1. © 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?

2. © 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

3. © 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

4. © Florida Atlantic University 2011 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: http://interact2.net

5. © 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 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

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

7. © 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?

8. © 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?

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

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

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

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

13. © 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?

14. © 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?

15. © 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?

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

17. © 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?

18. © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Communication Tools Decision Support Tools Advance Care Planning Tools Quality Improvement Tools

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

20. © 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

21. © 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?

22. © 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?

23. © 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?

24. © 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

25. © 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?

26. © 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?

27. © 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:

28. © 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?

29. © 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?

30. © 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?

31. © Florida Atlantic University 2011 The INTERACT Program: Background and Why it Matters CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries

32. © Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Why does this matter? A national perspective (3)  Financial and regulatory incentives are changing The INTERACT Program: What is It and Why Does It Matter?

33. © 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?

34. © 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?

35. © 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?

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

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

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

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

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

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

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

43. © Florida Atlantic University 2011  Questions?  Comments?  Suggestions? jousland@fau.edu The INTERACT Program: What is It and Why Does It Matter?