By Lola Butcher
When a nursing home resident becomes short of breath or develops another serious symptom, chances are he or she will end up in the hospital. That's typically a given, says Joseph G. Ouslander, MD, a geriatrician at the Charles E. Schmidt College of Medicine at Florida Atlantic University.
"It's often just easier to send the resident to the hospital," he says. "Then nursing home staff do not have to handle the time-consuming evaluations."
This helps explain why almost one in four hospital patients who are transferred to skilled nursing facilities are readmitted to the hospital within 30 days, according to 2006 data highlighted in a Health Affairsstudy. Many of these costly admissions are unnecessary. One expert panel concluded that 68 percent of 200 hospital admissions from nursing homes could have been avoided.
Ouslander is trying to improve these statistics through Interventions to Reduce Acute Care Transfers (INTERACT), a quality improvement program he developed with a colleague under a contract with the Centers for Medicare & Medicaid Services (CMS). INTERACT is designed to reduce avoidable nursing home-to-hospital transfers. "Some nursing home residents who would otherwise be transferred to a hospital, generally for evaluation in the emergency department, can be managed safely and effectively without transfer." says Ouslander, who serves as INTERACT's project director.
Reducing transfers is a goal that many hospitals can get behind as well, as they stand to get hit with financial penalties for high readmission rates under Medicare's Hospital Readmission Reduction Program. Beginning in October, the CMS will lower payment rates for all Medicare discharges if a hospital experiences higher-than-average readmission rates for acute myocardial infarction, heart failure, and pneumonia.
A 2011 study predicts great promise for INTERACT. Twenty-five nursing homes spent, on average, only $7,700 to implement the program over a six-month period. Altogether, the facilities experienced a 17 percent decrease in hospitalization rates, compared with the same six-month period the year before. Medicare could save $125,000 per year for every 100-bed nursing home that adopts INTERACT, according to the study authors.
Skilled nursing facilities that embrace INTERACT work closely with local hospitals, primary care physicians, and residents and their families to manage the residents' care effectively and safely in the nursing home-without transfer, whenever possible. "The focus is on helping nursing home staff make person-centered decisions and determine how to best manage the needs of a resident who has a change in status," says Ouslander.
To reduce hospital transfers, INTERACT has identified four primary objectives-and provides free tools that nursing homes can adopt to meet each of these objectives.
Early detection of signs and symptoms. The INTERACT program is designed to help nursing home staff-from orderlies and certified nursing assistants (CNAs) to registered nurses (RNs) and top administrators-be alert to any change in a resident's health status at the earliest moment. As soon as a change is noticed, the patient's status is assessed, documented, and communicated to primary care providers and family members so all parties can help decide whether a hospital transfer is needed. INTERACT has developed a flow diagram that illustrates the main steps in this process.
INTERACT also recommends that CNAs adopt the STOP AND WATCH tool to evaluate a resident's status and inform the RN or licensed practical nurse (LPN) on duty:
Communication with primary care providers. The SBAR communication tool (for Situation/Background/Assessment/Request) provides a four-step process for nurses and CNAs to use when discussing a resident's status with a provider, allowing for a fully informed decision about whether to transfer the patient to the hospital.
Early management of clinical conditions. By using INTERACT's evidence-based care paths, nursing home RNs and LPNs can address some patient problems, such as dehydration and congestive heart failure symptoms, and prevent a hospital transfer.
Discussions with families about hospitalizations. INTERACT has developed a guide to help nursing facility staff handle end-of-life discussions with residents and their families. Ideally, residents should have an advanced care plan in place that states what type of treatment a resident prefers when his or her function severely declines. These advanced care plans can help avoid the stress of a hospital admission for patients who prefer to receive comfort care.
Beaumont Rehabilitation and Skilled Nursing Center in Westborough, Mass., has seen its hospitalization rate fall by more than 75 percent since it adopted INTERACT. In 2009, the facility's rate was 2.16 hospitalizations per 1,000 residents. Today, its rate is below 0.50 hospitalizations per 1,000 residents.
Although many nursing homes would automatically send a resident with pneumonia and other common medical conditions to the hospital, Beaumont can often treat them onsite, eliminating stress and disruption to residents and their families.
