© florida atlantic university 2011 joseph ouslander, md florida atlantic university gerri lamb,...

© Florida Atlantic University 2011

Joseph Ouslander, MD Florida Atlantic University

Gerri Lamb, PhD, RN, FAAN Arizona State University

Laurie Herndon, GNP Mass Senior Care

Ruth Tappen, EdD, RN, FAAN Florida Atlantic University

Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence

The INTERACT Program:What is It and Why Does It Matter?


Joseph G. Ouslander, MD Florida Atlantic UniversityLaurie Herndon, GNP Mass Senior Care FoundationGerri Lamb, PhD, RN, FAAN Arizona State UniversityRuth Tappen, EdD, RN, FAAN Florida Atlantic UniversitySanya Diaz, MD Florida Atlantic UniversityJohn Schnelle, PhD Vanderbilt UniversitySandra Simmons, PhD Vanderbilt UniversityAnnie Rahman, MSW California Association of LTC MedicineJo Taylor, RN, MPH The Carolinas Center for Medical ExcellenceMary Perloe, GNP The Georgia Medical Care FoundationDan Osterweil, MD California Association of LTC MedicineAlice Bonner, PhD, GNP Center for Medicare and Medicaid Services

In collaboration with participating nursing homes


The INTERACT Interdisciplinary Team


(“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


Includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources

The basic program is located on the internet:

http://interact2.net



Acknowledgement

The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Center for Medicare and Medicaid Services.

The current version of the INTERACT Program, including the INTERACT II Tools, educational materials, and implementation strategies were developed by Drs. Ouslander, Gerri Lamb, Alice Bonner, and Ruth Tappen, and Ms. Laurie Herndon with input from many direct care providers and national experts in a project based at Florida Atlantic University supported by The Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.

Some materials herein are © Florida Atlantic University 2011. Such materials and the trademark INTERACTTM may be used with the permission of Florida Atlantic University.

Permission can be granted by Dr. Ouslander ([email protected])



“BOOST”(Better Outcomes for Older Adults

Through Safe Transitions)http://www.hospitalmedicine.org

“Project RED”(Re-Engineered Discharge)

https://www.bu.edu/fammed/projectred

•Enhanced hospital discharge planning

“Care Transition Program”http://www.caretransitions.org

•Transition coach•Trained volunteers•Empowered patients and caregivers

“POLST” (or “MOLST”)(Physician (or Medical) OrdersFor life Sustaining Treatment)

http://www.ohsu.edu/polst

•Advance care planning

“Bridge Model”http://www.transitionalcare.org/the-bridge-model

•Social Worker coordinating Aging Resource Center Services at hospital discharge

“Transitional Care Model”http://www.transitionalcare.info/index.html

•APN coordinates care during and after discharge•Home, SNF, and clinic visits

“INTERACT”(Interventions to Reduce

Acute Care Transfers)http://interact2.net

•Communication Tools, Care Paths, Advance Care Planning Tools, and QI tools for nursing homes and SNFs

High Quality Care Transitions for

Older Adults &Caregivers

High Quality Care Transitions for

Older Adults &Caregivers

INTERACT is One of Several Evidence-Based Care Transitions Interventions



Hospitalization

At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning,

pressure ulcers

At the beauty salon


Why Does This Matter?


1. Hospital transfers are common and often result in complications in older NH residents

2. Some hospital transfers are preventable

3. Care can be improved, resulting in fewer complications and reduced cost

4. Cost savings to Medicare can be shared with NHs to further improve care

5. Financial and regulatory incentives are changing

Why Does This Matter?



What are your experiences?

Have you seen unnecessary hospitalizations of residents of your facility?

Have you had a resident suffer a complication during an unnecessary hospitalization?



1. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition

2. Managing some conditions in the NH without transfer when this is feasible and safe

3. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents

Can help your facility safely reduce hospital transfers by:



The goal of INTERACT is to improve care, not to prevent all hospital transfers In fact, INTERACT can help with more

rapid transfer of residents who need hospital care



Sadie Sara Sam

A Tale of Three Siblings



Hospitalized for UTI and dehydration Discharged back to the NH after 4 days Re-hospitalized 7 days later for

dehydration and recurrent UTI

SadieA 96 year old long-stay NH resident

Avoidable?

