Gerri Lamb, PhD,RN, FAAN Associate Professor Arizona State University

1. Gerri Lamb, PhD,RN, FAAN Associate Professor Arizona State University College of Nursing and Health Innovation INTERACT Curriculum Session 2 Tracking Hospital Transfers and the Quality Improvement Review Tool The development and evaluation of the INTERACT quality improvement program and Curriculum are supported by grants from the Retirement Research Foundation and The Commonwealth Fund

2. INTERACT Curriculum Session 2 • If you are participating in a teleconferenceproceed to the next slide for instructions • If you are reviewing this session as a self-learning activity: • Proceed to slide # 4 • Click the speaker at the bottom of each slide to listen to the audio • If you do not have audio, click on “View” on the toolbar, and select “Normal” to view the text below each slide – if necessary select “Zoom” to make all of the slide and text visible.

3. INTERACT Curriculum Session 2 Teleconference Instructions • If the leader is not on the call when you call in, please wait

4. Tracking Hospital Transfers and the Quality Improvement Review Tool Welcome and Introductions • This session is designed for the entire interdisciplinary team, including the: • Project champion and co-champion • DON, key RNs, LPNs, and CNAs • Medical director, primary care MDs, and NPs/PAs • Social workers • Administrators

5. Gerri Lamb, PhD, RN, FAAN is Associate Professor at the College of Nursing and Health Innovation at Arizona State University in Phoenix Arizona. She is a member of the team that developed and evaluated the INTERACT tools. She is well-known for her research on case management and transitional care for older adults Dr. Lamb’s work is now focused on coordination of care for older adults across our health care system and assisting patients, families, and health care providers improve care transitions. Tracking Hospital Transfers and the Quality Improvement Review Tool Gerri.Lamb@asu.edu

6. Tracking Hospital Transfers and the Quality Improvement Review Tool • The INTERACT Interdisciplinary Team • Joseph Ouslander, MD Florida Atlantic University • Laurie Herndon, GNPMass Senior Care Foundation • Ruth Tappen, EdD, RN, FAAN Florida Atlantic University • Sanya Diaz, MD Florida Atlantic University • John Schnelle, PhD Vanderbilt University • Sandra Simmons, PhD Vanderbilt University • Annie Rahman, MSW Miami University • Jo Taylor, RN, MPH Carolinas Center for Medical Excellence • Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services In collaboration with participating nursing homes

7. Tracking Hospital Transfers and the Quality Improvement Review Tool What This Session Will Cover • Why track hospital transfers • Factors linked to hospital transfers • Asking the question: can we improve what we’re doing to reduce hospital transfers? • Using the Quality Improvement (QI) Review Tool

8. Tracking Hospital Transfers and the Quality Improvement Review Tool Pre-Session #2 Quiz • Please complete the Pre-Session Quiz • If you take the Quiz in a paper and pencil format, please make sure your facility champion or co-champion gets a copy • If you are reviewing this session on-line, you can take the on-line Quiz, or take the Quiz using a hard copy obtained from your facility champion or co-champion, and return it to them

9. Tracking Hospital Transfers and The Quality Improvement Review Tool INTERACT and Hospital Transfers • The goal of the INTERACT programis 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

10. Tracking Hospital Transfers and The Quality Improvement Review Tool Why track transfers? • Tracking hospital transfers allows you to: • Identify situations that commonly result in transfers of your residents to the hospital • Determine which situations you can potentially manage effectively and safely in your facility without transfer • Improve quality of care for your residents

11. Tracking Hospital Transfers and the Quality Improvement Review Tool • Look for patterns in clinical situations that result in transfers • Work together on strategies on situations you believe can be managed safely and effectively without transfers Tracking Hospital Transfers

12. Tracking Hospital Transfers and the Quality Improvement Review Tool

13. Tracking Hospital Transfers and the Quality Improvement Review Tool Common Reasons for Transfers • Some of the common reasons for transfer of residents to the hospital included: • Change in medical status • Family expectations • Services available within the nursing home • Availability and communication with primary care providers • Advance directives of lack of advance care planning

14. Tracking Hospital Transfers and the Quality Improvement Review Tool • Lots of factors may be involved • Staff involved in the decision may be unsure and uncomfortable • Discovering situations that might have been safely treated in the facility may also be uncomfortable at first Transfer Decisions are Complicated

15. Tracking Hospital Transfers and the Quality Improvement Review Tool Think prevention and early intervention using the INTERACT tools • Early detection of signs Stop and Watch and symptoms • Communication with SBAR primary care providers • Early management of Care Paths, File Cards clinical conditions • Discussions with family Advance Care Planning about hospitalization

