projectred

http://www.caretransitions.org/

http://www.ohsu.edu/polst

http://www.transitionalcare.org/the-bridge-model

http://www.transitionalcare.info/index.html

http://interact2.net/



Acknowledgement The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Centers for Medicare & Medicaid Services (CMS).

The current version of the INTERACT Program was developed by members of the INTERACT Team with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.

Permission can be granted via the “Contact Us”” section of the INTERACT website:http://interact2.net

The INTERACTTM logo is trademarked by FAU and most of the INTERACT Program materials are copyrighted (©) by FAU. The INTERACTTM logo and copyrighted materials may be used with the permission of FAU.

Users of these materials and/or the trademark INTERACTTM logo in any form in products for sale, including electronic health records of other forms of health information technology, must have a license agreement with FAU.

Use of the Program

http://interact2.net/


The goal of INTERACT is to improve care, not to prevent all hospital transfers

In fact, INTERACT can help with more rapid transfer of residents who need hospital care


HALTUnnecessary

Hospital Stays


1. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition

2. Managing some conditions in the NH without transfer when this is feasible and safe

3. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents

Can help safely reduce hospital transfers by:




Sadie Sara Sam

A Tale of Three Siblings



Hospitalized for UTI and dehydration

Discharged back to the NH after 4 days

Re-hospitalized 7 days later for dehydration and recurrent UTI

SadieA 96 year old long-stay NH resident

Preventable?

INTERACT strategy: Prevent conditions from becoming severe enough to require

hospitalization through early detection and evaluation



Hospitalized for a lower respiratory infection, but had normal vital signs and oxygen saturation

Developed delirium in the hospital, fell, fractured her pubis, and developed a pressure ulcer

Sara (Sadie’s younger sister)A 92 year old long-stay NH resident

Preventable?

INTERACT strategy: Manage some conditions in the NH without transfer



Hospitalized for the 4th time in 2 months for aspiration pneumonia related to end-stage Alzheimer’s disease

Transferred to hospice on the day of admission

Sam (Sara and Sadie’s older brother)A 101 year old long-stay NH resident

Preventable?

INTERACT strategy: Improve advance care planning and the use of palliative care

plans when appropriate as an alternative to hospitalization


1. Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates

2. Tools were acceptable to staff3. Significant reduction in hospitalizations 4. Significant reduction in transfers rated as

avoidable by an expert panel

CMS Pilot Study Results

Ouslander et al: J Amer Med Dir Assoc 9: 644-652, 2009



The program and tools were revised based on CMS pilot study, and input from front-line NH staff and national experts

The revised program and INTERACT II Tools are available at: http://interact2.net


Supported by a grant from the Commonwealth Fund


On site training (part of one day)

Facility-based champion Collaborative phone calls with up to 10

facility champions twice monthly facilitated by an experienced nurse practitioner Availability for telephone and email consults

Completion and faxing of QI Review Tools

Implementation Model in the Commonwealth Fund Grant Collaborative



Commonwealth Fund Project Results

Facilities

Mean Hospitalization Rate per 1000 resident days

Mean Change p value

Relative Reduction in All-

Cause Hospitalizations

Pre intervention

During Intervention

All INTERACT facilities (N = 25) 3.99 3.32 - 0.69 0.02

17%

Engaged facilities (N = 17) 4.01 3.13 - 0.90

0.0124%

Not engaged facilities (N = 8) 3.96 3.71 - 0.26

0.696%Ouslander et al, J Am Geriatr Soc 59:745–753, 2011



Commonwealth Fund Project Results - Implications

1. For a 100-bed NH, a reduction of 0.69 hospitalizations/1000 resident days would result in: 25 fewer hospitalizations in a year (~2 per month) $125,000 in savings to Medicare Part A (using a conservative

DRG payment of $5,000)

2. The intervention as implemented in this project cost of $7,700 per facility

3. Net savings ~ $117,000 per facility per year Medicare could share these savings to support NHs to further

improve care


Ouslander et al, J Am Geriatr Soc 59:745–753, 2011


Communication Tools

Decision Support Tools

Advance Care Planning Tools

Quality Improvement Tools

Putting the Tools to Work in Everyday Practice



The program and tools are currently being updated

INTERACT III tools and an updated INTERACT website should be available by the end of 2012

Note



eINTERACTTM is being developed

A User Advisory Group is being formed

http://www.einteract.org

PointClickCare Users

http://www.einteract.org/



Will be available on Medline University in early 2013

Implementation Training Curriculum


The INTERACT III tools are meant to be used together in your daily work in the nursing home

http://interact2.net




In order to implement a quality improvement program you must do at least two things:

1. Track, trend, and benchmark well-defined measures

2. Root cause analyses to learn and guide care improvement and educational activities

Getting Started: Keys to a QI Program




)

What Measures Should You

Track?







