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© Florida Atlantic University 2011 The INTERACT Program This handout is intended for use by this audience only - please do not distribute Improving Nursing.

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Presentation on theme: "© Florida Atlantic University 2011 The INTERACT Program This handout is intended for use by this audience only - please do not distribute Improving Nursing."— Presentation transcript:

1 © Florida Atlantic University 2011 The INTERACT Program This handout is intended for use by this audience only - please do not distribute Improving Nursing Home Care and Reducing Unnecessary Hospital Transfers, Admissions, and Readmissions

2 © Florida Atlantic University 2011 In collaboration with participating nursing homes The INTERACT Program: What is It and Why Does It Matter? The INTERACT Interdisciplinary Team Joseph Ouslander, MDFlorida Atlantic University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jill Shutes, GNPFlorida Atlantic University Nancy Henry, PhD, GNPFlorida Atlantic University Michelle Duhaney, DOFlorida Atlantic University Maria Rojido, MDFlorida Atlantic University Sanya Diaz, MDFlorida Atlantic University Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation Jo Taylor, RN, MPHThe Carolinas Center for Medical Excellence Gerri Lamb, PhD, RN, FAANArizona State University Annie Rahman, PhD, MSWUSC Davis School of Gerontology Dan Osterweil, MD California Association of Long Term Care Medicine Amy E. Boutwell, MD, MPPCollaborative Healthcare Strategies Adrienne Mihelic, PhDColorado Foundation for Medical Care Mary Perloe, GNPGeorgia Medical Care Foundation John Schnelle, PhDVanderbilt University Sandra Simmons, PhDVanderbilt University Alice Bonner, PhD, GNPCenter for Medicare and Medicaid Services

3 © Florida Atlantic University 2011 Disclosures The INTERACT Program: What is It and Why Does It Matter?  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

4 © Florida Atlantic University 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 INTERACT Program: What is It and Why Does It Matter?

5 © Florida Atlantic University 2011  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 The INTERACT Program: What is It and Why Does It Matter?

6 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? 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?

7 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Video Clip: Why This Matters

8 © Florida Atlantic University 2011 Why Does This Matter? The INTERACT Program: What is It and Why Does It Matter? 1.Hospital transfers are common and often result in complications in older NH residents 2.Some hospital transfers are preventable 3.Care can be improved, resulting in fewer complications and reduced cost 4.Cost savings to Medicare can be shared with NHs to further improve care 5.Financial and regulatory incentives are changing

9 © Florida Atlantic University 2011 Mor et al. Health Affairs 29: 57-64, in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion The INTERACT Program: What is It and Why Does It Matter?

10 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Maslow, K and, Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, (Available at: content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdfhttp://www.ltqa.org/wp- content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf

11 © Florida Atlantic University 2011  Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize Maslow, K and, Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, (Available at: content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdfhttp://www.ltqa.org/wp- content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf The INTERACT Program: What is It and Why Does It Matter?

12 © Florida Atlantic University  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

13 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Was the Hospitalization Avoidable? Definitely/Probably YES Definitely/Probably NO Medicare A69%31% Other65%35% HIGH Hospitalization Rate Homes 75%25% LOW Hospitalization Rate Homes 59%41% TOTAL68%32% CMS Special Study in Georgia Expert Ratings of Potentially Avoidable Hospitalizations Ouslander et al: J Amer Ger Soc 58: , 2010 Based review of 200 hospitalizations from 20 NHs

14 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries

15 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  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 Sutton FBI Ten Most Wanted Fugitives Born/Died ChargesBank robbery CaughtFebruary 1952 During his forty year criminal career he stole an estimated $2 million, and eventually spent more than half his adult life in prison.

16 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  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

17 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? $ Costs HIGH LOW Quality LOW HIGH $ $ Incentives for Providers Improved Quality, Reduced Costs Reduced Avoidable Hospitalizations Opportunities for You and Your Facility Costs Avoided

18 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? 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

19 © Florida Atlantic University 2011 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? The INTERACT Program: What is It and Why Does It Matter?

20 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition

21 © Florida Atlantic University 2011  Includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources  The basic program is located on the internet: The INTERACT Program: What is It and Why Does It Matter?

