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© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
Joseph Ouslander, MD Florida Atlantic University
Ruth Tappen, EdD, RN, FAAN Florida Atlantic University
Jill Shutes, GNP Florida Atlantic University
Nancy Henry, PhD, GNP Florida Atlantic University
Michelle Duhaney, DO Florida Atlantic University
Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation
Gerri Lamb, PhD, RN, FAAN Arizona State University
Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence
© Florida Atlantic University 2011
In collaboration with participating nursing homes
The INTERACT Program:What is It and Why Does It Matter?
The INTERACT Interdisciplinary TeamJoseph Ouslander, MD Florida Atlantic UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversityJill Shutes, GNP Florida Atlantic UniversityNancy Henry, PhD, GNP Florida Atlantic UniversityMichelle Duhaney, DO 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 MedicineAmy E. Boutwell, MD, MPP Collaborative Healthcare Strategies Mary Perloe, GNP Georgia Medical Care FoundationJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services
© Florida Atlantic University 2011
College of Medicine College of Nursing
New Dorms
NewFOOTBALL STADIUM
The INTERACT Program:Background and Why it Matters
© Florida Atlantic University 2011
1. Discuss key health policy issues related to the future of nursing home care
2. Provide a broad overview of the INTERACT quality improvement program and how it fits with health care reform initiatives
3. Highlight future directions for INTERACT
4. Discuss key concepts for eINTERACT
Objectives of this Presentation
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The Affordable Care Act is focused on a “triple aim”:
1. Improving care2. Improving health3. Making care affordable
This presents major opportunities to improve geriatric care in the U.S.
Health Care Reform
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Financial incentives in the Medicare fee-for-service program incentivize overuse of diagnostic tests and procedures that do not benefit many elderly people, and can result in morbidity and costs
By far, the most costly example in the geriatric population is potentially preventable hospitalizations
Medicare Fee-for-Service
Willie SuttonFBI Ten Most Wanted Fugitives
Born/Died 1901 -1980
Charges Bank robbery
Caught February 1952
During his forty year criminal career he stole an estimated $2 million, and eventually spent more than half his adult life in prison.
The INTERACT Program:Background and Why it Matters
© Florida Atlantic University 2011
1. Accelerate Reduction in Harm to Patients in Hospitals Achieve a 40% reduction in preventable harm by 2013 ~ 1.8 million fewer injuries to patients; ~ 60 000 lives saved;
~ $20 billion in health care costs avoided
2. Decrease Preventable Hospital Readmissions Within 30 Days of Discharge
Reduce readmissions by 20% by 2013 ~1.6 million hospital readmissions prevented and ~ $15 billion
in health care costs avoided
The U.S. Department of Health and Human Services “Partnership for Patients”
http://www.healthcare.gov/center/programs/partnership
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Pay-for-Performance (“P4P”) 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
Changes in Medicare Financing
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
1. Hospital transfers are common and often result in complications in older NH residents
2. Some hospital transfers are preventable
3. Care can be improved, resulting in fewer complications and reduced cost
4. Cost savings to Medicare can be shared with NHs to further improve care
5. Financial and regulatory incentives are changing
Why Does This Matter?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011Mor 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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Hospitalization
At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning,
pressure ulcers
At the beauty salon
The INTERACT Program:What is It and Why Does It Matter?
Why Does This Matter?
© Florida Atlantic University 2011
• As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate
Saliba et al, J Amer Geriatr Soc
48:154-163, 2000
• In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnoses”
Grabowski et al, Health Affairs
26: 1753-1761, 2007
U .S . H e a lth c a re S y s te mU .S . H e a lth c a re S y s te m
T r a n q u il Ga r d e n sN u r s in g H o m e
H o m eC a re
A c u te C a r eF a c ilit y
O u tp a t ie n t /A m b u la to r y
F a c ilit y
L o n g T e rm C a r eF a c ilit y
Some Hospitalizations of NH Residents are Avoidable
The INTERACT Program:Background and Why it Matters
© Florida Atlantic University 2011
Was the Hospitalization Avoidable?
Definitely/Probably YES
Definitely/Probably NO
Medicare A 69% 31%
Other 65% 35%
HIGH Hospitalization Rate Homes
75% 25%
LOWHospitalization Rate Homes
59% 41%
TOTAL 68% 32%
CMS Special Study in Georgia – Expert Ratings of Potentially Avoidable Hospitalizations
Ouslander et al: J Amer Ger Soc 58: 627-635, 2010
Based review of 200 hospitalizations from 20 NHs
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The INTERACT Program:Background and Why it Matters
CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries
© Florida Atlantic University 2011
$ Costs HIGHLOW
Qu
alit
y
LOW
HIGH
Costs Avoided$
$ Incentives for Providers
Improved Quality,Reduced Costs
Reduced AvoidableHospitalizations
Opportunities for You and Your Facility
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012.
(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021
512_2.pdf
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize
Risk adjustment is very complicated
Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012.