INTERACT strategy: Prevent conditions from becoming severe enough to require

hospitalization through early detection and evaluation



Hospitalized for a lower respiratory infection, but had normal vital signs and oxygen saturation

Developed delirium in the hospital, fell, fractured her pubis, and developed a pressure ulcer

Sara (Sadie’s younger sister)A 92 year old long-stay NH resident

Avoidable?

INTERACT strategy: Manage some conditions in the NH without transfer



Hospitalized for the 4th time in 2 months for aspiration pneumonia related to end-stage Alzheimer’s disease

Transferred to hospice on the day of admission

Sam (Sara and Sadie’s older brother)A 101 year old long-stay NH resident

Avoidable?

INTERACT strategy: Improve advance care planning and the use of palliative care

plans when appropriate as an alternative to hospitalization



Originally developed in a project supported by the Center for Medicare and Medicaid Services (CMS)

Revised based on input from staff from several nursing homes and national experts in a project supported by The Commonwealth Fund



Criteria for Tools Evidence-based Simple Feasible and efficient to use Acceptable to staff Consistent with federal regulations and

guidance for surveyors Incorporate into HIT

Objectives of the Tools Improve management of acute

changes in clinical status: Identification Evaluation Manage in the facility when safe Documentation Communication

Internal and with hospitals



Communication Tools

Decision Support Tools

Advance Care Planning Tools

Quality Improvement Tools



1. Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates

2. Tools were acceptable to staff3. Significant reduction in hospitalizations 4. Significant reduction in transfers rated as

avoidable by an expert panel

CMS Pilot Study Results

Ouslander et al: J Amer Med Dir Assoc 9: 644-652, 2009



The program and tools were revised based on CMS pilot study, and input from front-line NH staff and national experts

The revised program and INTERACT II Tools are available at: http://interact2.net


Supported by a grant from the Commonwealth Fund


The INTERACT II tools are meant to be used together in your daily work in the nursing home

http://interact2.net



On site training (part of one day)

Facility-based champion Collaborative phone calls with up to 10

facility champions twice monthly facilitated by an experienced nurse practitioner Availability for telephone and email consults

Completion and faxing of QI Review Tools

Implementation Model in the Commonwealth Fund Grant Collaborative



Commonwealth Fund Project Results

Facilities

Mean Hospitalization Rate per 1000 resident days (SD)

Mean Change (SD)

95% Confidence Interval

p value Relative Reduction in

All-Cause Hospitalizations

Pre intervention

During Intervention

All INTERACT facilities (N = 25) 3.99 (2.30) 3.32 (2.04) - 0.69 (1.47) -0.08 to -1.30 0.02

17%

Engaged facilities (N = 17) 4.01 (2.56) 3.13 (2.27) - 0.90 (1.28) -0.23 to -1.56

0.0124%

Not engaged facilities (N = 8) 3.96 (1.79) 3.71 (1.53) - 0.26 (1.83) -1.79 to 1.27

0.696%

Comparison facilities (N = 11) 2.69 (2.23) 2.61 (1.82) - 0.08 (0.74) - 0.41 to 0.58

0.723%

Ouslander et al, J Am Geriatr Soc 59:745–753, 2011



Commonwealth Fund Project Results - Implications

1. For a 100-bed NH, a reduction of 0.69 hospitalizations/1000 resident days would result in: 25 fewer hospitalizations in a year (~2 per month) $125,000 in savings to Medicare Part A (using a conservative

DRG payment of $5,000)

2. The intervention as implemented in this project cost of ~ $7,700 per facility

3. Net savings ~ $117,000 per facility per year Medicare could share these savings to support NHs to further

improve care


Ouslander et al, J Am Geriatr Soc 59:745–753, 2011


Why does this matter?A national perspective (1)

Emergency room visits, observation stays hospitalizations, and readmissions of nursing home residents are:

Common

Result in complications Expensive


© Florida Atlantic University 2011Mor et al. Health Affairs 29: 57-64, 2010

1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion



Distress and discomfort for the resident and familyDelirium PolypharmacyFallsIncontinence and catheter useHospital acquired infectionsUnintentional weight loss and poor nutritionImmobility, de-conditioning, pressure ulcers


Hospitalizations can cause many complications:



Some hospital transfers, ER visits, observation stays, hospital admissions, and readmissions are “avoidable”, “preventable”, or “unnecessary”



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



Was the Hospitalization Avoidable?

