Improving Geriatric Care by Reducing Potentially Avoidable Hospitalizations Laurie Herndon, MSN, GNP-BC, ANP-BC Director of Clinical Quality Massachusetts.

Improving Geriatric Care by Reducing Potentially Avoidable

HospitalizationsLaurie Herndon, MSN, GNP-BC, ANP-BC

Director of Clinical QualityMassachusetts Senior Care Foundation

[email protected]

Today we will…Today we will…

Review background of INTERACT II toolkitReview background of INTERACT II toolkit

Describe the key components of the INTERACT II Describe the key components of the INTERACT II toolkittoolkit

Share some lessons learned so farShare some lessons learned so far

Discuss the tools in the context of the cross Discuss the tools in the context of the cross continuum teamscontinuum teams

Hospitalizations of NH Hospitalizations of NH residents are commonresidents are common

1 in 5 Medicare 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 In any six month period, more than 15% of long stay residents are hospitalizedstay residents are hospitalized– O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially

Preventable Hospitalizations” Journal of the American Geriatrics Society 52, no. Preventable Hospitalizations” Journal of the American Geriatrics Society 52, no. 10(2004): 1730-173610(2004): 1730-1736

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 billionMor et al. Health Affairs 29 (No. 1): 57-64, 2010

Many Hospitalizations are Many Hospitalizations are AvoidableAvoidable

As many as 45% of admissions of nursing home residents to As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriateacute hospitals may be inappropriate

Saliba et al, J Amer Geriatr SocSaliba et al, J Amer Geriatr Soc

48:154-163, 200048:154-163, 2000

In 2004 in NY, Medicare spent close to $200 million on In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory hospitalization of long-stay NH residents for “ambulatory

care sensitive diagnoses” care sensitive diagnoses”

Grabowski et al, Health AffairsGrabowski et al, Health Affairs

26: 1753-1761, 200726: 1753-1761, 2007

Why This Matters

The OpportunityThe Opportunity

Reducing potentially avoidable Reducing potentially avoidable hospitalizations of NH residents hospitalizations of NH residents represents an opportunity to:represents an opportunity to:– Decrease emotional trauma to the Decrease emotional trauma to the

resident and familyresident and family– Decrease complications of Decrease complications of

hospitalizationhospitalization– Reduce overall health care costsReduce overall health care costs

INTERACTINTERACTDefinitions and GoalsDefinitions and Goals

INTERACT stands for “INTERACT stands for “Interventions Interventions to Reduce Acute Care Transfers”to Reduce Acute Care Transfers”

It is a program designed to improve It is a program designed to improve the care of nursing home residents the care of nursing home residents by:by:– Identifying situations that commonly Identifying situations that commonly

result in transfers to the hospital—and result in transfers to the hospital—and working together to manage them working together to manage them effectively and safely in the nursing effectively and safely in the nursing home without transfer whenever home without transfer whenever possiblepossible

INTERACTINTERACTDefinitions and GoalsDefinitions and Goals

The goal of INTERACT is to improve The goal of INTERACT is to improve quality of care, quality of care, not not to prevent all to prevent all hospital transfers hospital transfers – In fact, INTERACT can result in In fact, INTERACT can result in more more

rapid transfer of residents who need rapid transfer of residents who need hospital carehospital care

Purpose of ToolkitPurpose of Toolkit

Aid in the early identification of Aid in the early identification of a resident change of status a resident change of status

Guide staff through a Guide staff through a comprehensive resident comprehensive resident assessment when a change has assessment when a change has been identified been identified

Improve documentation Improve documentation condition condition

Enhance around resident Enhance around resident change in communication with change in communication with other health care providers other health care providers about a resident change of about a resident change of statusstatus

Design of ToolkitDesign of Toolkit

Dr. Ouslander “Simple Test” Feasible and efficient Part of the “way we do

business” Acceptable to staff

Building Evidence CMS Pilot

– 50% reduction of hospitalization in 3 NHs with high 50% reduction of hospitalization in 3 NHs with high baseline rates baseline rates

– 36% reduction in hospitalizations rated as potentially 36% reduction in hospitalizations rated as potentially avoidableavoidable

Commonwealth Fund Project– 17% reduction all facilities– 24% reduction in highly engaged facilities

Practice Change Fellowship– 100+MA facilities– Data from ~30

Organization of Tools in ToolkitOrganization of Tools in Toolkit

Communication ToolsCommunication Tools

Clinical Care PathsClinical Care Paths

Advance Care Planning ToolsAdvance Care Planning Tools

Making the Cross Making the Cross Continuum Continuum ConnectionConnection

Know that this is a Know that this is a prioritypriority

““Heads Up” from Heads Up” from acute care to SNF on acute care to SNF on dischargedischarge

““If you could If you could predict….”predict….”

What do YOU know What do YOU know about the resident about the resident that will help us target that will help us target the right symptoms the right symptoms once they are once they are transferred?transferred?

