© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon,

© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 Joseph G. Ouslander, MD Florida Atlantic University Laurie Herndon, GNP Mass Senior Care Foundation Gerri Lamb, PhD, RN, FAAN Arizona State University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Sanya Diaz, MD Florida Atlantic University John Schnelle, PhD Vanderbilt University Sandra Simmons, PhD Vanderbilt University Annie Rahman, MSW California Association of LTC Medicine Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Mary Perloe, GNP The Georgia Medical Care Foundation Dan Osterweil, MD California Association of LTC Medicine Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services In collaboration with participating nursing homes The INTERACT Program: What is It and Why Does It Matter? The INTERACT Interdisciplinary Team

© Florida Atlantic University 2011 (“Interventions to Reduce Acute Care Transfers”) 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

© 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: http://interact2.net The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 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 2011. Such materials and the trademark INTERACT TM may be used with the permission of Florida Atlantic University. Permission can be granted by Dr. Ouslander (jousland@fau.edu)jousland@fau.edu The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 “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) Orders For 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 The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 Hospitalization  At risk for complications  Delirium  Polypharmacy  Falls  Incontinence and catheter use  Hospital acquired infections  Immobility, de-conditioning, pressure ulcers  At the beauty salon The INTERACT Program: What is It and Why Does It Matter? Why Does This Matter?

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

© Florida Atlantic University 2011 What are your experiences?  Have you seen unnecessary hospitalizations of residents of your facility?  Have you had a resident suffer a complication during an unnecessary hospitalization? The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 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 your facility safely reduce hospital transfers by: The INTERACT Program: What is It and Why Does It Matter?

© 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?

© Florida Atlantic University 2011  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 Avoidable? INTERACT strategy:  Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  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 Avoidable? INTERACT strategy:  Manage some conditions in the NH without transfer The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  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 Avoidable? INTERACT strategy:  Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  Originally developed in a project supported by the Center for Medicare and Medicaid Services (CMS)  Revised based on input from staff from several nursing homes and national experts in a project supported by The Commonwealth Fund The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 Criteria for Tools  Evidence-based  Simple  Feasible and efficient to use  Acceptable to staff  Consistent with federal regulations and guidance for surveyors  Incorporate into HIT Objectives of the Tools  Improve management of acute changes in clinical status:  Identification  Evaluation  Manage in the facility when safe  Documentation  Communication  Internal and with hospitals The INTERACT Program: What is It and Why Does It Matter?

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

© 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: http://interact2.net The INTERACT Program: What is It and Why Does It Matter? Supported by a grant from the Commonwealth Fund

© Florida Atlantic University 2011 The INTERACT II tools are meant to be used together in your daily work in the nursing home http://interact2.net The INTERACT Program: What is It and Why Does It Matter?

© 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 email 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?

© Florida Atlantic University 2011 Commonwealth Fund Project Results Facilities Mean Hospitalization Rate per 1000 resident days (SD) Mean Change (SD) 95% Confidence Interval p value Relative Reduction in All-Cause Hospitalizations Pre intervention During Intervention All INTERACT facilities (N = 25) 3.99 (2.30)3.32 (2.04)- 0.69 (1.47)-0.08 to -1.30 0.02 17% Engaged facilities (N = 17) 4.01 (2.56)3.13 (2.27)- 0.90 (1.28)-0.23 to -1.56 0.01 24% Not engaged facilities (N = 8) 3.96 (1.79)3.71 (1.53)- 0.26 (1.83)-1.79 to 1.27 0.69 6% Comparison facilities (N = 11) 2.69 (2.23)2.61 (1.82)- 0.08 (0.74)- 0.41 to 0.58 0.72 3% Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 The INTERACT Program: What is It and Why Does It Matter?

© 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

© Florida Atlantic University 2011 Why does this matter? A national perspective (1)  Emergency room visits, observation stays hospitalizations, and readmissions of nursing home residents are :  Common  Result in complications  Expensive The INTERACT Program: What is It and Why Does It Matter?

