Strengthening Care Systems
and Quality of Life
Madeleine Biondolillo, MD
Corporate Medical Director Radius Management Services
Today we will…
Review background of development of INTERACT
Describe the key components of the INTERACT toolkit
Share “early lessons” from current INTERACT
collaborative project
Provide strategies for training your staff for immediate
implementation of INTERACT tools at your facility
Hospitalizations of NH residents are
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 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
Of ~1.8 million SNF admissions in the
U.S. in 2006, 23.5% were re-admitted
to an acute hospital within 30 days
Cost of these readmissions = $4.3 billion
Mor et al. Health Affairs 29 (No. 1): 57-64, 2010
Many Hospitalizations are Avoidable
As many as 45% of admissions of nursing home residents to acute
hospitals may be inappropriate
Saliba et al, J Amer Geriatr Soc
48:154-163, 2000
In 2004 in NY, Medicare spent close to $200 million on
hospitalization of long-stay NH residents for “ambulatory care
sensitive diagnoses”
Grabowski et al, Health Affairs
26: 1753-1761, 2007
Why this matters…
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 and
prepare for payment changes
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
CMS Special Study Results
Of 200 hospitalizations, an expert clinician
panel rated
2/3 as potentially avoidable
Ouslander et al: J Amer Ger Soc, 2010
CMS Special Study Results
The overall frequency of hospitalizations
was reduced by 50%
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
Toolkit refined
Implement and evaluate refined toolkit in 30
nursing homes in MA, NY, FL for 6 months
– What works and what doesn’t
– What does it take to make it work?
Collaborative calls
Working Together to Improve
Care, Communication, and
Continuity for our Residents
Organization of Tools in Toolkit
Champion Resource Binder
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
Communication Tools
Early Warning Tool
 SBAR and Progress Note
 Transfer Checklist
 Resident Transfer Form
How communication impacts
hospital transfers
CNA-Nurse Communication
– “I knew she wasn’t right”
Nurse-MD/NP Communication
– “Just send him”
Nursing Home-Hospital Communication
– “Doesn’t that nursing home know what they are
More to the communication story
Saint Elsewhere Hospital Discharge Summary
“Patient is stable for transfer”
Shangri-La Nursing Home Nurses Note
“Patient arrived to facility in acute distress”
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
“This isn’t so
different from what
we usually do”
“Gets easier with
Take old forms off
Now, we don’t hear
much at all about this
tool on the calls
“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”…
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
Lessons so far….
Leadership “buy in” is
 “This is great…we
would love to do this
at our facility”
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
“I’m seeing it
happen…walking on the units
and seeing the nurses using
the SBAR…it’s great.”
Champion Responsibilities
Work on buy-in from key people
 Think about finding a partner/team of
your own
 Think about the off shift
 Develop plan for training staff
Training: What we did
1/2 to ¾ day at each site
 Met with key staff for 30-45 min each
– Administrator/DON/Medical Director/Dept
– Nursing staff
– CNA staff
– Social Workers
– Rehab staff
– NPs when available
Training: What we did
Champion able to observe both teaching
strategies and content several times
 Champion introduced and endorsed by
project team
 Champion then finished up with staff who
missed initial training session
Relationships matter:
Who to include in your training
“Our NP told me she couldn’t believe how much
the nursing assessments have improved since
we started this”
 “Does the ED staff know about this project?
They keep calling to ask about the forms.”
 “Does this mean they will be checking up on
 “It’s all about teamwork”
Feedback on the training
Team approach from the beginning
 Frequent repeats
 Small groups
 1:1
 Find out what they fear and address it
 Find out what they like and reinforce it
Implementation Strategies
Think About
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”
– Preparation
– How to use the website
– What is a champion and why do I need one?
– All of the tools with instructions for each
– Continuous Quality Improvement
– Marketing
Next Steps
Leadership and front line buy in
 Case study or data may be helpful
 Share your vision
 Download/print materials
 Training sessions
 Distribute materials to units
 Remove old forms
Why It Matters
Thank You!

INTERACT II: Interventions to Reduce Acute Care Transfers