16. Tracking Hospital Transfers and the Quality Improvement Review Tool Think prevention and early intervention using the INTERACT tools • Early detection of signs Stop and Watch and symptoms • Communication with SBAR primary care providers • Early management of Care Paths, File Cards clinical conditions • Discussions with family Advance Care Planning about hospitalization

17. The different INTERACT tools are meant to be used together in your daily work in the nursing home The Quality Improvement Review Tool is meant to identify opportunities to improve management of changes in condition

18. Tracking Hospital Transfers and the Quality Improvement Review Tool • Consider integrating review of hospital transfers into your regular quality process • The same principles apply as you review hospital transfers • Look for common situations that you can work on together • Avoid blaming individuals Quality Review of Hospital Transfers

19. Tracking Hospital Transfers and the Quality Improvement Review Tool • Retrospective • Designed to assist you to review situations that commonly result in transfers in your facility The Quality Improvement Review Tool

20. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Goal

21. Tracking Hospital Transfers and the Quality Improvement Review Tool • Helpful for: • Identifying situations that commonly result in hospital transfers • Determining situations that may be managed effectively in your facility • Improving quality and reducing preventable transfers The Quality Improvement Review Tool

22. Tracking Hospital Transfers and the Quality Improvement Review Tool • Background Information • Change in Condition • Evaluation and Management • Transfer Information • Opportunities for Improvement The QI Review Tool: 5 Sections

23. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Section 1: Background Info

24. Tracking Hospital Transfers and the Quality Improvement Review Tool Looking for Patterns in: Section 1: Background Info

25. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Section 2: Change in Condition

26. Tracking Hospital Transfers and the Quality Improvement Review Tool Looking for Patterns in: Section 2: Change in Condition

27. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Section 3: Evaluation and Management

28. Tracking Hospital Transfers and the Quality Improvement Review Tool Looking for Patterns in: Section 3: Evaluation and Management

29. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Section 4: Transfer Information

30. Tracking Hospital Transfers and the Quality Improvement Review Tool Looking for Patterns in: Section 4: Transfer Information

31. Tracking Hospital Transfers and the Quality Improvement Review Tool The Quality Improvement Review Tool Section 5: Opportunities for Improvement

32. Tracking Hospital Transfers and the Quality Improvement Review Tool • Does this situation offer an opportunity to improve care? Tracking Hospital Transfers

33. Tracking Hospital Transfers and the Quality Improvement Review Tool Key Points of Session 2 • Tracking hospital transfers allows you to study situations that commonly result in hospital transfers in your facility • There are many factors including clinical, family, and nursing home issues that influence transfers and staff attitudes about them • Having a standard tracking and quality improvement process for hospital transfers keep the focus on improving patient care

34. Tracking Hospital Transfers and the Quality Improvement Review Tool Key Points of Session 2 (continued) • The INTERACT QI Review Tool is designed to help your team identify opportunities to improve your transfers and quality of care. • Prevention, early detection and management are central to improving care – once a resident is acutely ill, it is difficult to prevent a transfer. • Each of the INTERACT tools you will learn about in upcoming sessions is designed to help staff identify and manage situations that commonly lead to hospital transfers.

35. Tracking Hospital Transfers and the Quality Improvement Review Tool INTERACT Implementation Activities • Your facility’s project champion is responsible for coordinating INTERACT implementation. She or he may ask you to complete specific activities before the next teleconference or before you review the next session on-line. • Suggested implementation activities before the next session: • Go to the INTERACT website (http://Interact2.net) and print a copy of the QI Review Tool. • Complete the QI Review Tool for a resident who was transferred to the hospital • Talk with other members of your team about factors they think might have contributed to the hospital transfer • Discuss your answers to the question about whether the transfer might have been prevented.

36. Tracking Hospital Transfers and the Quality Improvement Review Tool Questions, Suggestions, Comments? • For teleconference participants please un-mute the line: Press # 6 Please re-mute your line after talking:Press * 6 • Questions and suggestions on Session 2 can also be directed to Dr. Lamb by email at: Gerri.lamb@asu.edu Please insert in the Subject Line: “Question about the INTERACT Curriculum”

37. Tracking Hospital Transfers and the Quality Improvement Review Tool The Next Session • The next teleconference will be held at the same time next week • The topic and participants are listed below

38. Tracking Hospital Transfers and the Quality Improvement Review Tool Post-Session #2 Quiz and Evaluation • Please complete the Post-Session Quiz and Evaluation • If you take the Quiz and complete the Evaluation in a paper and pencil format, please make sure your facility champion or co-champion gets a copy • If you are reviewing this session on-line, you can take the on-line Quiz and complete the evaluation on-line.