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Alice Bonner, PhD, RN, FAAN

Northeastern University

April 30th, 2015

Photo:Alex Tenappel

I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor for CMS.

This handout is intended for use by this audience only. Please do not distribute.

After the presentation the learner will be able to:

1. Describe the role of nursing home leaders on cross-continuum teams

2. 2. Explain how a QAPI program such as INTERACT, when fully implemented, may lead to reduced avoidable hospitalizations, improved quality of care and quality of life

3. 3. Discuss how use of the Advancing Excellence hospitalization quality measure can help an organization to meet the intent of the Affordable Care Act (ACA) nursing home QAPI provision

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How can we transform our communities so that people have a choice about how and where they age?

How can we ensure quality of life during transitions for the most vulnerable older adults and their caregivers?

Health and Well-being Model

Deeper dive into the issue: Who are all these old people and where did they

come from?????

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The demand for direct-care workforce is set to increase by 48% over the next decade This demand and lack of retention could lead to a shortage Turnover and issues with access create particular problems during care transitions

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Specifically: lack of affordable and accessible housing, transportation, nutrition programs (meals on wheels)

Lack of behavioral/mental health services

Need for personal attendant service/additional service hours

Need to acquire independent living skills prior to transition

Many others

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What tools and systems will you use to understand your data and make meaningful changes based on that data?

How will you excite your staff around using data?

Advancing Excellence Hospitalization Tool

Preferences for Everyday Living Inventory (PELI)

Consistent assignment tool Having the same caregivers makes a difference!

Staff stability High turnover may lead to ineffective transitions. It

may also put facility at risk of deficiency citations on surveys, risk of more complaints from residents, families

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Care Transitions Model Four pillars

Dynamic, person-centered record

Medical self-management

Follow up

Red flags

Care management (coaching model)

CTM-3 measure

Transitional Care Model Uses APRNs with high risk populations (e.g., CHF,

dementia, SMI)

Early data showed cost savings of about $5,000 per patient in frail older adults with CHF

Care management – “whatever it takes”

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The INTERACT Quality Improvement

Program

A Practical Approach To Safely Reducing Rehospitalizations

Thanks to Laurie Herndon, APRN-BC, GNP

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 interdisciplinary team under the

leadership of Dr. Joseph G. Ouslander, M.D. with input from many

direct care providers and national experts in projects based at

Florida Atlantic University (FAU) supported by The Commonwealth

Fund.

1. Prevent conditions from becoming severe enough to require

hospitalization through early identification and evaluation of

changes in resident condition

2. Manage some conditions without transfer when this is feasible

and safe

3. Improve advance care planning and the use of palliative

care plans when appropriate as an alternative to hospitalization

for some residents

4. Improve documentation and communication within LTC

facilities and programs, and between LTC and acute care

INTERACT Strategies

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Rehospitalizations of

SNF Residents are Common and

Costly

1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30

days at a cost of $4.3 billion

Source: Mor, et al. (2010) Medicare SNF Rehospitalizations: Implications for Medicare Payment Reform, Health Affairs.

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?

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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 and Readmissions

are Avoidable

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Medical Care: August 2013 - Volume 51 - Issue 8 - p 673-681 doi: 10.1097/MLR.0b013e3182984bff

Subjects: The population of interest is a cohort of long-stay NH residents.

Data are from the Nursing Home Stay file, a sample of residents in 10% of

certified NHs in the United States (2006–2008).

Results: Three fifths of hospitalizations were potentially avoidable and the

majority was for infections, injuries, and congestive heart failure.

Background:

Many Are Avoidable

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

State Duals Programs and Medicaid Managed Care

Other models – e.g. most recent CMS contracts for reducing unnecessary hospitalizations of long-stay NH residents

Changes in Medicare and Health Care Financing are

Changing Incentives

The Bottom Line

“Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them”

A. E. Boutwell, M. B. Johnson, P. Rutherford et al., "An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions," Health Affairs, July 2011 30(7):1272–80

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Quality Improvement Tools

Communication Tools

Decision Support Tools

Advance Care Planning Tools

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

2. Tools were acceptable to staff 3. 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

Implementation Model in the Commonwealth Fund Grant Collaborative

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

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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

0.01

24%

Not engaged facilities

(N = 8) 3.96 3.71 - 0.26

0.69

6%

Commonwealth Fund Project Results

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

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How many transfers from your nursing home?

When do they occur?

How many days since admit?

“Ah ha” moments

Online version

Root Cause Analysis: The Rest of the Story

Demographics What happened Contributing factors Attempts to manage in SNF Avoidable? Staff thoughts about this Opportunities for

improvement Cross continuum review of

cases

Enhanced Nursing Assessment

Builds on early recognition

Standard approach

MD/NP response

Warm hand over

How might this complement disease management?

