1. The INTERACT ® Program Home Health Agencies Carol Higgins, OTR (Ret.), CPHQ Certified INTERACT ® Educator Qualis Health Washington

2. 2 Qualis Health A leading national healthcare consulting organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIN-QIO Program One of the largest federal programs dedicated to improving health quality at the local level

3. 3 Today’s Objectives Provide an overview of quality improvement relative to Home Health Agencies utilizing components of the INTERACT ® Program Provide an expanded view of individual Tools Discuss tips for implementation of the tools and experience with use

4. 4 “Drivers” of Poor Transitions Lack of patient and family activation Health literacy Self-management skills & tools Motivation, locus of control Lack of standard and known processes Patient discharge, hand-over Internal work flow Lack of information transfer Especially cross-setting Delays, inaccuracies, missing information

5. 5 Two Approaches to Interventions System changes –Hardwiring standard and reliable processes –Benefit: Broad reach for all patients, all payers, all units –Challenge: Improving and sustaining processes is hard work! Targeted population interventions –Usually chronic condition-specific (like HF) –Coaching, case management –Benefit: care based on identified risk –Challenge: narrow focus, may not move overall readmit rate The INTERACT ® Program is a system/culture change intervention

6. 6 The INTERACT ® Program Includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources The program is located at http://interact2.net

7. 7 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 versions of the INTERACT ® Program were developed by the INTERACT ® interdisciplinary team under the leadership of Dr. Joseph G. Ouslander, MD with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.

8. 8 The INTERACT ® Program is Much More than a Toolkit This program is not just for SNFs anymore Most providers are only aware of INTERACT ® as a few tools like “Stop and Watch” or “SBAR” The overall Program is much more and can provide significant benefit to both post-acute providers and hospitals Prime examples are the full program components and use of the Quality Improvement Tools

9. 9 Overview INTERACT ® Documents Home Health INTERACT ® Home Health Version 1.0 Tools Using the INTERACT ® Home Health Version 1.0 Tools in Every Day Care Home Health Version 1.0 Tool Implementation Guide 2013

10. 10 Differences with the INTERACT ® Program Agencies using the INTERACT ® Program components are focused on improving the quality of care for patients and reducing hospital readmissions Use of INTERACT ® tools provide staff guidelines for assessment and intervention to identify changes in condition sooner INTERACT ® tools assist agencies to identify and provide for educational needs of staff Use of evidence-based, standardized tools allows for clear, comprehensive communication and coordination across all settings, particularly during transfers

11. 11 The INTERACT ® Program

12. 12 Organization of Tools Communication ToolsDecision Support ToolsAdvance Care Planning Tools Quality Improvement Tools

13. 13 Organization of Tools Communication ToolsDecision Support ToolsAdvance Care Planning Tools Quality Improvement Tools

14. 14 Quality Improvement Tools Acute Care Transfer Log Quality Improvement Tool for Review of Acute Care Transfers Quality Improvement Summary Worksheet Implementation Checklist

15. 15 Quality Improvement Tool Purpose Review each transfer to understand the reasons for transfer Identify possible opportunities to prevent avoidable transfers When to Use Within 24-48 hours after transfer Representative sample of transfers to look for common patterns & identify improvements

16. 16 Quality Improvement Tool Who –Incorporate into existing QI process –Form an acute care transfer team –If one staff person, they interview team members –Include rehab and social work staff –Family members may have important contribution

17. 17 Quality Improvement Tool Root Cause Analysis: The Rest of the Story Demographics What happened? Contributing factors Attempts to manage in home Avoidable? Staff thoughts about this “Ah ha” moments Should have returned sooner? Opportunities for improvement Cross continuum review of cases Consider return to SNF if patient came from that setting rather than sending to ED or hospital

18. 18 QI Summary Worksheet Moves the focus from individual QI Tools (one patient) to patterns across all QI Tools (multiple patients) Allows patterns to begin to form Focuses improvement activities Unfortunately not often used – a missed opportunity!

19. 19 QI Summary Worksheet Step 1: Number and timeframe of individual QI Tools in the summary Step 2: Compares across categories Patient characteristics Changes in condition Actions taken Hospital transfers and contributing factors Potentially preventable? Step 3: Summarizes common factors

20. 20 Root Cause Analysis (RCA) Identifies causal factors leading to acute care transfers Shows what efforts were made to treat in home or return to SNF if appropriate Highlights common patterns Identifies possible gaps in either facility processes or staff knowledge

21. 21 Organization of Tools Communication ToolsDecision Support ToolsAdvance Care Planning Tools Quality Improvement Tools

22. 22 Communication Tools Two sections of Communications Tools: 1.Communications within the agency 2.Communications between agency and hospital

23. 23 Communication Tools 1.Communications within the agency Stop and Watch Early Warning Tool SBAR Communication Form and Progress Note for Home Health

