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Transcript of © Florida Atlantic University 2011 The INTERACT Program This handout is intended for use by this...
© Florida Atlantic University 2011© Florida Atlantic University 2011
The INTERACT Program
This handout is intended for use by this audience only - please do not distribute
Improving Nursing Home Care and Reducing Unnecessary Hospital Transfers, Admissions, and
Readmissions
© Florida Atlantic University 2011In 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 StrategiesAdrienne Mihelic, PhD Colorado Foundation for Medical Care 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
Disclosures
The INTERACT Program:What is It and Why Does It Matter?
No members of the INTERACT Team derive any personal income from the INTERACT program except for compensation for time spent delivering educational programs
The further development and dissemination of INTERACT is supported by grants from:
NINR/NIH Centers for Medicare & Medicaid Services The Commonwealth Fund The Patient Centered Outcomes Research
Institute PointClickCare Medline Industries
© Florida Atlantic University 2011
1. Provide a broad overview of the INTERACT quality improvement program and how it fits with health care reform initiatives
2. Describe barriers to implementing the INTERACT program and strategies to overcome them
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”:
• Improving care• Improving health• 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
The INTERACT Program:What is It and Why Does It Matter?
Hospitalization
At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning,
pressure ulcers
At the beauty salon
Why Does This Matter?
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Video Clip:
Why This Matters
© Florida Atlantic University 2011
Why Does This Matter?
The INTERACT Program:What is It and Why Does It Matter?
1. Hospital transfers are common and often result in complications in older NH residents
2. Some hospital transfers are preventable3. Care can be improved, resulting in fewer
complications and reduced cost4. Cost savings to Medicare can be shared
with NHs to further improve care5. Financial and regulatory incentives are
changing
© 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
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//PreventableHospitalizations_021512_2.pdf
© Florida Atlantic University 2011
Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize
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_021512_2.pdf
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
12
Several studies suggest that a substantial percent of hospital transfers , admissions, and readmissions are unnecessary and can be prevented
Some Hospitalizations of NH Residents are Preventable
The INTERACT Program:Background and Why it Matters
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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 GeorgiaExpert Ratings of Potentially Avoidable Hospitalizations
Ouslander et al: J Amer Ger Soc 58: 627-635, 2010
Based review of 200 hospitalizations from 20 NHs
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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.
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
$ Costs HIGHLOW
Qu
alit
y
LOW
HIGH
$
$ Incentives for Providers
Improved Quality,Reduced Costs
Reduced AvoidableHospitalizations
Opportunities for You and Your Facility
Costs Avoided
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
Opportunities Related to the New QAPI Requirement
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 to meet the QAPI requirement
© Florida Atlantic University 2011
Safe Reduction in Unnecessary Acute Care Transfers
Infrastructure
Incentives
QI Programs
Tools
Morbidity
Costs Quality
What Do Nursing Homes Need to Take Advantage of These Opportunities?
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?
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
The INTERACT Program:What is It and Why Does It Matter?
“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
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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 Team with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.
Permission can be granted via the “Contact Us”” section of the INTERACT website:http://interact2.net
The INTERACTTM logo is trademarked by FAU and most of the INTERACT Program materials are copyrighted (©) by FAU. The INTERACTTM logo and copyrighted materials may be used with the permission of FAU.
Users of these materials and/or the trademark INTERACTTM logo in any form in products for sale, including electronic health records of other forms of health information technology, must have a license agreement with FAU.
Use of the Program
© 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
The INTERACT Program:What is It and Why Does It Matter?
HALTUnnecessary
Hospital Stays
© 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 safely reduce hospital transfers by:
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?
Sadie Sara Sam
A Tale of Three Siblings
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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
© 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
0.0124%
Not engaged facilities (N = 8) 3.96 3.71 - 0.26
0.696%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
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
Putting the Tools to Work in Everyday Practice
eINTERACTTM is being developed
A User Advisory Group is being formed
http://www.einteract.org
PointClickCare Users
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
Will be available on Medline University in early 2013
Implementation Training Curriculum
© Florida Atlantic University 2011
The INTERACT III 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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
In order to implement a quality improvement program you must do at least two things:
1. Track, trend, and benchmark well-defined measures
2. Root cause analyses to learn and guide care improvement and educational activities
Getting Started: Keys to a QI Program
© 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_021512_2.pdf
)
What Measures Should You
Track?
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
INTERACT has a paper and pencil worksheet to help track acute care transfers
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Group Exercise:
Let’s Calculate Some Hospitalization Rates
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
You want to calculate your average unplanned hospitalization rate for the first quarter of 2013. You census in January was 110, in February 112, and in March 108. During these 3 months you transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter?
