The INTERACT Quality Improvement Program

1. The INTERACT Quality Improvement Program A Practical Approach To Safely Reducing Rehospitalizations Laurie Herndon, MSN, GNP-BC Director of Clinical Quality Massachusetts Senior Care Foundation lherndon@maseniorcare.org This handout is intended for use by this audience only. Please do not distribute.

2. 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 Centers for Medicare & Medicaid Services (CMS). • The current version of the INTERACT Program was developed by members of the INTERACT interdisciplinary team under the leadership of Dr. Joseph G. Ouslander, M.D. with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.

3. Objectives • Discuss background of INTERACT program • Provide brief overview of tools • Discuss how INTERACT can be used as a platform for building and working with your cross continuum team

4. What is INTERACT?

5. What is INTERACT? • INTERACT: Interventions to Reduce Acute Care Transfers • A Quality Improvement Program

6. INTERACT 3.0 • January 2013 • National Expert Review • All tools revised/reformatted • New tools added • Care paths • Electronic data tracking • Implementation Checklist • Tools for acute care

7. INTERACT Purpose and Design Purpose: • Improve care • Reduce the frequency of potentially avoidable acute care transfers of nursing home residents Design • Improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. • Target is avoidable transfers, NOT to prevent all transfers

8. Background: Why Focus on Rehospitalizations? 1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion Rehospitalizations Of SNF Residents Is Common and Costly Source: Vincent Mor, et al. (2010) Medicare SNF Rehospitalizations: Implications for Medicare Payment Reform, Health Affairs

9. Background:Many Are Avoidable Subjects: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States (2006–2008). Results: Three fifths of hospitalizations were potentially avoidable and the majority was for infections, injuries, and congestive heart failure. Medical Care: August 2013 - Volume 51 - Issue 8 - p 673-681 doi: 10.1097/MLR.0b013e3182984bff

10. We Are All In This Together The Bottom Line “Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them” A. E. Boutwell, M. B. Johnson, P. Rutherford et al., "An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions," Health Affairs, July 2011 30(7):1272–80

11. Using INTERACT As A Starting Point

12. Quality Improvement Tools Communication Tools Decision Support Tools Organization of Tools www.interact2.net Advance Care Planning Tools

13. Quality Improvement Tools Numbers Stories

14. Disclaimer Screen Shots of Tools

15. Quality Improvement Tools

16. Quality Improvement Tools • How many transfers from your hospital or nursing home (for home health)? • When do they occur? • How many days since admit? • “Ah ha” moments • Online version

17. Quality Improvement Tools Root Cause Analysis: The Rest of the Story • Demographics • What happened • Contributing factors • Attempts to manage in SNF • Avoidable? • Staff thoughts about this • Opportunities for improvement • Cross continuum review of cases

18. Communication Tools Enhanced Nursing Assessment • Builds on early recognition • Standard approach • MD/NP response • Warm hand over • How might this compliment disease management?

19. Communication Tools • Communication Tools Across Settings • Nursing Home Capabilities Checklist • Medication Reconciliation Worksheet • Transfer forms both directions • Data lists both directions • Can use as platform to start discussion about which elements nurses will use for warm hand off

20. Communication Tools: Not About The Forms Returned Unopened Poor Communication=Poor Outcomes

21. Decision Support Tools

22. Decision Support Tools

23. Lessons Learned About Implementation

24. Lessons Learned About Implementation “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’m seeing it happen…walking on the units and seeing the nurses using the SBAR…it’s great.”

25. Lessons Learned About Implementation • For the SNF: one unit • For the hospital: one SNF • For HH/AL: one case • For surveyors: one conversation • For all: one CC meeting

26. Lessons Learned About Implementation Within Your Setting Across Settings

27. Lessons Learned About Implementation

28. Lessons Learned About Implementation: Simplicity Works

29. Lessons Learned About Implementation: IT CAN BE DONE

30. Most Important Lesson About Implementation

31. Building Evidence CMS Pilot Study Results • Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates • Tools were acceptable to staff • Significant reduction in hospitalizations • Significant reduction in transfers rated as avoidable by an expert panel Ouslander et al: J Amer Med Dir Assoc 9: 644-652, 2009

32. Building Evidence Implementation Model in the Commonwealth Fund Grant Collaborative • On site training (part of one day) • Facility-based champion • Collaborative phone calls with up to 10 facility champions twice monthly facilitated by an experienced nurse practitioner • Availability for telephone and email consults • Completion and faxing of QI Review Tools

33. Building Evidence Commonwealth Fund Project Results Ouslander et al, J Am Geriatr Soc 59:745–753, 2011

34. Building Evidence

35. Lessons Learned: Big Picture What Is Driving This Change?

36. Lessons Learned: Big Picture • The Future Is Now! • ACO language includes INTERACT • Hospital Engagement Networks

37. Now Available: Assisted Living and Home Health www.interact2.net

38. Interacting with Acute Care Hospitals The Important Role of Your Facility Team Facility Leaders: Improving Relationships Frontline Staff: Improving Quality of Care

39. Interacting with Acute Care Hospitals Facility Leaders • Be prepared • Initiate contact • Know your data • Share your story • Know what tools/data/information you want to share • Set date for next meeting

40. Interacting with Acute Care Hospitals “Are you guys doing anything to educate hospitals about what INTERACT is? The local ACO leader, who is a friend of mine is requiring us to use INTERACT but has no idea what INTERACT is” Executive Director, A Massachusetts SNF

41. Interacting with Acute Care Hospitals • Lots of interest in this form • Bring it with you • Offer to update regularly • Be sure you can do what you say you can

42. Interacting with Acute Care Hospitals The Role of the Frontline Staff in Improving Quality of Care (and how these day to day improvements can impact the bigger picture/relationship)

43. Interacting with Acute Care Hospitals • Frontline tools • Transfer Form • Transfer Checklist • SBAR • They need to be filled out completely • They need to be used consistently • You need to get to the hospital before the forms

44. Interacting with Acute Care Hospitals Improving Quality: • When used as intended, these forms provide a comprehensive history about the resident when they are transferred to the hospital. • Providers have information necessary to determine the most appropriate plan in the most appropriate setting

45. Interacting with Acute Care Hospitals “It is not about the forms: It is about the relationship” • Enhancing the relationship by using the Warm Hand Over

46. Interacting with Acute Care Hospitals The Warm Hand Over • What is it? • Who does it? • How do you do it? • Why hasn’t this been easier? • Why isn’t everybody doing it?

47. Interacting with Acute Care Hospitals The Warm Hand Over • The SNF community has the chance to take the lead • Tools to consider • SBAR • Transfer Form • Data Lists • Best option • The Power of One

48. Interacting with Acute Care Hospitals • The Warm Hand Over • The Power of One • One SNF nurse • One hospital nurse • One meeting • One trial • How did it go? • Modify • Try again • Spread • Cross Continuum Meeting • Frontline work intersects with work of leadership= improved care Results Are Shared

49. Interacting with Acute Care Hospitals In Summary: • The future is now. Payment reform is driving change. • Acute care hospitals are very interested in what is going on with SNFs and are asking about INTERACT • Use your work with INTERACT to inform your local hospitals and to help develop a dynamic working relationship

50. Interacting with Acute Care Hospitals In Summary: “It’s not about the forms, it’s about the relationships” INTERACT Champion