1. A Practical Approach To Safely Reducing Rehospitalizations
The INTERACT Quality Improvement Program
A Practical Approach To Safely Reducing Rehospitalizations
Laurie Herndon, MSN, GNP-BC
Director of Clinical Quality
Massachusetts Senior Care Foundation
This handout is intended for use by this audience only.
Please do not distribute.

2. 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 interdisciplinary team under the leadership of Dr. Joseph G. Ouslander, M.D. with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.

3. Objectives Discuss background of INTERACT program
Provide brief overview of tools
Discuss how INTERACT can be used as a platform for building and working with your cross continuum team

4. What is INTERACT?
Toolkit
Interact2.net
INTERACT 3.0

5. What is INTERACT?
INTERACT: Interventions to Reduce Acute Care Transfers
A Quality Improvement Program

6. INTERACT 3.0 January 2013 National Expert Review
All tools revised/reformatted
New tools added
Care paths
Electronic data tracking
Implementation Checklist
Tools for acute care

7. INTERACT Purpose and Design
Improve care
Reduce the frequency of potentially avoidable acute care transfers of nursing home residents
Design
Improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.
Target is avoidable transfers, NOT to prevent all transfers

8. Background: Why Focus on Rehospitalizations?
Rehospitalizations Of SNF Residents Is Common and Costly
1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion
Source: Vincent Mor, et al. (2010) Medicare SNF Rehospitalizations: Implications for Medicare Payment Reform, Health Affairs

9. Background: Many Are Avoidable
Subjects: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States (2006–2008).
Results: Three fifths of hospitalizations were potentially avoidable and the majority was for infections, injuries, and congestive heart failure.
Medical Care: August Volume 51 - Issue 8 - p doi: /MLR.0b013e bff

10. We Are All In This Together
The Bottom Line
“Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them”
A. E. Boutwell, M. B. Johnson, P. Rutherford et al., "An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions," Health Affairs, July (7):1272–80

11. Using INTERACT As A Starting Point

12. Organization of Tools Quality Improvement Tools Communication Tools
Decision Support Tools
Advance Care Planning Tools

13. Quality Improvement Tools
Numbers
Stories

14. Disclaimer
Screen Shots of Tools

15. Quality Improvement Tools

16. Quality Improvement Tools
How many transfers from your hospital or nursing home (for home health)?
When do they occur?
How many days since admit?
“Ah ha” moments
Online version

17. Quality Improvement Tools
Root Cause Analysis: The Rest of the Story
Demographics
What happened
Contributing factors
Attempts to manage in SNF
Avoidable?
Staff thoughts about this
Opportunities for improvement
Cross continuum review of cases

18. Communication Tools Enhanced Nursing Assessment
Builds on early recognition
Standard approach
MD/NP response
Warm hand over
How might this compliment disease management?

19. Communication Tools Communication Tools Across Settings
Nursing Home Capabilities Checklist
Medication Reconciliation Worksheet
Transfer forms both directions
Data lists both directions
Can use as platform to start discussion about which elements nurses will use for warm hand off

20. Communication Tools: Not About The Forms
Returned Unopened
Poor Communication=Poor Outcomes

21. Decision Support Tools

22. Decision Support Tools

23. Lessons Learned About Implementation

24. Lessons Learned About Implementation
“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’m seeing it happen… walking on the units and seeing the nurses using the SBAR…it’s great.”

25. Lessons Learned About Implementation
For the SNF: one unit
For the hospital: one SNF
For HH/AL: one case
For surveyors: one conversation
For all: one CC meeting

26. Lessons Learned About Implementation
Within Your Setting
Across Settings

27. Lessons Learned About Implementation

28. Lessons Learned About Implementation: Simplicity Works

29. Lessons Learned About Implementation: IT CAN BE DONE

30. Most Important Lesson About Implementation

31. CMS Pilot Study Results
Building Evidence
CMS Pilot Study Results
Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates
Tools were acceptable to staff
Significant reduction in hospitalizations
Significant reduction in transfers rated as avoidable by an expert panel
Ouslander et al: J Amer Med Dir Assoc 9: , 2009

32. Building Evidence Implementation Model in the
Commonwealth Fund Grant Collaborative
On site training (part of one day)
Facility-based champion
Collaborative phone calls with up to 10 facility champions twice monthly facilitated by an experienced nurse practitioner
Availability for telephone and consults
Completion and faxing of QI Review Tools

33. Building Evidence Commonwealth Fund Project Results 17% 24% 6%
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

34. Building Evidence

35. Lessons Learned: Big Picture
Acute Care
Skilled Nursing
Home With Home Health
Assisted Living
What Is Driving This Change?

36. Lessons Learned: Big Picture
The Future Is Now!
ACO language includes INTERACT
Hospital Engagement Networks

37. Now Available: Assisted Living and Home Health

38. Interacting with Acute Care Hospitals
The Important Role of Your Facility Team
Facility Leaders: Improving Relationships
Frontline Staff:
Improving Quality of Care

39. Interacting with Acute Care Hospitals
Facility Leaders
Be prepared
Initiate contact
Know your data
Share your story
Know what tools/data/information you want to share
Set date for next meeting

40. Interacting with Acute Care Hospitals
“Are you guys doing anything to educate hospitals about what INTERACT is? The local ACO leader, who is a friend of mine is requiring us to use INTERACT but has no idea what INTERACT is”
Executive Director,
A Massachusetts SNF

41. Interacting with Acute Care Hospitals
Lots of interest in this form
Bring it with you
Offer to update regularly
Be sure you can do what you say you can

42. Interacting with Acute Care Hospitals
The Role of the Frontline Staff in Improving Quality of Care
(and how these day to day improvements can impact the bigger picture/relationship)

43. Interacting with Acute Care Hospitals
Frontline tools
Transfer Form
Transfer Checklist
SBAR
They need to be filled out completely
They need to be used consistently
You need to get to the hospital before the forms

44. Interacting with Acute Care Hospitals
Improving Quality:
When used as intended, these forms provide a comprehensive history about the resident when they are transferred to the hospital.
Providers have information necessary to determine the most appropriate plan in the most appropriate setting

45. Interacting with Acute Care Hospitals
“It is not about the forms: It is about the relationship”
Enhancing the relationship by using the Warm Hand Over

46. Interacting with Acute Care Hospitals
The Warm Hand Over
What is it?
Who does it?
How do you do it?
Why hasn’t this been easier?
Why isn’t everybody doing it?

47. Interacting with Acute Care Hospitals
The Warm Hand Over
The SNF community has the chance to take the lead
Tools to consider
SBAR
Transfer Form
Data Lists
Best option
The Power of One

48. Interacting with Acute Care Hospitals
The Warm Hand Over
The Power of One
One SNF nurse
One hospital nurse
One meeting
One trial
How did it go?
Modify
Try again
Spread
Cross Continuum Meeting
Frontline work intersects with work of leadership= improved care
Results Are Shared

49. Interacting with Acute Care Hospitals
In Summary:
The future is now. Payment reform is driving change.
Acute care hospitals are very interested in what is going on with SNFs and are asking about INTERACT
Use your work with INTERACT to inform your local hospitals and to help develop a dynamic working relationship

50. Interacting with Acute Care Hospitals
In Summary:
“It’s not about the forms, it’s about the relationships”
INTERACT Champion

51. Thank You!
Laurie Herndon, MSN, GNP-BC Director of Clinical Quality Massachusetts Senior Care Foundation