Session 1d Overview of the INTERACT Program This session is designed for: Administrators Social Workers Therapists (PT, OT, RT) Other Direct Care Staff

Session 1d

Overview of the INTERACT Program

This session is designed for:

•Administrators•Social Workers

•Therapists (PT, OT, RT)•Other Direct Care Staff

The development and evaluation of the INTERACT quality improvement program and curriculum have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation.

The INTERACT Interdisciplinary Team

Joseph Ouslander, MD Florida Atlantic UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversityJill Shutes, GNP Florida Atlantic UniversityNancy Henry, PhD, GNP Florida Atlantic UniversityMaria Rojido, MD Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityLaurie Herndon, MSN, GNP-BC Mass Senior Care FoundationJo Taylor, RN, MPH The Carolinas Center for Medical ExcellenceGerri Lamb, PhD, RN, FAAN Arizona State UniversityAnnie Rahman, PhD, MSW USC Davis School of GerontologyDan Osterweil, MD California Association of Long Term Care MedicineMary Perloe, GNP Georgia Medical Care FoundationJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services

In collaboration with participating nursing homes


Definition and goals of the INTERACT Program

Why it matters to you and your organization

An overview of the INTERACT Program and tools

What This Module Will Cover


(“Interventions to Reduce Acute Care Transfers”)

Is a quality improvement program designed to improve the care of nursing home residents

with acute changes in condition


The INTERACT program includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources

The basic program is located on the internet:

http://interact2.net


Acknowledgement

When using the INTERACT Program and tools, an appropriate acknowledgement should be included, and permission should be obtained to use the INTERACT trademark and copyrighted tools.

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 Center for Medicare and Medicaid Services. The current version of the INTERACT Program was designed by the INTERACT team, with input from many direct care providers and national experts in a project based at Florida Atlantic University and supported by The Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.

The INTERACTTM trademark and copyrighted materials may be used with the permission of Florida Atlantic University, which can be obtained via the “Contact Us” section of the INTERACT website (http://interact2.net )

Permission must be obtained for the use of any aspects of the INTERACT program for profit, or for incorporation of INTERACT tools into an electronic health record.


http://interact2.net/

#5. INTERACT responds to a real problem that is now receiving national and state attention.

Top 5…….Reasons to like INTERACT


The Problem…

Emergency room visits, observation stays hospitalizations, and readmissions of nursing home residents are:

Common

Costly Complicated Often avoidable


Mor et al. Health Affairs 29: 57-64, 2010

1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion


Common and costly….

Video Clip

Patient who suffers a complication during an unnecessary hospitalization


Often Avoidable…

Some hospital transfers, ER visits, observation stays, hospital admissions, and readmissions are rated by expert clinicians as “avoidable”, “preventable”, or “unnecessary”

Studies in which clinical experts have reviewed medical records suggest that between 1/4 and 2/3 of hospitalizations might be unnecessary


Now Receiving National and State Attention…

Financial and regulatory incentives are changing

The INTERACT Program:What is It and Why Does It Matter?Overview of the INTERACT Program

Pay-for-Performance Incentives for improved quality

No payment for certain complications; disincentives for

avoidable hospitalizations

Bundling of payments for episodes of care

Accountable Care Organizations that include

hospitals, physicians, home health agencies, and SNFs that

are responsible for the care of a defined group of patients

Other (e.g. Patient Centered Medical Homes, state programs

for Medicare/Medicaid dually eligible beneficiaries)

Changes in Medicare Financing


Improve quality of care for your residents Share in savings to Medicare by reducing

unnecessary ER visits, observation stays, hospital admissions, and readmissions

Your facility can take advantage of the opportunities in health care reform


Why Does This Matter to You and Your Facility?

The health care reform law also mandates that each facility

have a Quality Assurance and Performance Improvement program (“QAPI”)

The regulation and related surveyor guidance are being written

Improving the management of acute change in condition and reducing unnecessary hospital transfers through the use of INTERACT is one potential focus of your QAPI work

In addition, “Reducing Hospitalizations Safely” is a new goal for the Advancing Excellence in America’s Nursing Homes campaign

(see http://www.nhqualitycampaign.org)


Why Does This Matter to You and Your Facility?

http://www.nhqualitycampaign.org/

# 4: INTERACT can be implemented in any nursing home, drawing on its existing resources.

Top Reasons to like INTERACT…


INTERACT tools:

•are available online at no charge.•are appropriate for use with both long-term and rehab residents.•integrate well with IT programs.•are rapidly becoming the standard of practice in many communities.•can increase referrals to your nursing home.


# 3: INTERACT promotes best practice.

Top reasons to like INTERACT…


1. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition

2. Managing some conditions in the NH without transfer when this is feasible and safe

3. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents

The INTERACT program uses 3 basic strategies:


The goal of INTERACT is to improve care, not to prevent all hospital transfers In fact, INTERACT can help with more rapid

transfer of residents who need hospital care The goal of INTERACT is to improve the

management of residents with a change in condition


Sadie Sara Sam

A Tale of Three Siblings


Hospitalized for UTI and dehydration Discharged back to the NH after 4 days Re-hospitalized 7 days later for

dehydration and recurrent UTI

SadieA 96 year old long-stay NH resident

Preventable?

