Interventions To Reduce Acute Care Transfers Research Articles

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

Influencing Factors Associated with Implementation of INTERACT (Interventions to Reduce Acute Care Transfers) in VA Community Living Centers (CLCs) Using the Consolidated Framework

ABSTRACT Our objective was to identify the influencing factors associated with the implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program within a national healthcare system. INTERACT focuses on early identification and management of changes in residents’ condition leading to a reduction in potentially preventable hospital transfers. The Consolidated Framework was used to evaluate implementation data from eight VA Community Living Centers. Qualitative implementation data suggest two influencing Consolidated Framework domains had a strong influence: 1) key attributes of the intervention (e.g., adaptability or complexity) and 2) internal organizational factors (e.g., culture or compatibility). Using the Consolidated Framework can assist future adaptations to this and other complex quality improvement initiatives.

The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review

Introduction Programs that seek to avoid emergency department (ED) visits from patients residing in long-term care facilities are increasing. We sought to identify existing programs where allied healthcare personnel are the primary providers of the intervention and, to evaluate their effectiveness and safety. Methods We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. We reviewed 11,176 abstracts and included 22 studies in our narrative synthesis, which we grouped by intervention category. Results We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Among studies measuring that outcome, 13/13 reported a decrease in ED visits, and 16/17 reported a decrease hospitalization in the intervention groups. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. Conclusion We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. However, most studies were observational and few assessed patient safety. Many identified programs focused on increased primary care for patients, and interventions addressing acute care issues, such as community paramedics, deserve more study.

LO15: Paramedic and allied health professional interventions at long-term care facilities to reduce emergency department visits: systematic review

Introduction: Emergency department (ED) crowding, long waits for care, and paramedic offload delay are of increasing concern. Older adults living in long-term care (LTC) are more likely to utilize the ED and are vulnerable to adverse events. We sought to identify existing programs that seek to avoid ED visits from LTC facilities where allied health professionals are the primary providers of the intervention and, to evaluate their efficacy and safety. Methods: We completed this systematic review based on a protocol we published apriori and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. Two investigators independently selected studies and extracted data using a piloted standardized form and evaluated the risk of bias of included studies. We report a narrative synthesis grouped by intervention categories. Results: We reviewed 11,176 abstracts and included 22 studies. Most studies were observational and few assessed patient safety. We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Of the 13 studies that reported ED visits, all (100%) reported a decrease, and of the 16/17 that reported hospitalization, 94.1% reported a decrease. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. When measured, studies reported decreased hospital length of stay, more time spent with patients by allied health professionals and cost savings. Conclusion: We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. Many identified programs focused on improved primary care for patients. Interventions addressing acute care issues such as those provided by community paramedics, patient preferences, and quality of life indicators all deserve more study.

Innovative care models across settings: Providing nursing care to older adults

The aging demographic shift occurring world-wide is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided. These models across settings emphasize maximizing the role of nurses and advanced practice nurses. The models reviewed include: On LOK and Programs of All-inclusive Care for the Elderly (PACE); Community Aging in Place, Advancing Better Living for Elders (CAPABLE); Teaching Nursing Homes; Interventions to Reduce Acute Care Transfers (INTERACT); Missouri Quality Initiative (MOQI); Evercare/Optum; Nurses Improving Care for Health System Elders (NICHE); Acute Care for the Elderly Unit (ACE Unit); Hospital Elder Life Program (HELP); Age-Friendly Health Systems; and the Transitional Care Model. Each model emphasizes education on the special needs of older adults, providing easy access to evidence-based tools and interventions, as well as strong interprofessional collaboration. Sustainable evidence-based nursing and interprofessional innovations are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults.

