1. INTERACT II: Interventions to Reduce Acute Care Transfers Joseph G. Ouslander, M.D. Professor of Clinical Biomedical Science Associate Dean for Geriatric Programs Charles E. Schmidt College of Biomedical Science Florida Atlantic University Assistant Dean for Geriatric Education University of Miami Miller School of Medicine (UMMSM) at Florida Atlantic University Laurie Herndon, MSN, GNP-BC, ANP-BC Director of Clinical Quality Massachusetts Senior Care Foundation Laurieherndon@yahoo.com

2. Today we will… Describe the key components of the INTERACT II toolkit Share “early lessons” from current INTERACT II collaborative project Provide strategies for immediate implementation of INTERACT II tools at your facility

3. Why this matters… Mr. DeMayo is an 97 year old long term care resident at your facility. Pancreatic cancer Functional decline No appetite “Ready to go be with Eleanor” DNR/DNI

4. Saturday morning wakes up and says he feels lousy. Stays in bed all day and doesn’t eat Sunday morning has a fever and has several episodes of vomiting Appears dehydrated and weak Son visits and expresses concern for his father. Wonders if “this is the beginning of the end?”

5. Nurse calls covering physician Reports that son is concerned Physician says to send this resident to the ED for evaluation

6. What just happened here? Did he want to go to the hospital? Did that conversation ever happen? Was the ED the best place for this resident to be evaluated? Could his needs have been met in the nursing home? Could this transfer have been prevented? How would you know? Where would you begin?

7. Hospitalizations of NH residents are common In any six month period, more than 15% of long stay residents are hospitalized –O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable Hospitalizations” Journal of the American Geriatrics Society 52, no. 10(2004): 1730-1736 Previous research suggests many such hospitalizations are inappropriate and are related to ambulatory care sensitive diagnoses 45% of admissions of 100 residents from 7 Los Angeles nursing homes to acute hospitals were rated as inappropriate Saliba et al, J Amer Geriatr Soc 48:154-163, 2000 Saliba et al, J Amer Geriatr Soc 48:154-163, 2000

8. Why this matters… Hospitalizations cause morbid complications for NH residents –Deconditioning –Pressure Ulcers –Delirium –Injurious Falls –Polypharmacy

9. Why this matters… Unnecessary hospitalizations are expensive  Medicare spent close to $200 million on hospitalizations related to Ambulatory Care Sensitive Diagnoses among long-stay NH residents in New York state in 2004  This figure does not include residents on the Part A skilled benefit, who get hospitalized frequently Grabowski et al, Health Affairs 26: 1753-1761, 2007

10. The Opportunity Reducing potentially avoidable hospitalizations of NH residents represents an opportunity to: –Decrease emotional trauma to the resident and family –Decrease complications of hospitalization – Reduce overall health care costs

11. Background CMS Special Study awarded to Georgia Medical Foundation July 2006-Jan 2008 –Looked at characteristics of NHs in Georgia with high and low hospitalization rates –Implemented toolkit in 3 NHs with high hospitalization rates –50% reduction in hospitalizations –36% reduction in hospitalizations rated as avoidable

12. Principal Investigator: Dr. Joseph G Ouslander Co-Principal Investigator: Dr. Gerri Lamb Independence Foundation and Independence Foundation and Wesley Woods Chair Wesley Woods Chair Associate Professor of Nursing Emory University Collaborators:Laurie Herndon, MSN, GNP-BC Collaborators:Laurie Herndon, MSN, GNP-BC Senior Project Coordinator Senior Project Coordinator Alice Bonner, PhD, RN Co-Investigator Massachusetts Department of Public Health Multidisciplinary teams from MA, NY, and FL INTERACT II Funded by the Commonwealth Fund

13. Methods Obtain input –National experts –Frontline staff Refine toolkit Implement and evaluate refined toolkit –Quality Improvement project –Principals of Institute for Healthcare Improvement (IHI) Collaborative Champion Collaborative Calls

14. Methods –Collect data during the Collaborative that will be used to: Understand factors and strategies that are important for successful implementation and sustained use of the toolkit Estimate the costs of implementing the toolkit to inform P4P initiatives –Explore incorporating key elements of the toolkit into health information technology (HIT) using web-based formats and/or an electronic health record

15. Working Together to Improve Care, Communication, and Continuity for our Residents

16. Organization of Tools in Toolkit Communication Tools Clinical Care Paths Advance Care Planning Tools

17. Purpose Of Toolkit Aid in the early identification of a resident change of status Guide staff through a comprehensive resident assessment when a change has been identified Improve documentation around resident change in condition Enhance communication with other health care providers about a resident change of status

18. Where to keep it Who should use it Different languages “Please fill this out so I am certain not to forget what you just told me”

19. “We use it for EVERYTHING” “Staff are really learning, gathering tools necessary to communicate with the physician” “Organize Your Thoughts Form”

20. “It took two nurses working together 30 minutes to fill this out” “This isn’t so different from what we usually do” “Gets easier with practice” Take old forms off units Now, we don’t hear much at all about this tool on the calls

22. Advance Care Planning Tools Identifying Residents to Consider for Palliative Care and Hospice Pocket Card Advance Care Planning Communication Guide File Cards Comfort Care Order Set File Cards Educational Information for Families Reprints

23. “My initial determination was based on the fact that ….if the patient was admitted….I automatically felt is was unavoidable…..but I’ve had a culture change with my thought process”…

24. Lessons so far…. Leadership “buy in” is important “This is great…we would love to do this at our facility”

25. But… The frontlines are where it happens

26. The Champion is key “I still think there is incredible value to this project and am going to keep working very hard on it” “I tell the staff to go out onto the units and look for transfers waiting to happen” “I am going to elicit an alliance” “I’m seeing it happen…walking on the units and seeing the nurses using the SBAR…it’s great.”

27. “Oh No! It’s Kryptonite!”

28. Relationships matter “Our NP told me she couldn’t believe how much the nursing assessments have improved since we started this” “Does the ED staff know about this project? They keep calling to ask about the forms.” “The EMT’s wouldn’t sign the envelope” “Does this mean they will be checking up on me?” “It’s all about teamwork”

29. Customizing the program Newsletter Grand Rounds Morbidity and Mortality Rounds NCR paper for Transfer Forms Tools part of new hire orientation Scratch cards, free lunch “Its about more than just the tools. It’s about culture and how you do business”

30. For tomorrow: www.interact.geriu.org Getting Started –About INTERACT II –How to use the website –What is a champion and why do I need one? –All of the tools with instructions for each

31. www.interact.geriu.org Implementation –Deciding when and where to start –Tips for training staff –Informing family members about INTERACT II –Improving communication with the hospital –Quality Improvement Review and feedback –Case Studies –How to download the whole toolkit Feedback

32. Feedback on the training Team approach from the beginning Frequent repeats Small groups 1:1 Couple it with other initiatives –MOLST/POLST –Consistent assignments

33. Think about Processes/systems already in place Strengths/gaps Other things going on in the building How will you enlist front line support How you are going to track your data

34. THANK YOU!!!