INTERACT has a paper and pencil worksheet to help track acute care transfers



Group Exercise:

Let’s Calculate Some Hospitalization Rates



You want to calculate your average unplanned hospitalization rate for the first quarter of 2013. You census in January was 110, in February 112, and in March 108. During these 3 months you transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter?

Choices:

3.533.234.043.74


Correct answer is b. Total unplanned admissions are 32 (3 of the 40 were planned, and 5 were admitted to observation, which is not considered an inpatient hospitalization). In the 3 months, multiplying the days in the month times the census, there were 9894 resident days. The rate per 1000 days is therefore 3.23 (divide total resident days by 1000 = 9.894; 32 divided by 9.894 is 3.23)



Let’s Calculate Some Hospitalization RatesYou want to calculate your average 30-day readmission rate for the first quarter of 2013. Your census in January was 110, in February 112, and in March 108. During these 3 months you had 66 admissions from your local hospital, and transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter? Choices:

a. You cannot calculate your 30-day readmission rate from these datab. 33.0%c. 60.6%d. 56.1%

Correct answer is a. You cannot calculate your 30-day readmission rate from these data for two reasons. First, you need to know if the residents who were hospitalized were the same ones admitted from the hospital. Second, you cannot calculate the 30-day readmission rate for March until the end of April. For example, a resident admitted to your facility on March 30 is at risk for a 30-day readmission until April 29.



What if the resident was initially discharged home, then came into the facility after 10 days at home, and is readmitted to the hospital the second day in your facility - does that count towards our 30-day readmission rate?

Yes or No?


Correct answer is YES. CMS is likely to count this as a 30-day readmission from the SNF, despite the fact the resident was at home most of the time between hospital discharge and admission to your SNF.



What if the resident is admitted to the hospital from your facility under observation status - does that count towards your 30-day readmission rate?

Yes or No?


Correct answer is NO. CMS does not plan to count observation stays in the numerator of this calculation. A separate quality measure involving observation stays may be developed in the future.



What if the resident is discharged from your facility after 20 days and is readmitted to the hospital 5 days later – does that count towards our 30-day readmission rate?

Yes or No?


Correct answer is IT Depends. The answer depends on how you calculate this percentage. CMS is likely to count the whole 30-day period, thus making skilled nursing facilities accountable for hospital admissions that occur after discharge from their facility, but 30 days or less from hospital discharge.

© Florida Atlantic University 2011 Advancing Excellence tool located at: http://www.nhqualitycampaign.org


Highlighting identifies residents at risk for 30-day readmission and those who returned to hospital within 30 days Flyover boxes provide

instructions for data entry

INTERACT has developed a Hospitalization Rate Tracker in collaboration with the Advancing Excellence Campaign

http://www.nhqualitycampaign.org/



Dropdown lists for easy data entry

Transfers that occur within 30 days of admission from the hospital are highlighted

Advancing Excellence tool located at: http://www.nhqualitycampaign.org




Advancing Excellence tool will be located at: http://www.nhqualitycampaign.org

Rates trended by month – in this graph 30-day readmissions from PAC, LTC, and total




Unplanned Transfer Assessment Data Collection Tool Facility Name: Name Date Completed: Date Time Period Being Reviewed: Using information from the Unplanned Transfer Assessments reviewed during the timeframe you have identified in Row #5, enter item totals in the following sections. Day of Hospital Transfer: # % Sunday 4 11% Monday 2 6% Tuesday 4 11% Wednesday 5 14% Thursday 6 17% Friday 7 19% Saturday 8 22% Total 36 100% How many transfers occurred on the following shifts: # % 1st Shift: 7AM-3PM 2 17% 2nd Shift: 3PM-11PM 4 33% 3rd Shift: 11PM-7AM 6 50% Total 12 100% Notes:

Summary



Small Group Exercise:

Root Cause Analyses Using the INTERACT Quality Improvement Tool


Video Clip:

Early Identification of and Communication About Acute Changes in Condition




Video Clip:

Effective Nurse – Primary Care Clinician Communication About Acute Changes in

Condition


Improve communication

Consistent language

Standardized criteria

Clear guidelines

Communication that is efficient

Communication that is effective


The Purpose of the SBAR


The INTERACT Change in Condition File Cards



INTERACT Care Paths

All structured the same way Provide guidance on when to

notify the MD/NP/PA consistent with File Cards

Suggest evaluation strategies Provide recommendations for

management and monitoring in the facility



Video Clip:

Advance Care Planning (1)

ADVANCE CARE PLANNING TOOLS


Advance Care Planning

ACP should occur at some time shortly after admission

Decisions should be reviewed regularly and at times of acute changes in condition



Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address:

Nutrition and hydration Activity Monitoring in the least

disruptive way Hygiene Comfort and safety

This material was adapted from the Birmingham VA Safe Harbor Project in 2007



Video Clip:

Advance Care Planning (2)


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Case Study

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81 year old retired schoolteacher admitted to the hospital from home with pneumonia

