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© 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?
© Florida Atlantic University 2011
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 Program:What is It and Why Does It Matter?
The INTERACT Interdisciplinary Team
© Florida Atlantic University 2011
(“Interventions to Reduce Acute Care Transfers”)
The INTERACT Program:What is It and Why Does It Matter?
Is a quality improvement program designed to improve the care of nursing home residents
with acute changes in condition
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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])
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
“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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Hospitalization
At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning,
pressure ulcers
At the beauty salon
The INTERACT Program:What is It and Why Does It Matter?
Why Does This Matter?
© Florida Atlantic University 2011
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?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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 INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Sadie Sara Sam
A Tale of Three Siblings
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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 INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
Supported by a grant from the Commonwealth Fund
© Florida Atlantic University 2011
The INTERACT II tools are meant to be used together in your daily work in the nursing home
http://interact2.net
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 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
The INTERACT Program:What is It and Why Does It Matter?
Ouslander et al, J Am Geriatr Soc 59:745–753, 2011
© Florida Atlantic University 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
The INTERACT Program:What is It and Why Does It Matter?
© 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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Distress and discomfort for the resident and familyDelirium PolypharmacyFallsIncontinence and catheter useHospital acquired infectionsUnintentional weight loss and poor nutritionImmobility, de-conditioning, pressure ulcers
The INTERACT Program:What is It and Why Does It Matter?
Hospitalizations can cause many complications:
© Florida Atlantic University 2011
Why does this matter?A national perspective (2)
Some hospital transfers, ER visits, observation stays, hospital admissions, and readmissions are “avoidable”, “preventable”, or “unnecessary”
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The INTERACT Program:Background and Why it Matters
CMS Study of Dually Eligible Medicare/Medicaid Beneficiaries
© Florida Atlantic University 2011
Why does this matter?A national perspective (3)
Financial and regulatory incentives are changing
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Why does this matter to you and your facility?
The INTERACT Program:What is It and Why Does It Matter?
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
© Florida Atlantic University 2011
$ Costs HIGHLOW
Qu
alit
y
LOW
HIGH
Costs Avoided$
$ Incentives for Providers
Improved Quality,Reduced Costs
Reduced AvoidableHospitalizations
Opportunities for You and Your Facility
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
The INTERACT Program:What is It and Why Does It Matter?
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
© Florida Atlantic University 2011
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?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
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
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Sadie Sara Sam
A Tale of Three Siblings
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
What are your experiences?
What are the top 3 reasons for hospital transfers at your facility?
Why Do Unnecessary Hospital Transfers Occur?
The INTERACT Program:What is It and Why Does It Matter?
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
The INTERACT Program:What is It and Why Does It Matter?
© 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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Why Start with the Acute Care Transfer Log and QI Review Tool?
Getting Started: Tracking Hospital Transfers and The Quality Improvement 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
© Florida Atlantic University 2011
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.
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Quality Assurance and Performance Improvement “QAPI”Requirement under the ACA
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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?
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Tracking Hospital Transfers:What Do You Track?
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
What are the Incentives to Hospitalize?
Hospital reimbursement NH Capabilities
Qualification for skilled nursing facility stay
Patient and family preferences
Liability
Physician reimbursement
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The INTERACT Quality Improvement Tool is meant to identify opportunities to improve management of changes in condition through a root cause analysis process
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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?
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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)
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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)
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Designed to assist you to review situations that commonly result in transfers in your facility through systematic root cause analysis
The Quality Improvement Tool
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
The Quality Improvement Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
1. Background Information
2. Change in Condition
3. Evaluation and Management
4. Transfer Information
5. Opportunities for Improvement
The QI Review Tool: 5 Sections
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The Quality Improvement Review Tool Section 1: Background Info
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The Quality Improvement Review Tool Section 2: Change in Condition
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The Quality Improvement Review Tool Section 3: Evaluation and Management
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The Quality Improvement Review Tool Section 4: Transfer Information
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
The Quality Improvement Review Tool Section 5: Opportunities for Improvement
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Use trends in the data to focus your improvement and educational efforts
Tracking and Reviewing Hospital Transfers
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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:
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
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?
© Florida Atlantic University 2011
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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
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%)
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Ratings of Avoidability in QI Tools
Lamb, G, Tappen, R, Diaz, S, et al: .J Am Geriatr Soc 59:1665–1672, 2011
© Florida Atlantic University 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
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
© Florida Atlantic University 2011
Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool
Let’s Review Some Sample QI Tools
© 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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
Do any of you use the Stop and Watch Tool? What is
your experience?
