Reducing Acute-Care Transfers

Reducing hospital readmission rates in nursing homes is good for the bottom line but even better for the health, welfare and overall well-being of the residents.

Those concepts are the driving force behind the program known as Interventions to Reduce Acute Care Transfers, or INTERACT, which Joseph Ouslander, MD, and Jill Shutes, GNP, developed a few years ago. It began as a tool kit but has become a quality improvement program for nursing homes throughout the United States, Canada, the United Kingdom and Singapore.

According to an article in the Journal of American Medical Directors Association that Ouslander and Shutes coauthored with several others last year, the program “focuses on improving the identification, evaluation and management of acute changes in condition of nursing home residents.”

New federal requirements include implementation of a quality assurance performance improvement program in all facilities. Ouslander et al. say the INTERACT program can be an important tool in meeting those requirements while also creating partnerships among nursing homes, hospitals, healthcare systems and managed care plans.

Additionally, they say INTERACT has been associated with a reduction in hospitalizations of nursing home residents of up to a 24% over a six-month period. They also note unnecessary hospitalizations and readmissions often result in complications acquired from the hospital setting, mortality and excess healthcare expenditures. Specifically, decreasing hospitalizations can result in more than $100,000 in Medicare savings annually in every nursing home that effectively implements INTERACT.

Initially, a tool kit was developed and tested in three nursing homes that had high hospitalization rates. That pilot test resulted in a 50% reduction in hospitalizations.

The INTERACT website (www.interactteam.org) has the resources necessary to get users started, including an implementation guide and checklist. The program includes quality improvement tools to track data and measure outcomes; communication tools to educate and train staff; decision support tools for nurses and physicians; medication reconciliation worksheets; and nursing-home-to-hospital and hospital-to-nursing-home transfer forms.

The program is designed to improve documentation and communication among staff in the nursing homes as well as between the nursing home and the hospital. For example, the “STOP AND WATCH” tool helps nursing home personnel identify changes in condition, such as a patient not acting or appearing normal. Personnel from housekeeping to dietary workers to administrators are trained to notice changes in a resident and then alert a nurse.

A licensed nurse then completes a comprehensive evaluation using the “SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note.” This tool guides the nurse through a structured evaluation of the resident to determine if a physician needs to be consulted.

The Centers for Medicare and Medicaid Services and Administration on Aging estimate that 45% of hospital admissions among Medicare-Medicaid enrollees from nursing homes can be avoided. Those hospitalizations translated to $2.6 billion in Medicare expenditures a decade ago. Hospitalizations also can have negative results for residents, including distress and discomfort, delirium, falls, incontinence, hospital-acquired infections and other disorders, which lead to more medical expenses.

Education for the Entire Staff

Kim Henderson is the clinical services director for St. Andrew’s Resources for Seniors in St. Louis, Mo., and he supports INTERACT for those very reasons. He attended the intensive three-day course to become a certified educator of the program and oversaw implementation of INTERACT at the eight St. Andrew’s skilled and long-term care facilities and other facilities in the region.

“The hospitals get penalized if our residents are readmitted within 30 days,” Henderson says. “But the bottom line is, the hospitals want to keep the patients healthy. We all want them to not have to return to the hospital in 30 days.”

St. Andrew’s was seeking a way to decrease hospitalizations and readmission rates when its leaders discovered INTERACT.

“There are several costs when a resident is sent to the hospital,” Henderson says. “There is the cost of care, and there is a loss of revenue for the nursing home when the resident is at the hospital. But it’s also disturbing for the resident to have to go back and forth. When they’re in skilled nursing care, they already have issues. Then they’re thrust into a hospital where the people don’t know the resident or the type of care they’re used to, or the resident’s habits. They come back to the nursing home, and they’re confused. We have to have more staff to help the resident readjust.”

Implementing INTERACT at St. Andrew’s facilities began with training everyone.

“It’s an education process for the entire staff,” Henderson says. “With the STOP AND WATCH tool, any staff member might notice early signs of a resident’s change in health. Someone who’s cleaning their room or seeing them at a meal is capable of detecting changes. Then the SBAR tool enables the nurse to evaluate and give the doctor a professional opinion to determine if they need further care. Everyone is trained, but the nurses get more intensive training.”

Henderson also notes that physician support is essential.

“Many of our physicians (affiliated with St. Andrew’s) specialize in geriatrics, so they already were mostly on board with something like this,” Henderson says. “In my initial training it came up that there might be physician resistance to nurses making requests of the doctors, but that’s not what we’ve observed. The physicians have embraced it. Telling the doctor that Mrs. Jones doesn’t look right doesn’t mean anything to the physician. But when we enable a nurse to give a good assessment—such as the patient is running a temperature or having cognition issues or complaining about urinary urgency—they can get a culture or the doctor can determine if they need to be admitted to the hospital.”

Henderson estimates that St. Andrew’s facilities have reduced hospitalizations and readmissions by about 10% since implementing INTERACT.

What advice does Henderson have for others who want to implement INTERACT as part of an overall quality improvement program?

“They have to implement it all at once instead of piece by piece, and train the staff and reiterate why it’s a good thing to do,” he says. “It needs to be clear that they are doing it not because they have to but because it improves overall care. Our standard approach is to make sure the staff understands why we’re doing it, and ultimately we’re doing it for better care.” 

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.

Take-Home Points

HOSPITALS—INTERACT has been associated with reductions in hospitalizations of nursing home residents of up to 24% over six months.

NURSING HOMES—Reduced hospitalizations associated with INTERACT can yield more than $100,000 a year in Medicare savings.

CARE SYSTEMS—Facilities in Missouri’s St. Andrew’s senior-care system have reduced hospitalizations and readmissions by about 10% with INTERACT.