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Communication Tools Across Settings

Nursing Home Capabilities Checklist

Medication Reconciliation Worksheet

Transfer forms both directions

Data lists both directions

Can use as platform to start discussion about which elements nurses will use for warm hand off

Returned Unopened

Poor Communication=Poor Outcomes

Decision Support Tools

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Decision Support Tools

For the SNF: one unit

For the hospital: one SNF

For HH/AL: one case

For surveyors: one conversation

For all: one CC meeting

The Important

Role of Your

Facility Team

Facility Leaders: Improving

Relationships

Direct Care Staff:

Improving Quality of Care

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Connect across provider types within each community Take the initiative – don’t wait for an invitation

Use existing resources Hospital Engagement Networks (HENs)

State Coalitions to Improve Dementia Care

Quality Improvement Networks (QINs, formerly QIOs). National Nursing Home Quality Care Collaborative (NNHQCC) change package

Advancing Excellence Local Area Networks for Excellence (LANEs)

Create the change you want to see!

Model the attitudes and behaviors you would like to see in your staff

Be visible

Send a clear, consistent message about your organization’s philosophy around transitions

Ask questions (“what do you need from me?” “What is most broken – what needs to be fixed first?” “How can we be the best at getting better?”)

Help staff embrace measuring improvement

Take action – but don’t try to do everything all at once. Start with small steps – but keep going!

Facility Leaders

Be prepared Initiate contact Know your data Share your story Know what tools,

data, information you want to share

Set date for next meeting

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Lots of interest in this form

Bring it with you

Offer to update regularly

Be sure you can do what you say you can

“It is not about the forms: It is about the relationship”

Enhancing the relationship by using the

Warm Hand Over

The Warm Hand Over

The Power of One One SNF nurse

One hospital nurse

One meeting

One trial

How did it go?

Modify

Try again

Spread

Cross Continuum Meeting

Frontline work intersects with work of leadership= improved care

Results Are Shared

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• Person-centered • Nurse led • APRN supported • Evidence is

building • Scalable

Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents

4 year initiative

15 partner facilities required, with average census >100 residents

Focus is long stay, dual eligible residents

Funded through the CMS Innovation Center and Medicare-Medicaid Coordination Office

Approximately $100 million for 7 projects

IU Geriatrics

Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care

$13.4 million over 4 years

19 partner facilities (~2000 residents)

Independents, regional and

national chains represented

Greg Sachs & Kathleen Unroe –

Project Directors

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Reduction in avoidable hospitalizations of long stay nursing home residents through:

improving medical care,

enhancing transitional care and

access to palliative care

RNs are embedded in each facility to lead delivery of the intervention, supported in managing residents by NPs who cover a group of facilities Unroe et al, JAGS 2014

RNs (18) placed at each facility to lead delivery of the intervention, supported in managing residents by NPs (6) who cover a group of facilities

2 RN managers (one with 50% and one 25% managerial time)

IU Geriatrics

Dedicated to one building

Full-time Monday-Friday

Quality Improvement champion

Mentorship in clinical assessment for facility staff

Liaison to the NP

IU Geriatrics

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Acute Change in Condition–INTERACT implementation; mentoring and coaching

Support NPs – identify patients; communication

Advance Care Planning – 2-3 patients per week

Collaborative Care Reviews –gather information

Quality Improvement – transfer root cause analyses; integrate into the QI facility efforts

IU Geriatrics

Cover 4-5 facilities

Available 10am-6pm Monday-Friday; 8-12 on weekends

Ability to see residents with a change in status or identified by RN as needing evaluation – discussing with PCP

Resident, family, staff education

IU Geriatrics

Acute change in condition

Transition Visits

Collaborative Care Reviews

Support RN in education efforts

IU Geriatrics

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IU Geriatrics

Wrist worn devices

physical activity (time, distance, calories, steps), sleep quality, temperature, galvanic skin response, heart rate, heart rate variability…)

Wall mounted sensors

motion, activity level, inferred behaviors, nicotine in air, etc.

Smart phone

Location, orientation, distance, voice quality (mood), light level, noise level

Others

clothing (ECG, respiration, …), tatoos (blood glucose), contact switches, computer interactions (cognitive measures), weight, BP, SaO2 …

Drs. Holly Jimison & Misha Pavel

Home health based on unobtrusive, continuous monitoring

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67 Pavel et al., IEEE Special Issue, in press

Hayes, ORCATECH 2007

Bedroom

Bathroom

Living Rm

Front Door

Kitchen

Sensor Events Private Home

Activity Monitoring in the Home

Hayes et al., www.orcatech.org

In 2013, 15.5 million caregivers provided over 17.7 billion hours of unpaid care

Valued at more than $220 billion

The vast majority of caregivers are women

Caregivers had over 9.3 billion in additional health care costs of their own

60% of caregivers rate the emotional stress of caregiving as high or very high; more than 1/3 report symptoms of depression

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Most care provided in the community by family members or others Some through state Medicaid waiver programs

(“money follows the person, community first” and others)

Only about 5% of older adults (about 1.5 million people) live in nursing homes

So what are some of the clinical and social issues that could benefit from innovation? Respite, falls, incontinence, self-care/self-

management, exercise, cognitive games, medication management

The future is now. Payment reform is driving change.

Acute care hospitals are very interested in what is going on in post-acute care and are asking about care coordination and programs for care transitions

Inform your local hospitals and other partners and help develop a dynamic working relationship

Be the leaders in innovation!

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Photo: Alex Tenappel