Interact version 3.0 tools

This thorough training course provides a detailed description of the Quality Improvement Program, care processes, tools, and other resources to improve care of changes in condition and prevent unnecessary hospitalizations. Quality Improvement Tools. Review, document and summarize resident transfers to identify opportunities to improve identification, evaluation and management of resident change in condition. This tool is a paper and pencil worksheet that can be used to calculate hospital transfer measures to enter into an Excel or other data base.

This tool for use by facility leadership and members of the quality committee can be used to calculate hospital transfer outcomes unplanned admissions, day admissions, emergency room visits without admission using standard definitions, and identify trends.

This QI form reviews and documents transfers to identify opportunities to improve identification, evaluation and management of resident change in condition and other situations that commonly result in transfers to the hospital; and when feasible and safe, to help prevent transfers. Communication Within the Nursing Home. Use these tools to prompt staff - including CNAs, dietary, rehab and environmental services - to communicate changes in condition with nursing staff.

Nursing staff can use the information to enhance nursing evaluations and communication with primary care clinicians. This tool provides a simple, clear way to communicate changes in condition to nursing staff.

This tool provides a simple, clear way to document and communicate changes in condition to nursing staff. This convenient 2-part, Spanish, pocket-sized "booked" version makes it easy to carry and document possible observed changes in a resident's condition.

The SBAR is designed to enhance the nursing evaluation of and documentation for residents who have an acute change in condition. This tool is intended to help structure and improve communication with primary care clinicians. For patients discharged from acute hospitals for post-acute care, medication reconciliation is a critical task. This worksheet is designed to help nurses, primary care providers and pharmacists develop accurate and safe medication orders at the time of admission for new admissions from the hospital or residents returning from the hospital.

Communication Between the Hospital and Nursing Home. Utilize these communication tools to help clearly and succinctly communicate a wide range of critical information to the hospital, as well as provide resident's medical documents and belongings to emergency room staff during acute care transfers.

These tip sheets provide keys to improving communication and collaboration with hospitals, a hospital engagement checklist, as well as, an explanation on how INTERACT can help hospitals better manage readmissions and why collaboration with nursing homes is important. This tool for use by all nursing home licensed nursing staff and ER staff provides a standardized pre-populated checklist explaining nursing home capabilities for decisions about transfers back to the nursing home.

It is recommended that it be posted in emergency rooms and provided to hospital discharge planners. This tool for use by all nursing home licensed nursing staff and ER staff provides recommended data elements to be included in paper or electronic forms. The Transfer Checklist Envelope is designed to ensure that personal belongings and contents, such as medical documents, necessary for emergency room staff to make appropriate evaluation of the resident, accompany the resident to the hospital.

This tool for use by all nursing home licensed nursing staff and primary care clinicians; and hospital discharge planners, nurses and discharging physicians provides recommended data elements to be included in paper or electronic forms at the time of transfer from the hospital to the nursing home or SNF. Decision Support Tools.

Use Decision Support Tools in everyday care to help the recognition, evaluation, management and reporting of specific symptoms and signs.

This stand-up guide provides decision support tools to help nursing staff determine whether to report specific symptoms, signs and lab results immediately versus non-immediately e. The pocket-sized guide provides decision support tools for the nursing staff to help with determining whether to report specific symptoms, signs and lab results immediately or non-immediately e. This pocket guide also contains all ten of the Care Paths including, dehydration, fever, and more. Care Paths Guide item MP This page, coil-bound book contains the ten Care Paths, educational decision support tools that provide guidance on the recognition, evaluation, and management of the conditions that commonly cause hospital transfers, and provide guidance on when to notify the primary care clinician.

The Care Paths are educational decision support tools that provide guidance on the recognition, evaluation, and management of the conditions that commonly cause hospital transfers, and offer guidance on when to notify the primary care clinician. Advance Care Planning Tools.

This educational tool lists criteria to help nursing home staff determine residents who may be appropriate for hospice care, palliative care or comfort care orders.

This tool for licensed nurses and primary care clinicians provides guidance in the form of examples of orders that may be appropriate for residents on palliative or comfort care plans who decline hospice. In order for these decision support tools to be effective in everyday practice, the medical director and all primary care clinicians, including those who cover after hours, must be familiar with and support the use of these tools.

One of the most common reasons cited by expert clinicians in rating hospitalizations of nursing home residents potentially avoidable is that for some residents with severe end-stage illness, the risks of hospitalization outweigh the benefits Moreover, family insistence on transfer to the hospital is a commonly cited reason for not attempting to manage changes in condition in the nursing home Research has clearly shown that such care transitions can be burdensome in this population 25 , and that implementation of advance care planning interventions can result in positive outcomes While an increasing number of nursing home residents have advance directives, the process of advance care planning and updating the advance directives at critical times may not be optimal.

As suggested in Figure 1 , advance care planning should be undertaken, regardless of whether advance directives are already in place, at the time of admission or readmission to the facility, at regular intervals for example at quarterly care planning meetings , and at the time of changes in condition. Residents and families may change their mind about advance care plans and directives in these situations. A fundamental theme underlying these tools is that advance care planning is a team endeavor and not just the responsibility of the primary care clinician.

