the interact ® program home health agencies carol higgins, otr (ret.), cphq certified interact ®...
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The INTERACT® ProgramHome Health Agencies
Carol Higgins, OTR (Ret.), CPHQ
Certified INTERACT® Educator
Qualis Health Washington
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Qualis Health • A leading national healthcare consulting organization• The Medicare Quality Innovation Network - Quality
Improvement Organization (QIN-QIO) for Idaho and Washington
The QIN-QIO Program • One of the largest federal programs dedicated to
improving health quality at the local level
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Today’s Objectives
Provide an overview of quality improvement relative to Home Health Agencies utilizing components of the INTERACT® Program • Provide an expanded view of individual
Tools• Discuss tips for implementation of the tools
and experience with use
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“Drivers” of Poor Transitions
Lack of patient and family activation• Health literacy• Self-management skills & tools• Motivation, locus of control
Lack of standard and known processes• Patient discharge, hand-over• Internal work flow
Lack of information transfer• Especially cross-setting • Delays, inaccuracies, missing information
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Two Approaches to Interventions
System changes – Hardwiring standard and reliable processes – Benefit: Broad reach for all patients, all payers, all units– Challenge: Improving and sustaining processes is hard work!
Targeted population interventions– Usually chronic condition-specific (like HF) – Coaching, case management– Benefit: care based on identified risk– Challenge: narrow focus, may not move overall readmit rate
The INTERACT® Program is a system/culture change intervention
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The INTERACT® Program
• Includes evidence and expert-recommended clinical practice tools, strategies to implement them, and related educational resources
• The program is located athttp://interact2.net
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Acknowledgement
• The INTERACT® Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Centers for Medicare & Medicaid Services (CMS).
• The current versions of the INTERACT® Program were developed by the INTERACT® interdisciplinary team under the leadership of Dr. Joseph G. Ouslander, MD with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund.
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The INTERACT® Program is Much More than a Toolkit
• This program is not just for SNFs anymore• Most providers are only aware of INTERACT® as a
few tools like “Stop and Watch” or “SBAR”• The overall Program is much more and can provide
significant benefit to both post-acute providers and hospitals
• Prime examples are the full program components and use of the Quality Improvement Tools
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Overview INTERACT® DocumentsHome Health
• INTERACT® Home Health Version 1.0 Tools
• Using the INTERACT® Home Health Version 1.0 Tools in Every Day Care
• Home Health Version 1.0 Tool Implementation Guide 2013
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Differences with the INTERACT® Program
• Agencies using the INTERACT® Program components are focused on improving the quality of care for patients and reducing hospital readmissions
• Use of INTERACT® tools provide staff guidelines for assessment and intervention to identify changes in condition sooner
• INTERACT® tools assist agencies to identify and provide for educational needs of staff
• Use of evidence-based, standardized tools allows for clear, comprehensive communication and coordination across all settings, particularly during transfers
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The INTERACT® Program
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Organization of Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
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Organization of Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
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Quality Improvement Tools
• Acute Care Transfer Log • Quality Improvement Tool for Review of
Acute Care Transfers• Quality Improvement Summary Worksheet• Implementation Checklist
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Quality Improvement Tool
Purpose • Review each transfer to understand the reasons
for transfer• Identify possible opportunities to prevent avoidable
transfers
When to Use• Within 24-48 hours after transfer• Representative sample of transfers to look for
common patterns & identify improvements
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Quality Improvement Tool
Who – Incorporate into existing QI process
– Form an acute care transfer team
– If one staff person, they interview team members
– Include rehab and social work staff
– Family members may have important contribution
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Quality Improvement Tool
• Root Cause Analysis: The Rest of the Story
• Demographics • What happened? • Contributing factors • Attempts to manage in
home • Avoidable? • Staff thoughts about this • “Ah ha” moments
• Should have returned sooner?
• Opportunities for improvement
• Cross continuum review of cases
• Consider return to SNF if patient came from that setting rather than sending to ED or hospital
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QI Summary Worksheet
• Moves the focus from individual QI Tools (one patient) to patterns across all QI Tools (multiple patients)
• Allows patterns to begin to form• Focuses improvement activities• Unfortunately not often used – a missed
opportunity!
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QI Summary Worksheet
• Step 1: Number and timeframe of individual QI Tools in the summary
• Step 2: Compares across categories• Patient characteristics• Changes in condition• Actions taken• Hospital transfers and contributing factors• Potentially preventable?