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

© Florida Atlantic University 2011  Distress and discomfort for the resident and family  Delirium  Polypharmacy  Falls  Incontinence and catheter use  Hospital acquired infections  Unintentional weight loss and poor nutrition  Immobility, de-conditioning, pressure ulcers The INTERACT Program: What is It and Why Does It Matter?  Hospitalizations can cause many complications:

© Florida Atlantic University 2011 Why does this matter? A national perspective (2)  Some hospital transfers, ER visits, observation stays, hospital admissions, and readmissions are “avoidable”, “preventable”, or “unnecessary” The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate Saliba et al, J Amer Geriatr Soc 48:154-163, 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: 1753-1761, 2007 The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 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: 627-635, 2010 Based review of 200 hospitalizations from 20 NHs” The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  The Affordable Care Act is focused on a “triple aim”: 1. Improving care 2. Improving health 3. 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?

© Florida Atlantic University 2011 1.Accelerate Reduction in Harm to Patients in Hospitals  Achieve a 40% reduction in preventable harm by 2013  ~ 1.8 million fewer injuries to patients; ~ 60 000 lives saved; ~ $20 billion in health care costs avoided 2.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 The U.S. Department of Health and Human Services “Partnership for Patients” http://www.healthcare.gov/center/programs/partnership The INTERACT Program: What is It and Why Does It Matter?

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

© Florida Atlantic University 2011 Why does this matter to you and your facility? The INTERACT Program: What is It and Why Does It Matter?  Improve quality of care for your residents  Share in savings to Medicare by reducing unnecessary ER visits, observation stays, hospital admissions, and readmissions  Your facility can take advantage of the opportunities in health care reform

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

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

© Florida Atlantic University 2011 Safe Reduction in Unnecessary Acute Care Transfers Infrastructure Incentives QI Programs Tools Morbidity Costs Quality What Do You and Your Facility Need to Take Advantage of These Opportunities? The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011  Will help you and facility:  Improve quality of care for your residents  Improve your communication and team work  Take advantage of everyone’s contributions to resident care The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 What are your experiences?  What are the top 3 reasons for hospital transfers at your facility? Why Do Unnecessary Hospital Transfers Occur? The INTERACT Program: What is It and Why Does It Matter?

© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 Why Start with the Acute Care Transfer Log and QI Review Tool? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool  The Affordable Care Act contains a new federal requirement for NHs: Quality Assurance and Performance Improvement (“QAPI” programs)  Knowing your baseline, tracking outcomes, and performing root cause analysis are fundamental to improving care for your residents and instituting a QAPI program

© Florida Atlantic University 2011  The Affordable Care Act: Section 6102 (c) requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI standards and provide technical assistance to nursing homes on the development of best practices in order to meet such standards. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Quality Assurance and Performance Improvement “QAPI” Requirement under the ACA

© Florida Atlantic University 2011 Five Elements of QAPI Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems, and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5: Systematic Analysis and Systemic Action Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 QAPI Element 1: Design and Scope Quality Assurance  Reactive  Single episode  Organizational mistake  Sometimes anecdotal  Retrospective  Monitoring based on audit  Sometimes punitive Process Improvement  Proactive  Aggregate Data  Organizational process  Always measureable  Concurrent  Monitoring is continuous  Positive change Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Use multiple data sources  Feedback incorporates staff, families, and residents  Set care processes and outcomes  Benchmark performance with internal and external goals  Track and trend adverse events  Full investigation for each incident or event every time QAPI Element 3: Feedback, Data Systems, and Monitoring Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Tracking hospital transfers allows you to:  Determine your baseline, set goals for improvement, and follow your progress  Identify situations that commonly result in transfers of your residents to the hospital Why Start By Tracking Transfers? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Many factors may be involved  Discovering situations that might have been safely treated in the facility may be uncomfortable when you start reviewing them Decisions to Transfer are Complicated Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Most incentives in the current system favor hospital transfer rather than managing acute changes in condition in the facility Incentives in the Current System of Care Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  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 Why Do Unnecessary Hospital Transfers Occur?  By far, the most costly examples in the geriatric population are unnecessary ER visits, observation stays, hospitalizations, and readmissions Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 What are the Incentives to Hospitalize? Hospital reimbursementNH Capabilities Qualification for skilled nursing facility stay Patient and family preferences Liability Physician reimbursement Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Incentives are going to change over the next few years  NHs and other health care providers will have incentives to manage acute changes in condition in the facility whenever feasible  You need to be prepared! Incentives in the Current System of Care Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 The INTERACT Quality Improvement Tool is meant to identify opportunities to improve management of changes in condition through a root cause analysis process Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 QAPI Process: Address Adverse Events Through Root Cause Analysis  Utilize standardized investigation form  Interview staff involved  Interview those who may have witnessed event  Has this event ever happened before?  Investigate contributing factors  How does this event tie into the overall PI plan? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  An analytic tool that can be used to perform a comprehensive, system-based review of critical incidents and adverse health events  Goal is to determine:  What happened?  Why did it happen?  What can be done to reduce the likelihood of recurrence? Root Cause Analysis (1) Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Systematic approach to problem solving  Identify issue as a team  Repeatedly asking at least 5 “why?” questions  Don’t stop at symptoms  Get to deeper layers to find the root cause  Identify relationships between different root causes Root Cause Analysis (2) Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Designed to assist you to review situations that commonly result in transfers in your facility through systematic root cause analysis The Quality Improvement Tool Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Integrate into the facility’s regular quality and educational processes  Look for common situations that you can work on together to improve  Avoid blaming individuals Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool The Quality Improvement Tool

