INTERACT II: Interventions to Reduce Acute Care Transfers

1. INTERACT II: Interventions to Reduce Acute Care Transfers Joseph G. Ouslander, M.D. Professor of Clinical Biomedical Science Associate Dean for Geriatric Programs Charles E. Schmidt College of Biomedical Science Florida Atlantic University Assistant Dean for Geriatric Education University of Miami Miller School of Medicine (UMMSM) at Florida Atlantic University Laurie Herndon, MSN, GNP-BC, ANP-BC Director of Clinical Quality Massachusetts Senior Care Foundation Clinical Instructor University of Massachusetts Graduate School of Nursing Worcester, MA

2. Key Components • Describe the key components of the INTERACT II toolkit • Share “early lessons” from current INTERACT II collaborative project • Provide strategies for immediate implementation of INTERACT II tools at your facility

3. Why this matters… • Mr. DeMayo is an 97 year old long term care resident at your facility. • Pancreatic cancer • Functional decline • No appetite • “Ready to go be with Eleanor” • DNR/DNI

4. Saturday morning wakes up and says he feels lousy. • Stays in bed all day and doesn’t eat • Sunday morning has a fever and has several episodes of vomiting • Appears dehydrated and weak • Son visits and expresses concern for his father. Wonders if “this is the beginning of the end?”

5. Nurse calls covering physician • Reports that son is concerned • Physician says to send this resident to the ED for evaluation

6. What just happened here? • Did he want to go to the hospital? • Did that conversation ever happen? • Was the ED the best place for this resident to be evaluated? • Could his needs have been met in the nursing home? • Could this transfer have been prevented? • How would you know? • Where would you begin?

7. Hospitalizations of NH residents are common • In any six month period, more than 15% of long stay residents are hospitalized • O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable Hospitalizations” Journal of the American Geriatrics Society 52, no. 10(2004): 1730-1736 • Previous research suggests many such hospitalizations are inappropriate and are related to ambulatory care sensitive diagnoses • 45% of admissions of 100 residents from 7 Los Angeles nursing homes to acute hospitals were rated as inappropriate Saliba et al, J Amer Geriatr Soc 48:154-163, 2000

8. Hospitalizations cause morbid complications for NH residents Deconditioning Pressure Ulcers Delirium Injurious Falls Polypharmacy Why this matters…

9. Why this matters… • Unnecessary hospitalizations are expensive • Medicare spent close to $200 million on hospitalizations related to Ambulatory Care Sensitive Diagnoses among long-stay NH residents in New York state in 2004 • This figure does not includeresidents on the Part A skilled benefit, who get hospitalized frequently Grabowski et al, Health Affairs 26: 1753-1761, 2007

10. The Opportunity • Reducing potentially avoidable hospitalizations of NH residents represents an opportunity to: • Decrease emotional trauma to the resident and family • Decrease complications of hospitalization • Reduce overall health care costs

11. Background • CMS Special Study awarded to Georgia Medical Foundation July 2006-Jan 2008 • Looked at characteristics of NHs in Georgia with high and low hospitalization rates • Implemented toolkit in 3 NHs with high hospitalization rates • 50% reduction in hospitalizations • 36% reduction in hospitalizations rated as avoidable

12. INTERACT IIFunded by the Commonwealth Fund • Principal Investigator: Dr. Joseph G Ouslander • Co-Principal Investigator: Dr. Gerri Lamb Independence Foundation and Wesley Woods Chair Associate Professor of Nursing Emory University • Collaborators: Laurie Herndon, MSN, GNP-BC Senior Project Coordinator Alice Bonner, PhD, RN Co-Investigator Massachusetts Department of Public Health (Currently at CMS) Multidisciplinary teams from MA, NY, and FL

13. Methods • Obtain input • National experts • Frontline staff • Refine toolkit • Implement and evaluate refined toolkit • Quality Improvement project • Principals of Institute for Healthcare Improvement (IHI) Collaborative • Champion • Collaborative Calls

14. Methods • Collect data during the Collaborative that will be used to: • Understand factors and strategies that are important for successful implementation and sustained use of the toolkit • Estimate the costs of implementing the toolkit to inform P4P initiatives • Explore incorporating key elements of the toolkit into health information technology (HIT) using web-based formats and/or an electronic health record

15. Massachusetts Sites • Harbor House Nursing and Rehab Center, Hingham • Colonial Nursing and Rehab Center, Weymouth • North End Nursing and Rehab Center, Boston • Knollwood Nursing and Rehab Center, Worcester • Lifecare Center of Auburn • Rosewood Nursing and Rehab, Peabody • Blair House of Tewksbury • Mary Immaculate Nursing and Restorative Center, Lawrence • Beaumont Skilled Nursing and Rehab Center, Westborough • Lifecare Center of Attleboro

16. Working Together to Improve Care, Communication, and Continuity for our Residents

17. Organization of Tools in Toolkit Communication Tools Clinical Care Paths Advance Care Planning Tools

18. Purpose Of Toolkit • Aid in the early identification of a resident change of status • Guide staff through a comprehensive resident assessment when a change has been identified • Improve documentation around resident change in condition • Enhance communication with other health care providers about a resident change of status • Culture Change yields increased oversight

19. Where to keep it Who should use it Different languages “Please fill this out so I am certain not to forget what you just told me”

20. “We use it for EVERYTHING” “Staff are really learning, gathering tools necessary to communicate with the physician” “Organize Your Thoughts Form” THE PHONE CALL

21. “It took two nurses working together 30 minutes to fill this out” “This isn’t so different from what we usually do” “Gets easier with practice” Take old forms off units Now, we don’t hear much at all about this tool on the calls

23. Advance Care Planning Tools

24. “My initial determination was based on the fact that ….if the patient was admitted….I automatically felt is was unavoidable…..but I’ve had a culture change with my thought process”…

25. Leadership “buy in” is important “This is great…we would love to do this at our facility” Census Management Patient Focused Overall Costs Reduced Lessons so far….

