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INTERACT II: Interventions to Reduce Acute Care Transfers


Associate Dean for Geriatric ... % of long stay residents are ... Decrease complications of hospitalization Reduce overall health care costs Background CMS ... – PowerPoint PPT presentation

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Title: INTERACT II: Interventions to Reduce Acute Care Transfers

INTERACT II Interventions to Reduce Acute Care
  • 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

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

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

  • Saturday morning wakes up and says he feels
  • Stays in bed all day and doesnt 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?

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

  • 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
  • Could his needs have been met in the nursing
  • Could this transfer have been prevented?
  • How would you know?
  • Where would you begin?

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
    48154-163, 2000

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

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 include residents on the
    Part A skilled benefit, who get hospitalized
  • Grabowski et al, Health Affairs 26 1753-1761,

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

  • 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

INTERACT II Funded 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

  • 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

  • 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

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,
  • Beaumont Skilled Nursing and Rehab Center,
  • Lifecare Center of Attleboro

Working Together to Improve Care, Communication,
and Continuity for our Residents
Organization of Tools in Toolkit
  • Communication Tools

Clinical Care Paths
Advance Care Planning Tools
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
  • Enhance communication with other health care
    providers about a resident change of status
  • Culture Change yields increased oversight

  • 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

  • We use it for EVERYTHING
  • Staff are really learning, gathering tools
    necessary to communicate with the physician
  • Organize Your Thoughts Form

  • It took two nurses working together 30 minutes
    to fill this out
  • This isnt so different from what we usually do
  • Gets easier with practice
  • Take old forms off units
  • Now, we dont hear much at all about this tool on
    the calls

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Advance Care Planning Tools
Identifying Residents to Consider for Palliative Care and Hospice Pocket Card
Advance Care Planning Communication Guide File Cards
Comfort Care Order Set File Cards
Educational Information for Families Reprints
My initial determination was based on the fact
that .if the patient was admitted.I
automatically felt is was unavoidable..but Ive
had a culture change with my thought process
Lessons so far.
  • Leadership buy in is important
  • This is greatwe would love to do this at our
  • Census Management
  • Patient Focused
  • Overall Costs Reduced

  • The frontlines are where it happens

The Champion is key
  • I still think there is incredible value to this
    project and am going to keep working very hard on
  • I tell the staff to go out onto the units and
    look for transfers waiting to happen
  • I am going to elicit an alliance
  • Im seeing it happenwalking on the units and
    seeing the nurses using the SBARits great.

Relationships matter
  • Our NP told me she couldnt 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 EMTs wouldnt sign the envelope
  • Does this mean they will be checking up on me?
  • Its all about teamwork

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. Its about
    culture and how you do business

For tomorrow
  • Getting Started
  • How to use the website
  • What is a champion and why do I need one?
  • All of the tools with instructions for each

  • 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

The Challenge
  • Get started even if the circumstances arent
  • Dont let anyone tell you that you wont survive
  • Know that youll have to fix some flats on the
  • Aim high

Worcester Galaxy IMPACT
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).

Funding of Project
  • January 2011, MTC responded to and was awarded
    funding under ONCs 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.

Worcester Galaxy IMPACT
  • IMPACT - Improving Massachusetts Post-Acute Care
  • 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

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)

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

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,
  • 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

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.

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  • Internet based Local Application for Network
  • Surrogate EHR Environment

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

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

  • .. 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.

Paul J. OConnell
  • 508-898-3490 ext. 3708