What is It and Why Does It Matter?

What is It and Why Does It Matter?
The INTERACT Program: What is It and Why Does It Matter? Joseph Ouslander, MD Florida Atlantic University Ruth Tappen, EdD, RN, FAAN Jill Shutes, GNP Nancy Henry, PhD, GNP Michelle Duhaney, DO Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation Gerri Lamb, PhD, RN, FAAN Arizona State University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence

The INTERACT Program: What is It and Why Does It Matter?
The INTERACT Interdisciplinary Team Joseph Ouslander, MD Florida Atlantic University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jill Shutes, GNP Florida Atlantic University Nancy Henry, PhD, GNP Florida Atlantic University Michelle Duhaney, DO Florida Atlantic University Maria Rojido, MD Florida Atlantic University Sanya Diaz, MD Florida Atlantic University Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Gerri Lamb, PhD, RN, FAAN Arizona State University Annie Rahman, PhD, MSW USC Davis School of Gerontology Dan Osterweil, MD California Association of Long Term Care Medicine Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Mary Perloe, GNP Georgia Medical Care Foundation John Schnelle, PhD Vanderbilt University Sandra Simmons, PhD Vanderbilt University Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services In collaboration with participating nursing homes

Background and Why it Matters
The INTERACT Program: Background and Why it Matters College of Medicine College of Nursing New Dorms New FOOTBALL STADIUM

What is It and Why Does It Matter? Objectives of this Presentation
The INTERACT Program: What is It and Why Does It Matter? Objectives of this Presentation Discuss key health policy issues related to the future of nursing home care Provide a broad overview of the INTERACT quality improvement program and how it fits with health care reform initiatives Highlight future directions for INTERACT Discuss key concepts for eINTERACT

The INTERACT Program: What is It and Why Does It Matter? Health Care Reform 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.

The INTERACT Program: Background and Why it Matters
Medicare Fee-for-Service 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 Willie Sutton FBI Ten Most Wanted Fugitives Born/Died 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.

The INTERACT Program: What is It and Why Does It Matter? The U.S. Department of Health and Human Services “Partnership for Patients” Accelerate Reduction in Harm to Patients in Hospitals Achieve a 40% reduction in preventable harm by 2013 ~ 1.8 million fewer injuries to patients; ~ lives saved; ~ $20 billion in health care costs avoided Decrease Preventable Hospital Readmissions Within 30 Days of Discharge Reduce readmissions by 20% by 2013 ~1.6 million hospital readmissions prevented and ~ $15 billion in health care costs avoided

What is It and Why Does It Matter? Changes in Medicare Financing
The INTERACT Program: What is It and Why Does It Matter? Changes in Medicare Financing 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

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

The INTERACT Program: What is It and Why Does It Matter? 1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion Mor et al. Health Affairs 29: 57-64, 2010

The INTERACT Program: What is It and Why Does It Matter? Why Does This Matter? At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning, pressure ulcers At the beauty salon Hospitalization

Some Hospitalizations of NH Residents are Avoidable As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate Saliba et al, J Amer Geriatr Soc 48: , 2000 In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnoses” Grabowski et al, Health Affairs 26: , 2007

CMS Special Study in Georgia – Expert Ratings of Potentially Avoidable Hospitalizations Based review of 200 hospitalizations from 20 NHs Was the Hospitalization Avoidable? Definitely/Probably YES NO Medicare A 69% 31% Other 65% 35% HIGH Hospitalization Rate Homes 75% 25% LOW 59% 41% TOTAL 68% 32% Ouslander et al: J Amer Ger Soc 58: , 2010

CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries

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

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, 2012. (Available at:

The INTERACT Program: What is It and Why Does It Matter? Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize Risk adjustment is very complicated Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012. (Available at:

Opportunities for You and Your Facility 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 of your QAPI

What is It and Why Does It Matter? Safe Reduction in Unnecessary
The INTERACT Program: What is It and Why Does It Matter? What Do You and Your Facility Need to Take Advantage of These Opportunities? QI Programs Tools Infrastructure Incentives Safe Reduction in Unnecessary Acute Care Transfers Morbidity Costs Quality