26. But… The frontlines are where it happens

27. “I still think there is incredible value to this project and am going to keep working very hard on it” “I tell the staff to go out onto the units and look for transfers waiting to happen” “I am going to elicit an alliance” “I’m seeing it happen…walking on the units and seeing the nurses using the SBAR…it’s great.” The Champion is key

28. Relationships matter • “Our NP told me she couldn’t believe how much the nursing assessments have improved since we started this” • “Does the ED staff know about this project? They keep calling to ask about the forms.” • “The EMT’s wouldn’t sign the envelope” • “Does this mean they will be checking up on me?” • “It’s all about teamwork”

29. Customizing the program • Newsletter • Grand Rounds • Morbidity and Mortality Rounds • NCR paper for Transfer Forms • Tools part of new hire orientation • Scratch cards, free lunch • “Its about more than just the tools. It’s about culture and how you do business”

30. For tomorrow:www.interact2.net • Getting Started • About INTERACT II • How to use the website • What is a champion and why do I need one? • All of the tools with instructions for each

31. www.interact2.net • Implementation • Deciding when and where to start • Tips for training staff • Informing family members about INTERACT II • Improving communication with the hospital • Quality Improvement Review and feedback • Case Studies • How to download the whole toolkit • Feedback

32. Get started even if the circumstances aren’t perfect Don’t let anyone tell you that you won’t survive Know that you’ll have to fix some flats on the road Aim high The Challenge

33. Worcester Galaxy IMPACT

34. Funding of Project • Massachusetts Technology Collaborative, on behalf of Massachusetts e-Health Institute (MeHI), applied to and received from the United States Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (“ONC”), two awards of funding under the American Recovery and Reinvestment Act (“ARRA”).

35. Funding of Project • January 2011, MTC responded to and was awarded funding under ONC’s Funding Opportunity Announcement for the Health Information Exchange Challenge Program in two challenge areas: Theme 2: Improving Long-Term and Post-Acute Care Transitions and Theme 5: Fostering Distributed Population-Level Analytics.

36. Worcester Galaxy IMPACT • IMPACT - Improving Massachusetts Post-Acute Care Transfers • IMPACT Goals: • Enable nursing homes and home health agencies to participate in regional and statewide Health Information Exchange • Improve the speed, efficiency, and satisfaction of processes to provide essential clinical data during transitions of care • Decrease avoidable ER visits, hospital admissions, and hospital readmissions • Reduce unnecessary tests and treatments • Reduce the total cost of care • Replicate this model in other communities

37. IMPACT - Objectives • Build on existing learning collaboratives to help design, implement and disseminate tools • Finish development and testing of Massachusetts Universal Transfer Form • Extend HL7 Continuity of Care Document (CCD) to include all UTF data elements (CCD+)

38. IMPACT – Objectives continued • Develop application to view/edit/send CCD+ • Develop consumer-oriented translator of CCD+ • Pilot tools in Worcester County • Measure outcomes

39. Worcester Galaxy IMPACT • Beaumont Rehabilitation and Skilled Nursing Center, Westborough • Christopher House of Worcester • Fairlawn Rehabilitation Hospital, Worcester • Family Health Center of Worcester • Holy Trinity Nursing & Rehabilitation Center, Worcester • Jewish Healthcare Center, Worcester • Life Care Center of Auburn • Millbury Healthcare Center • Notre Dame Long Term Care Center, Worcester • Overlook Visiting Nurses Association • Radius Healthcare Center Worcester • Reliant Medical Group (formerly known as Fallon Clinic), Worcester • Saint Vincent Hospital, Worcester • UMass Memorial Health Care, Worcester • VNA Care Network and Hospice, Worcester

40. Worcester Galaxy IMPACT • These 15 healthcare organizations will first pilot and validate a paper Universal Transfer Form over the next four months, followed by the electronic version of the form next year. Developed by the Massachusetts Department of Public Health, the Universal Transfer Form is critical to ensure that patients receive safer, more efficient and a higher quality of health care when making the transition between acute care and post-acute care settings. The form is critical to ensure that patients receive safer, more efficient and a higher quality of health care when making the transition between acute care and post-acute care settings.

41. I-LAND AND SEE

43. I-LAND AND SEE • Internet based Local Application for Network Distribution • Surrogate EHR Environment

44. Worcester Galaxy IMPACT • Transitions in Care Collaborative was chosen to participate in the federal government’s "Community Based Care Transitions Program” under Section 3026 of the Affordable Care Act.

45. Accountable Care Organization • Atrius Health • Beth Israel Deaconess Physician Organization • Mount Auburn Cambridge Independent Practice Association • Eastern Maine Healthcare System • Dartmouth-Hitchcock ACO.

46. ….. proponents say, such systems provide financial incentives for health care providers to give better care at lower cost by improving communication between specialists and primary care doctors, reducing unnecessary tests, and focusing on preventive care.

47. Paul J. O’Connell • poconnell@salmonhealth.com • 508-898-3490 ext. 3708