Definitely/Probably YES

Definitely/Probably NO

Medicare A 69% 31%

Other 65% 35%

HIGH Hospitalization Rate Homes

75% 25%

LOWHospitalization Rate Homes

59% 41%

TOTAL 68% 32%

CMS Special Study in Georgia – Expert Ratings of Potentially Avoidable Hospitalizations

Ouslander et al: J Amer Ger Soc 58: 627-635, 2010

Based review of 200 hospitalizations from 20 NHs”



The INTERACT Program:Background and Why it Matters

CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries



Financial and regulatory incentives are changing



The Affordable Care Act is focused on a “triple aim”:

1. Improving care2. Improving health3. Making care affordable

This presents major opportunities to improve geriatric care in the U.S.

Health Care Reform



1. Accelerate Reduction in Harm to Patients in Hospitals Achieve a 40% reduction in preventable harm by 2013 ~ 1.8 million fewer injuries to patients; ~ 60 000 lives saved;

~ $20 billion in health care costs avoided

2. Decrease Preventable Hospital Readmissions Within 30 Days of Discharge

Reduce readmissions by 20% by 2013 ~1.6 million hospital readmissions prevented and ~ $15 billion

in health care costs avoided

The U.S. Department of Health and Human Services “Partnership for Patients”

http://www.healthcare.gov/center/programs/partnership



Pay-for-Performance (“P4P”) No payment for certain complications;

disincentives for avoidable hospitalizations

Bundling of payments for episodes of care Accountable Care Organizations that

include hospitals, physicians, home health agencies, and SNFs that are responsible for the care of a defined group of patients

Changes in Medicare Financing



Why does this matter to you and your facility?


Improve quality of care for your residents

Share in savings to Medicare by reducing unnecessary ER visits, observation stays, hospital admissions, and readmissions

Your facility can take advantage of the opportunities in health care reform


$ Costs HIGHLOW

Qu

alit

y

LOW

HIGH

Costs Avoided$

$ Incentives for Providers

Improved Quality,Reduced Costs

Reduced AvoidableHospitalizations

Opportunities for You and Your Facility




Opportunities for You and Your Facility

The Affordable Care Act mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”)

The regulation and related surveyor guidance are being written

Improving management of acute change in condition and reducing unnecessary hospital transfers is one potential focus of your QAPI


Safe Reduction in Unnecessary Acute Care Transfers

Infrastructure

Incentives

QI Programs

Tools

Morbidity

Costs Quality

What Do You and Your Facility Need to Take Advantage of These Opportunities?



Will help you and facility: Improve quality of care for your residents Improve your communication and team work Take advantage of everyone’s contributions

to resident care



Sadie Sara Sam

A Tale of Three Siblings



What are your experiences?

What are the top 3 reasons for hospital transfers at your facility?

Why Do Unnecessary Hospital Transfers Occur?



Questions? Comments? Suggestions?

[email protected]








Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool


Why Start with the Acute Care Transfer Log and QI Review Tool?


The Affordable Care Act contains a new federal requirement for NHs: Quality Assurance and Performance Improvement (“QAPI” programs)

Knowing your baseline, tracking outcomes, and performing root cause analysis are fundamental to improving care for your residents and instituting a QAPI program


The Affordable Care Act: Section 6102 (c) requires the Centers for Medicare & Medicaid Services (CMS) to establish QAPI standards and provide technical assistance to nursing homes on the development of best practices in order to meet such standards.


Quality Assurance and Performance Improvement “QAPI”Requirement under the ACA


Five Elements of QAPI

Element 1: Design and Scope Element 2: Governance and Leadership Element 3: Feedback, Data Systems, and Monitoring Element 4: Performance Improvement Projects (PIPs) Element 5: Systematic Analysis and Systemic Action



QAPI Element 1: Design and Scope

Quality Assurance

ReactiveSingle episodeOrganizational mistakeSometimes anecdotalRetrospectiveMonitoring based on auditSometimes punitive

Process Improvement

ProactiveAggregate DataOrganizational processAlways measureableConcurrentMonitoring is continuousPositive change



Use multiple data sources Feedback incorporates staff, families, and residents Set care processes and outcomes Benchmark performance with internal and external goals Track and trend adverse events Full investigation for each incident or event every time

QAPI Element 3: Feedback, Data Systems, and Monitoring



Tracking hospital transfers allows you to: Determine your baseline, set goals for

improvement, and follow your progress Identify situations that commonly result in

transfers of your residents to the hospital

Why Start By Tracking Transfers?




