Interventions to Reduce Acute
Care Transfers
Joseph G. Ouslander, M.D.
Professor of Clinical Biomedical Science
Associate Dean for Geriatric Programs
Charles E. Schmidt College of Biomedical Science
Florida Atlantic University
Assistant Dean for Geriatric Education
University of Miami Miller School of Medicine (UMMSM) at Florida Atlantic University
Laurie Herndon, MSN, GNP-BC, ANP-BC
Director of Clinical Quality
Massachusetts Senior Care Foundation
Today we will…
Describe the key components of the
Share “early lessons” from current
INTERACT II collaborative project
Provide strategies for immediate
implementation of INTERACT II tools at
your facility
Why this matters…
Mr. DeMayo is an 97 year old long term
care resident at your facility.
Pancreatic cancer
Functional decline
No appetite
“Ready to go be with Eleanor”
Saturday morning wakes up and says he
feels lousy.
Stays in bed all day and doesn’t eat
Sunday morning has a fever and has
several episodes of vomiting
Appears dehydrated and weak
Son visits and expresses concern for his
father. Wonders if “this is the beginning of
the end?”
Nurse calls covering physician
Reports that son is concerned
Physician says to send this resident to the
ED for evaluation
What just happened here?
Did he want to go to the hospital?
Did that conversation ever happen?
Was the ED the best place for this resident
to be evaluated?
Could his needs have been met in the
nursing home?
Could this transfer have been prevented?
How would you know?
Where would you begin?
Hospitalizations of NH residents
are common
In any six month period, more than 15% of long stay
residents are hospitalized
O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable Hospitalizations”
Journal of the American Geriatrics Society 52, no. 10(2004): 1730-1736
Previous research suggests many such hospitalizations are
inappropriate and are related to ambulatory care sensitive
45% of admissions of 100 residents from 7 Los Angeles
nursing homes to acute hospitals were rated as
Saliba et al, J Amer Geriatr Soc 48:154-163, 2000
Why this matters…
cause morbid
complications for
NH residents
Pressure Ulcers
Injurious Falls
Why this matters…
Unnecessary hospitalizations are expensive
 Medicare spent close to $200 million on hospitalizations
related to Ambulatory Care Sensitive Diagnoses among
long-stay NH residents in New York state in 2004
 This figure does not include residents on the Part A
skilled benefit, who get hospitalized frequently
Grabowski et al, Health Affairs 26: 1753-1761, 2007
The Opportunity
Reducing potentially avoidable
hospitalizations of NH residents
represents an opportunity to:
– Decrease emotional trauma to the
resident and family
– Decrease complications of
– Reduce overall health care costs
CMS Special Study awarded to Georgia
Medical Foundation July 2006-Jan 2008
– Looked at characteristics of NHs in Georgia
with high and low hospitalization rates
– Implemented toolkit in 3 NHs with high
hospitalization rates
– 50% reduction in hospitalizations
– 36% reduction in hospitalizations rated as
Funded by the Commonwealth Fund
Principal Investigator:
Dr. Joseph G Ouslander
Co-Principal Investigator:
Dr. Gerri Lamb
Independence Foundation and
Wesley Woods Chair
Associate Professor of Nursing
Emory University
Laurie Herndon, MSN, GNP-BC
Senior Project Coordinator
Alice Bonner, PhD, RN
Massachusetts Department of Public
Multidisciplinary teams from MA, NY, and FL
Obtain input
– National experts
– Frontline staff
Refine toolkit
Implement and evaluate refined toolkit
– Quality Improvement project
– Principals of Institute for Healthcare
Improvement (IHI) Collaborative
Collaborative Calls
– Collect data during the Collaborative that will be used
Understand factors and strategies that are
important for successful implementation and
sustained use of the toolkit
Estimate the costs of implementing the toolkit to
inform P4P initiatives
– Explore incorporating key elements of the toolkit into
health information technology (HIT) using web-based
formats and/or an electronic health record
Working Together to Improve Care,
Communication, and Continuity for
our Residents
Organization of Tools in Toolkit
Communication Tools
Clinical Care Paths
Advance Care Planning Tools
Purpose Of Toolkit
Aid in the early identification of a resident
change of status
Guide staff through a comprehensive resident
assessment when a change has been identified
Improve documentation around resident change
in condition
Enhance communication with other health care
providers about a resident change of status
Where to keep it
Who should use it
Different languages
“Please fill this out
so I am certain not to
forget what you just
told me”
“We use it for
“Staff are really
learning, gathering
tools necessary to
communicate with the
“Organize Your
Thoughts Form”
“It took two nurses
working together 30
minutes to fill this out”
“This isn’t so different
from what we usually
“Gets easier with
Take old forms off
Now, we don’t hear
much at all about this
tool on the calls
Advance Care Planning Tools
Identifying Residents to
Consider for Palliative
Care and Hospice
Advance Care Planning
Communication Guide
Pocket Card
Comfort Care Order Set
File Cards
Educational Information
for Families
File Cards
“My initial determination was based on the fact that ….if the patient
was admitted….I automatically felt is was unavoidable…..but I’ve had
a culture change with my thought process”…
Lessons so far….
Leadership “buy in” is
“This is great…we
would love to do this
at our facility”
The frontlines are where it happens
The Champion is key
“I still think there is incredible
value to this project and am
going to keep working very
hard on it”
“I tell the staff to go out onto
the units and look for transfers
waiting to happen”
“I am going to elicit an alliance”
“I’m seeing it happen…walking
on the units and seeing the
nurses using the SBAR…it’s
“Oh No! It’s
Relationships matter
“Our NP told me she couldn’t believe how much
the nursing assessments have improved since
we started this”
“Does the ED staff know about this project?
They keep calling to ask about the forms.”
“The EMT’s wouldn’t sign the envelope”
“Does this mean they will be checking up on
“It’s all about teamwork”
Customizing the program
Grand Rounds
Morbidity and Mortality Rounds
NCR paper for Transfer Forms
Tools part of new hire orientation
Scratch cards, free lunch
“Its about more than just the tools. It’s
about culture and how you do business”
For tomorrow:
Getting Started
– How to use the website
– What is a champion and why do I need one?
– All of the tools with instructions for each
Deciding when and where to start
Tips for training staff
Informing family members about INTERACT II
Improving communication with the hospital
Quality Improvement Review and feedback
Case Studies
How to download the whole toolkit
Feedback on the training
Team approach from the beginning
Frequent repeats
Small groups
Couple it with other initiatives
– Consistent assignments
Think about
Processes/systems already in place
Other things going on in the building
How will you enlist front line support
How you are going to track your data

INTERACT II: Interventions to Reduce Acute Care Transfers