The INTERACT Program: What is It and Why Does It Matter? (“Interventions to Reduce Acute Care Transfers”) Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition

The INTERACT Program: What is It and Why Does It Matter? 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? 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 Center for Medicare and Medicaid Services. The current version of the INTERACT Program, including the INTERACT II Tools, educational materials, and implementation strategies were developed by Drs. Ouslander, Gerri Lamb, Alice Bonner, and Ruth Tappen, and Ms. Laurie Herndon with input from many direct care providers and national experts in a project based at Florida Atlantic University supported by The Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system. Some materials herein are © Florida Atlantic University Such materials and the trademark INTERACTTM may be used with the permission of Florida Atlantic University. Permission can be granted by Dr. Ouslander

INTERACT is One of Several Evidence-Based Care Transitions Interventions “BOOST” (Better Outcomes for Older Adults Through Safe Transitions) “Project RED” (Re-Engineered Discharge) 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

The INTERACT Program: What is It and Why Does It Matter? HALT Unnecessary Hospital Stays 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? Can help your facility safely reduce hospital transfers by: Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition Managing some conditions in the NH without transfer when this is feasible and safe Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents

What is It and Why Does It Matter? A Tale of Three Siblings
The INTERACT Program: What is It and Why Does It Matter? A Tale of Three Siblings Sadie Sara Sam

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

What is It and Why Does It Matter? A 92 year old long-stay NH resident
The INTERACT Program: What is It and Why Does It Matter? Sara (Sadie’s younger sister) A 92 year old long-stay NH resident 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 Avoidable? INTERACT strategy: Manage some conditions in the NH without transfer

Sam (Sara and Sadie’s older brother) A 101 year old long-stay NH resident 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 Avoidable? INTERACT strategy: Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization

What is It and Why Does It Matter? CMS Pilot Study Results
The INTERACT Program: What is It and Why Does It Matter? CMS Pilot Study Results Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates Tools were acceptable to staff Significant reduction in hospitalizations Significant reduction in transfers rated as avoidable by an expert panel Ouslander et al: J Amer Med Dir Assoc 9: , 2009

The INTERACT Program: What is It and Why Does It Matter? 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: Supported by a grant from the Commonwealth Fund

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 consults Completion and faxing of QI Review Tools

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 0.01 24% Not engaged facilities (N = 8) 3.96 3.71 - 0.26 0.69 6% [This slide should build as it does on this slide] This slide illustrates the findings. We obtained baseline hospitalization rates for July-December 2008 from each facility, and they reported hospitalization rates for the months of July-December 2009 while implementing the INTERACT program. The numbers on this slide represent all-cause hospitalizations for all residents. They are calculated as a rate per 1000 resident days to adjust for census – so, in a typical 100-bed nursing home, this would represent the number of hospitalizations in 10 days. So, for all 25 facilities on this slide, the baseline hospitalization rate was 3.99 [highlight]. This would mean in a 100 bed facility, there were 4 hospitalizations every 10 days, which is a high rate of hospitalization. 25 of the 30 facilities completed the project and were able to provide baseline and current hospitalization rates. The hospitalization rate decreased by 17% in these 25 facilities. [highlight] We also rated the participating nursing homes on their level of engagement in the project independent of knowing their hospitalization rates. Engagement was rated using data from how many telephone calls the champions participated on, how many quality improvement review tools were submitted, and level of interest and participation on the collaborative calls. There were 17 facilities rated as engaged [highlight] . In these 17 facilities the hospitalization rate dropped a dramatic 24% [highlight] In the 8 facilities that were rated as less engaged [highlight], the hospitalization rate decreased, but by only 6% [highlight]. Although this project was not conducted as a true randomized controlled trial, which offers the best evidence of effectiveness, the findings suggest that INTERACT has a strong effect in the participating nursing homes, especially those that were more engaged in INTERACT implementation. Ouslander et al, J Am Geriatr Soc 59:745–753, 2011

Commonwealth Fund Project Results - Implications 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) The intervention as implemented in this project cost of ~ $7,700 per facility 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

