The INTERACT Program Improving Nursing Home Care and Reducing Unnecessary Hospital Transfers, Admissions, and Readmissions This handout is intended for use by this audience only - please do not distribute © Florida Atlantic University 2011 © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 Adrienne Mihelic, PhD Colorado Foundation for Medical Care 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 © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? Disclosures No members of the INTERACT Team derive any personal income from the INTERACT program except for compensation for time spent delivering educational programs The further development and dissemination of INTERACT is supported by grants from: NINR/NIH Centers for Medicare & Medicaid Services The Commonwealth Fund The Patient Centered Outcomes Research Institute PointClickCare Medline Industries © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? Objectives of this Presentation Provide a broad overview of the INTERACT quality improvement program and how it fits with health care reform initiatives Describe barriers to implementing the INTERACT program and strategies to overcome them © Florida Atlantic University 2011
What is It and Why Does It Matter? 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. © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
Video Clip: Why This Matters Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Video Clip: Why This Matters 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. © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
What is It and Why Does It Matter? 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: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012. (Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf © Florida Atlantic University 2011
Background and Why it Matters The INTERACT Program: Background and Why it Matters Some Hospitalizations of NH Residents are Preventable Several studies suggest that a substantial percent of hospital transfers , admissions, and readmissions are unnecessary and can be prevented 12 © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? 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: 627-635, 2010 © Florida Atlantic University 2011
CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries The INTERACT Program: What is It and Why Does It Matter? CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries © Florida Atlantic University 2011
Medicare Fee-for-Service FBI Ten Most Wanted Fugitives The INTERACT Program: What is It and Why Does It Matter? 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 1901 -1980 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. © Florida Atlantic University 2011
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 © Florida Atlantic University 2011
Opportunities for You and Your Facility 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 LOW $ Costs Avoided $ Costs LOW HIGH © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? Opportunities Related to the New QAPI Requirement The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”) The regulation and related surveyor guidance are being written Improving management of acute change in condition and reducing unnecessary hospital transfers is one potential focus to meet the QAPI requirement © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? What Do Nursing Homes Need to Take Advantage of These Opportunities? QI Programs Tools Infrastructure Incentives Safe Reduction in Unnecessary Acute Care Transfers Morbidity Costs Quality © Florida Atlantic University 2011
What is It and Why Does It Matter? 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
What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
“Care Transition Program” High Quality Care Transitions for The INTERACT Program: What is It and Why Does It Matter? INTERACT is One of Several Evidence-Based Care Transitions Interventions “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 © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? Acknowledgement The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Centers for Medicare & Medicaid Services (CMS). The current version of the INTERACT Program was developed by members of the INTERACT Team with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund. The INTERACTTM logo is trademarked by FAU and most of the INTERACT Program materials are copyrighted (©) by FAU. The INTERACTTM logo and copyrighted materials may be used with the permission of FAU. Users of these materials and/or the trademark INTERACTTM logo in any form in products for sale, including electronic health records of other forms of health information technology, must have a license agreement with FAU. Use of the Program Permission can be granted via the “Contact Us”” section of the INTERACT website: http://interact2.net © Florida Atlantic University 2011
What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? Can help 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 © Florida Atlantic University 2011
A Tale of Three Siblings The INTERACT Program: What is It and Why Does It Matter? A Tale of Three Siblings Sadie Sara Sam © Florida Atlantic University 2011
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 Preventable? INTERACT strategy: Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation © Florida Atlantic University 2011
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 Preventable? INTERACT strategy: Manage some conditions in the NH without transfer © Florida Atlantic University 2011
A 101 year old long-stay NH resident The INTERACT Program: What is It and Why Does It Matter? 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 Preventable? INTERACT strategy: Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization © Florida Atlantic University 2011