Tracking Hospital Transfers:What Do You Track?


Many factors may be involved Discovering situations that might have

been safely treated in the facility may be uncomfortable when you start reviewing them

Decisions to Transfer are Complicated



Most incentives in the current system favor hospital transfer rather than managing acute changes in condition in the facility

Incentives in the Current System of Care



Financial incentives in the Medicare fee-for-service program incentivize overuse of diagnostic tests and procedures that do not benefit many elderly people, and can result in morbidity and costs

Why Do Unnecessary Hospital Transfers Occur?

By far, the most costly examples in the geriatric population are unnecessary ER visits, observation stays, hospitalizations , and readmissions



What are the Incentives to Hospitalize?

Hospital reimbursement NH Capabilities

Qualification for skilled nursing facility stay

Patient and family preferences

Liability

Physician reimbursement



Incentives are going to change over the next few years

NHs and other health care providers will have incentives to manage acute changes in condition in the facility whenever feasible

You need to be prepared!

Incentives in the Current System of Care



The INTERACT Quality Improvement Tool is meant to identify opportunities to improve management of changes in condition through a root cause analysis process



QAPI Process: Address Adverse Events

Through Root Cause Analysis

Utilize standardized investigation form Interview staff involved Interview those who may have witnessed event Has this event ever happened before? Investigate contributing factors How does this event tie into the overall PI plan?



An analytic tool that can be used to perform a comprehensive, system-based review of critical incidents and adverse health events

Goal is to determine: What happened? Why did it happen? What can be done to reduce the likelihood

of recurrence?

Root Cause Analysis (1)



Systematic approach to problem solving Identify issue as a team Repeatedly asking at least 5 “why?” questions

Don’t stop at symptoms Get to deeper layers to find the root cause Identify relationships between different root causes

Root Cause Analysis (2)



Designed to assist you to review situations that commonly result in transfers in your facility through systematic root cause analysis

The Quality Improvement Tool



Integrate into the facility’s regular quality and educational processes Look for common situations that you can

work on together to improve Avoid blaming individuals


The Quality Improvement Tool


1. Background Information

2. Change in Condition

3. Evaluation and Management

4. Transfer Information

5. Opportunities for Improvement

The QI Review Tool: 5 Sections



The Quality Improvement Review Tool Section 1: Background Info



The Quality Improvement Review Tool Section 2: Change in Condition



The Quality Improvement Review Tool Section 3: Evaluation and Management



The Quality Improvement Review Tool Section 4: Transfer Information



The Quality Improvement Review Tool Section 5: Opportunities for Improvement



Use trends in the data to focus your improvement and educational efforts

Tracking and Reviewing Hospital Transfers



Look for patterns in transfers and the clinical situations that result in them

Identify situations you believe can be managed safely and effectively without transfer

Work together to develop strategies to manage these situations

Develop education on specific topics

The Transfer Log and QI Tool Will Help Your Facility:



Each of the INTERACT II tools you will learn about in upcoming sessions is designed to help identify and manage situations that commonly lead to hospital transfers




What is Your Experience?

What are the most important incentives related to hospital transfer at your facility?

Can you identify the types of change in condition that can be managed safely and effectively without transfer at your facility?


Acute change in condition with unstable vital signs Family expectations Lack of availability or communication problems

with primary care physicians Services required are unavailable in the facility Lack of advance care planning and advance

directives

Common Reasons for Transfers Identified in QI Tools



Reason Rated Avoidable or Possibly Avoidable

(N=216)

Rated Not avoidable(N=843)

Missed prevention opportunities related to staff, PCP

69 (32%) 42 (5%)

Resident or family insists on transfer 30 (14%) 49 (6%)

Communication gaps between nursing staff, PCP, external facilities

26 (13%) 7 (1%)

Advance directives/hospice not in place or not used

24 (11%) 35 (4%)

Nursing staff gap in knowledge or skill 21 (10%) 1 (0.1%)

Level of acuity requires transfer 20 (9%) 601 (71%)

PCP orders transfer 15 (7%) 76 (9%)Facility capacity to provide needed treatments or tests

12 (6%) 54 (6%)


Ratings of Avoidability in QI Tools

Lamb, G, Tappen, R, Diaz, S, et al: .J Am Geriatr Soc 59:1665–1672, 2011


“ There’s been a culture change here. We started out thinking if they’re sent to the hospital, it’s not avoidable. Now we recognize we missed early warning signs.”