10 Years of INTERACT: The Push for Better SNF Care

10 Years of INTERACT: The Push for Better SNF Care

Transitions in Assisted Living

Transitions in Assisted Living

Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program Associated with Number of Hospitalizations

To determine whether degree of implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) program is associated with number of hospitalizations and emergency department (ED) visits of skilled nursing facility (SNF) residents. Secondary analysis from a randomized controlled trial. SNFs from across the United States (N=264). Two hundred of the SNFs from the randomized trial that provided baseline and intervention data on INTERACT use. During a 12-month period, intervention SNFs received remote training and support for INTERACT implementation; control SNFs did not, although most control facilities were using various components of the INTERACT program before and during the trial on their own. INTERACT use data were based on monthly self-reports for SNFs randomized to the intervention group and pre- and postintervention surveys for control SNFs. Primary outcomes were rates of all-cause hospitalizations, potentially avoidable hospitalizations (PAHs), ED visits without admission, and 30-day hospital readmissions. The 65 SNFs (32 intervention, 33 control) that reported increases in INTERACT use had reductions in all-cause hospitalizations (0.427 per 1,000 resident-days; 11.2% relative reduction from baseline, p<.001) and PAHs (0.221 per 1,000 resident-days; 18.9% relative reduction, p<.001). The 34 SNFs (12 intervention, 22 control) that reported consistently low or moderate INTERACT use had statistically insignificant changes in hospitalizations and ED visit rates. Increased reported use of core INTERACT tools was associated with significantly greater reductions in all-cause hospitalizations and PAHs in both intervention and control SNFs, suggesting that motivation and incentives to reduce hospitalizations were more important than the training and support provided in the trial in improving outcomes. Further research is needed to better understand the most effective strategies to motivate SNFs to implement and sustain quality improvement programs such as INTERACT.

Transitioning to ED: A Difficult but Improvable Process

Transitioning to ED: A Difficult but Improvable Process

Alternative Payment Models Evolving but Still Elusive in Post-Acute and Long-Term Care

Alternative Payment Models Evolving but Still Elusive in Post-Acute and Long-Term Care

A Medical Director’s Perspective: Influencing Rehospitalization Rates

A Medical Director’s Perspective: Influencing Rehospitalization Rates

INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies

Studies have shown that hospitalizations of nursing home (NH) residents lead to complications and poorer quality of life. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement (QI) Program assists licensed NH staff in avoiding such hospitalizations. INTERACT aims to improve the management of acute changes in residents' conditions by providing tools to help staff recognize subtle changes in condition, improve communication, and implement QI strategies. INTERACT has been vetted by national clinical leaders and experts in long term care (LTC). Multiple NHs have implemented INTERACT and it has been adopted in Canada, the United Kingdom, and Singapore. QI initiatives involve adaptation to the organizational context in which it is being implemented. We report adaptation of the INTERACT QI program and implementation training into Veteran Affairs (VA) Community Living Centers (CLCs) (VA equivalent NH) and summarize the efforts to introduce and train nursing leadership to integrate the intervention into selected CLCs.