The advantages of the INTERACT program extend beyond the facility's residents to family members, nursing home staff, and the federal budget, says Beaumont administrator Paul O'Connell. "In the three years we have been using it, we have clearly saved millions of dollars because we're not sending people to the hospital, which costs three or four times the rate of a skilled nursing facility," he says. "There's no ambulance ride to and from. And the additional tests and other care that patients get in the hospital are avoided."
After Beaumont demonstrated that its hospital admission rate could be lowered, the other facilities owned by its parent company also started tracking their rates. "It's now something that the administrators are required to report at least on a monthly basis," says O'Connell. "We are all positioning our facilities to be a lower cost, high-outcome alternative to hospitalization.
"That's another part of INTERACT that I truly love: telling people that this is a medical model," he continues. "As much as we would like to make it home, it's still a medical model, and we are able to treat a number of varied diagnoses in this building, which saves a lot of those unnecessary trips to the ED or admissions to a hospital."
The 120-bed Life Care Center of Nashoba Valley, located in Littleton, Mass., started using the INTERACT program in July 2010. Administrator Ellen Levinson says it has not yet reduced its 30-day hospital admission rate, which remains at about 20 percent, but she says the tools and strategies have tremendously improved patient care and the facility's relationships with local hospitals.
One of the biggest benefits has come from the INTERACT II resident transfer form, which includes a checklist that allows the nursing home staff to communicate a lot of information about a resident without writing a long narrative.
"It is wonderfully easy for us to use on our end, and easy for hospital staff to scan and get a very good picture of the patient they are receiving," she says.
That improved communication has resulted in less finger-pointing. "What used to happen was, we would hear the ED clinicians at the hospital say, 'Those fools at the nursing home don't know how to take care of people. Look what they sent.' On our side, we would be saying, 'Look, they messed up our patient. They didn't answer our questions.' Now people are not wasting time by putting blame on the other organization, and we have a true continuum of care."
Hundreds of facilities are using some of the free INTERACT tools, says Ouslander. But he believes relatively few nursing homes have comprehensively adopted the entire INTERACT program and mission, primarily because it requires a major change in the way care is delivered.
However, this organizationwide commitment seems to be critical to reducing avoidable hospitalizations. Of the 25 skilled nursing facilities that participated in the 2011 study of INTERACT, 17 were fully engaged, or had embraced most of the opportunities to implement INTERACT. These engaged facilities saw their hospital admission rates fall 24 percent. In contrast, the six nonengaged facilities saw a drop of only 6 percent.
Interestingly, staff at the six nonengaged facilities were more likely to rate hospital transfers as unavoidable than staff at engaged facilities, according to another INTERACT study. Although a resident's medical condition is a primary factor in determining the need for a transfer, many other reasons come into play, including communication gaps with the primary care provider and a family's insistence that a resident be transferred, says Gerri Lamb, PhD, RN, FAAN, project co-director of INTERACT.
"There are social and relationships issues that come into play as nursing home staff consider a hospital transfer," says Lamb who is also associate professor, ASU College of Nursing and Health Innovation, Phoenix. "For instance, family members may want a resident to go to the hospital. Or a primary care provider, who is not on-site at the facility, may not feel comfortable determining if hospitalization is needed based only on what the nursing home nurse is telling him on the phone. And so, he admits the patient."
Because of all these complex issues, a wide-scale culture change is needed. "To be successful, this really requires changes across the whole nursing home. The administrators have to be actively involved, and staff have to be really engaged in the work."
Ouslander believes the INTERACT tools and strategies should become standard protocols for nursing homes. "It's absolutely consistent with the federal goals to improve care, improve health, and in this case, prevent unnecessary complications and morbidity leading to hospital transfers-and, at the same time, save money," he says. "Long-term care providers and geriatric health professionals have a golden opportunity right now to be part of the solution."
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article (in order of appearance):
Joseph G. Ouslander, MD, is project director, INTERACT, and senior associate dean for geriatric programs, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Fla. (Joseph.Ouslander@fau.edu)
Paul J. O'Connell is administrator, Beaumont Rehabilitation and Skilled Nursing Center, Westborough, Mass. (poconnell@SalmonHealthAndRetirement.com)
Ellen Levinson is executive director, Life Care Center of Nashoba Valley, Littleton, Mass. (Ellen_Levinson@lcca.com).
Gerri Lamb, PhD, RN, FAAN, is project co-director, INTERACT, and associate professor, ASU College of Nursing and Health Innovation, Phoenix (Gerri.Lamb@asu.edu).
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