Improving Geriatric Care by Reducing Potentially Avoidable Hospitalizations Laurie Herndon, MSN, GNP-BC, ANP-BC Director of Clinical Quality Massachusetts Senior Care Foundation

Today we will… Review background of INTERACT II toolkit Review background of INTERACT II toolkit Describe the key components of the INTERACT II toolkit Describe the key components of the INTERACT II toolkit Share some lessons learned so far Share some lessons learned so far Discuss the tools in the context of the cross continuum teams Discuss the tools in the context of the cross continuum teams

Hospitalizations of NH residents are common 1 in 5 Medicare fee-for-service patients admitted to an acute hospital are re-admitted within 30 days In any six month period, more than 15% of long stay residents are hospitalized In any six month period, more than 15% of long stay residents are hospitalized –O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable Hospitalizations” Journal of the American Geriatrics Society 52, no. 10(2004):

Of ~1.8 million SNF admissions in the U.S. in 2006, 23.5% were re-admitted to an acute hospital within 30 days Cost of these readmissions = $4.3 billion Mor et al. Health Affairs 29 (No. 1): 57-64, 2010

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

Why This Matters

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

INTERACT Definitions and Goals INTERACT stands for “ Interventions to Reduce Acute Care Transfers” INTERACT stands for “ Interventions to Reduce Acute Care Transfers” It is a program designed to improve the care of nursing home residents by: It is a program designed to improve the care of nursing home residents by: –Identifying situations that commonly result in transfers to the hospital—and working together to manage them effectively and safely in the nursing home without transfer whenever possible

INTERACT Definitions and Goals The goal of INTERACT is to improve quality of care, not to prevent all hospital transfers The goal of INTERACT is to improve quality of care, not to prevent all hospital transfers –In fact, INTERACT can result in more rapid transfer of residents who need hospital care

Purpose of Toolkit Aid in the early identification of a resident change of status Aid in the early identification of a resident change of status Guide staff through a comprehensive resident assessment when a change has been identified Guide staff through a comprehensive resident assessment when a change has been identified Improve documentation condition Improve documentation condition Enhance around resident change in communication with other health care providers about a resident change of status Enhance around resident change in communication with other health care providers about a resident change of status Design of Toolkit Dr. Ouslander “Simple Test” Feasible and efficient Part of the “way we do business” Acceptable to staff

Building Evidence CMS Pilot –50% reduction of hospitalization in 3 NHs with high baseline rates –36% reduction in hospitalizations rated as potentially avoidable Commonwealth Fund Project – 17% reduction all facilities – 24% reduction in highly engaged facilities Practice Change Fellowship – 100+MA facilities – Data from ~30

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

Making the Cross Continuum Connection Know that this is a priority Know that this is a priority “Heads Up” from acute care to SNF on discharge “Heads Up” from acute care to SNF on discharge “If you could predict….” “If you could predict….” What do YOU know about the resident that will help us target the right symptoms once they are transferred? What do YOU know about the resident that will help us target the right symptoms once they are transferred?

Making the Cross Continuum Connection Consider using for “Warm Hand Off” Consider using for “Warm Hand Off” Review on admit to ED and to the floor Review on admit to ED and to the floor How might this be specifically targeted to your work? (i.e CHF programs) How might this be specifically targeted to your work? (i.e CHF programs)

Making the Cross Continuum Connection These are well received by SNF nurses These are well received by SNF nurses Used with SBAR to promote critical thinking Used with SBAR to promote critical thinking Think about sharing teaching resources you have started in the hospital Think about sharing teaching resources you have started in the hospital

Making the Cross Continuum Connection DOES THIS HELP? DOES THIS HELP? Be sure to provide feedback one way or another Be sure to provide feedback one way or another Ask facilities about it Ask facilities about it Could this be a template for disease management efforts? Could this be a template for disease management efforts?

Communication Across Settings

Making the Cross Continuum Connection: The Transfer Form Is this the information YOU need? Is this the information YOU need? Please be sure to review the information on the second page—this is critical information WE need to share with you Please be sure to review the information on the second page—this is critical information WE need to share with you (Knowing the baseline is AS IMPORTANT with SNF residents as any other part of the assessment)

Spotlight on Innovation Met with ED staff Met with ED staff Revisions made to transfer form and format (3 hole punch) Revisions made to transfer form and format (3 hole punch) Open lines of communication Open lines of communication Importance of relationships/trust Importance of relationships/trust Case Review now possible Case Review now possible

The QI Review and Process Improvement Internal Processes Internal Processes –Missing early warning signs Cross Continuum Processes Cross Continuum Processes –7 day readmits –Primarily cardiac diagnosis –Consider using/modifying to review cases together

Model for Implementation Train the trainer Train the trainer Leadership Leadership Champion Champion Finding the Gaps Finding the Gaps Avoiding Duplication Avoiding Duplication Tracking the Data Tracking the Data MAKING IT RELEVANT MAKING IT RELEVANT

Lessons so far…. Leadership “buy in” is important Leadership “buy in” is important “This is great…we would love to do this at our facility” “This is great…we would love to do this at our facility” Morning meeting Morning meeting Quarterly QI Agenda item Quarterly QI Agenda item Morning RN report Morning RN report

But… The frontlines are where it happens

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

Relationships matter: Who to include in your training sessions “Our NP told me she couldn’t believe how much the nursing assessments have improved since we started this” “Our NP told me she couldn’t believe how much the nursing assessments have improved since we started this” “Does the ED staff know about this project? They keep calling to ask about the forms.” “Does the ED staff know about this project? They keep calling to ask about the forms.” “Does this mean they will be checking up on me?” “Does this mean they will be checking up on me?” “It’s all about teamwork” “It’s all about teamwork”

Lessons Learned It can be done It can be done Allow 3 months to get started Allow 3 months to get started Anticipate questions Anticipate questions Anticipate enthusiasm Anticipate enthusiasm Be ready for refining and critical thinking at months Be ready for refining and critical thinking at months –Ex. Cross Continuum Team –Transfer Form –Post Acute Checklist

INTERACT II Quick Tips The Champion—key to the effort in the skilled nursing facility—this is the who you should ask for! The Champion—key to the effort in the skilled nursing facility—this is the who you should ask for! A live meeting is best A live meeting is best Schedule regular follow up Schedule regular follow up How do efforts compliment each other? How do efforts compliment each other? Where are the gaps? Where are the gaps? Small tests of change Small tests of change

INTERACT II in Context of Other Initiatives MA Statewide Strategic Plan for Care Transitions MA Statewide Strategic Plan for Care Transitions STAAR Project STAAR Project Cross Continuum Teams Cross Continuum Teams 3026 Applications 3026 Applications MOLST/POLST MOLST/POLST Accountable Care Organizations Accountable Care Organizations Universal Transfer Form/IMPACT Project in Worcester Universal Transfer Form/IMPACT Project in Worcester Blue Cross Blue Shield of MA Blue Cross Blue Shield of MA MA Department of Public Health MA Department of Public Health MA Senior Care RWJ PIN Grant MA Senior Care RWJ PIN Grant

Thank You!!!