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INTERACT 3.0

"Interventions to

Reduce Acute Care Transfers" ®

1. Understand INTERACT as an evidence-based tool designed to Reduce Acute Care Transfers

2. Understand how INTERACT will improve your daily goal of safety and resident centered care

Objectives

3. Describe and understand how to put the INTERACT tools to use in every day practice

4. Describe and understand how to deploy INTERACT in your nursing home

5. Gain insight from fellow professionals about the benefits and barriers of the implementation of INTERACT

The Opportunity for Improvement

The national average readmission rate has remained steady at slightly above

19% for several years19% for several years

Kaiser Health News, August 13, 2012/ Analysis of CMS Data

www.kaiserhealthnews.org/stories/2012/medicare-hospitals-readmissions-penalities

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Reduce …- hospital re-admissions by 20%- avoidable admissions from skilled nursing

National Priority

facilities by 15%- improve patient safety outcomes

Period: Present - July 2014

What is INTERACT

A quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status

INTERACT

Include evidence and expert-recommended clinical practice tools, implementation strategies, and related educational resources

http://interact2.net2011 Florida Atlantic University

History

INTERACT Program

Originally developed in 2006 by Joseph Ouslander MD p

Studied 200 hospitalizations from 20 nursing homes

Found that 2/3 of hospitalizations were potentially avoidable

LeadingAgeMedline May, 2013

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Influencers

Availability of medical staff Skill level of staff Diagnostic / pharmacy services Preferences Legal & regulatory concerns Advance care planning Financing misalignmentsLeadingAgeMedline May, 2013

The Data

Avoidable Hospitalizations

• 45% of hospitalizations among beneficiaries receiving Medicare SNF services or Medicaid NF services are potentially avoidable

• Combined Medicare and Medicaid costs for these 314,000 potentially avoidable hospital admissions total $2.7 billion per year, and Medicare costs account for $2.6 billion of that total

Walsh, Freiman, Haber, Bragg, Ouslander, & Wiener, 2010

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Five conditions responsible for 78% of the potentially avoidable hospitalizations:

1. Pneumonia

Avoidable Hospitalizations

1. Pneumonia 2. Congestive heart failure 3. Urinary tract infection4. Dehydration5. COPD/ Asthma

Walsh, Freiman, Haber, Bragg, Ouslander, & Wiener, 2010

Avoidable Hospitalizations SNF

One in 4 Medicare beneficiaries admitted to a SNF are re-admitted to hospital within 30 days at a cost of 4.3 billion

Up to 2/3 of hospital transfers are rated as Up to 2/3 of hospital transfers are rated as potentially avoidable by expert LTC health professionals

Financial incentives through pay-for-performance, bundled payments and other strategies

Mor et al. Health Affairs Medline May, 2013

Improvement

INTERACT can help you IMPROVE CAREand prepare for changes in Medicare

REIMBURSEMENTREIMBURSEMENT

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INTERACT

What is the Purpose of INTERACT

Goal: Reduce frequency of potentially avoidable transfers to the acute hospitalp

Early identificationEarly assessment Improve documentation Improve communication

INTERACT Tools

Management of acute care changes in resident condition through the use of

clinical and educational tools and clinical and educational tools and strategies for use in every day practice

in long-term care facilities

Facility Sharing

Robin Bradford RNC MSN NHARobin Bradford, RNC, MSN, NHAHighlands Health & Rehab

Scottsboro, Alabama

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INTERACT

Quality Improvement Tools

Communication Tools

Overview of the INTERACT Tools

Communication Tools

Decision Support Tools

Advance Care Planning Tools

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 CMS

• The current version of the INTERACT Program was developed by members of the INTERACT Team with input from many direct care providers and national experts in projects based at Florida Atlantic University supported by The Commonwealth Fund

INTERACT Goal

• Improve Care

• Not prevent all hospital transfers

• Be used in everyday care in the nursing home

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Promising Interventions

Communication

CNAs are busy giving direct care

Unit managers are busy giving busy giving medications, taking physician orders, and admitting new residents

Stop and Watch

Stop and Watch Role Play

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Stop and Watch

• To guide direct care staff through a brief review of early changes in resident’s condition.

