Brookdale Senior Living's Innovative Transitions of Care Project

Abstract

Perhaps no issue is hotter in postacute and long-term care than avoidable rehospitalizations. Evidence suggests that the rate of avoidable rehospitalizations can be reduced by 1) improving discharge-planning and transition processes within the hospital, 2) better coordinating care between settings, and 3) improving coaching, education, and support for patient self-management. The University of North Texas Health Science Center is testing how hospital admission and rehospitalization rates can be improved among community-dwelling and assisted living residents receiving home health care. In partnership with multistate–facility owner Brookdale Senior Living, the university has received a Centers for Medicare & Medicaid Services (CMS) Innovation Grant to test transitions of care practices developed in skilled nursing facilities (SNFs). The program will employ clinical nurse leaders (CNLs) to act as managers. They will in turn train special care-transition nurses and other staff on the use of the Interventions to Reduce Acute Care Transfers (INTERACT) program and health information technology to manage residents’ medical needs. Brookdale is the largest owner-operator of senior living communities in the United States, operating about 640 such sites for more than 60,000 residents and clients in independent living, personalized assisted living, specialized dementia care, rehabilitation, skilled nursing, home health, and hospice. Interviewed together, Dr. Kevin O'Neil, CMD, and Rita Vann, both of the company's clinical services department, and Scott Ranson, chief information officer, said that by 2015, the project will: reduce hospital admissions across multiple community settings, improve care coordination and transitions in 67 Brookdale communities, and reduce hospitalization costs by $9.7 million. The key drivers of success, they said, will be three: use of a version of the INTERACT program adapted for multiple settings and services, deployment of CNLs to coordinate INTERACT training and implementation, and creation of an information technology platform that will help facilities coordinate transitions. The project requires considerable collaboration with a range of partners. One is Dr. Joseph Ouslander, CMD, associate dean for geriatric programs at Florida Atlantic University, Boca Raton, and one of INTERACT's authors. He is helping the new program modify the SNF-focused INTERACT tool for the assisted living and home health care settings and to translate its electronic format into one compatible with Brookdale's electronic health information systems. Admission, discharge, and transfer data from Brookdale will be matched with that from hospitals and compared against CMS data. The result will be transition-outcome measurements from 3 years before the use of INTERACT and related interventions and from 3 years after. The Brookdale leaders project that hospital admissions and readmissions can be reduced by at least 11% and that overall health care expenditures to these Medicare beneficiaries can be reduced 2%. The savings will pay the cost of hiring CNLs, training for an estimated 11,000 staff, the INTERACT modifications, information technology, and data analysis. Will these results be realized? Surely there are question marks. Adapting the INTERACT tool so it can identify changes in condition among home health clients and assisted living residents is one thing, but when and how the tool is utilized, by whom, and how the data are handled in these settings are greater challenges. Obviously, both populations and staffs in home care and assisted living are different from their counterparts in SNFs. Above all, homes and even most assisted living facilities do not have licensed nurses around the clock. Project leaders will have to modify the chain of communication from caregiver to nurse to clinical practitioner. Remaining almost unchanged will be the “Stop and Watch” portion of INTERACT, which systematically prompts staff to report any change in a resident that could be an early warning sign of a problem. Even here, the information will flow differently from what occurs in an SNF. Yet the emphasis will remain on identifying and treating disease symptoms as fast as possible to keep Medicare beneficiaries from getting so sick that they need to be hospitalized. The challenges for Brookdale are the same as with any new protocol: making sure that staff education is complete and that its effect continues, especially when staff turn over. This is precisely why the research is being conducted and why CMS is so interested. According to Dr. O'Neil, the reasons that Caring for the Ages readers should also pay attention to this project are straightforward. “All of us in this field want to prevent things from falling through the cracks,” he said, “and so we focus on developing systems and policies and procedures. Certainly, checklists, algorithms, and protocols are important, but more important are relationships between settings.” Dr. O'Neil emphasized that Brookdale Senior Living intends to share whatever it learns with other postacute-care providers. New tools and strategies for reducing hospital admissions and readmissions and providing better quality of care across the long-term care continuum would be valuable for us all.