© Florida Atlantic University 2011 The INTERACT Program: What is It and Why Does It Matter? Joseph...

© 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


In collaboration with participating nursing homes


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


College of Medicine College of Nursing

New Dorms

NewFOOTBALL STADIUM

The INTERACT Program:Background and Why it Matters


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 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



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.



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



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



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?


© 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



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?


• 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



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




CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries


$ Costs HIGHLOW

Qu

alit

y

LOW

HIGH

Costs Avoided$

$ Incentives for Providers

Improved Quality,Reduced Costs

Reduced AvoidableHospitalizations

Opportunities for You and Your Facility



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



Defining “Preventable”, “Avoidable”, “Unnecessary” hospitalizations is challenging because numerous factors and incentives influence the decision to hospitalize

Risk adjustment is very complicated


(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021

512_2.pdf




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


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?



(“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


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

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])



“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 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



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:



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

Avoidable?

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

Avoidable?

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

Avoidable?

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

plans when appropriate as an alternative to hospitalization



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 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


Supported by a grant from the Commonwealth Fund


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



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



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


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


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


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

http://interact2.net



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




(Available at: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//Pr

eventableHospitalizations_021512_2.pdf)


Advancing Excellence tool will be located at: http://www.nhqualitycampaign.org


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




Dropdown lists for easy data entry

Transfers that occur within 30 days of admission from the hospital are highlighted




Rates trended by month – in this graph 30-day readmissions from PAC, LTC, and total



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


The INTERACT Change in Condition File Cards:

The case of Mrs. S: a classic case that illustrates their purpose



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


INTERACT Care Paths


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


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



Information Transfer From the Hospital


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


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


Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



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



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


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


Examples of HIT Applications Using INTERACT Tools

HIT


HIT

Facility QI Reports

Information for hospital transfer

Quality Measures



HIT Nursing assistant notes

Automated alerts to licensed nurses




HIT


HIT Secure information transfer to emergency room or acute care unit

CCD that meets national standards



Questions? Comments? Suggestions?

[email protected]


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