• To improve communication between frontline staff and the nurse in charge about early changes in condition.

Stop and Watch

Who can use it?• CNAs• Therapist• Dietary• Housekeeping• Housekeeping• Activities• Laundry• Maintenance• Business Office• Family/Friends• Anyone with direct resident contact on a regular

basis

Stop and Watch

Changes?

• Actions or behaviors that are not part of their normal routine

• Change from baselineg

• Changes in mental status

• Changes in physical status

• Changes in function

• Changes in behavior

• Changes in pain level

When in doubt, Fill it out!

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Stop and Watch

STOP

• Seems different than usual• Talks or communicates less• Talks or communicates less• Overall needs more help• Pain level new or worsening• Participated less in activities

Stop and Watch

AND

• Ate less• No bowel movement• Drank less

Stop and Watch

WATCH

• Weight change

A it t d th l• Agitated or nervous more than usual

• Tired, weak, confused, or drowsy

• Change in skin color or condition

• Help with walking, transferring, toileting more than usual

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Case Example

• CNA notices Ms. Jones is not eating like she usually does. She has chicken and dumplings, her favorite, and she hardly took a bite.

• Housekeeping notices Mr. Smith has been in his room everyday for the last few days when they clean it at 2pm. He usually always goes to Bingo at this time.

• The physical therapy assistant notices Mrs. Bradford is requiring 2 people for transfers. She usually only has to have 1 person stand by.

• The son comes to visit his dad and notices not only is his short term memory worse, he is having difficulty with his long term memory.

Barriers to Success

• Inconsistent assignment/turnover

• Unit nurse with insufficient resident knowledge

• Broken relationships and communication betweenBroken relationships and communication between nurse and CNA

• Resistance to change –verbal method of communication

Close the Loop

• “Thanks Sally. When you noticed Ms. J not eating well, we assessed her further and found she had a UTI. By catching it early, we were able to treat her here and kept her from being sent to the hospital.”

• “Jane, thanks for filling out the Stop and Watch. We were , g pable to notify the physician and do some lab work and have changed his meds.”

• “Mrs. Bradford’s blood pressure meds had been changed and were too strong for her. Thanks for letting us know about her change.”

• “Thanks for letting us know about your concerns for your dad. We did some lab work and the physician is starting him on some new medications.”

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Case Study

• Sadie Jones is an 81 year-old retired schoolteacher admitted to the hospital from home with pneumonia. Past medical history includes COPD, CHF, and Osteoarthritis. She admitted to your facility with plans to return home after rehab.

• CNA notes she isn’t herself early that morning.

• She is somewhat irritable, not interested in breakfast and doesn’t want to go to therapy.

• She tells the CNA she is having trouble breathing.

• Finished her last dose of Levofloxacin yesterday.

• CXR shows persistent left lower lobe infiltrate and hyperinflation of both lungs consistent with COPD

• BP 130/70 HR 90 RR 22 Temp 100.5

Change in Condition File Cards and Care Paths

• Change in Condition File Cards

– Based on AMDA Clinical Practice Guideline

– Meant to be used to reference when to notify a physician

• Care Paths

– Provide guidance on when to notify the MD/NP/PA

– Suggest evaluation strategies

– Provide recommendations for management and monitoring in the facility

– Educational tool

Case Study

• Sadie Jones is an 81 year-old retired schoolteacher admitted to the hospital from home with pneumonia. Past medical history includes COPD, CHF, and Osteoarthritis. She admitted to your facility with plans to return home after rehab.

• CNA notes she isn’t herself early that morning.

• She is somewhat irritable, not interested in breakfast and doesn’t want to go to therapy.

• She tells the CNA she is having trouble breathing.

• Finished her last dose of Levofloxacin yesterday.

• CXR shows persistent left lower lobe infiltrate and hyperinflation of both lungs consistent with COPD

• BP 130/70 HR 90 RR 22 Temp 100.5

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SBAR

Purpose of the SBAR

• Improve communication

• Consistent language• Consistent language

• Standardized criteria

• Clear guidelines

• Communication that is efficient

• Communication that is effective

SBAR

Review SBAR

• Before calling

Sit ti• Situation

• Background

• Assessment

• Request

SBAR

SBAR Role Play

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SBAR

• Sadie Jones is an 81 year-old retired schoolteacher admitted to the hospital from home with pneumonia. Past medical history includes COPD, CHF, and Osteoarthritis. She admitted to your facility with plans to return home after rehab.