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Video Clip
Examples of poor communication between CNA and licensed nurse, and improved
communication using the Stop and Watch Tool
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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?
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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.
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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!
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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?
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Ate less than usual
(Not because of dislike of food)
NDrank less than usual
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Instructions: “Stop and Watch”
Staff ____________________________
Reported to ______________________
Date __/__/__ Time ____________
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Video Clip
Example of how good evaluation and communication using SBAR can prevent an
acute care transfer and hospitalization
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Getting a comprehensive history: Who to involve
CNAs Social Workers Rehab, Activities, Dietary Other staff Family members
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Progress Note
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
Do any of you use the SBAR? What is your experience?
© Florida Atlantic University 2011
INTERACT Decision Support Tools:Care Paths and Change in Condition File Cards
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Who Uses the INTERACT Decision Support Tools?
RN’s LPN’s Nurse supervisors Nurse educators MDs, NPs, PAs
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The INTERACT Change in Condition File Cards include recommendations
Immediate vs. non-immediate notification for specific:
Vital signs Lab results Symptoms and signs
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
The INTERACT Change in Condition File Cards:
The case of Mrs. S: a classic case that illustrates their purpose
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
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
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
Putting the Tools to Work in Everyday Practice
© Florida Atlantic University 2011
Interacting with Your Hospitals
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
© Florida Atlantic University 2011
Have you had challenges interacting with your local hospital(s)?
What have you done that has been successful?
Interacting with Your Hospitals
© Florida Atlantic University 2011
Video Clip
Examples of information transfer –
both bad and good, and how the latter can prevent a hospitalization
Interacting with Your Hospitals
© Florida Atlantic University 2011
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
Interacting with Your Hospitals
© Florida Atlantic University 2011
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
Interacting with Your Hospitals
© Florida Atlantic University 2011
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.
Interacting with Your Hospitals
© Florida Atlantic University 2011
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.
Interacting with Your Hospitals
© Florida Atlantic University 2011
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
Interacting with Your Hospitals
© Florida Atlantic University 2011
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
Interacting with Your Hospitals
© Florida Atlantic University 2011
Implementation Strategies
Notify your local Emergency Departments
Notify your EMS/Ambulance Services
Consider alternative format for checklist
Interacting with Your Hospitals
© Florida Atlantic University 2011
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
Interacting with Your Hospitals
© Florida Atlantic University 2011
Make Sure the Hospital Knows Your Facility’s Capabilities
Interacting with Your Hospitals
This tool can be posted in the ER and in Case Managers’ offices
© Florida Atlantic University 2011
Information Transfer From the Hospital
Interacting with Your Hospitals
© Florida Atlantic University 2011
Information Transfer From the Hospital
FHA – FADONA – FMDA – CARES – AHCA
Readmission Initiative
Draft, October 2011
Interacting with Your Hospitals
© Florida Atlantic University 2011
Questions? Comments? Suggestions?
Interacting with Your Hospitals
© Florida Atlantic University 2011
ADVANCE CARE PLANNING TOOLS
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
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Advance Care Planning (ACP)
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Video Clip
The role of ACP in providing good comfort care: example of what happens when ACP
has not vs. has been done
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
How is ACP done in your facility?
Who is responsible for obtaining advance directives?
Advance Care Planning (ACP)
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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 TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Advance Care Planning
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Video Clip
The role of the interdisciplinary team in Advance Care Planning
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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:
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
Originally adapted from:
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Documenting ACP in Your Facility
Originally adapted from:
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
National effort to implement
POLST/MOLST
http://www.ohsu.edu/polst/
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
Adapted from Tulsky, JA. Beyond Advance Directives – Importance of Communication Skills at the End of Life. JAMA 2005; 294:359-365.
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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.
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
This material was adapted from the Birmingham VA Safe Harbor Project in 2007
ADVANCE CARE PLANNING TOOLS
© Florida Atlantic University 2011
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
ADVANCE CARE PLANNING TOOLS
© 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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
1. Select Your Team Pearl of Wisdom:
Selection of the Champion and Co-Champion is one of the most important decisions you will make
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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.
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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)
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
Overcoming Barriers to Implementation
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
Overcoming Barriers to Implementation (2)
Barriers Strategies to Overcome
“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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
Overcoming Barriers to Implementation (3)
Barriers Strategies to Overcome
“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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
Overcoming Barriers to Implementation (4)
Barriers Strategies to Overcome
“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
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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)
Tips on Getting Started and Keeping It Going
© Florida Atlantic University 2011
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)
Tips on Getting Started and Keeping It Going