Choices:
3.533.234.043.74
Let’s Calculate Some Hospitalization Rates
Correct answer is b. Total unplanned admissions are 32 (3 of the 40 were planned, and 5 were admitted to observation, which is not considered an inpatient hospitalization). In the 3 months, multiplying the days in the month times the census, there were 9894 resident days. The rate per 1000 days is therefore 3.23 (divide total resident days by 1000 = 9.894; 32 divided by 9.894 is 3.23)
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Let’s Calculate Some Hospitalization RatesYou want to calculate your average 30-day readmission rate for the first quarter of 2013. Your census in January was 110, in February 112, and in March 108. During these 3 months you had 66 admissions from your local hospital, and transferred a total of 40 residents to the hospital. Of these 40, one was directly admitted for a planned revision of a colostomy, a second for a scheduled replacement of a displaced artificial hip, and one for monthly chemotherapy. Five residents were admitted into observation status. What was your average unplanned admission rate per 1000 resident days for this quarter? Choices:
a. You cannot calculate your 30-day readmission rate from these datab. 33.0%c. 60.6%d. 56.1%
Correct answer is a. You cannot calculate your 30-day readmission rate from these data for two reasons. First, you need to know if the residents who were hospitalized were the same ones admitted from the hospital. Second, you cannot calculate the 30-day readmission rate for March until the end of April. For example, a resident admitted to your facility on March 30 is at risk for a 30-day readmission until April 29.
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
What if the resident was initially discharged home, then came into the facility after 10 days at home, and is readmitted to the hospital the second day in your facility - does that count towards our 30-day readmission rate?
Yes or No?
Let’s Calculate Some Hospitalization Rates
Correct answer is YES. CMS is likely to count this as a 30-day readmission from the SNF, despite the fact the resident was at home most of the time between hospital discharge and admission to your SNF.
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
What if the resident is admitted to the hospital from your facility under observation status - does that count towards your 30-day readmission rate?
Yes or No?
Let’s Calculate Some Hospitalization Rates
Correct answer is NO. CMS does not plan to count observation stays in the numerator of this calculation. A separate quality measure involving observation stays may be developed in the future.
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
What if the resident is discharged from your facility after 20 days and is readmitted to the hospital 5 days later – does that count towards our 30-day readmission rate?
Yes or No?
Let’s Calculate Some Hospitalization Rates
Correct answer is IT Depends. The answer depends on how you calculate this percentage. CMS is likely to count the whole 30-day period, thus making skilled nursing facilities accountable for hospital admissions that occur after discharge from their facility, but 30 days or less from hospital discharge.
© Florida Atlantic University 2011 Advancing Excellence tool 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
INTERACT has developed a Hospitalization Rate Tracker in collaboration with the Advancing Excellence Campaign
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Dropdown lists for easy data entry
Transfers that occur within 30 days of admission from the hospital are highlighted
Advancing Excellence tool located at: http://www.nhqualitycampaign.org
© 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
© 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
The INTERACT III 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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Small Group Exercise:
Root Cause Analyses Using the INTERACT Quality Improvement Tool
© Florida Atlantic University 2011
The INTERACT III 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
Video Clip:
Early Identification of and Communication About Acute Changes in Condition
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 III 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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Video Clip:
Effective Nurse – Primary Care Clinician Communication About Acute Changes in
Condition
© Florida Atlantic University 2011
Improve communication
Consistent language
Standardized criteria
Clear guidelines
Communication that is efficient
Communication that is effective
Putting the Tools to Work in Everyday Practice
The Purpose of the SBAR
© 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 III 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
The INTERACT Change in Condition File Cards
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
INTERACT Care Paths
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
© Florida Atlantic University 2011
The INTERACT III 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
Video Clip:
Advance Care Planning (1)
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Advance Care Planning
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
Video Clip:
Advance Care Planning (2)
ADVANCE CARE PLANNING TOOLS
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© Florida Atlantic University 2011
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Case Study
83
© Florida Atlantic University 2011
81 year old retired schoolteacher admitted to the hospital from home with pneumonia
Past Medical History- COPD, Osteoarthritis, CAD, CHF
While hospitalized, had a myocardial infarction (a heart attack)
Transferred to your facility 5 days ago for rehab with ultimate goal to return to living independently at home
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Case Study
84
© Florida Atlantic University 2011
Early a.m CNA notes that resident isn’t herself
Somewhat irritable Seems to be a little confused Not interested in breakfast Doesn’t go to therapy Reports to nurse at change of
shift ( 3 pm )
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Case Study
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© Florida Atlantic University 2011
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3:30 pm
“The resident in 3B says she is having trouble breathing”
Case Study
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© Florida Atlantic University 2011
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You think:a. She probably aspirated
b. Three other residents on that side have URIs—could she have picked it up?
c. She just finished her Levofloxacin. The pneumonia should be better
d. She also has CHF: it could be CHF
e. How will I know if it is CHF or pneumonia?
Case Study
© Florida Atlantic University 2011
How would Care Paths help the nursing evaluation?
Where would you keep these so that nurses would have easy access to them?