Five-Star System Shines Light on CMDs

PHOENIX — The Five-Star Quality Rating System that is tightening networks and driving referrals and reimbursement is also giving certified medical directors the opportunity to “shine” and to meaningfully influence the quality of care in their facilities, Sabine von Preyss-Friedman, MD, CMD, said at the Annual Conference of AMDA – the Society for Post-Acute and Long-Term Care. “We’re at a happy place where quality and reimbursement are meeting each other,” she said. “All of a sudden administrators have skin in the game, and that’s where you as medical directors can really influence quality.” Dr. von Preyss-Friedman, the chief medical officer for Avalon Health Care, a provider of skilled nursing and assisted living facilities, encouraged directors who are just stepping up their quality improvement efforts to concentrate first on rehospitalization. Beginning in January of this year, five new quality measures were fully integrated into the calculation of the Five-Star Quality Rating System’s quality measure (QM) ratings. A measure of the percentage of short-stay residents who were rehospitalized after a nursing home admission is one of four new measures (out of the five) that are short-stay measures, and one of three that are based on Medicare claims rather than the Minimum Data Set (MDS). Each of the claims-based measures applies only to fee-for-service Medicare patients, which is “good news for us,” she said. The short-stay rehospitalization measure covers unplanned readmission to the hospital within 30 days of admission to the skilled nursing facility and includes discharged patients. Other new measures cover the percentage of short-stay residents who have an outpatient emergency department visit, and the percentage of residents who are successfully discharged to the community. As of last year, the national short-stay rehospitalization rate was 21%, according to data from the Centers for Medicare & Medicaid Services, and “at this point, many [hospitals and insurance networks] want it below 12%,” she said. “I think you should make this your goal.” (Avalon’s national short-stay rehospitalization rate now stands at 17%, she noted.) Dr. von Preyss-Friedman, also a clinical associate professor at the University of Washington, encouraged use of the INTERACT (Interventions to Reduce Acute Care Transfers) program. “Maybe just focus on the SBAR [Situation, Background, Assessment, Recommendation] communication form ... do something that focuses on early recognition of changes in condition,” she advised, adding that she had learned so much about the trends leading to hospital transfers in her facilities by using INTERACT’s Quality Improvement Tool for Review of Acute Care Transfers. (Dr. von Preyss-Friedman does not have any financial interest in the INTERACT program.) “If you have a high rehospitalization rate, I also really encourage you to form a rehospitalization committee,” she said. The committee should meet monthly and include the medical director, director of nursing, administrator, and charge nurse. Among other considerations, she highlighted the following: •MDS accuracy is still key. Even though the short-stay rehospitalization measure is claims-based (as are the measures for emergency department visits and successful discharge), the MDS-based covariates for functional status and conditions or diagnoses are part of a complex risk adjustment system that adjusts for facility risk. “It’s really important that your MDS coordinator is really good at what they do, because [their work] can affect your quality measures in a big way,” she said.•Hospice and end-of-life discussions should be integrated as early as necessary. This is because hospice-enrolled patients are excluded from the rehospitalization measure (as well as the other two claims-based short-stay measures). “If patients are entitled to a hospice benefit, bring up the conversation — don’t short-change them, because you’re short-changing [your facility] as well,” she said.•Time is of the essence. The data framing the new claims-based short-stay QMs are based on a rolling 12-month period, so they will not be up to date, she said. “You have to work on these things right now because it will take some time for your work to be reflected in updated measures.” Moreover, she added, only a Five-Star rating on the quality domain of the Five-Star system will affect a facility’s overall Five-Star rating. “You should fight for every single quality measure, every single point,” she emphasized. For more details on the Five-Star system and how ratings are calculated, see “The Fault in Our Stars: Does the Five-Star System Fall Short?” in the March 2017 issue of Caring. Christine Kilgore is a freelance writer in Falls Church, VA. •Start with Health Inspection rating•Add one star to the Step 1 result if staff rating is four or five stars and greater than the health inspection rating•Subtract one star if staffing is one star•Add one star to the Step 2 result if quality measure rating is five stars•Subtract one star if quality measure rating is one star

What Are Nursing Facilities Doing to Reduce Potentially Avoidable Hospitalizations?

ObjectivesHospitalizations among nursing facility residents are frequent and often potentially avoidable. A number of initiatives and interventions have been developed to reduce excessive hospitalizations; however, little is known about the specific approaches nursing facilities use to address this issue. The objective of this study is to better understand which types of interventions nursing facilities have introduced to reduce potentially avoidable hospitalizations of long-stay nursing facility residents. DesignCross-sectional survey. Setting236 nursing facilities from 7 states. ParticipantsNursing facility administrators. MeasurementsWeb-based survey to measure whether facilities introduced any policies or procedures designed specifically to reduce potentially avoidable hospitalizations of long-stay nursing facility residents between 2011 and 2015. We surveyed facilities about seven types of interventions and quality improvement activities related to reducing avoidable hospitalizations, including use of Interventions to Reduce Acute Care Transfers (INTERACT) and American Medical Directors Association tools. ResultsNinety-five percent of responding nursing facilities reported having introduced at least one new policy or procedure to reduce nursing facility resident hospitalizations since January 2011. The most common practice reported was hospitalization rate tracking or review, followed by standardized communication tools, such as Situation, Background, Assessment, Recommendation (SBAR). We found some variation in the extent and types of these reported interventions. ConclusionsNearly all facilities surveyed reported having introduced a variety of initiatives to reduce potentially avoidable hospitalizations, likely driven by federal, state, and corporate initiatives to decrease hospital admissions and readmissions.