Putting the Tools to Work in
Everyday Practice Communication Tools Decision Support Tools Advance Care Planning Tools Quality Improvement Tools

Everyday Practice Note The program and tools are currently being updated “INTERACT III tools” and an updated INTERACT website should be available by the end of 2012 © Florida Atlantic University 2011

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

Getting Started: Keys to a QI Program
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Getting Started: Keys to a QI Program Tracking, trending, and benchmarking well-defined measures Root cause analysis to learn and guide care improvement and educational activities © 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, 2012. (Available 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 This is a screen shot of one of the data entry screens for the tracking tool available on the INTERACT website, modified from the one developed for the Advancing Excellence Campaign. The original tool can be located on the Advancing Excellence website at the address shown on this slide. The tool allows for easy and efficient entry of data and automatically calculates the four measures we discussed on a monthly basis. Advancing Excellence tool will be located at: © Florida Atlantic University 2011

Dropdown lists for easy data entry Transfers that occur within 30 days of admission from the hospital are highlighted In addition to calculating hospitalization measures on a monthly basis, the tool can help you trend your facility’s data over time and benchmark it against your previous performance, as well as that of other facilities [This should be accompanied by a moving arrow that illustrates trends, and also shows “your facility’s trend” and “other facilities” trend] In the full implementation training curriculum, you can learn more about how to use this tool. Advancing Excellence tool will be located at: © Florida Atlantic University 2011

Rates trended by month – in this graph 30-day readmissions from PAC, LTC, and total In addition to calculating hospitalization measures on a monthly basis, the tool can help you trend your facility’s data over time and benchmark it against your previous performance, as well as that of other facilities [This should be accompanied by a moving arrow that illustrates trends, and also shows “your facility’s trend” and “other facilities” trend] In the full implementation training curriculum, you can learn more about how to use this tool. Advancing Excellence tool will be located at: © Florida Atlantic University 2011

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 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 2nd Shift: 3PM-11PM 33% 3rd Shift: 11PM-7AM 50% 12 Notes: Summary

Everyday Practice

Everyday Practice The INTERACT Change in Condition File Cards: The case of Mrs. S: a classic case that illustrates their purpose

Everyday Practice

Everyday Practice INTERACT Care Paths 9 conditions 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

Interacting with Your Hospitals
The new INTERACT III NH to Hospital Data List will contain recommended data elements consistent with national standards for CCDs The sample 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
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 Information Transfer From the Hospital
The new INTERACT III Hospital to PAC Data List will contain recommended data elements consistent with national standards for CCDs, and data that is critical for safe care in the first hours The sample Hospital to PAC sample Transfer Form will provide an example of how to put the data in easy to read format for the receiving clinician.

ADVANCE CARE PLANNING TOOLS
When? 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: .

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

Future Directions for INTERACT
Test INTERACT in clinical trials to improve the evidence-base NIH grant (funded) VA grant (scheduled for funding later in 2012) Refine the program and the implementation training curriculum (Medline Industries grant) Further spread the INTERACT program in conjunction with the QAPI roll-out (Commonwealth Fund grant) Develop ethnically and culturally sensitive person-centered decision tools about hospital transfer (Patient-Centered Outcomes Research Institute grant)

Future Directions for INTERACT
Further spread the INTERACT program in other settings ALFs, home care (CMS Innovations Grant) Other countries (e.g. England, Canada, Singapore) Combine INTERACT with other interventions Care transition interventions (CMS Innovations Grant) Telemedicine and others Work with regulators and payers to incentivize INTERACT implementation (underway with CMS) Embed INTERACT into HIT (PointClickCare) EMRs (LTC software) Inter-facility transfer platforms

Examples of HIT Applications
Using INTERACT Tools HIT

Using INTERACT Tools HIT Facility QI Reports Information for hospital transfer Quality Measures

Using INTERACT Tools HIT Nursing assistant notes Automated alerts to licensed nurses

Using INTERACT Tools HIT

Using INTERACT Tools HIT Secure information transfer to emergency room or acute care unit CCD that meets national standards

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