1. Session 1c Overview of the INTERACT Program This session is designed for: Certified Nursing Assistants (CNAs) All non-nursing staff with direct resident contact such as those working in activities, housekeeping, dietary, and laundry departments The development and evaluation of the INTERACT quality improvement program have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation.

2. The INTERACT Interdisciplinary Team Joseph Ouslander, MDFlorida Atlantic University Ruth Tappen, EdD, RN, FAAN Florida Atlantic University Jill Shutes, GNPFlorida Atlantic University Nancy Henry, PhD, GNPFlorida Atlantic University Maria Rojido, MDFlorida Atlantic University Sanya Diaz, MDFlorida Atlantic University Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation Jo Taylor, RN, MPHThe Carolinas Center for Medical Excellence Gerri Lamb, PhD, RN, FAANArizona State University Annie Rahman, PhD, MSWUSC Davis School of Gerontology Dan Osterweil, MD California Association of Long Term Care Medicine Mary Perloe, GNPGeorgia Medical Care Foundation John Schnelle, PhDVanderbilt University Sandra Simmons, PhDVanderbilt University Alice Bonner, PhD, GNPCenter for Medicare and Medicaid Services In collaboration with participating nursing homes Overview of the INTERACT Program

3.  What is INTERACT?  Why does INTERACT matter to you?  How does INTERACT work? Questions Answered in This Module Overview of the INTERACT Program

4. “Interventions to Reduce Acute Care Transfers” What is INTERACT? A quality improvement program to improve the care of nursing home residents who have acute changes in condition Overview of the INTERACT Program

5. The INTERACT Program includes:  Tools and how to use them  Educational resources The basic program is located on the internet: http://interact2.net Overview of the INTERACT Program

6. 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. Overview of the INTERACT Program

7. Hospital transfers are common, often result in complications in older NH residents, and are very expensive. $$$ Why Does INTERACT Matter? Overview of the INTERACT Program

8. Hospital transfers Break in continuity of care Changed routines New caregivers New environment Why Does INTERACT Matter? Overview of the INTERACT Program

9. Overview of the INTERACT Program Why Does INTERACT Matter? 1 in 4 patients admitted to a skilled nursing facility are readmitted to the hospital within 30 days. Cost of 30 day rehospitalizations is $4.3 billion.

10. Mor et al. Health Affairs 29: 57-64, 2010 Overview of the INTERACT Program

11. 1.Distress and discomfort for resident and family 2.Delirium 3.Polypharmacy 4.Falls 5.Incontinence and catheter use Hospitalizations can cause many complications. 10 Common Complications of Hospitalization of Older Adults Overview of the INTERACT Program

12. 6. Hospital acquired infections 7. Weight loss and poor nutrition 8. Immobility 9. Loss of function 10. Pressure ulcers Hospitalizations can cause many complications. 10 Common Complications of Hospitalization of Older Adults Overview of the INTERACT Program

13. Video Clip Patient who suffers a complication during an unnecessary hospitalization Overview of the INTERACT Program

14. Why does this matter? A national perspective Some hospital transfers are preventable. Care can be improved with fewer complications and less cost. Overview of the INTERACT Program

15. Why does this matter? A national perspective Regulations and payment for services provided in the nursing home are changing. The INTERACT Program: What is It and Why Does It Matter? Overview of the INTERACT Program

16. Affordable Care Act is focused on a “triple aim.” 1. Improving care 2. Improving health 3. Making care affordable Berwick, DM, Nolan, TW, and Whittington, J. The Triple Aim: Care, Health, and Cost. Health Affairs 27:759-769, 2008. This presents major opportunities to improve the care of older adults in the U.S. Health Care Reform The INTERACT Program: What is It and Why Does It Matter? Overview of the INTERACT Program

17. Why does this matter to you and your facility?  Improve quality of care for your residents.  Your facility may be able to get more money from Medicare by reducing hospitalizations. Your facility can take advantage of the opportunities in health care reform Overview of the INTERACT Program

18. Opportunities for You and Your Facility  The Affordable Care Act requires each facility to have a Quality Assurance and Performance Improvement program (QAPI). Reducing hospitalizations safely is new goal for Advancing Excellence in America’s Nursing Homes campaign (see http://www.nhqualitycampaign.org)http://www.nhqualitycampaign.org Overview of the INTERACT Program

19. What are your experiences?  What do you think are the major causes of unnecessary hospitalizations of residents from the facility or facilities that you work in? Overview of the INTERACT Program

20. Interventions to Reduce Acute Care Transfers Is a quality improvement program to improve the care of nursing home residents with acute changes in condition. Overview of the INTERACT Program

21. 1.Prevents conditions from becoming severe enough for hospitalization through early identification and assessment of changes in resident condition. 2.Manages some conditions in the NH without transfer when this is practical and safe. 3.Improves advance care planning and the use of palliative care instead of hospitalization for some residents. How does INTERACT Work? Overview of the INTERACT Program

22. 1.Prevents conditions from becoming severe enough for hospitalization through early identification and assessment of changes in resident condition. Step # 1 means: Direct care staff identify and report early changes in resident behavior, appearance, and condition using an Early Warning Tool called STOP and WATCH. Nurse completes an assessment and communicates with the physician using a special communication tool called SBAR. How does INTERACT Work? Overview of the INTERACT Program

23. 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. Overview of the INTERACT Program

24.  Sadie  Sara  Sam A Tale of Three Siblings Overview of the INTERACT Program

25.  Hospitalized for urinary tract infection and dehydration  Discharged back to the NH after 4 days  Re-hospitalized 7 days later for dehydration and same infection 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. Overview of the INTERACT Program

26.  Hospitalized for a lower respiratory infection, but had normal vital signs  Developed delirium in the hospital, fell, fractured her pelvis, 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. Overview of the INTERACT Program

27.  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 instead of hospitalization. Overview of the INTERACT Program

28.  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 projects supported by The Commonwealth Fund Overview of the INTERACT Program

29. Communication Tools Decision Support Tools Advance Care Planning Tools Quality Improvement Tools Overview of the INTERACT Program

30. Use the INTERACT II tools together in your daily work http://interact2.net

31.  On site training  Facility INTERACT champion  Phone calls with facility champions twice a month  Use of QI Review Tools Commonwealth Fund INTERACT Project Overview of the INTERACT Program

32. Commonwealth Fund Project Results Facilities Reduction in Hospitalizations All INTERACT facilities (N = 25) 17% Engaged facilities (N = 17) 24% Comparison facilities (N = 11) 3% Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 Overview of the INTERACT Program

33. Commonwealth Fund Project Results For a 100-bed NH, this decrease would result in:  25 fewer hospitalizations per year  $117,000 in savings Medicare could share these savings to support NHs to further improve care. Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 Overview of the INTERACT Program

34. Safe Reduction in Unnecessary Acute Care Transfers Fewer Complications Lower Costs Higher Quality Overview of the INTERACT Program

35.  Medline University INTERACT modules  The INTERACT website http://interact2.nethttp://interact2.net  Other Overview of the INTERACT Program Educational Resources

36.  Please complete the Quiz and Evaluation  If you do not complete them:  You will not receive continuing education credit  If your facility is tracking who completes specific modules, you will not be counted Quiz and Evaluation Overview of the INTERACT Program

37. The development and evaluation of the INTERACT quality improvement program and curriculum have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation. In this module, we have:  Defined and discussed the goals of the INTERACT Program  Provided insights into why the program matters to you and your organization  Shared an overview of the INTERACT Program and tools