More to Quality Care Than Rehospitalization Rates

More to Quality Care Than Rehospitalization Rates

Hospital Transfers of Skilled Nursing Facility (SNF) Patients Within 48 Hours and 30 Days After SNF Admission

BackgroundClose to 1 in 5 patients admitted to a skilled nursing facility (SNF) are readmitted to the acute hospital within 30 days, and a substantial percentage are readmitted within 2 days of the SNF admission. These rapid returns to the hospital may provide insights for improving care transitions between the acute hospital and the SNF. ObjectivesTo describe the characteristics of SNF to hospital transfers that occur within 48 hours and 30 days of SNF admission based on root cause analyses (RCAs) performed by SNF staff, and identify potential areas of focus for improving transitions between hospitals and SNFs. DesignTrained staff from SNFs enrolled in a randomized, controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States. Participants64 of 88 SNFs randomized to the intervention group submitted RCAs. InterventionsSNFs were implementing the INTERACT quality improvement program. MeasuresData were abstracted from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. ResultsAmong 4658 transfers for which data on the time between SNF admission and hospital transfer were available, 353 (8%) occurred within 48 hours of SNF admission, 524 (11%) 3 to 6 days after SNF admission, 1450 (31%) 7 to 29 days after SNF admission, and 2331 (50%) occurred 30 days or longer after admission. Comparisons between transfers that occurred within 48 hours and within 30 days of SNF admission to transfers that occurred 30 days or longer after SNF admission revealed several statistically significant differences between patient risk factors for transfer, symptoms and signs precipitating the transfers, and other characteristics of the transfers. Hospitalization in the last 30 days and year was significantly more common among those with rapid returns to the hospital. Shortness of breath was significantly more common among those transferred within 48 hours or 30 days, and falls, functional decline, suspected respiratory infection, and new urinary incontinence less common. SNF staff rated a higher proportion of transfers within 30 days versus 30 days or longer as potentially preventable (25.1% vs 21.5%, P = .005). Case descriptions derived from the QI tools of transfers back to the hospital within 48 hours of SNF admission illustrate several factors underlying these rapid returns to the hospital. ConclusionRCAs on transfers back to the hospital shortly after SNF admission provide insights into strategies that both hospitals and SNFs can consider in collaborative efforts to reduce potentially avoidable hospital readmissions.

Lessons Learned From Root Cause Analyses of Transfers of Skilled Nursing Facility (SNF) Patients to Acute Hospitals: Transfers Rated as Preventable Versus Nonpreventable by SNF Staff

BackgroundDetermining if a transfer of a skilled nursing facility (SNF) patient/resident to an acute hospital is potentially avoidable or preventable is challenging. Most previous research on potentially avoidable or preventable hospitalizations is based on diagnoses without in-depth root cause analysis (RCA), and few studies have examined SNF staff perspective on preventability of transfers. ObjectivesTo examine factors associated with hospital transfers rated as potentially preventable versus nonpreventable by SNF staff. DesignTrained staff from SNFs enrolled in a randomized controlled clinical trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program performed retrospective RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States. ParticipantsSixty-four of 88 SNFs randomized to the intervention group submitted RCAs with a rating of whether the transfer was determined to be potentially preventable or nonpreventable. InterventionsSNFs were implementing the INTERACT Quality Improvement (QI) program. MeasuresData were abstracted from the INTERACT QI tool, a structured, retrospective RCA on hospital transfers. ResultsA total of 4527 RCAs with a rating of preventability were submitted during the 12-month implementation period, of which 1044 (23%) were rated as potentially preventable by SNF staff. In unadjusted univariate analyses, factors associated with ratings of potentially preventable included acute changes in condition of fever, decreased food or fluid intake, functional decline, shortness of breath, and new urinary incontinence; other factors included the clinician, resident, and/or family insisting on the transfer, transfers that occurred fewer than 30 days from SNF admission and that occurred on weekends, transfers ordered by a covering physician (as opposed to the primary physician), and transfers that resulted in an emergency department (ED) visit with return to the SNF. Factors associated with ratings of nonpreventable included on-site evaluation by a physician or other clinician, and transfers related to falls. Among factors precipitating the transfers, clinician and resident and/or family insistence on transfer, and transfers related to fever and falls remained significant in a multivariate analysis. There were no significant differences among characteristics of SNFs that rated a relatively high versus low proportion of transfers as potentially preventable. ConclusionSNF staff rated a substantial proportion of transfers as potentially preventable on retrospective RCAs. Factors associated with ratings of preventability, as well as illustrative case examples, provide important insights that can assist SNFs in focusing education and care process improvements in order to reduce unnecessary hospital transfers and their associated morbidity and costs.

