Many of the companies interviewed for this article rely to one extent or another on the Interventions to Reduce Avoidable Hospitalizations of Nursing Home Residents (INTERACT II) program.
The program includes clinical and educational tools and strategies that long term care facilities can use every day to reduce unplanned hospitalizations. The initial INTERACT tools were developed by Joseph Ouslander, MD, and Mary Perloe, RN, GNP, with the Georgia Medical Care Foundation, the state’s Medicare quality improvement organization, under contract with the Centers for Medicare & Medicaid Services.
The INTERACT II program, available for free at http://interact2.net, includes clinical and educational tools and strategies that long term care facilities can use every day to reduce unplanned hospitalizations. They were designed to be simple and feasible to incorporate into the everyday routine of long term care staff.
Identify And Communicate
The tools in INTERACT are essentially geared to help facilities more quickly identify changes of condition in residents—this being crucial to catching a developing condition quickly and intervening before hospitalization is necessary—and more effectively communicate those changes and other relevant clinical information up the clinical hierarchy, from nurse assistant to director of nursing to physician and, ultimately, to the hospital should a transfer become necessary.
The tools also assist staff in managing those difficult advance care planning discussions that are so necessary and help staff in their quality improvement efforts. SavaSeniorCare, Atlanta, has “embraced” the INTERACT II program, says Donna Hendrickson, Sava’s senior vice president of clinical services.
Sava started a pilot with the program at the end of 2009, says Hendrickson, focusing on Michigan, Maryland, and the Gulf Coast of Texas. They worked with staff to give the program its best chance of success so that they could get a good idea of to what extent the program could reduce hospitalizations.
The INTERACT II program hasn’t been implemented in all nursing facilities in Sava’s portfolio. The company carefully reviewed each nursing facility to see if it was a good candidate for the program.
Communication Tools
Change-Of-Condition File Cards. Hendrickson especially likes INTERACT’s “Stop and Watch” pocket card that all CNAs—called resident care specialists at Sava—carry in their pockets and that are available at a centrally located kiosk where any employee, such as a housekeeper or dietary staff, can pick one up if they notice something off about one of the resident’s behavior or functioning. The card walks CNAs or other staff through the things to keep in mind when being around a resident, starting with a general impression of the person’s well-being and questions about their mental status and physical functioning. The cards are given to the nurse or head nurse on each shift.
Care Paths. To help nurses identify whether a situation requires a call to a physician or can be managed within the facility are six care paths that cover conditions that commonly result in transfers to the hospital: dehydration, fever, mental status change, congestive heart failure, lower respiratory infection, and urinary tract infection.
The care paths walk staff through taking vital signs and further evaluation, clearly indicating via a flow chart at what points a physician should be called immediately and when it should be managed in-house.
Situational Background Assessment Recommendations (SBAR). When a physician does need to be notified, the nurse fills out an SBAR, a communication tool that helps nurses and doctors convey information in a way that everyone understands. The tool facilitates the evaluation of a resident’s condition—as well as the communication of the information gleaned—to the primary care physician. It follows standardized criteria and provides clear guidelines. It also documents what was communicated.
When a resident has a change of condition, before calling the doctor, the nurse checks with other staff members—CNAs, rehabilitation staff, social workers, activities staff—who have regular contact with the resident to get an accurate history and possibly a family member to clarify advance directives. The nurse then reviews the resident’s chart for diagnoses, medications, and recent progress notes from the primary care clinician and nurses, and fills out the SBAR and calls the primary care clinician, keeping the medical chart nearby for easy reference.
Acute-Care Transfer Package. When the resident is ready to go to the hospital, a packet of medical information goes with them. On the front of this packet is a checklist to ensure that such things as a medication list; advance directive; the SBAR; summary of the most recent history and physical; any recent hospital discharge; recent primary care clinician’s orders; relevant lab results or X-rays; whether the resident has glasses, a hearing aid, or a dental appliance sent with them; and a space for the ambulance staff taking the packet of documents to sign his or her name.
A copy of the checklist is kept for the facility’s records. This packet of valuable information will help emergency room staff do the most appropriate evaluation on the resident and ensure that the hand-off is done safely. A phone call from the primary care clinician to the doctor at the emergency room is recommended, as is a phone call from the long term care nurse to the hospital nurse, so that all relevant information is communicated.
Advance Directives. INTERACT’s advance care planning tools help nurses initiate the conversation from the very beginning about end-of-life care, advance directives, and palliative care and helps staff determine when a resident is in the dying phase of life. All staff should be familiar with end-of-life care so they can respond to families’ questions. INTERACT’s advice is that before ever having the first conversation about advance care planning, make sure the resident’s conditions and prognosis are clear, then find a private environment where the resident and staff member can have the discussion.
Start by encouraging them to talk and recognize resident and family concerns. Identify loss, legitimize and explore feelings, and offer support. Ask what everyone understands about advance care planning and about the resident’s condition and prognosis. Ask what their goals for care are. Ask about their advance care planning wishes, including cardiopulmonary resuscitation, artificial hydration and nutrition, and palliative care. Communicate the need to hope for the best while preparing for the worst. Focus on the positive, be humble, and don’t force decisions.
Quality Improvement (QI). Hendrickson says INTERACT’s QI tools are another key component of the program so Sava can find out “what can we learn from this so we can work with our staff” on ways to improve care. The QI tools include an acute-care transfer log and a quality improvement tool for the review of transfers.
Get a list of all emergency room transfers twice a month, and complete the QI review tool for two to three transfers per week. This helps staff identify what triggered the hospitalization and whether it could have been avoided and how.
Source: INTERACT II, Florida Atlanta University, Boca Raton, Fla.