Readmissions: Process Improvement using the INTERACT II

Tools

Linda Denison Bub MSN, RN, GCNS-BC

Director of Senior Health Services

SNF Readmissions

Objectives

•Describe nurses role in influencing readmissions

•Explain the INTERACT tool for SNF

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)

SNF Readmission

In one year

nearly 30,000 people in Wisconsin experienced a potentially preventable

readmission

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

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

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%

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

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

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

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

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

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

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

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

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

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.