What is It and Why Does It Matter? 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: 644-652, 2009 © Florida Atlantic University 2011
What is It and Why Does It Matter? 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: http://interact2.net Supported by a grant from the Commonwealth Fund © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? 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 email consults Completion and faxing of QI Review Tools © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? 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% Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 © Florida Atlantic University 2011
What is It and Why Does It Matter? The INTERACT Program: What is It and Why Does It Matter? 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 © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice Communication Tools Decision Support Tools Advance Care Planning Tools Quality Improvement Tools © Florida Atlantic University 2011
Putting the Tools to Work in 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
Putting the Tools to Work in Everyday Practice PointClickCare Users eINTERACTTM is being developed A User Advisory Group is being formed http://www.einteract.org © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice Implementation Training Curriculum Will be available on Medline University in early 2013 © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
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 In order to implement a quality improvement program you must do at least two things: Track, trend, and benchmark well-defined measures Root cause analyses to learn and guide care improvement and educational activities © Florida Atlantic University 2011
What Measures Should You Track? Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool What Measures Should You Track? [this slide builds] Let’s discuss what measures you might track in your efforts to reduce unnecessary hospital transfers. Many facilities are already tracking one or more of these measures, but they are probably not doing it in a consistent way. We will define each measure in the next few slides. First, you can track all unplanned hospital admissions. There are certain admissions that are planned, such as follow up surgical procedures and chemotherapy. These will likely not be included as admissions in federal definitions. Second, you can track all readmissions within 30 days. This is a subset of all admissions, and is of great interest now because of financial penalties for hospitals with high rates of readmissions for specific conditions. Those admissions that are not 30-day readmissions are labeled “new admissions” on this diagram. Each of these categories can be further broken down into a subgroup that includes hospitalizations for specific conditions that are often listed as ones that can be potentially managed outside of the hospital. These are the common conditions that cause transfers, and as we will discuss later, tracking them can help you target educational and quality improvement activities. Apart from tracking hospitalizations, it is useful to track transfers to the Emergency Room, as these are disruptive and expensive as well. Finally, an increasing number of older people are being admitted to hospitals under observation status. Like ER visits, observation stays are disruptive and expensive. They also put residents at risk for hospital acquired complications, and have significant implications for Medicare reimbursement and out-of-pocket expenses for the resident. If your facility is currently or considering becoming involved in an Accountable Care Organization or in a bundled payment model, you should be tracking all of these measures. Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012. (Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf) © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool INTERACT has a paper and pencil worksheet to help track acute care transfers © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Group Exercise: Let’s Calculate Some Hospitalization Rates 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. © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates You want to calculate your average unplanned hospitalization rate for the first quarter of 2013. You census in January was 110, in February 112, and in March 108. During these 3 months you transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter? Choices: 3.53 3.23 4.04 3.74 Correct answer is b. Total unplanned admissions are 32 (3 of the 40 were planned, and 5 were admitted to observation, which is not considered an inpatient hospitalization). In the 3 months, multiplying the days in the month times the census, there were 9894 resident days. The rate per 1000 days is therefore 3.23 (divide total resident days by 1000 = 9.894; 32 divided by 9.894 is 3.23) 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. © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates You want to calculate your average 30-day readmission rate for the first quarter of 2013. Your census in January was 110, in February 112, and in March 108. During these 3 months you had 66 admissions from your local hospital, and transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter? Choices: You cannot calculate your 30-day readmission rate from these data 33.0% 60.6% 56.1% 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. Correct answer is a. You cannot calculate your 30-day readmission rate from these data for two reasons. First, you need to know if the residents who were hospitalized were the same ones admitted from the hospital. Second, you cannot calculate the 30-day readmission rate for March until the end of April. For example, a resident admitted to your facility on March 30 is at risk for a 30-day readmission until April 29. © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates What if the resident was initially discharged home, then came into the facility after 10 days at home, and is readmitted to the hospital the second day in your facility - does that count towards our 30-day readmission rate? Yes or No? Correct answer is YES. CMS is likely to count this as a 30-day readmission from the SNF, despite the fact the resident was at home most of the time between hospital discharge and admission to your SNF. 