© Florida Atlantic University 2011 1.Background Information 2.Change in Condition 3.Evaluation and Management 4.Transfer Information 5.Opportunities for Improvement The QI Review Tool: 5 Sections Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Use trends in the data to focus your improvement and educational efforts Tracking and Reviewing Hospital Transfers Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Look for patterns in transfers and the clinical situations that result in them  Identify situations you believe can be managed safely and effectively without transfer  Work together to develop strategies to manage these situations  Develop education on specific topics The Transfer Log and QI Tool Will Help Your Facility: Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011  Each of the INTERACT II tools you will learn about in upcoming sessions is designed to help identify and manage situations that commonly lead to hospital transfers Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool What is Your Experience?  What are the most important incentives related to hospital transfer at your facility?  Can you identify the types of change in condition that can be managed safely and effectively without transfer at your facility?

© Florida Atlantic University 2011  Acute change in condition with unstable vital signs  Family expectations  Lack of availability or communication problems with primary care physicians  Services required are unavailable in the facility  Lack of advance care planning and advance directives Common Reasons for Transfers Identified in QI Tools Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 Reason Rated Avoidable or Possibly Avoidable (N=216) Rated Not avoidable (N=843) Missed prevention opportunities related to staff, PCP 69 (32%)42 (5%) Resident or family insists on transfer 30 (14%)49 (6%) Communication gaps between nursing staff, PCP, external facilities 26 (13%)7 (1%) Advance directives/hospice not in place or not used 24 (11%)35 (4%) Nursing staff gap in knowledge or skill 21 (10%)1 (0.1%) Level of acuity requires transfer 20 (9%)601 (71%) PCP orders transfer 15 (7%)76 (9%) Facility capacity to provide needed treatments or tests 12 (6%)54 (6%) Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Ratings of Avoidability in QI Tools Lamb, G, Tappen, R, Diaz, S, et al:.J Am Geriatr Soc 59:1665–1672, 2011

© Florida Atlantic University 2011 “ There’s been a culture change here. We started out thinking if they’re sent to the hospital, it’s not avoidable. Now we recognize we missed early warning signs.” An INTERACT Champion Changing Perceptions of Avoidability Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool

© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Objectives  Describe the purpose and use of:  Stop and Watch  SBAR Communication Form and Progress Note  Decision Support Tools  Change in Condition File Cards  Care Paths Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Purpose of “Stop and Watch”  To guide frontline staff through a brief review of early changes in the resident’s condition  To improve communication between frontline staff and the nurse in charge Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Video Clip Examples of poor communication between CNA and licensed nurse, and improved communication using the Stop and Watch Tool Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  Stop and Watch helps frontline staff identify important changes in the resident’s condition  Who is frontline staff?  CNA’s and other nursing staff, rehab therapists, dietary staff, housekeeping staff, activities staff and any staff member with direct resident contact  Family members may also contribute valuable observations Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  Changes in mental status – sleepy, confused, agitated, anxious  Changes in physical status – problems with walking, transferring  Changes in function – problems with ADL’s  Changes in behavior – wandering, combative, yelling, verbal or physical aggression  Changes in pain level What early changes in condition should be reported? Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Stop and Watch is the primary method for CNAs to alert the LPN/RNs of changes in the resident’s condition and for the nurse to hear what the CNAs have to say. Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  Important changes to report are:  Actions or behaviors that are not part of the resident’s normal routine  A change from the resident’s usual condition Recognizing Changes in Condition Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Your Eyes Are the Best Frontline staff:  Know the resident best  See changes in condition first  Should identify important changes in the resident’s condition during their normal care routine  Must be empowered to communicate what they know and see Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 It helps …  The staff know what kinds of changes to report  The nurse understand what you have to say is important and when to take action “Stop and Watch” is a great way to communicate changes Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Unit nurses are busy giving medications and taking physician orders CNA’s are busy giving direct care “Stop and Watch” reporting can help close the gap! Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Instructions for “Stop and Watch”  If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. More than one change may be marked on the same form Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 S eems different than usual  Not their usual self? Change in personality or behavior? T alks or communicates less than usual  Quieter? Drowsier? Confused? Altered speech? O verall needs more help than usual  Needs more assistance? Changes in gait, transfer or balance? P articipated in activities less than usual  Withdrawn? Decline in ADL’s? Change in normal routine? Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 W eight change A gitated or nervous more than usual T ired, weak, confused or drowsy C hange in skin color or condition H elp with walking, transferring, toileting more than usual Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Instructions: “Stop and Watch” Staff ____________________________ Reported to ______________________ Date __/__/__ Time ____________ Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 The SBAR is a tool for LPNs and RNs to evaluate changes in the resident’s condition and communicate them to the MD/NP/PA and document them Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Video Clip Example of how good evaluation and communication using SBAR can prevent an acute care transfer and hospitalization Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Purpose of the SBAR Communication Form and Progress Note  Improve communication  Standardized evaluation  Consistent language  Communication that is efficient and effective  Documentation that is thorough and focused Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Getting a comprehensive history: Who to involve  CNAs  Social Workers  Rehab, Activities, Dietary  Other staff  Family members Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Making the Case for SBAR  Assists nurses in organizing their evaluation  Improves communication with MDs/NPs/PAs  Improves shift to shift communication  Alerts all providers about a change in condition  Enhances documentation  Can be copied and sent to ER with resident Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The INTERACT Care Paths and Change in Condition File Cards are decision support tools  Available for guidance when changes in status or specific symptoms and signs occur Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The Change in Condition File Cards and Care Paths help guide decisions about:  Further evaluation of changes in condition  When to communicate with the MD/NP/PA  When to consider transfer to the hospital  How to manage some conditions in the NH Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The Care Paths and Change in Condition File Cards are meant to be used with other tools  The change in condition or new symptom or sign may have been noted using the Stop and Watch Tool  Nurses should consider completing an SBAR Form and Progress Note using guidance from these tools Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The INTERACT decision support tools are based on established clinical guidelines published by several national professional organizations  Most are based on expert opinion because we lack definitive scientific clinical trials Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  Recommendations in the INTERACT Care Paths and Change in Condition File Cards are not fixed in stone  They are meant to guide decision making, not dictate it  Your clinical team may choose to modify specific recommendations  The systematic, clearly defined approach to symptoms and signs is more important than the specific recommendations Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The INTERACT Change in Condition File Cards include recommendations  Immediate vs. non-immediate notification for specific:  Vital signs  Lab results  Symptoms and signs Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011 Using the Change in Condition File Cards  Staff education to develop critical thinking skills  Nurse educators and managers use Change of Condition File Cards when teaching staff nurses who are assessing a resident’s change in condition  Strategies  5-minute huddle on the unit  Morning stand-up meeting  Report between shifts Putting the Tools to Work in Everyday Practice

© Florida Atlantic University 2011  The INTERACT Care Paths focus on 6 conditions that are:  Common reasons for hospital transfer  Often manageable in the nursing home  Frequent causes of potentially avoidable and preventable transfers or hospitalizations  The INTERACT Care Paths :  Acute mental status change  Fever  Dehydration  Symptoms of CHF  Symptoms of Lower Respiratory Illness  Symptoms of UTI Putting the Tools to Work in Everyday Practice

© 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

© Florida Atlantic University 2011 Interacting with Your Hospitals Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence

© Florida Atlantic University 2011 Purpose of the Transfer Checklist and Resident Transfer Form  Provide essential information to emergency department staff that will lead to the most appropriate evaluation of your resident  Insure that the safe handoff of your resident to the emergency department Interacting with Your Hospitals

© Florida Atlantic University 2011 The Resident Transfer Form and Transfer Checklist Envelope are tools for facility staff to effectively communicate information critical to evaluating the resident to hospital staff Interacting with Your Hospitals