An INTERACT Champion

Changing Perceptions of Avoidability




Let’s Review Some Sample QI Tools







Putting the Tools to Work in Everyday Practice


Objectives

Describe the purpose and use of: Stop and Watch SBAR Communication Form and

Progress Note Decision Support Tools

Change in Condition File Cards Care Paths




Do any of you use the Stop and Watch Tool? What is

your experience?


Purpose of “Stop and Watch”

To guide frontline staff through a brief review of early changes in the resident’s condition

To improve communication between frontline staff and the nurse in charge



Video Clip

Examples of poor communication between CNA and licensed nurse, and improved

communication using the Stop and Watch Tool



Stop and Watch helps frontline staff identify important changes in the resident’s condition

Who is frontline staff? CNA’s and other nursing staff, rehab therapists,

dietary staff, housekeeping staff, activities staff and any staff member with direct resident contact

Family members may also contribute valuable observations



Changes in mental status – sleepy, confused, agitated, anxious

Changes in physical status – problems with walking, transferring

Changes in function – problems with ADL’s Changes in behavior – wandering, combative,

yelling, verbal or physical aggression Changes in pain level

What early changes in condition should be reported?



Stop and Watch is the primary method forCNAs to alert the LPN/RNs of changes in the resident’s conditionand for the nurse to hear what the CNAs have to say.



Important changes to report are: Actions or behaviors that are not part

of the resident’s normal routine A change from the resident’s usual

condition

Recognizing Changes in Condition



Your Eyes Are the Best

Frontline staff: Know the resident best See changes in condition first Should identify important changes in

the resident’s condition during their normal care routine

Must be empowered to communicate what they know and see



It helps … The staff know what kinds of changes to

report The nurse understand what you have to

say is important and when to take action

“Stop and Watch” is a great way to communicate changes



Unit nurses are busy giving medications

and taking physician orders

CNA’s are busy giving direct care

“Stop and Watch”reporting can help

close the gap!



Instructions for “Stop and Watch”

If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.

More than one change may be marked on the same form



S eems different than usual Not their usual self? Change in personality or behavior?

T alks or communicates less than usual Quieter? Drowsier? Confused? Altered speech?

O verall needs more help than usual Needs more assistance? Changes in gait, transfer or

balance?

P articipated in activities less than usual Withdrawn? Decline in ADL’s? Change in normal routine?



Ate less than usual

(Not because of dislike of food)

NDrank less than usual



W eight change

A gitated or nervous more than usual

T ired, weak, confused or drowsy

C hange in skin color or condition

H elp with walking, transferring, toileting more than usual



Instructions: “Stop and Watch”

Staff ____________________________

Reported to ______________________

Date __/__/__ Time ____________



The SBAR is a tool for LPNs and RNs to evaluate changes in the resident’s condition and communicate them to the MD/NP/PA and document them



Video Clip

Example of how good evaluation and communication using SBAR can prevent an

acute care transfer and hospitalization



Purpose of the SBAR Communication Form and Progress Note

Improve communication Standardized evaluation Consistent language Communication that is efficient

and effective Documentation that is thorough

and focused



Getting a comprehensive history: Who to involve

CNAs Social Workers Rehab, Activities, Dietary Other staff Family members



Progress Note



Making the Case for SBAR Assists nurses in organizing their evaluation

Improves communication with MDs/NPs/PAs

Improves shift to shift communication

Alerts all providers about a change in condition

Enhances documentation

Can be copied and sent to ER with resident




Do any of you use the SBAR? What is your experience?


