Improving Geriatric Care by Reducing Potentially Avoidable Hospitalizations

1. 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

2. 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

3. Hospitalizations of NH residents are common • 1 in 5Medicare 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

4. 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

5. 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

6. Why This Matters

7. 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

8. INTERACTDefinitions 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

9. INTERACTDefinitions 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

10. Design of Toolkit • Dr. Ouslander “Simple Test” • Feasible and efficient • Part of the “way we do business” • Acceptable to staff 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

11. 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

12. Clinical Care Paths Advance Care Planning Tools Organization of Tools in Toolkit Communication Tools

13. 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?

14. 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)

15. 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

16. 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?

17. Communication Across Settings

18. 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)

19. 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

21. 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

23. Model for Implementation • Train the trainer • Leadership • Champion • Finding the Gaps • Avoiding Duplication • Tracking the Data • MAKING IT RELEVANT

24. 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

25. But… The frontlines are where it happens

26. 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.”

27. 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”

28. 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

29. 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

30. 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

31. Thank You!!!