• CNA notes she isn’t herself early that morning.

• She is somewhat irritable, not interested in breakfast and doesn’t want to go to therapy.

• She tells the CNA she is having trouble breathing.

• Finished her last dose of Levofloxacin yesterday.

• CXR shows persistent left lower lobe infiltrate and hyperinflation of both lungs consistent with COPD

• BP 130/70 HR 90 RR 22 Temp 100.5

Discussion

Questions/comments you may have• “This is going to take so long!”

– Time it– Avoid redundancy

• “What about the “A” section?”• What about the A section?– Does not ask for a diagnosis– DOES capitalize on staff knowledge– DOES capture unique knowledge staff may have

about history• “Do I have to use it for everything?”

– No– Used for change in condition

Nursing Home Capabilities List

• Used to let physicians, nurse practitioners, emergency rooms, hospitals, and case manager know what your facility can take care of, or what services you provide

• Aides in the decision making of if a resident can be managed in your facility or if they need to be hospitalized

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Acute Care Transfer Log

• Paper and Pencil tool for tracking transfers

• Not necessary if you are using the INTERACT Hospitalization Rate Tracking Tool INTERACT Hospitalization Rate Tracking Tool or Advancing Excellence Campaign Hospitalization Tracking Tool

• Maybe helpful when you start to summarize and use as a worksheet

Quality Improvement Tool for Review of Acute Care Transfers

• Tool to help analyze hospital transfers

• Helps identify opportunities to reduce transfers that are preventable

H l t l t t l i• Helps team complete a root cause analysis

• Helps identify common reasons for transfers

• Helps team focus on educational and care process improvement activities

Quality Improvement Tool for Review of Acute Care Transfers

Section 1

• Describe Resident Characteristics

• Some diagnoses are more prone for transfers (CHF, COPD, etc)

• Some residents have a tendency to have frequent readmissions

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Quality Improvement Tool for Review of Acute Care Transfers

Section 2

• Describe the acute change in condition and other non-clinical factors that contributed to the transfer

• When did the change first occur?• Describe the change• Was it due to a change or a new sign or

symptom, abnormal lab work?• Did the family or physician want the

transfer?

Quality Improvement Tool for Review of Acute Care Transfers

Section 3

• Describe action(s) taken to evaluate and manage the change in condition prior to manage the change in condition prior to transfer

• What tools did you use?• Was the resident evaluated medically?• Did we do tests?• Did we have interventions?• Did we review Advance Directives?

Quality Improvement Tool for Review of Acute Care Transfers

Section 4

• Describe the hospital transferD t d ti• Date and time

• Who ordered the transfer?• What was the outcome?• Hospital diagnosis

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Quality Improvement Tool for Review of Acute Care Transfers

Section 5

• Identify opportunities for improvementDi i f t if t bl h t • Discussion for team on if preventable, what could we have done differently

• Reasons-communication, resources, preferences, advance directives

Hospitalization Tracking Tool

Campaign Website:

www.nhqualitycampaign.org

www.nhqualitycampaign.org

Supporting Data

Advancing Excellencein America’s Nursing Homes

30 Day Readmission Rates Graph

www.nhqualitycampaign.org

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Decisions for Facility

• Who is the Champion?• Where to keep the tools?• Who do you give the Stop & Watch to after

l i ?completion?• Who completes the Care Paths / SBAR?• Who closes the loop?

Panel Discussion

Learn how INTERACT can help improve care and prepare for Medicare financial incentives and prepare for Medicare financial incentives

to reduce potentially avoidable hospital transfers

There are no problems we cannot solve together, and

very few that we can solve by ourselves.

Lyndon Johnson

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THANK YOU!

This material was prepared by AQAF, the Medicare Quality Improvement Organization for Alabama, under a contract

with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents do not necessarily reflect CMS policy.

10SOW-AL- C7-13-78

Alabama Quality Assurance Foundation

Birmingham, Alabama

205-970-1600