INTERACT Decision Support Tools:Care Paths and Change in Condition File Cards



The INTERACT Care Paths and Change in Condition File Cards are decision support tools

Available for guidance when changes in status or specific symptoms and signs occur



The Change in Condition File Cards and Care Paths help guide decisions about:

Further evaluation of changes in condition When to communicate with the MD/NP/PA When to consider transfer to the hospital How to manage some conditions in the NH



Who Uses the INTERACT Decision Support Tools?

RN’s LPN’s Nurse supervisors Nurse educators MDs, NPs, PAs



The Care Paths and Change in Condition File Cards are meant to be used with other tools

The change in condition or new symptom or sign may have been noted using the Stop and Watch Tool

Nurses should consider completing an SBAR Form and Progress Note using guidance from these tools



The INTERACT decision support tools are based on established clinical guidelines published by several national professional organizations

Most are based on expert opinion because we lack definitive scientific clinical trials



Recommendations in the INTERACT Care Paths and Change in Condition File Cards are not fixed in stone They are meant to guide decision making, not

dictate it Your clinical team may choose to modify specific

recommendations The systematic, clearly defined approach to

symptoms and signs is more important than the specific recommendations



The INTERACT Change in Condition File Cards include recommendations

Immediate vs. non-immediate notification for specific:

Vital signs Lab results Symptoms and signs



The INTERACT Change in Condition File Cards:

The case of Mrs. S: a classic case that illustrates their purpose



Using the Change in Condition File Cards

Staff education to develop critical thinking skills Nurse educators and managers use Change of

Condition File Cards when teaching staff nurses who are assessing a resident’s change in condition

Strategies 5-minute huddle on the unit Morning stand-up meeting Report between shifts



The INTERACT Care Paths focus on 6 conditions that are: Common reasons for hospital

transfer Often manageable in the

nursing home Frequent causes of potentially

avoidable and preventable transfers or hospitalizations

The INTERACT Care Paths : Acute mental status

change Fever Dehydration Symptoms of CHF Symptoms of Lower

Respiratory Illness Symptoms of UTI



INTERACT Care Paths

All structured the same way Provide guidance on when to

notify the MD/NP/PA consistent with File Cards

Suggest evaluation strategies Provide recommendations for

management and monitoring in the facility




[email protected]



Interacting with Your Hospitals







Have you had challenges interacting with your local hospital(s)?

What have you done that has been successful?



Video Clip

Examples of information transfer –

both bad and good, and how the latter can prevent a hospitalization



Purpose of the Transfer Checklist and Resident Transfer Form

Provide essential information to emergency department staff that will lead to the most appropriate evaluation of your resident

Insure that the safe handoff of your resident to the emergency department



The Resident Transfer Form and Transfer Checklist Envelope are tools for facility staff to effectively communicate information critical to evaluating the resident to hospital staff



The Resident Transfer Form has two pages.

The first page has information that ED physicians and nurses identified as essential to make decisions about the resident.



The second page of the

Resident Transfer Form MAY be sent to the ED within 7-12 hours of the transfer, especially if the transfer involves a 9-1-1 transfer or if the resident is unstable on transfer.

If the transfer is non acute, it is likely more efficient to send both pages at the same time.



Implementation Strategies

Remove old forms from the units Consider contacting printer to have

forms printed on NCR paper If not on NCR paper, forms need to

be copied and one copy needs to stay in the facility



This Transfer Checklist can be printed or taped onto an envelope, and is meant to compliment the Transfer Form by indicating which documents are included with the Form



Implementation Strategies

Notify your local Emergency Departments

Notify your EMS/Ambulance Services

Consider alternative format for checklist



Interacting with Your Local Hospitals Schedule in-person meetings

Offer a tour of your facility Create an agenda

Start with who staff you already interact with on a regular basis ED staff Case Managers

Emphasize 2-way communication Set mutual expectations



Make Sure the Hospital Knows Your Facility’s Capabilities


This tool can be posted in the ER and in Case Managers’ offices


Information Transfer From the Hospital



Information Transfer From the Hospital

FHA – FADONA – FMDA – CARES – AHCA

Readmission Initiative

Draft, October 2011




[email protected]



ADVANCE CARE PLANNING TOOLS







Advance Care Planning (ACP)

What is it?

ACP is a process of communicating with residents and others who may be making health care decisions for them

The focus is on preferences for treatment in the event of changes in condition, and in particular at the end of life

Discussions include explanation of options, benefits, and risks




What are the Goals?