22 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? “BOOST” (Better Outcomes for Older Adults Through Safe Transitions) “Project RED” (Re-Engineered Discharge) https://www.bu.edu/fammed/projectred Enhanced hospital discharge planning “Care Transition Program” Transition coach Trained volunteers Empowered patients and caregivers “POLST” (or “MOLST”) (Physician (or Medical) Orders For life Sustaining Treatment) Advance care planning “Bridge Model” Social Worker coordinating Aging Resource Center Services at hospital discharge “Transitional Care Model” APN coordinates care during and after discharge Home, SNF, and clinic visits “INTERACT” (Interventions to Reduce Acute Care Transfers) 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

23 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? 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: The INTERACT TM logo is trademarked by FAU and most of the INTERACT Program materials are copyrighted (©) by FAU. The INTERACT TM logo and copyrighted materials may be used with the permission of FAU. Users of these materials and/or the trademark INTERACT TM 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

24 © Florida Atlantic University 2011  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 The INTERACT Program: What is It and Why Does It Matter? HALT Unnecessary Hospital Stays

25 © Florida Atlantic University 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: The INTERACT Program: What is It and Why Does It Matter?

26 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  Sadie  Sara  Sam A Tale of Three Siblings

27 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  Hospitalized for UTI and dehydration  Discharged back to the NH after 4 days  Re-hospitalized 7 days later for dehydration and recurrent UTI Sadie A 96 year old long-stay NH resident Preventable? INTERACT strategy:  Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation

28 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  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

29 © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter?  Hospitalized for the 4 th 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

30 © Florida Atlantic University 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: , 2009 The INTERACT Program: What is It and Why Does It Matter?

31 © Florida Atlantic University 2011  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: The INTERACT Program: What is It and Why Does It Matter? Supported by a grant from the Commonwealth Fund

32 © Florida Atlantic University 2011  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 consults  Completion and faxing of QI Review Tools Implementation Model in the Commonwealth Fund Grant Collaborative The INTERACT Program: What is It and Why Does It Matter?

33 © Florida Atlantic University 2011 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) % Engaged facilities (N = 17) % Not engaged facilities (N = 8) % Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 The INTERACT Program: What is It and Why Does It Matter?

34 © Florida Atlantic University 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 The INTERACT Program: What is It and Why Does It Matter? Ouslander et al, J Am Geriatr Soc 59:745–753, 2011

35 © Florida Atlantic University 2011 Communication Tools Decision Support Tools Advance Care Planning Tools Quality Improvement Tools Putting the Tools to Work in Everyday Practice

36 © Florida Atlantic University 2011 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

37 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice  eINTERACT TM is being developed  A User Advisory Group is being formed PointClickCare Users

38 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice  Will be available on Medline University in early 2013 Implementation Training Curriculum

39 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

40 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool  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

41 © Florida Atlantic University 2011 Maslow, K and, Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, (Available at: content/themes/ltqaMain/custom/images//Prev entableHospitalizations_021512_2.pdf)http://www.ltqa.org/wp- content/themes/ltqaMain/custom/images//Prev entableHospitalizations_021512_2.pdf What Measures Should You Track? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

42 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool  INTERACT has a paper and pencil worksheet to help track acute care transfers

43 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Group Exercise: Let’s Calculate Some Hospitalization Rates

44 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool You want to calculate your average unplanned hospitalization rate for the first quarter of 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: Let’s Calculate Some Hospitalization Rates 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 is 3.23)

45 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates You want to calculate your average 30-day readmission rate for the first quarter of 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 data b.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.

46 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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? Let’s Calculate Some Hospitalization Rates 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.

47 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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? Let’s Calculate Some Hospitalization Rates 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.

48 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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? Let’s Calculate Some Hospitalization Rates 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.

49 © Florida Atlantic University 2011 Advancing Excellence tool located at: Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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

50 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Dropdown lists for easy data entry Transfers that occur within 30 days of admission from the hospital are highlighted Advancing Excellence tool located at:

51 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Advancing Excellence tool will be located at: Rates trended by month – in this graph 30-day readmissions from PAC, LTC, and total

52 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

53 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

54 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

55 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

56 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

57 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

58 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

59 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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: #% Sunday411% Monday26% Tuesday411% Wednesday514% Thursday617% Friday719% Saturday822% Total36100% How many transfers occurred on the following shifts: #% 1st Shift: 7AM-3PM217% 2nd Shift: 3PM-11PM433% 3rd Shift: 11PM-7AM650% Total12100% Notes: Summary

60 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

61 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Small Group Exercise: Root Cause Analyses Using the INTERACT Quality Improvement Tool

62 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

63 © Florida Atlantic University 2011 Video Clip: Early Identification of and Communication About Acute Changes in Condition Putting the Tools to Work in Everyday Practice