(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021
512_2.pdf
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
Opportunities for You and Your Facility
The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”)
The regulation and related surveyor guidance are being written
Improving management of acute change in condition and reducing unnecessary hospital transfers is one potential focus of your QAPI
© Florida Atlantic University 2011
Safe Reduction in Unnecessary Acute Care Transfers
Infrastructure
Incentives
QI Programs
Tools
Morbidity
Costs Quality
What Do You and Your Facility Need to Take Advantage of These Opportunities?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
(“Interventions to Reduce Acute Care Transfers”)
The INTERACT Program:What is It and Why Does It Matter?
Is a quality improvement program designed to improve the care of nursing home residents
with acute changes in condition
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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 Center for Medicare and Medicaid Services.
The current version of the INTERACT Program, including the INTERACT II Tools, educational materials, and implementation strategies were developed by Drs. Ouslander, Gerri Lamb, Alice Bonner, and Ruth Tappen, and Ms. Laurie Herndon with input from many direct care providers and national experts in a project based at Florida Atlantic University 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.
Some materials herein are © Florida Atlantic University 2011. Such materials and the trademark INTERACTTM may be used with the permission of Florida Atlantic University.
Permission can be granted by Dr. Ouslander ([email protected])
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
“BOOST”(Better Outcomes for Older Adults
Through Safe Transitions)http://www.hospitalmedicine.org
“Project RED”(Re-Engineered Discharge)
https://www.bu.edu/fammed/projectred
•Enhanced hospital discharge planning
“Care Transition Program”http://www.caretransitions.org
•Transition coach•Trained volunteers•Empowered patients and caregivers
“POLST” (or “MOLST”)(Physician (or Medical) OrdersFor life Sustaining Treatment)
http://www.ohsu.edu/polst
•Advance care planning
“Bridge Model”http://www.transitionalcare.org/the-bridge-model
•Social Worker coordinating Aging Resource Center Services at hospital discharge
“Transitional Care Model”http://www.transitionalcare.info/index.html
•APN coordinates care during and after discharge•Home, SNF, and clinic visits
“INTERACT”(Interventions to Reduce
Acute Care Transfers)http://interact2.net
•Communication Tools, Care Paths, Advance Care Planning Tools, and QI tools for nursing homes and SNFs
High Quality Care Transitions for
Older Adults &Caregivers
High Quality Care Transitions for
Older Adults &Caregivers
INTERACT is One of Several Evidence-Based Care Transitions Interventions
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
HALTUnnecessary
Hospital Stays
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
Can help your facility safely reduce hospital transfers by:
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Sadie Sara Sam
A Tale of Three Siblings
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
Avoidable?
INTERACT strategy: Prevent conditions from becoming severe enough to require
hospitalization through early detection and evaluation
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
Avoidable?
INTERACT strategy: Manage some conditions in the NH without transfer
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
Avoidable?
INTERACT strategy: Improve advance care planning and the use of palliative care
plans when appropriate as an alternative to hospitalization
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
1. Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates
2. Tools were acceptable to staff3. Significant reduction in hospitalizations 4. Significant reduction in transfers rated as
avoidable by an expert panel
CMS Pilot Study Results
Ouslander et al: J Amer Med Dir Assoc 9: 644-652, 2009
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The program and tools were revised based on CMS pilot study, and input from front-line NH staff and national experts
The revised program and INTERACT II Tools are available at: http://interact2.net
The INTERACT Program:What is It and Why Does It Matter?
Supported by a grant from the Commonwealth Fund
© Florida Atlantic University 2011
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
Implementation Model in the Commonwealth Fund Grant Collaborative
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Commonwealth Fund Project Results
Facilities
Mean Hospitalization Rate per 1000 resident days
Mean Change p value
Relative Reduction in All-
Cause Hospitalizations
Pre intervention
During Intervention
All INTERACT facilities (N = 25) 3.99 3.32 - 0.69 0.02
17%
Engaged facilities (N = 17) 4.01 3.13 - 0.90
0.01 24%
Not engaged facilities (N = 8) 3.96 3.71 - 0.26
0.69 6%
Ouslander et al, J Am Geriatr Soc 59:745–753, 2011
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Commonwealth Fund Project Results - Implications
1. For a 100-bed NH, a reduction of 0.69 hospitalizations/1000 resident days would result in: 25 fewer hospitalizations in a year (~2 per month) $125,000 in savings to Medicare Part A (using a conservative
DRG payment of $5,000)
2. The intervention as implemented in this project cost of ~ $7,700 per facility
3. Net savings ~ $117,000 per facility per year Medicare could share these savings to support NHs to further
improve care
The INTERACT Program:What is It and Why Does It Matter?
Ouslander et al, J Am Geriatr Soc 59:745–753, 2011
© Florida Atlantic University 2011
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
The program and tools are currently being updated
“INTERACT III tools” and an updated INTERACT website should be available by the end of 2012
Note
© Florida Atlantic University 2011
The INTERACT tools are meant to be used together in your daily work in the nursing home
http://interact2.net
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Tracking, trending, and benchmarking well-defined measures
Root cause analysis to learn and guide care improvement and educational activities
Getting Started: Keys to a QI Program
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012.