• Step 3: Summarizes common factors
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Root Cause Analysis (RCA)
• Identifies causal factors leading to acute care transfers
• Shows what efforts were made to treat in home or return to SNF if appropriate
• Highlights common patterns• Identifies possible gaps in either facility
processes or staff knowledge
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Organization of Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
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Communication Tools
Two sections of Communications Tools:
1. Communications within the agency
2. Communications between agency and hospital
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Communication Tools
1. Communications within the agency
• Stop and Watch Early Warning Tool• SBAR Communication Form and Progress
Note for Home Health
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Stop and Watch Early Warning Tool
Purpose – Identify and document changes in patients
– Communicate changes to other members of the team
– Identify possible opportunities to prevent a hospital transfer
– Improve over all level of care
When to use– Tool should be completed for ALL changes on a visit-by visit
basis, by staff with direct contact with the patient
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SBAR Communication Tool
• Used by all licensed staff to evaluate and communicate acute changes in condition to MD, NP, and/or PA
• Documentation tool for both the evaluation and the communication
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Communication Tools
2. Communications between home health agency and hospital:
• Home Health Capabilities List• Home Health to Hospital Transfer Form• Home Health to Hospital Data List• Acute Care Transfer Document Checklist• Hospital to Home Health Transfer Form• Hospital to Home Health Data List• Medication Reconciliation Worksheet for Post-
Hospital Care
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Medication Reconciliation Worksheet
Structured medication reconciliation for new admissions or patients returning from the hospital to identify discrepancies and other issues
• Part 1: Hospital recommended medications needing clarification
• Part 2: Medications Prior to hospitalization needing clarification
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Effective Communication
• It is not about the forms…
it is about the connections• Receivers need to be aware of what the form
or document includes• Goal is to have receiver use the information• Poor communications = poor outcomes
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Organization of Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
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Decision Support Tools
• Vital elements of the overall INTERACT® Program
• Builds on the basic structure of the Quality Improvement and Communication tools
• Provides evidence-based guides for assessment and management of common changes in patient status
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Change in Condition File Cards and Care Paths
Purpose• Guide the assessment and management of common
changes in patient status that result in acute care transfers
• Provide evidence-based assessment & management
• Insure timely assessments, communication with providers and acute care transfer as needed
• Manage in place when feasible and safe
• Improve the overall level of care for patients with changes in status
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Change in Condition File Cards
• Decision support tools for the staff to help with determining whether to report specific symptoms, signs, and lab results immediately, vs. non-immediately (e.g. the next day)
• These comprehensive, alphabetized tools include explicit criteria for notifying primary care clinicians
• Engagement and buy-in of the medical director and primary care clinicians is critical to their success
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Care Paths
• Acute Mental Status Change
• Change in Behavior – New or Worsening Symptoms
• Dehydration
• Fever
• GI Symptoms: Nausea, vomiting, diarrhea
• Shortness of Breath
• Symptoms of lower respiratory illness
• Symptoms of CHF
• Symptoms of UTI
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Change of Condition File Cards and Care Paths
Helpful Tips – Use in educational in-services
– Modify specific recommendations per input from interdisciplinary team
– Hang posters in high visibility location for reference
– Include in staff packets
– Use a log to notify primary care MDs of condition changes not requiring immediate notification
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Organization of Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
Quality Improvement Tools
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Advance Care Planning
In order to make a difference, we must change our focus away from forms and toward work systems
• Proactive communication about stages of illness and progressive frailty
• Anticipate complications• Use values to set goals• Use goals to make decisions• Offer specific alternatives
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Advance Care Planning Tools Purpose:
• Guide conversations about EOL, advance directives and comfort/palliative care
• Communicate effectively with patients & family members
• Provide patients with comfort and dignity measures• Assure patients receive level of care consistent
with their wishes• Increase staff dialogue about EOL care, advance
directives and comfort / palliative care
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Advance Care Planning Tools
• Advance Care Planning Overview• Advance Care Planning Tracking Form• Identifying Patients Appropriate for Hospice or
Comfort Care• Comfort Care Interventions• Educational Information
Deciding About Going to the Hospital
Education on CPR and Tube Feeding
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Advance Care Planning Tracking Form
• Documents and tracks advance care planning discussions and refers to more detailed notes about the discussion
• Shows changes over time as needed or appropriate
• Includes:• Status at admission (within about a week of
admission/readmission)• Advance Care Plan review and/or discussion
updates
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Advance Care Planning Resources
Additional Resources for Staff and Families (available free on the internet)
• American Association for Retired Persons • The Coalition for Compassionate Care • The Conversation Project • Closure.org • Caring Connections of the National Hospice and
Palliative Care Organization
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Summary
Today we have delved into the background of the need for an improved focus on safe and effective transitions of patients between settings
– What is of concern– How you fit into the overall picture– The roll of the INTERACT® Program– The need to emphasize the Quality Improvement
components of the INTERACT® Program– Tips on implementation of all of the Tools
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Round Table Discussionand Sharing
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Questions?
Carol Higgins, OTR (Ret.), CPHQ Qualis Health
For more information:
www.Medicare.QualisHealth.org/projects/care-transitions
This material was prepared by Qualis Health, the Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-C3-QH-1696-03-15