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations

BackgroundPerforming root cause analyses (RCA) on transfers of skilled nursing facility (SNF) patients to acute hospitals can help identify opportunities for care process improvements and education that may help prevent unnecessary emergency department (ED) visits, hospitalizations, and hospital readmissions. ObjectivesTo describe the results of structured, retrospective RCAs performed by SNF staff on hospital transfers to identify lessons learned for reducing these transfers. DesignSNFs enrolled in a randomized, controlled implementation trial of the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program submitted RCAs on hospital transfers during a 12-month implementation period. SettingSNFs from across the United States that volunteered and met the enrollment criteria for the implementation trial. ParticipantsSixty-four of 88 SNFs randomized to the intervention group performed and submitted retrospective RCAs on hospital transfers. InterventionsSNFs received education and technical assistance in INTERACT implementation. MeasuresData were summarized from the INTERACT Quality Improvement (QI) tool, a structured, retrospective RCA on hospital transfers. ResultsA total of 4856 QI tools were submitted during the 12-month implementation period. Most transfers were precipitated by multiple symptoms and signs, many of them nonspecific. Patient and/or family preference or insistence was noted to have played a role in 16% of the transfers. Hospital transfers were relatively equally distributed among days of the week, and 29% occurred on the night or evening shift. Approximately 1 in 5 transfers occurred within 6 days of SNF admission from a hospital, and 1 in 10 occurred within 2 days of SNF admission. After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. Common reasons for these ratings included recognition that the condition could have been detected earlier and/or could have been managed safely in the SNF, and that earlier advance care planning and discussions with patients and families about preferences for care may have prevented some transfers. ConclusionSummarizing findings from RCAs of transfers of SNF patients to acute hospitals can provide important insights into areas of focus for care process improvements and related education that may help prevent unnecessary ED visits, hospital admissions, and readmissions.

Process Evaluation of a Quality Improvement Project to Decrease Hospital Readmissions From Skilled Nursing Facilities

ObjectiveTo describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). DesignRetrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. SettingFive SNFs in Connecticut. ParticipantsSNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. InterventionQIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. MeasurementsBaseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. ResultsSuccess occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. ConclusionThis process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects.

The INTERACT Institute: Observations on Dissemination of the INTERACT Quality Improvement Program Using Certified INTERACT Trainers.

Unnecessary hospitalizations of vulnerable nursing home (NH) residents can lead to hospital-acquired conditions, morbidity, mortality, and excess health care expenditures. Previous research has shown that a substantial percentage of these hospitalizations are preventable. Interventions to reduce acute care transfers (INTERACT) is a quality improvement program that has been adopted by many NHs throughout the United States. The original INTERACT toolkit was first created in a project supported by the Centers for Medicare and Medicaid Services. The toolkit was further refined and tested in a collaborative quality improvement project involving 30 NHs in 3 states, which resulted in a 17% reduction in all-cause hospitalizations. This study was limited because it was not randomized or controlled. Nevertheless, the data provide evidence that the program, even in the absence of strong regulatory oversight or financial incentives, is feasible to implement and that more active program engagement is associated with higher reductions in hospitalization. This paper describes dissemination of the INTERACT program using a pragmatic and relatively low cost model to prepare certified INTERACT Trainers in collaboration with several professional organizations.