To honor resident preferences for care To document preferences clearly and

communicate them so they can be honored at the appropriate times in the facility as well as after discharge



An advance directive is a general term that describes legal documents expressing a person’s preferences for care (e.g. Living Will, Durable Power of Attorney for Health Care)

Specific orders should be written that can help make sure residents’ wishes documented in advance directives are followed, for example: Do Not Resuscitate (“DNR”) No Tube Feeding Do Not Hospitalize (“DNH”) unless necessary for comfort

Advance Directives



Video Clip

The role of ACP in providing good comfort care: example of what happens when ACP

has not vs. has been done



How is ACP done in your facility?

Who is responsible for obtaining advance directives?




What is the Role of ACP in the INTERACT Program?

Residents nearing the end-of-life are often transferred to the hospital

Many of these transfers result in increased discomfort, distress and complications

Comfort and/or palliative care can often be provided within the nursing home



What is the Role of INTERACT Tools in ACP?

The Advance Care Planning Tools can be helpful in: Educating staff Refining policies and procedures for ACP Communicating with residents, families, and other

health care decision makers Providing examples of comfort care measures



Advance Care Planning

When?

ACP should occur at some time shortly after admission

Decisions should be reviewed regularly and at times of acute changes in condition




Who? The MD is responsible for discussing risks

and benefits of various treatments and writing orders consistent with preferences

But, ACP is an interdisciplinary team responsibility

Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust



Video Clip

The role of the interdisciplinary team in Advance Care Planning




How?

INTERACT ACP tools and other resources are helpful in educating staff and for policies and procedures

Use a systematic approach towards evaluating and refining your current ACP practices



Steps to Improve ACP in Your Facility

1. Assess the Current Situation a. Approaches currently used and people responsible

b. Percent of residents with documentation of initial discussions

c. Percent of residents with advance directives, living will, and a health care surrogate decision maker

2. Select ACP as an area for potential improvement based upon preliminary assessment

3. Review state laws and regulations on ACP

Originally adapted from:



4. Identify areas for improvement in processes and practices:a. Current policies and protocols

b. Actual practice related to ACP

c. Issues that have arisen related to ACP

d. Previous attempts to address need for improvement

5. Identify barriers and challenges to improvement and strategies to overcome them

6. Reinforce practices that are already optimal

7. Implement needed changes and re-evaluate

Steps to Improve ACP in Your Facility




Documenting ACP in Your Facility


ADVANCE CARE PLANNING TRACKING FORM

RESIDENT NAME:______________________________________________________

ADMISSION (within a few days of admission or readmission) (Select One) □ Resident and/or responsible party does NOT want to have this discussion□ Discussion about advance care planning held with (circle): resident surrogate (name) both

___________________________ _________________(Staff or health care provider name) (Title)

Signature: ____________________________ Date of Discussion: ______/_____/_____ Location of Advance Care Plan documentation (i.e., medical record, plan of care, progress

notes:Use Continuation Pages to document additional Advance Care Planning

reviews and discussions



This material was adapted from the Birmingham VA Safe Harbor Project in 2007

ACP is especially important among residents at high risk of dying in the near future

This tool provides examples of residents who are at such risk



National effort to implement

POLST/MOLST

http://www.ohsu.edu/polst/



Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



Explain comfort care “Comfort care helps people live as well as they can for as long as they can.”

Reassure “Comfort care can help you and your family make the most of the time you have

left.”

Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.



Comfort or palliative care, whether or not the resident is enrolled in a hospice program, should include standard orders that address: Nutrition and hydration Activity Monitoring in the least

disruptive way Hygiene Comfort and safety




Comfort care orders should also anticipate symptoms that can cause distress and discomfort, such as: Shortness of breath,

dyspnea, and terminal “death rattle”

Pain Anorexia Anxiety Seizures




Caring Connections – downloadable educational information and forms from the National Hospice and Palliative Care Organization (www.caringinfo.org)

Coalition for Compassionate Care of California - Resources for both health care providers and for lay people who want to talk about advance care planning, including downloadable forms and factsheets. http://www.coalitionccc.org/advance-health-planning.php

Alzheimer’s Association - Comprehensive recommendations aimed at improving communication and care at end of life. http://www.alz.org/national/documents/brochure_DCPRphase3.pdf