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. © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates What if the resident is admitted to the hospital from your facility under observation status - does that count towards your 30-day readmission rate? Yes or No? Correct answer is NO. CMS does not plan to count observation stays in the numerator of this calculation. A separate quality measure involving observation stays may be developed in the future. 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. © Florida Atlantic University 2011
Let’s Calculate Some Hospitalization Rates Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Let’s Calculate Some Hospitalization Rates What if the resident is discharged from your facility after 20 days and is readmitted to the hospital 5 days later – does that count towards our 30-day readmission rate? Yes or No? Correct answer is IT Depends. The answer depends on how you calculate this percentage. CMS is likely to count the whole 30-day period, thus making skilled nursing facilities accountable for hospital admissions that occur after discharge from their facility, but 30 days or less from hospital discharge. 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. © Florida Atlantic University 2011
Advancing Excellence tool located at: http://www.nhqualitycampaign.org Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool INTERACT has developed a Hospitalization Rate Tracker in collaboration with the Advancing Excellence Campaign 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 located at: http://www.nhqualitycampaign.org © Florida Atlantic University 2011
Advancing Excellence tool located at: http://www.nhqualitycampaign.org Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Dropdown lists for easy data entry Transfers that occur within 30 days of admission from the hospital are highlighted 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 located at: http://www.nhqualitycampaign.org © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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: http://www.nhqualitycampaign.org © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool 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. © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Unplanned Transfer Assessment Data Collection Tool Facility Name: Name Date Completed: Date Time Period Being Reviewed: Using information from the Unplanned Transfer Assessments reviewed during the timeframe you have identified in Row #5, enter item totals in the following sections. Day of Hospital Transfer: # % 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 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Root Cause Analyses Using the INTERACT Quality Improvement Tool Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Small Group Exercise: Root Cause Analyses Using the INTERACT Quality Improvement Tool 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice Video Clip: Early Identification of and Communication About Acute Changes in Condition 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool Video Clip: Effective Nurse – Primary Care Clinician Communication About Acute Changes in Condition 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The Purpose of the SBAR Improve communication Consistent language Standardized criteria Clear guidelines Communication that is efficient Communication that is effective © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT Change in Condition File Cards © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice 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 © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Advance Care Planning (1) ADVANCE CARE PLANNING TOOLS Video Clip: Advance Care Planning (1) 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. © Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS ACP should occur at some time shortly after admission Decisions should be reviewed regularly and at times of acute changes in condition © Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365 . © Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS 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 © Florida Atlantic University 2011
Advance Care Planning (2) ADVANCE CARE PLANNING TOOLS Video Clip: Advance Care Planning (2) 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. © Florida Atlantic University 2011
Case Study © Florida Atlantic University 2011 82
Case Study 81 year old retired schoolteacher admitted to the hospital from home with pneumonia Past Medical History- COPD, Osteoarthritis, CAD, CHF While hospitalized, had a myocardial infarction (a heart attack) Transferred to your facility 5 days ago for rehab with ultimate goal to return to living independently at home © Florida Atlantic University 2011 83
Case Study Early a.m CNA notes that resident isn’t herself Somewhat irritable Seems to be a little confused Not interested in breakfast Doesn’t go to therapy Reports to nurse at change of shift ( 3 pm ) © Florida Atlantic University 2011 84