Case Study
© Florida Atlantic University 2011
Case Study
© Florida Atlantic University 2011
“DO YOU HAVE…..”
Case Study
© Florida Atlantic University 2011
Case Study
© Florida Atlantic University 2011
Additional Information: CXR-Persistent left lower
lobe infiltrate, hyperinflation bilateral lung fields consistent with COPD
WBC 15,000 BP 130/70 HR 90 RR 22
Temp100.5 Pulse ox is 91% on room air Chem panel is normal
Case Study
© Florida Atlantic University 2011
How would you complete the SBAR Change in Condition Progress Note with the information from this case?
Would the SBAR be helpful? (nurse and doctor?) How? (be specific)
Case Study
© Florida Atlantic University 2011
What might have been different if the Stop and Watch was completed in this case?
What might be some barriers to robust “uptake” of this tool in your facilities?
What strategies would you use to promote use of this tool in your facility?
Case Study
© Florida Atlantic University 2011
Interacting with Your Hospitals
Video Clip:
Effective Communication with Hospitals
© Florida Atlantic University 2011
The INTERACT III 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
The 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
© 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
FHA – FADONA – FMDA – CARES – AHCA
Readmission Initiative
Draft, October 2011
Interacting with Your Hospitals
© Florida Atlantic University 2011
Nursing Home Capabilities List
Interacting with Your Hospitals
Hang it in the ED Give it to case
managers Give it to hospitalists Give it to on-call primary
care clinicians in your facility
© Florida Atlantic University 2011
Interacting with Your Hospitals
Medications Recommended by Hospital at Discharge for
which Clarification is Needed
Clarification Needed * Resolution for Final Medication Orders
(Continue, Stop, Change)
Medication Reconciliation Worksheet for Post-Hospital Care
Part 1: Hospital Recommended Medications Needing Clarification
*Examples: unclear diagnosis or indication, uncertain dose or route of administration, stop date, hold parameters, lab
tests needed for monitoring, dose different than before hospitalization, medication duplication
© Florida Atlantic University 2011
Interacting with Your Hospitals
Medications Taken Before Hospitalization Not
Currently on Hospital-Recommended List
Comments(Who provided the information, reason for the
medication, reason it was stopped in the hospital if known)
Resolution for Final Medication Orders
(Continue, Stop, Change)
Medication Reconciliation Worksheet for Post-Hospital Care
Part 2: Medications Prior to Hospitalization Needing Clarification
© Florida Atlantic University 2011
102
Effective implementation is critical to long-term sustainability of the program
The program cannot be effectively implemented or sustained without strong support from facility leadership
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
103
General Principles
1.Make INTERACT a key aspect of your facility’s quality improvement activities and QAPI program
2.Implementation should be consistent with the way you provide care in your facility
3.Integrate the INTERACT program and tools into your everyday practice
4.Recognize that organizational change takes time - programs such as INTERACT can take several months to fully implement
Tips on Getting Started and Keeping It Going
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© Florida Atlantic University 2011
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Tips on Getting Started and Keeping It Going
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© Florida Atlantic University 2011
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© Florida Atlantic University 2011
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Tips on Getting Started and Keeping It Going
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© Florida Atlantic University 2011
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© Florida Atlantic University 2011
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© Florida Atlantic University 2011
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© Florida Atlantic University 2011
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Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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Overcoming Barriers to Implementation
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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Overcoming Barriers to Implementation (1)
Barriers Strategies to Overcome“We don’t have a problem with hospital transfers”
Regularly track hospital transfers and follow trends; you may have a problem and not know it
“We don’t have control over who gets admitted”
Using INTERACT tools to improve management of acute changes and communication with physicians and emergency rooms staff will give you more control
“The doctors won’t cooperate” The medical director and the primary care providers must buy in to the INTERACT program
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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Overcoming Barriers to Implementation (2)
Barriers Strategies to Overcome
“We don’t have the staff or time”
Improving the management of acute changes in condition has to be a priority of the facility and its leadership
“We have too many other things going on”
INTERACT must be one of the major quality improvement initiatives at the facility
“We are in our survey window”
INTERACT implementation will result in improved care and adherence to multiple F Tags and other requirements
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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Overcoming Barriers to Implementation (3)
Barriers Strategies to Overcome
“Things don’t go well when the Champion is not here”
Appointing a co-champion and embedding INTERACT tools into everyday practice will help overcome staff absences and turnover
“We already have similar forms and processes”
Use your tools, or use or modify the INTERACT tools based on what your facility already has in place
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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Overcoming Barriers to Implementation (4)
Barriers Strategies to Overcome
“Families want residents hospitalized”
Families need to be educated about the risks as well as benefits of hospitalization
“We could get sued” There is no fail-safe way to prevent law suits – but the INTERACT program provides tools for evidence-based and expert recommended care, and improves communication and documentation
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
The INTERACT Program: