1. Readmissions: Process Improvement using the INTERACT II Tools Linda Denison Bub MSN, RN, GCNS-BC Director of Senior Health Services

2. SNF Readmissions Objectives Describe nurses role in influencing readmissions Explain the INTERACT tool for SNF

3. SNF Readmissions Why is this important? Unplanned/unnecessary re-hospitalizations are prevalent and costly (Jencks et al, 2009) Medicare: 20% in 30 days; 34% in 90 days 50.2% had no bill for MD visit between index admission and readmission LOS for second stay is longer About 10% of readmissions are planned Cost to Medicare = $17.4 billion (2004)

4. SNF Readmission In one year nearly 30,000 people in Wisconsin experienced a potentially preventable readmission

5. National Admissions per 1000 Beneficiaries 1/2011-12/2011

6. National el Readmissions per 1000 Beneficiaries 1/2011-12/2011

7. SNF Readmissions Wisconsin DC Dispositions Self Care 52% Skilled Nursing Facility 22.7% Home Health Care 10% Inpatient Rehab Facility (IRF) 2.4% Other Hospital 2.2% Intermediate Care Facility (ICF) 2%

8. SNF Readmissions Retrospective study on rehospitalization rates, diagnoses and DC location for 75+yo between 7-30 days post DC (Hain, 2012) 6809 patients 12% re-hospitalization rate SNF 15% HH 13% Home 8% Conclusion: Nursing has a significant impact on re-hospitalization rates

9. SNF Readmissions SNF 30 day readmissions (Ouslander 2011) 2007-2008 Medicare FFS beneficiaries 75yo+ 30% DC to SNF 18% Readmitted with 30 days Of the readmissions, 1/3 readmitted in 7 days Index admission with highest readmissions GU (30%) CV (25%) Readmission reasons HF, UTI, Renal Failure, Pnuemonia/COPD

10. Nursing Impact on SNF Readmissions Acuity of SNF is increasing with SAR transfers Nursing can impact transitions through education, protocols and collaboration INTERACT II designed as a quality improvement intervention for SNF/LTC reduce readmissions improve care and outcomes

11. INTERACT II "Interventions to Reduce Acute Care Transfers“ (Ouslander 2011) 25 SNF in 3 states over 6 months Provided Tools (protocols) On site education for staff Teleconference every 2 weeks Facilitated by an NP

15. INTERACT II INTERACT II impact (Ouslander 2011) 17% reduction in readmissions Fully engaged SNFs; 24% reduction Not engaged SNFs 6% Comparison group 3% Cost savings $7700 Projected Medicare savings $125,000

16. WFH journey Initial work October 2011 General look at readmissions Began identifying trends Develop action plans (December) January 2012 Created word document for QI tool Nurses responsible for filling out within 24 hours

17. WFH Journey February 2011 Developed a goal for each facility (10% reduction from previous year average) April 2011 First cross sight communication June 2011 CNA and RN education on early warning signs of CHF August/September 2012 Collaborative meetings with other health systems

18. WFH Journey Continued work Identify true evaluation of readmissions Focus on Palliative Care education for all staff Quarterly reporting of readmissions to system workgroups Continued communication across settings and health systems Participation in Dr Ouslander NIH study of phase two INTERACT

19. Lessons Learned Need a champion to promote work and continue enthusiasm Include staff from beginning Make work meaningful, how will this impact residents This is where care is going, leave comfort zone Get involved in local, state and national projects

20. References Hain, D.J., Tappen, R., Diaz, S.,Ouslander, J.G. (2012). Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implications for nursing practice. Journal of Gerontological Nursing:38(8):32-44. Jencks, S.F., Williams, M.V., Coleman,E.A. (2009) Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine; 360:1418-1428 Ouslander, J.G., Diaz S., Hain, D., Tappen R. (2011). Frequency and Diagnoses Associated With 7- and 30-Day Readmission of Skilled Nursing Facility Patients to a Nonteaching Community Hospital. Journal of the American Medical Director Association: 12 (3): 195-203. Ouslander, J.G., Lamb, G., Tappen, R., Herndon L., Diaz S., Roos B., Grabowski D., Bonner A. (2011). Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. Journal of the American Geriatrics Society: 59(4): 745-753.