Presentation - PatientCareLink

Interventions to Reduce Acute
Care Transfers
Joseph G. Ouslander, M.D.
Professor of Clinical Biomedical Science
Associate Dean for Geriatric Programs
Charles E. Schmidt College of Biomedical Science
Florida Atlantic University
Assistant Dean for Geriatric Education
University of Miami Miller School of Medicine (UMMSM) at Florida Atlantic University
Laurie Herndon, MSN, GNP-BC, ANP-BC
Director of Clinical Quality
Massachusetts Senior Care Foundation
Clinical Instructor
University of Massachusetts
Graduate School of Nursing
Worcester, MA
Key Components
Describe the key components of the
Share “early lessons” from current
INTERACT II collaborative project
Provide strategies for immediate
implementation of INTERACT II tools at
your facility
Why this matters…
Mr. DeMayo is an 97 year old long term
care resident at your facility.
Pancreatic cancer
Functional decline
No appetite
“Ready to go be with Eleanor”
Saturday morning wakes up and says he
feels lousy.
Stays in bed all day and doesn’t eat
Sunday morning has a fever and has
several episodes of vomiting
Appears dehydrated and weak
Son visits and expresses concern for his
father. Wonders if “this is the beginning of
the end?”
Nurse calls covering physician
Reports that son is concerned
Physician says to send this resident to the
ED for evaluation
What just happened here?
Did he want to go to the hospital?
Did that conversation ever happen?
Was the ED the best place for this resident
to be evaluated?
Could his needs have been met in the
nursing home?
Could this transfer have been prevented?
How would you know?
Where would you begin?
Hospitalizations of NH residents
are common
In any six month period, more than 15% of long stay
residents are hospitalized
O Intrator, J. Zinn, and V. Mor, “Nursing Home Characteristics and Potentially Preventable Hospitalizations”
Journal of the American Geriatrics Society 52, no. 10(2004): 1730-1736
Previous research suggests many such hospitalizations are
inappropriate and are related to ambulatory care sensitive
45% of admissions of 100 residents from 7 Los Angeles
nursing homes to acute hospitals were rated as
Saliba et al, J Amer Geriatr Soc 48:154-163, 2000
Why this matters…
cause morbid
complications for
NH residents
Pressure Ulcers
Injurious Falls
Why this matters…
Unnecessary hospitalizations are expensive
 Medicare spent close to $200 million on hospitalizations
related to Ambulatory Care Sensitive Diagnoses among
long-stay NH residents in New York state in 2004
 This figure does not include residents on the Part A
skilled benefit, who get hospitalized frequently
Grabowski et al, Health Affairs 26: 1753-1761, 2007
The Opportunity
Reducing potentially avoidable
hospitalizations of NH residents
represents an opportunity to:
– Decrease emotional trauma to the
resident and family
– Decrease complications of
– Reduce overall health care costs
CMS Special Study awarded to Georgia
Medical Foundation July 2006-Jan 2008
– Looked at characteristics of NHs in Georgia
with high and low hospitalization rates
– Implemented toolkit in 3 NHs with high
hospitalization rates
– 50% reduction in hospitalizations
– 36% reduction in hospitalizations rated as
Funded by the Commonwealth Fund
Principal Investigator:
Dr. Joseph G Ouslander
Co-Principal Investigator:
Dr. Gerri Lamb
Independence Foundation and
Wesley Woods Chair
Associate Professor of Nursing
Emory University
Laurie Herndon, MSN, GNP-BC
Senior Project Coordinator
Alice Bonner, PhD, RN
Massachusetts Department of Public
Health (Currently at CMS)
Multidisciplinary teams from MA, NY, and FL
Obtain input
– National experts
– Frontline staff
Refine toolkit
Implement and evaluate refined toolkit
– Quality Improvement project
– Principals of Institute for Healthcare
Improvement (IHI) Collaborative
Collaborative Calls
– Collect data during the Collaborative that will be used
Understand factors and strategies that are
important for successful implementation and
sustained use of the toolkit
Estimate the costs of implementing the toolkit to
inform P4P initiatives
– Explore incorporating key elements of the toolkit into
health information technology (HIT) using web-based
formats and/or an electronic health record
Massachusetts Sites
Harbor House Nursing and Rehab Center, Hingham
Colonial Nursing and Rehab Center, Weymouth
North End Nursing and Rehab Center, Boston
Knollwood Nursing and Rehab Center, Worcester
Lifecare Center of Auburn
Rosewood Nursing and Rehab, Peabody
Blair House of Tewksbury
Mary Immaculate Nursing and Restorative Center,
9. Beaumont Skilled Nursing and Rehab Center,
10. Lifecare Center of Attleboro
Working Together to Improve Care,
Communication, and Continuity for
our Residents
Organization of Tools in Toolkit
Communication Tools
Clinical Care Paths
Advance Care Planning Tools
Purpose Of Toolkit
Aid in the early identification of a resident
change of status
Guide staff through a comprehensive resident
assessment when a change has been identified
Improve documentation around resident change
in condition
Enhance communication with other health care
providers about a resident change of status
Culture Change yields increased oversight
Where to keep it
Who should use it
Different languages
“Please fill this out
so I am certain not to
forget what you just
told me”
“We use it for
“Staff are really
learning, gathering
tools necessary to
communicate with the
“Organize Your
Thoughts Form”
“It took two nurses
working together 30
minutes to fill this out”
“This isn’t so different
from what we usually
“Gets easier with
Take old forms off
Now, we don’t hear
much at all about this
tool on the calls
Advance Care Planning Tools
Identifying Residents to
Consider for Palliative
Care and Hospice
Advance Care Planning
Communication Guide
Pocket Card
Comfort Care Order Set
File Cards
Educational Information
for Families
File Cards
“My initial determination was based on the fact that ….if the
patient was admitted….I automatically felt is was
unavoidable…..but I’ve had a culture change with my thought
Lessons so far….
