INTERACT 4 Patty Abele, FNP BC (No relevant financial relationships to disclose) TODAY WE WILL Identify the risks and disadvantages associated with avoidable hospitalizations Identify the goals of the INTERACT program and the strategies it uses to improve care and prevent avoidable hospitalizations Identify the quality improvement, communication, advance care planning, and decision support tools used in the INTERACT 4 program MISSOURI QUALITY IMPROVEMENT (MOQI) INTIATIVE FOR NURSING HOMES Response to Centers for Medicare and Medicaid Services (CMS) funding opportunity: Initiative to Reduce Avoidable Hospitalizations University of Missouri Sinclair School of Nursing, Quality Improvement Program for Missouri (QIPMO), Primaris (Missouri Quality Improvement Organization), MHC (Missouri Health Connection, a federally designated Health Information Exchange service for MO) and others 14.8 million dollar grant Four year demonstration project 16 nursing homes in St. Louis Area Initiated early 2013 1
WHY ST. LOUIS? Identified as a region with the highest rehospitalizations for key diagnoses of AMI, CHF, pneumonia, and high 30 day hospital readmissions. Identified NHs with good quality care/survey history with high hospitalization rates to high re hospitalization hospitals HOSPITALIZATIONS ARE EXPENSIVE AND DANGEROUS FOR FRAIL ELDERS 1 in 5 Medicare patients discharged from hospital in US are readmitted within 30 days at cost of over $15 billion each year 45% of re admissions could be avoided 30 67% of hospitalizations among NH residents could be prevented AGS 58:627 635, 2010 r 2010, Copyright the Authors Journal compilation r 2010, The American Geriatrics Society N Engl J Med 2011; 365:1165 116 2
Potentially Avoidable Hospitalization (PAH) Rates by State for 2009. SOURCE: Chronic Condition Warehouse, 2009. MMRR 2014: Volume 4 (1) Highly Prevalent Conditions Associated with Potentially Avoidable Hospitalizations in 2009 NOTE: * Pneumonia was only considered as the primary diagnosis for a potentially avoidable hospitalizations for beneficiaries in institutions. SOURCE: Chronic Condition Warehouse, 2009. MMRR 2014: Volume 4 (1) Hospitalized Residents Risk: Disorientation Delirium Functional decline Immobility Pressure ulcers Falls Poly pharmacy Medication errors Incontinence and catheter use Hospital acquired infections 3
WHAT ARE THE MAJOR CAUSES OF UNNECESSARY HOSPITALIZATIONS FROM LONG TERM CARE FACILITIES? Not recognizing changes in condition soon enough Lack of adequate staffing Lack of lab, x ray or pharmacy services Lack of availability of on site physicians, NPs, PAs Poor communication with HCP, on call provider Lack of advance care planning or advance directives Resident and/or family preferences Concern about possible legal liability concern about possible survey citations Others? What can the hospital/er do for my patient that I can t do right here? Know your nursing home s capabilities: Lab work Xray, ultrasound, doppler, EKG SQ fluids, IV fluids, and antibiotics Tube feeding Oxygen, CPAP, breathing treatments, trach care Complex wound management PT/OT/ST WHY IT MATTERS Improve quality of care for residents with fewer complications and reduced cost Financial and regulatory incentives changing: Current situation, which favors hospital transfers, is going to change. Medicare changing payment to reward lower rates of avoidable hospitalizations. Surveyors will be examining how facilities assess and manage acute changes in status. Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement (QAPI) program. Improving management of acute change in condition and reducing avoidable hospital transfers is one potential focus for QAPI work Reducing Hospitalizations Safely is a new goal for Advancing Excellence in America s Nursing Homes campaign 4
INTERACT stands for 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. INTERACT PROGRAM The INTERACT Program was designed by Dr. Joseph Ouslander, MD and Mary Perloe, GNP at the Georgia Medical Care Foundation Project was supported by Centers for Medicare and Medicaid Services (CMS) The program was designed to help nursing homes improve their early illness detection skills so that residents could remain in the NH, and receive care for acute illnesses Revised based on input from staff from several nursing homes and national experts in a project supported by The Commonwealth Fund Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project (J Am Geriatric Soc 59:745 753, 2011) 25 NHs, 3 states, 6 month project providing tools, on site education, facility based champion, biweekly teleconferences facilitated by APRN Overall 17 % reduction in hospital admissions: 24%, compared with 6%, in NHs rated as engaged For an average size 100 bed NH, this would mean an average decrease of ~25 hospitalizations per year, or ~2 less per month Cost of implementation $7,700 per NH Would result in $125,000 savings to Medicare Part A per year Total projected savings based on 100 bed NH $117,000 per year per NH Challenges in implementing: no potent incentive to NH, competing priorities, high turnover, hospitalization rates self reported with questionable accuracy, short interval of study 5