INTERACT strategy: Prevent conditions from becoming severe enough to require

hospitalization through early detection and evaluation


Hospitalized for a lower respiratory infection, but had normal vital signs and oxygen saturation

Developed delirium in the hospital, fell, fractured her pubis, and developed a pressure ulcer

Sara (Sadie’s younger sister)A 92 year old long-stay NH resident

Preventable?

INTERACT strategy: Manage some conditions in the NH without transfer


Hospitalized for the 4th time in 2 months for aspiration pneumonia related to end-stage Alzheimer’s disease

Transferred to hospice on the day of admission

Sam (Sara and Sadie’s older brother)A 101 year old long-stay NH resident

Preventable?

INTERACT strategy: Improve advance care planning and the use of palliative care

plans when appropriate as an alternative to hospitalization


What are your experiences?

What do you think are the major causes of unnecessary hospitalizations of residents from the facility or facilities that you work in?


# 2: INTERACT is evidence-based and by design, user-friendly and practical to implement.



Originally developed in a project supported by the Center for Medicare and Medicaid Services (CMS)

Revised based on input from staff from several nursing homes and national experts in a project supported by The Commonwealth Fund


Communication Tools

Decision Support Tools

Advance Care Planning Tools

Quality Improvement Tools



Easy to use by design. A case in point:

Stop & Watch: If you have identified an important change while caring for a resident today, please circle the change (from a list of possible changes on the form) and discuss it with the charge nurse before the end of your shift.

The INTERACT II tools are meant to be used together in your daily work in the nursing home

http://interact2.net


Not all staff members will use all INTERACT II tools, but most will use at least some.


Stop & Watch: CNAs, therapists, social workers, nurses, even family members

Care Paths, Acute Change in Condition File Cards: Nurses, physicians

Advance Care Planning Tools: Social workers, nurses, physicians

SBAR: Nurses

Transfer Checklist, Resident Transfer Form: Discharge planners, admissions staff, nurses

QI tools: QA staff, administrators, medical directors

# 1: INTERACT delivers.



30 NHs – 10 in FL, 10 in Mass, 10 in NY On site training (part of one day)

Facility-based champion Phone calls with up to 10 facility champions twice

monthly facilitated by an experienced nurse practitioner

Completion and faxing of Quality Improvement Review tools monthly for 6 months

Evidence of INTERACT Effectiveness: The Commonwealth Fund Grant Collaborative


Ouslander et al, J Am Geriatr Soc 59:745–753, 2011

Commonwealth Fund Project Results

Facilities

Mean Hospitalization Rate per 1000 resident days (SD)

Mean Change (SD)

95% Confidence Interval

p value Relative Reduction in

All-Cause Hospitalizations

Pre intervention

During Intervention

All INTERACT facilities (N = 25) 3.99 (2.30) 3.32 (2.04) - 0.69 (1.47) -0.08 to -1.30 0.02

17%

Engaged facilities (N = 17) 4.01 (2.56) 3.13 (2.27) - 0.90 (1.28) -0.23 to -1.56

0.0124%

Not engaged facilities (N = 8) 3.96 (1.79) 3.71 (1.53) - 0.26 (1.83) -1.79 to 1.27

0.696%

Comparison facilities (N = 11) 2.69 (2.23) 2.61 (1.82) - 0.08 (0.74) - 0.41 to 0.58

0.723%



Commonwealth Fund Project Results: Implications

1. For a 100-bed NH, the average decrease would result in about 25 fewer hospitalizations per year, or about 2 fewer per month

2. This would result in $125,000 in savings to Medicare Part A using an average hospital DRG payment of $5,000

3. The INTERACT program as implemented in this project cost of about $7,700 per facility

4. Overall, this would result in $117,000 in savings per facility per year

Medicare could share these savings to support NHs to further improve care



$ Costs HIGHLOW

Qu

alit

y

LOW

HIGH

Medicare Savings$

$ Shared Savings for

Providers

Improved Quality,Reduced Costs

Reduce UnnecessaryHospitalizations

Opportunities for You and Your Facility to Benefit from Shared Savings


Safe Reduction in Unnecessary Acute Care Transfers

• Infrastructure (trained staff, lab support)

• Adequate reimbursement and financial incentives

• Quality improvement programs

• Educational resources• Clinical practice tools

Morbidity

Costs Quality

What Do You and Your Facility Need to Take Advantage of These Opportunities?


Medline University INTERACT curriculum

The INTERACT website (http://interact2.net)

Other Resources


Educational Resources

http://interact2.net/

Please complete the Quiz and Evaluation If you do not complete them:

You will not receive continuing education credit If your facility is tracking who completes specific

modules, you will not be counted

Quiz and Evaluation


Documents

Session 1d Overview of the INTERACT Program This session is designed for: Administrators Social Workers Therapists (PT, OT, RT) Other Direct Care Staff