Leadership “buy in” is
“This is great…we
would love to do this
at our facility”
Census Management
Patient Focused
Overall Costs
The frontlines are where it happens
The Champion is key
“I still think there is incredible
value to this project and am
going to keep working very
hard on it”
“I tell the staff to go out onto
the units and look for transfers
waiting to happen”
“I am going to elicit an alliance”
“I’m seeing it happen…walking
on the units and seeing the
nurses using the SBAR…it’s
Relationships matter
“Our NP told me she couldn’t believe how much
the nursing assessments have improved since
we started this”
“Does the ED staff know about this project?
They keep calling to ask about the forms.”
“The EMT’s wouldn’t sign the envelope”
“Does this mean they will be checking up on
“It’s all about teamwork”
Customizing the program
Grand Rounds
Morbidity and Mortality Rounds
NCR paper for Transfer Forms
Tools part of new hire orientation
Scratch cards, free lunch
“Its about more than just the tools. It’s
about culture and how you do business”
For tomorrow:
Getting Started
– How to use the website
– What is a champion and why do I need one?
– All of the tools with instructions for each
Deciding when and where to start
Tips for training staff
Informing family members about INTERACT II
Improving communication with the hospital
Quality Improvement Review and feedback
Case Studies
How to download the whole toolkit
The Challenge
Get started even if the
circumstances aren’t
Don’t let anyone tell
you that you won’t
Know that you’ll have
to fix some flats on
the road
Aim high
Worcester Galaxy IMPACT
Funding of Project
Massachusetts Technology Collaborative,
on behalf of Massachusetts e-Health
Institute (MeHI), applied to and received
from the United States Department of
Health and Human Services’ Office of the
National Coordinator for Health
Information Technology (“ONC”), two
awards of funding under the American
Recovery and Reinvestment Act (“ARRA”).
Funding of Project
January 2011, MTC responded to and was
awarded funding under ONC’s Funding
Opportunity Announcement for the Health
Information Exchange Challenge Program
in two challenge areas: Theme 2:
Improving Long-Term and Post-Acute Care
Transitions and Theme 5: Fostering
Distributed Population-Level Analytics.
Worcester Galaxy IMPACT
IMPACT - Improving Massachusetts PostAcute Care Transfers
Enable nursing homes and home health
agencies to participate in regional and
statewide Health Information Exchange
Improve the speed, efficiency, and
satisfaction of processes to provide
essential clinical data during transitions of
IMPACT - Objectives
Build on existing learning collaboratives to
help design, implement and disseminate
Finish development and testing of
Massachusetts Universal Transfer Form
Extend HL7 Continuity of Care Document
(CCD) to include all UTF data elements
IMPACT – Objectives continued
Develop application to view/edit/send
Develop consumer-oriented translator of
Pilot tools in Worcester County
Measure outcomes
Worcester Galaxy IMPACT
Beaumont Rehabilitation and Skilled Nursing Center, Westborough
Christopher House of Worcester
Fairlawn Rehabilitation Hospital, Worcester
Family Health Center of Worcester
Holy Trinity Nursing & Rehabilitation Center, Worcester
Jewish Healthcare Center, Worcester
Life Care Center of Auburn
Millbury Healthcare Center
Notre Dame Long Term Care Center, Worcester
Overlook Visiting Nurses Association
Radius Healthcare Center Worcester
Reliant Medical Group (formerly known as Fallon Clinic), Worcester
Saint Vincent Hospital, Worcester
UMass Memorial Health Care, Worcester
VNA Care Network and Hospice, Worcester
Worcester Galaxy IMPACT
These 15 healthcare organizations will first pilot and
validate a paper Universal Transfer Form over the next
four months, followed by the electronic version of the
form next year. Developed by the Massachusetts
Department of Public Health, the Universal Transfer
Form is critical to ensure that patients receive safer,
more efficient and a higher quality of health care when
making the transition between acute care and post-acute
care settings. The form is critical to ensure that patients
receive safer, more efficient and a higher quality of
health care when making the transition between acute
care and post-acute care settings.
Internet based Local Application for
Network Distribution
Surrogate EHR Environment
Worcester Galaxy IMPACT
Transitions in Care Collaborative was
chosen to participate in the federal
government’s "Community Based Care
Transitions Program” under Section 3026
of the Affordable Care Act.
Accountable Care Organization
Atrius Health
Beth Israel Deaconess Physician
Mount Auburn Cambridge Independent
Practice Association
Eastern Maine Healthcare System
Dartmouth-Hitchcock ACO.
….. proponents say, such systems provide
financial incentives for health care
providers to give better care at lower cost
by improving communication between
specialists and primary care doctors,
reducing unnecessary tests, and focusing
on preventive care.
Paul J. O’Connell
[email protected]
508-898-3490 ext. 3708

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