INTERACT Strengthening Care Systems and Quality of Life

1. INTERACT Strengthening Care Systems and Quality of Life Madeleine Biondolillo, MD Corporate Medical Director Radius Management Services

2. Today we will… • Review background of development of INTERACT • Describe the key components of the INTERACT toolkit • Share “early lessons” from current INTERACT collaborative project • Provide strategies for training your staff for immediate implementation of INTERACT tools at your facility

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 and prepare for payment changes

8. Background • CMS Special Study awarded to Georgia Medical Foundation July 2006-Jan 2008 • Looked at characteristics of NHs in Georgia with high and low hospitalization rates • Implemented toolkit in 3 NHs with high hospitalization rates

9. CMS Special Study Results Of 200 hospitalizations, an expert clinician panel rated 2/3 as potentially avoidable Ouslander et al: J Amer Ger Soc, 2010

10. CMS Special Study Results The overall frequency of hospitalizations wasreduced by 50%

11. INTERACT IIFunded by the Commonwealth Fund • Principal Investigator: Dr. Joseph G Ouslander • Co-Principal Investigator: Dr. Gerri Lamb Independence Foundation and Wesley Woods Chair Associate Professor of Nursing Emory University • Collaborators: Laurie Herndon, MSN, GNP-BC Senior Project Coordinator Alice Bonner, PhD, RN Co-Investigator Massachusetts Department of Public Health Multidisciplinary teams from MA, NY, and FL

12. Methods • Toolkit refined • Implement and evaluate refined toolkit in 30 nursing homes in MA, NY, FL for 6 months • What works and what doesn’t • What does it take to make it work? • Champion • Collaborative calls

13. Working Together to Improve Care, Communication, and Continuity for our Residents

14. Organization of Tools in ToolkitChampion Resource Binder Communication Tools Clinical Care Paths Advance Care Planning Tools

15. 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 around resident change in condition • Enhance communication with other health care providers about a resident change of status

17. Communication Tools • Early Warning Tool • SBAR and Progress Note • Transfer Checklist • Resident Transfer Form

18. How communication impacts hospital transfers • CNA-Nurse Communication • “I knew she wasn’t right” • Nurse-MD/NP Communication • “Just send him” • Nursing Home-Hospital Communication • “Doesn’t that nursing home know what they are doing?”

19. More to the communication story Saint Elsewhere Hospital Discharge Summary “Patient is stable for transfer” Shangri-La Nursing Home Nurses Note “Patient arrived to facility in acute distress”

20. Where to keep it Who should use it Different languages “Please fill this out so I am certain not to forget what you just told me”

21. “We use it for EVERYTHING” “Staff are really learning, gathering tools necessary to communicate with the physician” “Organize Your Thoughts Form”

22. “It took two nurses working together 30 minutes to fill this out” “This isn’t so different from what we usually do” “Gets easier with practice” Take old forms off units Now, we don’t hear much at all about this tool on the calls

24. “My initial determination was based on the fact that ….if the patient was admitted….I automatically felt is was unavoidable…..but I’ve had a culture change with my thought process”…

25. Fever • Mental Status Change • Dehydration • UTI • CHF

26. Advance Care Planning Tools

27. Leadership “buy in” is important “This is great…we would love to do this at our facility” Lessons so far….

28. “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.” The Champion is key

29. Champion Responsibilities • Work on buy-in from key people • Think about finding a partner/team of your own • Think about the off shift • Develop plan for training staff

30. Training: What we did • 1/2 to ¾ day at each site • Met with key staff for 30-45 min each • Administrator/DON/Medical Director/Dept heads • Nursing staff • CNA staff • Social Workers • Rehab staff • NPs when available

31. Training: What we did • Champion able to observe both teaching strategies and content several times • Champion introduced and endorsed by project team • Champion then finished up with staff who missed initial training session

32. 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”

33. Feedback on the training • Team approach from the beginning • Frequent repeats • Small groups • 1:1 • Find out what they fear and address it • Find out what they like and reinforce it

34. Implementation StrategiesThink About

35. Customizing the program • Newsletter • Grand Rounds • Morbidity and Mortality Rounds • NCR paper for Transfer Forms • Tools part of new hire orientation • Scratch cards, free lunch • “Its about more than just the tools. It’s about culture and how you do business”

36. www.interact2.net • Preparation • How to use the website • What is a champion and why do I need one? • All of the tools with instructions for each • Continuous Quality Improvement • Marketing

37. Next StepsLogistics • Leadership and front line buy in • Case study or data may be helpful • Share your vision • Download/print materials • Training sessions • Distribute materials to units • Remove old forms

38. Why It Matters

40. mbiondolillo@radiusmanagement.com Thank You!