© 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

© Florida Atlantic University 2011 The second page of the Resident Transfer Form MAY be sent to the ED within 7-12 hours of the transfer, especially if the transfer involves a 9-1-1 transfer or if the resident is unstable on transfer.  If the transfer is non acute, it is likely more efficient to send both pages at the same time. Interacting with Your Hospitals

© Florida Atlantic University 2011 Implementation Strategies  Remove old forms from the units  Consider contacting printer to have forms printed on NCR paper  If not on NCR paper, forms need to be copied and one copy needs to stay in the facility Interacting with Your Hospitals

© 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

© Florida Atlantic University 2011 Implementation Strategies  Notify your local Emergency Departments  Notify your EMS/Ambulance Services  Consider alternative format for checklist Interacting with Your Hospitals

© Florida Atlantic University 2011 Interacting with Your Local Hospitals  Schedule in-person meetings  Offer a tour of your facility  Create an agenda  Start with who staff you already interact with on a regular basis  ED staff  Case Managers  Emphasize 2-way communication  Set mutual expectations Interacting with Your Hospitals

© Florida Atlantic University 2011 ADVANCE CARE PLANNING TOOLS Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence

© Florida Atlantic University 2011 Advance Care Planning (ACP) What is it?  ACP is a process of communicating with residents and others who may be making health care decisions for them  The focus is on preferences for treatment in the event of changes in condition, and in particular at the end of life  Discussions include explanation of options, benefits, and risks ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Advance Care Planning (ACP) What are the Goals?  To honor resident preferences for care  To document preferences clearly and communicate them so they can be honored at the appropriate times in the facility as well as after discharge ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011  An advance directive is a general term that describes legal documents expressing a person’s preferences for care (e.g. Living Will, Durable Power of Attorney for Health Care)  Specific orders should be written that can help make sure residents’ wishes documented in advance directives are followed, for example:  Do Not Resuscitate (“DNR”)  No Tube Feeding  Do Not Hospitalize (“DNH”) unless necessary for comfort Advance Directives ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 What is the Role of ACP in the INTERACT Program?  Residents nearing the end-of-life are often transferred to the hospital  Many of these transfers result in increased discomfort, distress and complications  Comfort and/or palliative care can often be provided within the nursing home ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 What is the Role of INTERACT Tools in ACP?  The Advance Care Planning Tools can be helpful in:  Educating staff  Refining policies and procedures for ACP  Communicating with residents, families, and other health care decision makers  Providing examples of comfort care measures ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Advance Care Planning When?  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

© Florida Atlantic University 2011 Advance Care Planning Who?  The MD is responsible for discussing risks and benefits of various treatments and writing orders consistent with preferences  But, ACP is an interdisciplinary team responsibility  Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Advance Care Planning How?  INTERACT ACP tools and other resources are helpful in educating staff and for policies and procedures  Use a systematic approach towards evaluating and refining your current ACP practices ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Steps to Improve ACP in Your Facility 1.Assess the Current Situation a.Approaches currently used and people responsible b.Percent of residents with documentation of initial discussions c.Percent of residents with advance directives, living will, and a health care surrogate decision maker 2.Select ACP as an area for potential improvement based upon preliminary assessment 3.Review state laws and regulations on ACP Originally adapted from: ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 4.Identify areas for improvement in processes and practices: a.Current policies and protocols b.Actual practice related to ACP c.Issues that have arisen related to ACP d.Previous attempts to address need for improvement 5.Identify barriers and challenges to improvement and strategies to overcome them 6.Reinforce practices that are already optimal 7.Implement needed changes and re-evaluate Steps to Improve ACP in Your Facility Originally adapted from: ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Documenting ACP in Your Facility Originally adapted from: ADVANCE CARE PLANNING TRACKING FORM RESIDENT NAME:______________________________________________________ ADMISSION (within a few days of admission or readmission) (Select One) □ Resident and/or responsible party does NOT want to have this discussion □ Discussion about advance care planning held with (circle): resident surrogate (name) both ___________________________ _________________ (Staff or health care provider name) (Title) Signature: ____________________________ Date of Discussion: ______/_____/_____ Location of Advance Care Plan documentation (i.e., medical record, plan of care, progress notes: Use Continuation Pages to document additional Advance Care Planning reviews and discussions ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 This material was adapted from the Birmingham VA Safe Harbor Project in 2007  ACP is especially important among residents at high risk of dying in the near future  This tool provides examples of residents who are at such risk ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Explain comfort care “Comfort care helps people live as well as they can for as long as they can.” Reassure “Comfort care can help you and your family make the most of the time you have left.” Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365. ADVANCE CARE PLANNING TOOLS

