Improving Geriatric Care by Reducing
Potentially Avoidable Hospitalizations
Laurie Herndon, MSN, GNP-BC, ANP-BC
Director of Clinical Quality
Massachusetts Senior Care Foundation
lherndon@maseniorcare.org
Today we will…

Review background of INTERACT II toolkit

Describe the key components of the INTERACT II toolkit

Share some lessons learned so far

Discuss the tools in the context of the cross continuum
teams
Hospitalizations of NH residents are
common
1 in 5 Medicare fee-for-service patients admitted to an
acute hospital are re-admitted within 30 days
 In any six month period, more than 15% of long stay
residents are hospitalized

–
O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable
Hospitalizations” Journal of the American Geriatrics Society 52, no. 10(2004): 1730-1736
Of ~1.8 million SNF admissions in the
U.S. in 2006, 23.5% were re-admitted
to an acute hospital within 30 days
Cost of these readmissions = $4.3 billion
Mor et al. Health Affairs 29 (No. 1): 57-64, 2010
Many Hospitalizations are Avoidable
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
Why This Matters
The Opportunity
 Reducing
potentially avoidable
hospitalizations of NH residents
represents an opportunity to:
– Decrease emotional trauma to the
resident and family
– Decrease complications of
hospitalization
– Reduce overall health care costs
INTERACT
Definitions and Goals
INTERACT stands for “Interventions to
Reduce Acute Care Transfers”
 It is a program designed to improve the
care of nursing home residents by:

– Identifying situations that commonly result in
transfers to the hospital—and working
together to manage them effectively and
safely in the nursing home without transfer
whenever possible
INTERACT
Definitions and Goals

The goal of INTERACT is to improve
quality of care, not to prevent all
hospital transfers
– In fact, INTERACT can result in more rapid
transfer of residents who need hospital
care
Design of Toolkit
Purpose of Toolkit


Aid in the early identification of
a resident change of status

Guide staff through a
comprehensive resident
assessment when a change
has been identified


Improve documentation
condition

Enhance around resident
change in communication with
other health care providers
about a resident change of
status


Dr. Ouslander “Simple Test”
Feasible and efficient
Part of the “way we do
business”
Acceptable to staff
Building Evidence

CMS Pilot
– 50% reduction of hospitalization in 3 NHs
with high baseline rates
– 36% reduction in hospitalizations rated as
potentially avoidable

Commonwealth Fund Project
–
–

17% reduction all facilities
24% reduction in highly engaged facilities
Practice Change Fellowship
–
–
100+MA facilities
Data from ~30
Organization of Tools in Toolkit
Communication Tools
Clinical Care Paths
Advance Care Planning Tools
Making the Cross
Continuum Connection

Know that this is a
priority

“Heads Up” from acute
care to SNF on discharge

“If you could predict….”

What do YOU know about
the resident that will help
us target the right
symptoms once they are
transferred?
Making the Cross
Continuum
Connection
Consider using for
“Warm Hand Off”
 Review on admit
to ED and to the
floor
 How might this be
specifically
targeted to your
work? (i.e CHF
programs)

Making the Cross
Continuum
Connection
These are well
received by SNF
nurses
 Used with SBAR
to promote
critical thinking
 Think about
sharing teaching
resources you
have started in
the hospital

Making the Cross
Continuum
Connection
DOES THIS HELP?
 Be sure to provide
feedback one way or
another
 Ask facilities about it
 Could this be a
template for disease
management
efforts?

Communication Across Settings
Making the Cross Continuum
Connection: The Transfer Form
Is this the information YOU need?
 Please be sure to review the information
on the second page—this is critical
information WE need to share with you
(Knowing the baseline is AS IMPORTANT
with SNF residents as any other part of
the assessment)

Spotlight on Innovation
Met with ED staff
 Revisions made to transfer form and
format (3 hole punch)
 Open lines of communication
 Importance of relationships/trust
 Case Review now possible

The QI Review and Process
Improvement

Internal Processes
– Missing early warning signs

Cross Continuum Processes
– 7 day readmits
– Primarily cardiac diagnosis
– Consider using/modifying to review cases
together
Model for Implementation
Train the trainer
 Leadership
 Champion
 Finding the Gaps
 Avoiding Duplication
 Tracking the Data
 MAKING IT RELEVANT

Lessons so far….





Leadership “buy in” is
important
“This is great…we
would love to do this
at our facility”
Morning meeting
Quarterly QI Agenda
item
Morning RN report
But…
The frontlines are where it happens
The Champion is key
“I still think there is incredible
value to this project and am
going to keep working very hard
on it”
•
“I tell the staff to go out onto
the units and look for transfers
waiting to happen”
•
“I am going to elicit an alliance”
•
“I’m seeing it happen…walking
on the units and seeing the
nurses using the SBAR…it’s
great.”
Relationships matter:
Who to include in your training
sessions
“Our NP told me she couldn’t believe how much
the nursing assessments have improved since
we started this”
 “Does the ED staff know about this project?
They keep calling to ask about the forms.”
 “Does this mean they will be checking up on
me?”
 “It’s all about teamwork”

Lessons Learned
It can be done
 Allow 3 months to get started
 Anticipate questions
 Anticipate enthusiasm
 Be ready for refining and critical thinking
at 12-18 months

– Ex. Cross Continuum Team
– Transfer Form
– Post Acute Checklist
INTERACT II Quick Tips
www.interact2.net
 The Champion—key to the effort in the
skilled nursing facility—this is the who you
should ask for!
 A live meeting is best
 Schedule regular follow up
 How do efforts compliment each other?
 Where are the gaps?
 Small tests of change

INTERACT II in Context of Other
Initiatives

MA Statewide Strategic Plan for Care Transitions

STAAR Project

Cross Continuum Teams

3026 Applications

MOLST/POLST

Accountable Care Organizations

Universal Transfer Form/IMPACT Project in Worcester

Blue Cross Blue Shield of MA

MA Department of Public Health

MA Senior Care RWJ PIN Grant
Thank You!!!