1. Session 1d Overview of the INTERACT Program This session is designed for: Administrators Social Workers Therapists (PT, OT, RT) Other Direct Care Staff 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.

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.  Definition and goals of the INTERACT Program  Why it matters to you and your organization  An overview of the INTERACT Program and tools What This Module Will Cover Overview of the INTERACT Program

4. (“Interventions to Reduce Acute Care Transfers”) Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition Overview of the INTERACT Program

5.  The INTERACT program 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 Overview of the INTERACT Program

6. Acknowledgement When using the INTERACT Program and tools, an appropriate acknowledgement should be included, and permission should be obtained to use the INTERACT trademark and copyrighted tools. 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 was designed by the INTERACT team, with input from many direct care providers and national experts in a project based at Florida Atlantic University and 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. The INTERACT TM trademark and copyrighted materials may be used with the permission of Florida Atlantic University, which can be obtained via the “Contact Us” section of the INTERACT website (http://interact2.net )http://interact2.net Permission must be obtained for the use of any aspects of the INTERACT program for profit, or for incorporation of INTERACT tools into an electronic health record. Overview of the INTERACT Program

7. #5. INTERACT responds to a real problem that is now receiving national and state attention. Top 5… ….Reasons to like INTERACT Overview of the INTERACT Program

8. The Problem…  Emergency room visits, observation stays hospitalizations, and readmissions of nursing home residents are :  Common  Costly  Complicated  Often avoidable Overview of the INTERACT Program

9. Mor et al. Health Affairs 29: 57-64, 2010 1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion Overview of the INTERACT Program Common and costly….

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

11. Often Avoidable…  Some hospital transfers, ER visits, observation stays, hospital admissions, and readmissions are rated by expert clinicians as “avoidable”, “preventable”, or “unnecessary”  Studies in which clinical experts have reviewed medical records suggest that between 1/4 and 2/3 of hospitalizations might be unnecessary Overview of the INTERACT Program

12. Now Receiving National and State Attention…  Financial and regulatory incentives are changing The INTERACT Program: What is It and Why Does It Matter? Overview of the INTERACT Program

13.  Pay-for-Performance  Incentives for improved quality  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  Other (e.g. Patient Centered Medical Homes, state programs for Medicare/Medicaid dually eligible beneficiaries) Changes in Medicare Financing Overview of the INTERACT Program

14.  Improve quality of care for your residents  Share in savings to Medicare by reducing unnecessary ER visits, observation stays, hospital admissions, and readmissions  Your facility can take advantage of the opportunities in health care reform Overview of the INTERACT Program Why Does This Matter to You and Your Facility?

15.  The health care reform law also mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”)  The regulation and related surveyor guidance are being written  Improving the management of acute change in condition and reducing unnecessary hospital transfers through the use of INTERACT is one potential focus of your QAPI work  In addition, “Reducing Hospitalizations Safely” is a new goal for the Advancing Excellence in America’s Nursing Homes campaign (see http://www.nhqualitycampaign.org)http://www.nhqualitycampaign.org Overview of the INTERACT Program Why Does This Matter to You and Your Facility?

16. # 4 : INTERACT can be implemented in any nursing home, drawing on its existing resources. Top Reasons to like INTERACT… Overview of the INTERACT Program

17. INTERACT tools: are available online at no charge. are appropriate for use with both long-term and rehab residents. integrate well with IT programs. are rapidly becoming the standard of practice in many communities. can increase referrals to your nursing home. Overview of the INTERACT Program

18. # 3: INTERACT promotes best practice. Top reasons to like INTERACT… Overview of the INTERACT Program

19. 1.Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition 2.Managing some conditions in the NH without transfer when this is feasible and safe 3.Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents  The INTERACT program uses 3 basic strategies: Overview of the INTERACT Program

20.  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  The goal of INTERACT is to improve the management of residents with a change in condition Overview of the INTERACT Program

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

22.  Hospitalized for UTI and dehydration  Discharged back to the NH after 4 days  Re-hospitalized 7 days later for dehydration and recurrent UTI Sadie A 96 year old long-stay NH resident Preventable? INTERACT strategy:  Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation Overview of the INTERACT Program