(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//Pr
eventableHospitalizations_021512_2.pdf)
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011© Florida Atlantic University 2011
Advancing Excellence tool will be located at: http://www.nhqualitycampaign.org
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Highlighting identifies residents at risk for 30-day readmission and those who returned to hospital within 30 days Flyover boxes provide
instructions for data entry
© Florida Atlantic University 2011© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Advancing Excellence tool will be located at: http://www.nhqualitycampaign.org
Dropdown lists for easy data entry
Transfers that occur within 30 days of admission from the hospital are highlighted
© Florida Atlantic University 2011© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Advancing Excellence tool will be located at: http://www.nhqualitycampaign.org
Rates trended by month – in this graph 30-day readmissions from PAC, LTC, and total
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Unplanned Transfer Assessment Data Collection Tool Facility Name: Name Date Completed: Date Time Period Being Reviewed: Using information from the Unplanned Transfer Assessments reviewed during the timeframe you have identified in Row #5, enter item totals in the following sections. Day of Hospital Transfer: # % Sunday 4 11% Monday 2 6% Tuesday 4 11% Wednesday 5 14% Thursday 6 17% Friday 7 19% Saturday 8 22% Total 36 100% How many transfers occurred on the following shifts: # % 1st Shift: 7AM-3PM 2 17% 2nd Shift: 3PM-11PM 4 33% 3rd Shift: 11PM-7AM 6 50% Total 12 100% Notes:
Summary
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The INTERACT Change in Condition File Cards:
The case of Mrs. S: a classic case that illustrates their purpose
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
9 conditions All structured the same way Provide guidance on when to
notify the MD/NP/PA consistent with File Cards
Suggest evaluation strategies Provide recommendations for
management and monitoring in the facility
Putting the Tools to Work in Everyday Practice
INTERACT Care Paths
© Florida Atlantic University 2011
The sample Resident Transfer Form has two pages:
The first page has information that ED physicians and nurses identified as essential to make decisions about the resident.
Interacting with Your Hospitals
The new INTERACT III NH to Hospital Data List will contain recommended data elements consistent with national standards for CCDs
© Florida Atlantic University 2011
This Transfer Checklist can be printed or taped onto an envelope, and is meant to compliment the Transfer Form by indicating which documents are included with the Form
Interacting with Your Hospitals
© Florida Atlantic University 2011
Information Transfer From the Hospital
Interacting with Your Hospitals
The sample Hospital to PAC sample Transfer Form will provide an example of how to put the data in easy to read format for the receiving clinician.
The new INTERACT III Hospital to PAC Data List will contain recommended data elements consistent with national standards for CCDs, and data that is critical for safe care in the first 24-72 hours
© Florida Atlantic University 2011
Advance Care Planning
When?
ACP should occur at some time shortly after admission
Decisions should be reviewed regularly and at times of acute changes in condition
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address: Nutrition and hydration Activity Monitoring in the least
disruptive way Hygiene Comfort and safety
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
1. Test INTERACT in clinical trials to improve the evidence-basea. NIH grant (funded)b. VA grant (scheduled for funding later in 2012)
2. Refine the program and the implementation training curriculum (Medline Industries grant)
3. Further spread the INTERACT program in conjunction with the QAPI roll-out (Commonwealth Fund grant)
4. Develop ethnically and culturally sensitive person-centered decision tools about hospital transfer (Patient-Centered Outcomes Research Institute grant)
Future Directions for INTERACT
© Florida Atlantic University 2011
4. Further spread the INTERACT program in other settings
a. ALFs, home care (CMS Innovations Grant)b. Other countries (e.g. England, Canada, Singapore)
5. Combine INTERACT with other interventions a. Care transition interventions (CMS Innovations Grant)b. Telemedicine and others
6. Work with regulators and payers to incentivize INTERACT implementation (underway with CMS)
7. Embed INTERACT into HIT (PointClickCare)• EMRs (LTC software)• Inter-facility transfer platforms
Future Directions for INTERACT
© Florida Atlantic University 2011
Examples of HIT Applications Using INTERACT Tools
HIT
© Florida Atlantic University 2011
HIT
Facility QI Reports
Information for hospital transfer
Quality Measures
Examples of HIT Applications Using INTERACT Tools
© Florida Atlantic University 2011
HIT Nursing assistant notes
Automated alerts to licensed nurses
Examples of HIT Applications Using INTERACT Tools
© Florida Atlantic University 2011
Examples of HIT Applications Using INTERACT Tools
HIT
© Florida Atlantic University 2011
Examples of HIT Applications Using INTERACT Tools
HIT
© Florida Atlantic University 2011
HIT Secure information transfer to emergency room or acute care unit
CCD that meets national standards
Examples of HIT Applications Using INTERACT Tools
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
The INTERACT Program:What is It and Why Does It Matter?