64 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

65 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

66 © Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Video Clip: Effective Nurse – Primary Care Clinician Communication About Acute Changes in Condition

67 © Florida Atlantic University 2011  Improve communication  Consistent language  Standardized criteria  Clear guidelines  Communication that is efficient  Communication that is effective Putting the Tools to Work in Everyday Practice The Purpose of the SBAR

68 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

69 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

70 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

71 © Florida Atlantic University 2011 The INTERACT Change in Condition File Cards Putting the Tools to Work in Everyday Practice

72 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

73 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

74 © Florida Atlantic University 2011 Putting the Tools to Work in Everyday Practice

75 © Florida Atlantic University 2011 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 Putting the Tools to Work in Everyday Practice

76 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

77 © Florida Atlantic University 2011 Video Clip: Advance Care Planning (1) ADVANCE CARE PLANNING TOOLS

78 © Florida Atlantic University 2011 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 ADVANCE CARE PLANNING TOOLS

79 © Florida Atlantic University 2011 Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294: ADVANCE CARE PLANNING TOOLS

80 © Florida Atlantic University 2011  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 ADVANCE CARE PLANNING TOOLS

81 © Florida Atlantic University 2011 Video Clip: Advance Care Planning (2) ADVANCE CARE PLANNING TOOLS

82 82 © Florida Atlantic University Case Study

83 83 © Florida Atlantic University 2011  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 83 Case Study

84 84 © Florida Atlantic University 2011  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 ) 84 Case Study

85 85 © Florida Atlantic University :30 pm “The resident in 3B says she is having trouble breathing” Case Study

86 86 © Florida Atlantic University  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

87 © Florida Atlantic University 2011  How would Care Paths help the nursing evaluation?  Where would you keep these so that nurses would have easy access to them? Case Study

88 © Florida Atlantic University 2011 Case Study

89 © Florida Atlantic University 2011 “DO YOU HAVE…..” Case Study

90 © Florida Atlantic University 2011 Case Study

91 © Florida Atlantic University 2011  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

92 © Florida Atlantic University 2011  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

93 © Florida Atlantic University 2011  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

94 © Florida Atlantic University 2011 Interacting with Your Hospitals Video Clip: Effective Communication with Hospitals

95 © Florida Atlantic University 2011 The INTERACT III tools are meant to be used together in your daily work in the nursing home Putting the Tools to Work in Everyday Practice

96 © Florida Atlantic University 2011 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. Interacting with Your Hospitals

97 © Florida Atlantic University 2011 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 Interacting with Your Hospitals

98 © Florida Atlantic University 2011 Information Transfer From the Hospital FHA – FADONA – FMDA – CARES – AHCA Readmission Initiative Draft, October 2011 Interacting with Your Hospitals

99 © Florida Atlantic University 2011 Nursing Home Capabilities List Interacting with Your Hospitals  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

100 © Florida Atlantic University 2011 Interacting with Your Hospitals 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

101 © Florida Atlantic University 2011 Interacting with Your Hospitals 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

102 © Florida Atlantic University  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

103 © Florida Atlantic University 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 Tips on Getting Started and Keeping It Going

104 104 © Florida Atlantic University Tips on Getting Started and Keeping It Going

105 105 © Florida Atlantic University Tips on Getting Started and Keeping It Going

106 106 © Florida Atlantic University Tips on Getting Started and Keeping It Going

107 107 © Florida Atlantic University Tips on Getting Started and Keeping It Going

108 108 © Florida Atlantic University Tips on Getting Started and Keeping It Going

109 109 © Florida Atlantic University Tips on Getting Started and Keeping It Going

110 110 © Florida Atlantic University Tips on Getting Started and Keeping It Going

111 © Florida Atlantic University Overcoming Barriers to Implementation Tips on Getting Started and Keeping It Going

112 © Florida Atlantic University Overcoming Barriers to Implementation (1) BarriersStrategies 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 Tips on Getting Started and Keeping It Going

113 © Florida Atlantic University Overcoming Barriers to Implementation (2) BarriersStrategies 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 Tips on Getting Started and Keeping It Going

114 © Florida Atlantic University Overcoming Barriers to Implementation (3) BarriersStrategies to Overcome “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 Tips on Getting Started and Keeping It Going

115 © Florida Atlantic University Overcoming Barriers to Implementation (4) BarriersStrategies to Overcome “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 Tips on Getting Started and Keeping It Going

116 © Florida Atlantic University 2011  Questions?  Comments?  Suggestions? The INTERACT Program:


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