© 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

© Florida Atlantic University 2011  Comfort care orders should also anticipate symptoms that can cause distress and discomfort, such as:  Shortness of breath, dyspnea, and terminal “death rattle”  Pain  Anorexia  Anxiety  Seizures This material was adapted from the Birmingham VA Safe Harbor Project in 2007 ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011  Caring Connections – downloadable educational information and forms from the National Hospice and Palliative Care Organization ( www.caringinfo.org ) www.caringinfo.org  Coalition for Compassionate Care of California - Resources for both health care providers and for lay people who want to talk about advance care planning, including downloadable forms and factsheets. http://www.coalitionccc.org/advance-health-planning.php http://www.coalitionccc.org/advance-health-planning.php  Alzheimer’s Association - Comprehensive recommendations aimed at improving communication and care at end of life. http://www.alz.org/national/documents/brochure_DCPRphase3.pdf http://www.alz.org/national/documents/brochure_DCPRphase3.pdf  Aging with Dignity - offers a document called “Five Wishes,” which makes ACP more user-friendly, valid in 40 states; downloadable for $5 ( www.agingwithdignity.org/5wishes.html) www.agingwithdignity.org/5wishes.html Examples of Resources for ACP ADVANCE CARE PLANNING TOOLS

© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon, GNP Mass Senior Care Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011  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

© Florida Atlantic University 2011 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  Integrate the INTERACT program and tools into your everyday practice 3.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

© Florida Atlantic University 2011 1.Select Your Team Pearl of Wisdom:  Selection of the Champion and Co-Champion is one of the most important decisions you will make Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 2.Find the Gaps Pearl of Wisdom:  Avoid redundancy - the INTERACT program should fill in gaps in your care processes and not create more work for your staff. Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 3.Carefully Plan Your Training Facility Characteristics Start with one unit or one tool and have all of the tools implemented by a set date Implement the whole toolkit all at once throughout the whole facility We are a small facility with no other major initiatives underway. x Our champion does very well teaching one on one. x Our champion is our in-service director and is experienced conducting large in- services. x We usually roll out programs for everyone at the same time. x We are a large facility with several nursing units. x We have a short time line to carry out the training and implement the program x Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011  8 online sessions  Not all staff need to complete every session  The facility champion and co-champion serve as the coordinators of the curriculum  Practice using the tools between sessions  Reports of staff completion rates  CEs for licensed nurses  Teleconference review of progress  Online technical assistance The INTERACT Curriculum If your facility or company is interested, inquire via the Contac Us section of the INTERACT website (http://interact2.net)http://interact2.net Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 4.Make the Tools Visible in for Easy Use in Everyday Practice Pearls of Wisdom:  Remove old forms from nursing units to avoid confusion and to encourage standard use of new tools and forms  Successful INTERACT Champions have found ways to keep the program visible on a daily basis through discussions at stand up meetings, on rounds and other strategies Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 5.Continue Tracking Your Data and Looking for Ways to Improve Your Care Pearls of Wisdom:  Complete Quality Improvement tools as soon after acute care transfers as possible so that details are fresh  Use the data to improve care processes and to focus educational activities  Set your own benchmarks and work on improving Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 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

© Florida Atlantic University 2011 Overcoming Barriers to Implementation (2) 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

© Florida Atlantic University 2011 Overcoming Barriers to Implementation (3) 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

© Florida Atlantic University 2011 Overcoming Barriers to Implementation (4) 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

© Florida Atlantic University 2011 1.Ensure ongoing leadership support 2.Make INTERACT a permanent part of your quality improvement activities and one of your programs for QAPI 3.Appoint and train a Co-Champion 4.Have new staff undergo training Sustaining the Program (1) Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 5.Continue to track changes in rates of hospital transfer and how you manage acute changes in condition 6.Learn from you Quality Improvement Review tools 7.Visit the INTERACT website for updates and new resources: http://interact2.nethttp://interact2.net 8.Don’t hesitate to contact us through the website Sustaining the Program (2) Tips on Getting Started and Keeping It Going

© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon,

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© Florida Atlantic University 2011 Joseph Ouslander, MD Florida Atlantic University Gerri Lamb, PhD, RN, FAAN Arizona State University Laurie Herndon,

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