Aging with Dignity - offers a document called “Five Wishes,” which makes ACP more user-friendly, valid in 40 states; downloadable for $5 (www.agingwithdignity.org/5wishes.html)

Examples of Resources for ACP








Tips on Getting Started and Keeping It Going


Effective implementation is critical to long-term sustainability of the program

The program cannot be effectively implemented or sustained without strong support from facility leadership



General Principles

1.Make INTERACT a key aspect of your facility’s quality improvement activities and QAPI program

2.Implementation should be consistent with the way you provide care in your facility

Integrate the INTERACT program and tools into your everyday practice

3.Recognize that organizational change takes time - programs such as INTERACT can take several months to fully implement



1. Select Your Team Pearl of Wisdom:

Selection of the Champion and Co-Champion is one of the most important decisions you will make



2. Find the Gaps

Pearl of Wisdom:

Avoid redundancy - the INTERACT program should fill in gaps in your care processes and not create more work for your staff.



3. Carefully Plan Your Training

Facility CharacteristicsStart with one unit or one tool

and have all of the tools implemented by a set date

Implement the whole toolkit all at once throughout the whole facility

We are a small facility with no other major initiatives underway. xOur champion does very well teaching one on one. xOur champion is our in-service director and is experienced conducting large in-services.

x

We usually roll out programs for everyone at the same time. xWe are a large facility with several nursing units. xWe have a short time line to carry out the training and implement the program x



8 online sessions Not all staff need to complete every

session

The facility champion and co-champion serve as the coordinators of the curriculum

Practice using the tools between sessions Reports of staff completion rates CEs for licensed nurses Teleconference review of progress Online technical assistance

The INTERACT Curriculum

If your facility or company is interested, inquire via the Contac Us section of the INTERACT website (http://interact2.net)



4. Make the Tools Visible in for Easy Use in Everyday Practice

Pearls of Wisdom:

Remove old forms from nursing units to avoid confusion and to encourage standard use of new tools and forms

Successful INTERACT Champions have found ways to keep the program visible on a daily basis through discussions at stand up meetings, on rounds and other strategies



5. Continue Tracking Your Data and Looking for Ways to Improve Your Care

Pearls of Wisdom:

Complete Quality Improvement tools as soon after acute care transfers as possible so that details are fresh

Use the data to improve care processes and to focus educational activities

Set your own benchmarks and work on improving



Overcoming Barriers to Implementation



Overcoming Barriers to Implementation (1)

Barriers Strategies to Overcome

“We don’t have a problem with hospital transfers”

Regularly track hospital transfers and follow trends; you may have a problem and not know it

“We don’t have control over who gets admitted”

Using INTERACT tools to improve management of acute changes and communication with physicians and emergency rooms staff will give you more control

“The doctors won’t cooperate” The medical director and the primary care providers must buy in to the INTERACT program





“Families want residents hospitalized”

Families need to be educated about the risks as well as benefits of hospitalization

“We could get sued” There is no fail-safe way to prevent law suits – but the INTERACT program provides tools for evidence-based and expert recommended care, and improves communication and documentation





“We don’t have the staff or time”

Improving the management of acute changes in condition has to be a priority of the facility and its leadership

“We have too many other things going on”

INTERACT must be one of the major quality improvement initiatives at the facility

“We are in our survey window”

INTERACT implementation will result in improved care and adherence to multiple F Tags and other requirements





“Things don’t go well when the Champion is not here”

Appointing a co-champion and embedding INTERACT tools into everyday practice will help overcome staff absences and turnover

“We already have similar forms and processes”

Use your tools, or use or modify the INTERACT tools based on what your facility already has in place



1. Ensure ongoing leadership support

2. Make INTERACT a permanent part of your quality improvement activities and one of your programs for QAPI

3. Appoint and train a Co-Champion

4. Have new staff undergo training

Sustaining the Program (1)



5. Continue to track changes in rates of hospital transfer and how you manage acute changes in condition

6. Learn from you Quality Improvement Review tools

7. Visit the INTERACT website for updates and new resources: http://interact2.net

8. Don’t hesitate to contact us through the website

Sustaining the Program (2)


© florida atlantic university 2011 joseph ouslander, md florida atlantic university gerri lamb,...

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