23.  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 Sara (Sadie’s younger sister) A 92 year old long-stay NH resident Preventable? INTERACT strategy:  Manage some conditions in the NH without transfer Overview of the INTERACT Program

24.  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 Preventable? INTERACT strategy:  Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization Overview of the INTERACT Program

25. 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

26. # 2: INTERACT is evidence-based and by design, user-friendly and practical to implement. Top reasons to like INTERACT… Overview of the INTERACT Program

27.  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 a project supported by The Commonwealth Fund Overview of the INTERACT Program

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

29. Easy to use by design. A case in point: Stop & Watch: If you have identified an important change while caring for a resident today, please circle the change (from a list of possible changes on the form) and discuss it with the charge nurse before the end of your shift.

30. The INTERACT II tools are meant to be used together in your daily work in the nursing home http://interact2.net Overview of the INTERACT Program

31. Not all staff members will use all INTERACT II tools, but most will use at least some. Overview of the INTERACT Program Stop & Watch: CNAs, therapists, social workers, nurses, even family members Care Paths, Acute Change in Condition File Cards: Nurses, physicians Advance Care Planning Tools: Social workers, nurses, physicians SBAR: Nurses Transfer Checklist, Resident Transfer Form: Discharge planners, admissions staff, nurses QI tools: QA staff, administrators, medical directors

32. # 1: INTERACT delivers. Top reasons to like INTERACT… Overview of the INTERACT Program

33.  30 NHs – 10 in FL, 10 in Mass, 10 in NY  On site training (part of one day)  Facility-based champion  Phone calls with up to 10 facility champions twice monthly facilitated by an experienced nurse practitioner  Completion and faxing of Quality Improvement Review tools monthly for 6 months Evidence of INTERACT Effectiveness: The Commonwealth Fund Grant Collaborative Overview of the INTERACT Program Ouslander et al, J Am Geriatr Soc 59:745–753, 2011

34. Commonwealth Fund Project Results Facilities Mean Hospitalization Rate per 1000 resident days (SD) Mean Change (SD) 95% Confidence Interval p value Relative Reduction in All-Cause Hospitalizations Pre intervention During Intervention All INTERACT facilities (N = 25) 3.99 (2.30)3.32 (2.04)- 0.69 (1.47)-0.08 to -1.30 0.02 17% Engaged facilities (N = 17) 4.01 (2.56)3.13 (2.27)- 0.90 (1.28)-0.23 to -1.56 0.01 24% Not engaged facilities (N = 8) 3.96 (1.79)3.71 (1.53)- 0.26 (1.83)-1.79 to 1.27 0.69 6% Comparison facilities (N = 11) 2.69 (2.23)2.61 (1.82)- 0.08 (0.74)- 0.41 to 0.58 0.72 3% Ouslander et al, J Am Geriatr Soc 59:745–753, 2011 Overview of the INTERACT Program

35. Commonwealth Fund Project Results: Implications 1.For a 100-bed NH, the average decrease would result in about 25 fewer hospitalizations per year, or about 2 fewer per month 2.This would result in $125,000 in savings to Medicare Part A using an average hospital DRG payment of $5,000 3.The INTERACT program as implemented in this project cost of about $7,700 per facility 4.Overall, this would result in $117,000 in savings 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 Overview of the INTERACT Program

36. $ Costs HIGH LOW Quality LOW HIGH Medicare Savings $ $ Shared Savings for Providers Improved Quality, Reduced Costs Reduce Unnecessary Hospitalizations Opportunities for You and Your Facility to Benefit from Shared Savings Overview of the INTERACT Program

37. Safe Reduction in Unnecessary Acute Care Transfers Infrastructure (trained staff, lab support) Adequate reimbursement and financial incentives Quality improvement programs Educational resources Clinical practice tools Morbidity Costs Quality What Do You and Your Facility Need to Take Advantage of These Opportunities? Overview of the INTERACT Program

38.  Medline University INTERACT curriculum  The INTERACT website (http://interact2.net)http://interact2.net  Other Resources Overview of the INTERACT Program Educational Resources

39.  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