24. 24 Stop and Watch Early Warning Tool Purpose –Identify and document changes in patients –Communicate changes to other members of the team –Identify possible opportunities to prevent a hospital transfer –Improve over all level of care When to use –Tool should be completed for ALL changes on a visit-by visit basis, by staff with direct contact with the patient

25. 25 SBAR Communication Tool Used by all licensed staff to evaluate and communicate acute changes in condition to MD, NP, and/or PA Documentation tool for both the evaluation and the communication

26. 26 Communication Tools 2.Communications between home health agency and hospital: Home Health Capabilities List Home Health to Hospital Transfer Form Home Health to Hospital Data List Acute Care Transfer Document Checklist Hospital to Home Health Transfer Form Hospital to Home Health Data List Medication Reconciliation Worksheet for Post- Hospital Care

27. 27 Medication Reconciliation Worksheet Structured medication reconciliation for new admissions or patients returning from the hospital to identify discrepancies and other issues Part 1: Hospital recommended medications needing clarification Part 2: Medications Prior to hospitalization needing clarification

28. 28 Effective Communication It is not about the forms… it is about the connections Receivers need to be aware of what the form or document includes Goal is to have receiver use the information Poor communications = poor outcomes

29. 29 Organization of Tools Communication ToolsDecision Support ToolsAdvance Care Planning Tools Quality Improvement Tools

30. 30 Decision Support Tools Vital elements of the overall INTERACT ® Program Builds on the basic structure of the Quality Improvement and Communication tools Provides evidence-based guides for assessment and management of common changes in patient status

31. 31 Change in Condition File Cards and Care Paths Purpose Guide the assessment and management of common changes in patient status that result in acute care transfers Provide evidence-based assessment & management Insure timely assessments, communication with providers and acute care transfer as needed Manage in place when feasible and safe Improve the overall level of care for patients with changes in status

32. 32 Change in Condition File Cards Decision support tools for the staff to help with determining whether to report specific symptoms, signs, and lab results immediately, vs. non-immediately (e.g. the next day) These comprehensive, alphabetized tools include explicit criteria for notifying primary care clinicians Engagement and buy-in of the medical director and primary care clinicians is critical to their success

33. 33 Care Paths Acute Mental Status Change Change in Behavior – New or Worsening Symptoms Dehydration Fever GI Symptoms: Nausea, vomiting, diarrhea Shortness of Breath Symptoms of lower respiratory illness Symptoms of CHF Symptoms of UTI

34. 34 Change of Condition File Cards and Care Paths Helpful Tips –Use in educational in-services –Modify specific recommendations per input from interdisciplinary team –Hang posters in high visibility location for reference –Include in staff packets –Use a log to notify primary care MDs of condition changes not requiring immediate notification

35. 35 Organization of Tools Communication ToolsDecision Support ToolsAdvance Care Planning Tools Quality Improvement Tools

36. 36 Advance Care Planning In order to make a difference, we must change our focus away from forms and toward work systems Proactive communication about stages of illness and progressive frailty Anticipate complications Use values to set goals Use goals to make decisions Offer specific alternatives

37. 37 Advance Care Planning Tools Purpose: Guide conversations about EOL, advance directives and comfort/palliative care Communicate effectively with patients & family members Provide patients with comfort and dignity measures Assure patients receive level of care consistent with their wishes Increase staff dialogue about EOL care, advance directives and comfort / palliative care

38. 38 Advance Care Planning Tools Advance Care Planning Overview Advance Care Planning Tracking Form Identifying Patients Appropriate for Hospice or Comfort Care Comfort Care Interventions Educational Information Deciding About Going to the Hospital Education on CPR and Tube Feeding

39. 39 Advance Care Planning Tracking Form Documents and tracks advance care planning discussions and refers to more detailed notes about the discussion Shows changes over time as needed or appropriate Includes: Status at admission (within about a week of admission/readmission) Advance Care Plan review and/or discussion updates

40. 40 Advance Care Planning Resources Additional Resources for Staff and Families (available free on the internet ) American Association for Retired Persons The Coalition for Compassionate Care The Conversation Project Closure.org Caring Connections of the National Hospice and Palliative Care Organization

41. 41 Summary Today we have delved into the background of the need for an improved focus on safe and effective transitions of patients between settings –What is of concern –How you fit into the overall picture –The roll of the INTERACT ® Program –The need to emphasize the Quality Improvement components of the INTERACT ® Program –Tips on implementation of all of the Tools

42. 42 Round Table Discussion and Sharing

43. 43 Questions? Carol Higgins, OTR (Ret.), CPHQ Qualis Health carolh@qualishealth.org 206-288-2454 For more information: www.Medicare.QualisHealth.org/projects/care-transitions This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-C3-QH-1696-03-15