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INTERACT GOALS Reduce hospital transfers by: Preventing conditions from becoming severe enough to require hospitalization Early recognition of resident change in condition Accurate documentation and communication of assessment Managing some conditions in the NH when this is feasible and safe Awareness of Capabilities of the nursing home Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization Early discussions with residents and families about hospitalizations Improving care transitions via improved communication with hospitals and medication reconciliation Analysis of acute care transfers to identify opportunities to reduce transfers that might be preventable Tracking hospitalizations, examining trends, root cause analysis to focus educational and care process improvement activities SUCCESS REQUIRES A WIDE SCALE CULTURAL CHANGE ACROSS THE WHOLE NURSING HOME Hundreds of nursing homes are using the INTERACT tools, but Dr. Ouslander believes relatively few have comprehensively adopted the entire program. Requires a major change in the way care is delivered Can not be effectively implemented or sustained without: Organizational commitment Administrators actively involved A team approach with a team champion; Engagement of staff and HCPs ( buy in ) Integration of program and tools into everyday care (tools visible and accessible) Many complex issues, social and relationship issues with family and HCP come into play as nursing home staff consider hospital transfers (Lola Butcher http://www.hfma.org/leadership/e Bulletins/2012/July) INTERACT TOOLS Communication Tools Stop & Watch SBAR Med Reconciliation Worksheet Post Hospital Nursing Home Capabilities List NH to Hospital Transfer Form Acute Care Transfer Checklist Decision Support Tools Change in Condition File Cards Care Paths Advanced Care Planning Tools Advanced Care Planning Tracking Tool Advanced Care Planning Communication Guide Comfort Care Order Set Educational Handouts: Going to the Hospital, CPR, Tube Feeding Quality Improvement Tool for Review of Acute Care Transfers 7
INTERACT Version 4.0 Tools New! Important changes include: 1. The SBAR Communication Form and Progress Note has been substantially revised to make it a more comprehensive and user friendly nursing evaluation that helps guide and document critical thinking in an efficient way. Changes have been made to several areas of terminology in response to user concerns and suggestions. 2. The criteria for notifying the clinician have been made more consistent between the Decision Support Tools (Change in Condition File Cards and Care Paths), and these criteria are now included in the revised SBAR. 3. The Stop and Watch early warning tool has been revised to facilitate its use in routine monitoring of high risk residents by adding a checkbox for "no change". 4. The Advance Care Planning Tracking Tool has been revised to include brief documentation of discussions, which are often not clearly communicated over time or during care transitions. STOP AND WATCH The Stop and Watch Early Warning Tool prompts staff, including CNAs, dietary, rehab and environmental services, to be alert for potential change in condition indicators. This tool provides a simple, clear way to communicate changes in condition to nursing staff. has been revised to facilitate its use in routine monitoring of high risk residents by adding a checkbox for no change. What does SBAR stand for? OLD VERSION: S = Situation INTERACT 4 VERSION: S = Situation B = Background B = Background A = Assessment A = Appearance R = Request R = Review and Notify 8
Action requested of SBAR Before calling Health Care Provider (HCP): Evaluate resident (see section B and A) Check Vital Signs Review Record: recent progress notes, labs, orders Review INTERACT Care Path or Acute Change in Condition card, if indicated (each nursing unit has this info) Have relevant info available when reporting SBAR INTERACT 4 SBAR 9
What does research say about use of SBAR? When INTERACT SBAR tool is consistently used: 1. HCP feel they are given better reports 2. Care of residents improves 3. Hospitalizations decline CHANGE IN CONDITION GUIDE Dehydration Fever Acute Mental Status Change/Confusion Behavioral Symptoms of Dementia New or Worsening Symptoms of CHF Symptoms of UTI Symptoms of LRI Shortness of Breath GI Symptoms CAREPATHS 10
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ADVANCE CARE PLANNING TOOLS ADVANCE CARE PLANNING EDUCATIONAL MATERIALS 12
A GOOD DEATH Is not the logical conclusion of healthy aging a good death? Myra Christopher 9 out of 10 adults polled in mid 1990 s would prefer to be cared for at home if they were terminally ill with 6 months or less to live 71% of Americans believe quality of life for the seriously ill is more important than extending life through every medical intervention possible DEATH DENYING SOCIETY We don t acknowledge the end of life like we do birth GOOD GERIATRIC CARE = GOOD PALLIATIVE CARE One way around end of life denial has been to discuss palliative care much earlier in a person s disease process or life. Nursing homes need to be in the business of providing high quality palliative and end of life care Huge opportunity for nursing homes to develop expertise in providing this care Robust advance care planning, care preferences clearly documented and followed, adept at caring for and managing symptoms like pain, partnering with palliative consultants and hospice 13
PUTTING IT ALL TOGETHER USING INTERACT THREE CHEERS FOR FINANCIAL INDEPENDENCE!! 3 GENERATIONS OF NURSES! 14