Making the Cross Making the Cross Continuum Continuum ConnectionConnection

Consider using Consider using for “Warm Hand for “Warm Hand Off”Off”

Review on Review on admit to ED and admit to ED and to the floorto the floor

How might this How might this be specifically be specifically targeted to your targeted to your work? (i.e CHF work? (i.e CHF programs)programs)

Making the Cross Making the Cross Continuum Continuum ConnectionConnection

These are well These are well received by received by SNF nurses SNF nurses

Used with SBAR Used with SBAR to promote to promote critical thinkingcritical thinking

Think about Think about sharing sharing teaching teaching resources you resources you have started in have started in the hospitalthe hospital

Making the Cross Making the Cross Continuum Continuum ConnectionConnection

DOES THIS HELP?DOES THIS HELP? Be sure to provide Be sure to provide

feedback one way feedback one way or anotheror another

Ask facilities Ask facilities about itabout it

Could this be a Could this be a template for template for disease disease management management efforts?efforts?

Communication Across Communication Across SettingsSettings

Making the Cross Making the Cross Continuum Connection: The Continuum Connection: The

Transfer FormTransfer Form Is this the information YOU need?Is this the information YOU need? Please be sure to review the Please be sure to review the

information on the second page—this information on the second page—this is critical information WE need to is critical information WE need to share with youshare with you

(Knowing the baseline is AS (Knowing the baseline is AS IMPORTANT with SNF residents as IMPORTANT with SNF residents as any other part of the assessment)any other part of the assessment)

Spotlight on InnovationSpotlight on Innovation

Met with ED staffMet with ED staff Revisions made to transfer form and Revisions made to transfer form and

format (3 hole punch)format (3 hole punch) Open lines of communicationOpen lines of communication Importance of relationships/trustImportance of relationships/trust Case Review now possibleCase Review now possible

The QI Review and Process The QI Review and Process ImprovementImprovement

Internal ProcessesInternal Processes– Missing early warning signsMissing early warning signs

Cross Continuum ProcessesCross Continuum Processes– 7 day readmits7 day readmits– Primarily cardiac diagnosisPrimarily cardiac diagnosis– Consider using/modifying to review Consider using/modifying to review

cases togethercases together

Model for ImplementationModel for Implementation

Train the trainerTrain the trainer LeadershipLeadership ChampionChampion Finding the GapsFinding the Gaps Avoiding DuplicationAvoiding Duplication Tracking the DataTracking the Data MAKING IT RELEVANTMAKING IT RELEVANT

Lessons so far….Lessons so far….

Leadership “buy Leadership “buy in” is importantin” is important

““This is great…we This is great…we would love to do would love to do this at our facility”this at our facility”

Morning meetingMorning meeting Quarterly QI Quarterly QI

Agenda itemAgenda item Morning RN reportMorning RN report

But…But…

The frontlines are where it The frontlines are where it happenshappens

The Champion is keyThe Champion is key““I still think there is I still think there is incredible value to this incredible value to this project and am going to project and am going to keep working very hard on keep working very hard on it”it”

• ““I tell the staff to go out I tell the staff to go out onto the units and look for onto the units and look for transfers waiting to transfers waiting to happen”happen”

• ““I am going to elicit an I am going to elicit an alliance”alliance”

• ““I’m seeing it happen…I’m seeing it happen…

walking on the units and walking on the units and seeing the nurses using the seeing the nurses using the SBAR…it’s great.” SBAR…it’s great.”

Relationships matter:Relationships matter:Who to include in your training Who to include in your training

sessionssessions ““Our NP told me she couldn’t believe how Our NP told me she couldn’t believe how

much the nursing assessments have much the nursing assessments have improved since we started this”improved since we started this”

““Does the ED staff know about this Does the ED staff know about this project? They keep calling to ask about project? They keep calling to ask about the forms.”the forms.”

““Does this mean they will be checking up Does this mean they will be checking up on me?”on me?”

““It’s all about teamwork”It’s all about teamwork”

Lessons LearnedLessons Learned

It can be doneIt can be done Allow 3 months to get startedAllow 3 months to get started Anticipate questionsAnticipate questions Anticipate enthusiasmAnticipate enthusiasm Be ready for refining and critical Be ready for refining and critical

thinking at 12-18 monthsthinking at 12-18 months– Ex. Cross Continuum TeamEx. Cross Continuum Team– Transfer FormTransfer Form– Post Acute ChecklistPost Acute Checklist

INTERACT II Quick TipsINTERACT II Quick Tips

www.interact2.net The Champion—key to the effort in the The Champion—key to the effort in the

skilled nursing facility—this is the who skilled nursing facility—this is the who you should ask for!you should ask for!

A live meeting is bestA live meeting is best Schedule regular follow upSchedule regular follow up How do efforts compliment each other?How do efforts compliment each other? Where are the gaps?Where are the gaps? Small tests of changeSmall tests of change

INTERACT II in Context of INTERACT II in Context of Other InitiativesOther Initiatives

MA Statewide Strategic Plan for Care TransitionsMA Statewide Strategic Plan for Care Transitions STAAR ProjectSTAAR Project Cross Continuum TeamsCross Continuum Teams 3026 Applications3026 Applications MOLST/POLSTMOLST/POLST Accountable Care OrganizationsAccountable Care Organizations Universal Transfer Form/IMPACT Project in Universal Transfer Form/IMPACT Project in

WorcesterWorcester Blue Cross Blue Shield of MABlue Cross Blue Shield of MA MA Department of Public Health MA Department of Public Health MA Senior Care RWJ PIN GrantMA Senior Care RWJ PIN Grant

Thank You!!!Thank You!!!