Quality Improvement Program for Skilled Nursing Facilities
Orlando—Generally, elderly hospital readmissions are associated with high cost and poor outcomes. Susceptible long-term care (LTC) residents who are frequently transferred to a hospital for acute care are at a heightened risk of morbidity and mortality. An increase in pay-for-performance initiatives is causing LTC providers to take measures to diminish unnecessary hospitalizations.
INTERACT is a quality improvement program launched by Joseph G. Ouslander, MD, Florida Atlantic University, to reduce the number of transfers from LTC facilities to the hospital by providing LTC staff better resources to respond locally to changes in a resident’s status. INTERACT offers LTC staff a thorough set of tools for identifying, assessing, documenting, and communicating changes in a resident’s status. These tools are used for tracking hospitalization rates, performing root cause analyses, communicating within the nursing home, communicating between the nursing home and the hospital, providing support following an acute change in a resident’s status, and helping residents with advance care planning. Across the country, many nursing homes are already using INTERACT and have reported both successes and challenges.
Two posters were presented at the American Geriatrics Society 2014 Annual Scientific Meeting regarding the implementation of INTERACT to ensure quality improvement in LTC facilities. One poster focused directly on the application of INTERACT for reducing hospital admissions in residents with specific needs, while the other poster focused on pinpointing and overcoming the pragmatic and recognizing barriers to INTERACT implementation.
A research team from the department of medicine and family medicine/geriatrics at the University of Texas Health Science Center (UTHSC), San Antonio, Texas, discussed their study that took place at a 240-bed skilled nursing facility in an impoverished area of Texas.
Using a 2-armed approach, the research team comprised of Brande M. Harris, DO, Sandra Liliana Oakes, MD, Jeanette Ross, MD, UTHSC, and Felecia Washington, EdD, MBA, MSN, RN, director of nursing Services, Buena Vida Nursing & Rehabilitation Center, San Antonio, Texas, aimed to reduce hospital readmissions of sicker patients with advanced needs.
When asked how they defined sicker patients and why they chose to focus on them in the study, the researchers responded by explaining how a readmission to the hospital poses many hazards to frail and elderly patients. Sicker patients are defined as patients with higher morbidity. Because these patients have the most risk for being readmitted into hospitals, the impact on their care would be of the greatest value for the study. There are multiple studies that show how readmission slows recovery time, puts the patient at further risk of hospital-acquired infections, delirium, prolonged length of stay, and increased risk of placement due to increased functional decline. There is also a large financial burden associated with hospital readmissions.
The first arm of the study was conducted using data collection from April 2011 through October 2011. The goal was to address subtle changes in health status early on and halt the potential readmission cycle in order to provide the most effective and efficient care for sick patients.
During the second arm of the study, utilizing data collect from January 2012 through November 2013, a palliative care plan was instilled for all new admissions. The palliative care plan included conversations about care goals, advanced directives, and code status with patients and families. The statistics from the study show that 25% of older adults in the end of life will account for 75% of the use of resources. Approximately 87% of older adults want to have a conversation about end-of-life care and to create a map for their care, yet only 40% have a documented living will.
Through an internal audit, the researchers observed that they had a high prevalence of cognitive disorders, congestive heart failure, and renal failure in older adults coming to their skilled nursing facility. Medicare also observes this same population of patients who are frequently hospitalized and comprise a large segment of reimbursements. The researchers believe that improving the care for these patients and allowing them to reside in a nursing facility with more acute care would improve their quality of life and decrease reimbursement.
The study results showed a decrease in the 30-day readmission rates. Using the tools provided by INTERACT, the readmission rate for patients residing in a skilled nursing facility decreased more than half, from 19% to 6%, over a 1-year period of data collection. By addressing code status, advance directives, and goals of care in second arm the 30-day readmission rate decreased again to <1%. This 30-day readmission rate was maintained for over 23 months.
Some noted barriers encountered during the study included competing time demands in a skilled nursing facility, including patient care, emergencies, and state visits. The primary barriers to implementing INTERACT were making time to educate all of the team members and developing habits of completing required paperwork. According to Benjamin Bensadon, EdM, PhD, and colleagues, another barrier to INTERACT implementation includes staff turnover. This often required facilities to provide several months of re-education. Another common barrier was often resistance from medical directors, physician groups, and family. The researchers said the barriers might be overcome in the future through frequent involvement with owners and administrators and frequent data presentation. They believe the team approach is a successful strategy to implementing new procedures, and they want all parties to buy into their vision.
A few common strategies emerged when the facilities staff was looking to overcome the barriers. Some facilities implemented a program overview and education into new employee orientation and yearly staff competencies. Another strategy, one-to-one coaching, was also reported as effective.
INTERACT reporting having an overall positive impact on the LTC facilities. Based on the researchers’ aggregated data, a positive change occurred in the following areas: communication (86%; 174/203), nursing assessment (82%; 168/204), documentation (73%; 149/203), quality improvement procedures (75%; 153/203), hospital relations (66%; 133/203), and reduced hospitalization rates (58%; 118/203).
In order for INTERACT to be successful, implementation of the program must be a gradual, methodical occurrence. The staff must be provided with a clear education about the program and understand that INTERACT will simplify current processes.
When asked about future directions of the study, the researchers explained that there are 4 future directions: (1) assist LTC facilities in implementing INTERACT with more fidelity and as part of their overall quality assurance performance improvement program; (2) expand INTERACT to assisted living and home health care settings; (3) work with health systems and accountable care organizations to implement INTERACT across all care settings; and (4) embed the INTERACT program into health information technology to facilitate the first 3 goals.
It is imperative that nursing facilities and hospitals change their approach to all areas of patient care. INTERACT offers a standardized process for implementing changes to improve the care and process of patient evaluation when multiple comorbidities are present at admission to a skilled nursing facility. Researchers believe that the new era in Medicare reimbursement warrants changes in culture at facilities by taking steps toward constant quality improvement and producing teams that are willing to try new strategies.—Jordyn Greenblatt