“The resident in 3B says she is having trouble breathing” Case Study 3:30 pm “The resident in 3B says she is having trouble breathing” © Florida Atlantic University 2011 85
Case Study You think: She probably aspirated Three other residents on that side have URIs—could she have picked it up? She just finished her Levofloxacin. The pneumonia should be better She also has CHF: it could be CHF How will I know if it is CHF or pneumonia? © Florida Atlantic University 2011 86
Case Study How would Care Paths help the nursing evaluation? Where would you keep these so that nurses would have easy access to them? © Florida Atlantic University 2011
Case Study © Florida Atlantic University 2011
Case Study “DO YOU HAVE…..” © Florida Atlantic University 2011
Case Study © Florida Atlantic University 2011
Case Study Additional Information: CXR-Persistent left lower lobe infiltrate, hyperinflation bilateral lung fields consistent with COPD WBC 15,000 BP 130/70 HR 90 RR 22 Temp100.5 Pulse ox is 91% on room air Chem panel is normal © Florida Atlantic University 2011
Case Study How would you complete the SBAR Change in Condition Progress Note with the information from this case? Would the SBAR be helpful? (nurse and doctor?) How? (be specific) © Florida Atlantic University 2011
Case Study What might have been different if the Stop and Watch was completed in this case? What might be some barriers to robust “uptake” of this tool in your facilities? What strategies would you use to promote use of this tool in your facility? © Florida Atlantic University 2011
Effective Communication with Hospitals Interacting with Your Hospitals Video Clip: Effective Communication with Hospitals 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. © Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice The INTERACT III tools are meant to be used together in your daily work in the nursing home http://interact2.net © Florida Atlantic University 2011
Interacting with Your Hospitals 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. © Florida Atlantic University 2011
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 © Florida Atlantic University 2011
Information Transfer From the Hospital Interacting with Your Hospitals Information Transfer From the Hospital FHA – FADONA – FMDA – CARES – AHCA Readmission Initiative Draft, October 2011 © Florida Atlantic University 2011
Nursing Home Capabilities List Interacting with Your Hospitals Nursing Home Capabilities List Hang it in the ED Give it to case managers Give it to hospitalists Give it to on-call primary care clinicians in your facility © Florida Atlantic University 2011
Interacting with Your Hospitals Medication Reconciliation Worksheet for Post-Hospital Care Part 1: Hospital Recommended Medications Needing Clarification Medications Recommended by Hospital at Discharge for which Clarification is Needed Clarification Needed * Resolution for Final Medication Orders (Continue, Stop, Change) *Examples: unclear diagnosis or indication, uncertain dose or route of administration, stop date, hold parameters, lab tests needed for monitoring, dose different than before hospitalization, medication duplication © Florida Atlantic University 2011
Interacting with Your Hospitals Medication Reconciliation Worksheet for Post-Hospital Care Part 2: Medications Prior to Hospitalization Needing Clarification Medications Taken Before Hospitalization Not Currently on Hospital-Recommended List Comments (Who provided the information, reason for the medication, reason it was stopped in the hospital if known) Resolution for Final Medication Orders (Continue, Stop, Change) © Florida Atlantic University 2011
Tips on Getting Started and Keeping It Going 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 © Florida Atlantic University 2011 102
Tips on Getting Started and Keeping It Going General Principles Make INTERACT a key aspect of your facility’s quality improvement activities and QAPI program Implementation should be consistent with the way you provide care in your facility Integrate the INTERACT program and tools into your everyday practice Recognize that organizational change takes time - programs such as INTERACT can take several months to fully implement © Florida Atlantic University 2011 103
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 104
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 105
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 106
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 107
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 108
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 109
Tips on Getting Started and Keeping It Going © Florida Atlantic University 2011 110
Tips on Getting Started and Keeping It Going Overcoming Barriers to Implementation © Florida Atlantic University 2011 111
Tips on Getting Started and Keeping It Going Overcoming Barriers to Implementation (1) Barriers Strategies 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 © Florida Atlantic University 2011 112
Tips on Getting Started and Keeping It Going Overcoming Barriers to Implementation (2) Barriers Strategies 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 © Florida Atlantic University 2011 113
Tips on Getting Started and Keeping It Going Overcoming Barriers to Implementation (3) Barriers Strategies 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 © Florida Atlantic University 2011 114
Tips on Getting Started and Keeping It Going Overcoming Barriers to Implementation (4) Barriers Strategies 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 © Florida Atlantic University 2011 115
Questions? Comments? Suggestions? The INTERACT Program: © Florida Atlantic University 2011