Past Medical History- COPD, Osteoarthritis, CAD, CHF

While hospitalized, had a myocardial infarction (a heart attack)

Transferred to your facility 5 days ago for rehab with ultimate goal to return to living independently at home

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Case Study

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Early a.m CNA notes that resident isn’t herself

Somewhat irritable Seems to be a little confused Not interested in breakfast Doesn’t go to therapy Reports to nurse at change of

shift ( 3 pm )

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Case Study

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3:30 pm

“The resident in 3B says she is having trouble breathing”

Case Study

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You think:a. She probably aspirated

b. Three other residents on that side have URIs—could she have picked it up?

c. She just finished her Levofloxacin. The pneumonia should be better

d. She also has CHF: it could be CHF

e. How will I know if it is CHF or pneumonia?

Case Study


How would Care Paths help the nursing evaluation?

Where would you keep these so that nurses would have easy access to them?

Case Study


Case Study


“DO YOU HAVE…..”

Case Study


Case Study


Additional Information: CXR-Persistent left lower

lobe infiltrate, hyperinflation bilateral lung fields consistent with COPD

WBC 15,000 BP 130/70 HR 90 RR 22

Temp100.5 Pulse ox is 91% on room air Chem panel is normal

Case Study


How would you complete the SBAR Change in Condition Progress Note with the information from this case?

Would the SBAR be helpful? (nurse and doctor?) How? (be specific)

Case Study


What might have been different if the Stop and Watch was completed in this case?

What might be some barriers to robust “uptake” of this tool in your facilities?

What strategies would you use to promote use of this tool in your facility?

Case Study


Interacting with Your Hospitals

Video Clip:

Effective Communication with Hospitals


The Resident Transfer Form has two pages.

The first page has information that ED physicians and nurses identified as essential to make decisions about the resident.



This Transfer Checklist can be printed or taped onto an envelope, and is meant to compliment the Transfer Form by indicating which documents are included with the Form



Information Transfer From the Hospital

FHA – FADONA – FMDA – CARES – AHCA

Readmission Initiative

Draft, October 2011



Nursing Home Capabilities List


Hang it in the ED Give it to case

managers Give it to hospitalists Give it to on-call primary

care clinicians in your facility



Medications Recommended by Hospital at Discharge for

which Clarification is Needed

Clarification Needed * Resolution for Final Medication Orders

(Continue, Stop, Change)

Medication Reconciliation Worksheet for Post-Hospital Care

Part 1: Hospital Recommended Medications Needing Clarification

*Examples: unclear diagnosis or indication, uncertain dose or route of administration, stop date, hold parameters, lab

tests needed for monitoring, dose different than before hospitalization, medication duplication



Medications Taken Before Hospitalization Not

Currently on Hospital-Recommended List

Comments(Who provided the information, reason for the

medication, reason it was stopped in the hospital if known)

Resolution for Final Medication Orders

(Continue, Stop, Change)

Medication Reconciliation Worksheet for Post-Hospital Care

Part 2: Medications Prior to Hospitalization Needing Clarification


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Effective implementation is critical to long-term sustainability of the program

The program cannot be effectively implemented or sustained without strong support from facility leadership

Tips on Getting Started and Keeping It Going


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General Principles

1.Make INTERACT a key aspect of your facility’s quality improvement activities and QAPI program

2.Implementation should be consistent with the way you provide care in your facility

3.Integrate the INTERACT program and tools into your everyday practice

4.Recognize that organizational change takes time - programs such as INTERACT can take several months to fully implement


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Overcoming Barriers to Implementation



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Overcoming Barriers to Implementation (1)

Barriers Strategies to Overcome“We don’t have a problem with hospital transfers”

Regularly track hospital transfers and follow trends; you may have a problem and not know it

“We don’t have control over who gets admitted”

Using INTERACT tools to improve management of acute changes and communication with physicians and emergency rooms staff will give you more control

“The doctors won’t cooperate” The medical director and the primary care providers must buy in to the INTERACT program



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Barriers Strategies to Overcome

“We don’t have the staff or time”

Improving the management of acute changes in condition has to be a priority of the facility and its leadership

“We have too many other things going on”

INTERACT must be one of the major quality improvement initiatives at the facility

“We are in our survey window”

INTERACT implementation will result in improved care and adherence to multiple F Tags and other requirements



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“Things don’t go well when the Champion is not here”

Appointing a co-champion and embedding INTERACT tools into everyday practice will help overcome staff absences and turnover

“We already have similar forms and processes”

Use your tools, or use or modify the INTERACT tools based on what your facility already has in place



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“Families want residents hospitalized”

Families need to be educated about the risks as well as benefits of hospitalization

“We could get sued” There is no fail-safe way to prevent law suits – but the INTERACT program provides tools for evidence-based and expert recommended care, and improves communication and documentation



Questions? Comments? Suggestions?

The INTERACT Program:

© florida atlantic university 2011 the interact program this handout is intended for use by this...

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