The Communication Guide is based largely on publications by Quill and colleagues 27 , 28 and is meant for staff education, including role playing. Other INTERACT tools have been carefully constructed to be simple and illustrative in order to assist residents and families in making decisions about hospital transfer and other interventions such as cardiopulmonary resuscitation and gastrostomy tube feeding The Comfort Care Interventions tool includes a sample set of palliative care orders and is intended to be helpful in situations where hospices which generally have similar order sets are either not available or not desired by the resident or family.

These same characteristics also provide the foundation for successfully overcoming common barriers to implementation. A sample of specific strategies used by executive leaders and INTERACT champions as well as examples of nursing facility culture that supports quality improvement are described in Table 1. Participating in review and discussion of data including acute care transfer rates and summary of Quality Improvement Review Tools.

This section further requires CMS to provide technical assistance, tools and resources for providers, in advance of CMS promulgating the new regulation. While focused on the upcoming requirement for QAPI, many facilities are simultaneously trying to position themselves to be attractive partners to ACOs.

As part of that strategy, facilities are looking at ways to reduce unnecessary hospitalizations of SNF and NF residents. A QAPI questionnaire conducted by Abt Associates in revealed that many nursing home organizations do not have the infrastructure, skills, expertise, or personnel to develop and implement comprehensive, facility-wide QAPI plans INTERACT may provide these organizations with a way to begin to develop their QAPI plans and become more attractive to ACOs, with an initial focus on reducing hospital readmissions that addresses many care processes throughout the entire organization.

While there has been widespread uptake of INTERACT, in some cases facilities may only be using some of the tools and processes; therefore fidelity to the original model is a concern. Facilities will need to demonstrate that comprehensive programs for dementia care, fall prevention, reducing hospitalizations and others are well integrated within the larger QAPI framework.

Similarly, engaging families in care processes, whether the issue is reducing pressure ulcer risk or maintaining continence can improve many other quality outcomes simultaneously, since the care team will have more information about the person living in the nursing home.

Having multiple, disparate initiatives will not meet the intent of section with respect to a comprehensive, systems-based QAPI program.

All have been made consistent with expert recommendations; the care path shown is based on one proven to reduce hospital admissions by Loeb and colleagues in Canadian nursing homes ref.

Clinicians may elect to use alternative specific criteria in the care paths and change in condition guidance, but working with nursing staff on common approaches, language, and explicit criteria for alerts is critical to the effectiveness of the INTERACT program. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication.

As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form.

Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. National Center for Biotechnology Information , U. J Am Med Dir Assoc. Author manuscript; available in PMC Mar 1.

Joseph G. Ouslander , M. P, 3 Laurie Herndon , M. Ouslander 1 Charles E. Jill Shutes 1 Charles E. Author information Copyright and License information Disclaimer. Corresponding Author: Joseph G. Ouslander, M. Copyright notice. See other articles in PMC that cite the published article. Abstract INTERACT is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents.

Open in a separate window. Figure 1. Quality Improvement Tools Fundamental aspects of implementing an effective quality improvement program include tracking, trending, and benchmarking well-defined process and outcome measures, and conducting and learning from root cause analyses of events. Figure 2. Communication Tools INTERACT includes tools designed to improve communication and documentation within the nursing home, as well as between the nursing home and hospital.

Advance Care Planning Tools One of the most common reasons cited by expert clinicians in rating hospitalizations of nursing home residents potentially avoidable is that for some residents with severe end-stage illness, the risks of hospitalization outweigh the benefits Recognizes that organizational improvement takes time and takes the lead in sustaining focus by keeping INTERACT as agenda item at all staff and quality meetings.

Successful implementation depends on the right person s in this role. Agrees or volunteers to be champion. Delivers training according to time available; starting on one unit at a time with one tool at a time if needed.

Provides medical director, MDs, NPs and PAs with data regarding acute care transfer rates and summary of Quality Improvement Reviews on regular basis and seeks input on strategies to improve care relative to findings of data collection. Training modules describe the vital role of leadership in providing resources for INTERACT implementation and the need for an ongoing dialogue between leadership and direct care staff.

Reports from the QI review tool may be shared with leadership and the Board so that they can determine next action steps. Board members are actively engaged with direct care staff and families, are visible on the units and can articulate QAPI principles to families and staff. Feedback, Data systems and Monitoring SBAR tool enhances communication, feedback and monitoring between nurses and primary care providers. Stop and Watch tool enhances communication among CNAs, other staff, family members and nurses.

Nurses provide feedback to direct care staff about their completion rates of the Stop and Watch tool, as well as the quality of the information. The QI review tool generates data and reports that are shared with direct care staff.

Changes in attitudes and behaviors with respect to early identification of change in condition are monitored by supervisors and leadership, and an open dialogue is encouraged.

Staff may use the transfer log and the list of people with a change in condition who are not transferred to review the decisions to transfer or not to transfer and make appropriate practice changes based on data. Input from direct care staff is encouraged, valued and accepted in a non-punitive atmosphere. Performance Improvement Projects PIPs Decision support tools such as the care paths can be implemented and tested in a PIP and modified to meet the specific needs of an individual facility.

Data from the QI review tools may lead to prioritizing decisions about areas of concern that may merit PIPs. For example, if transfers are occurring due to bleeding and it is noted that INR values are often out of range, a PIP with respect to lab monitoring might be initiated.

Systematic Analysis and Systemic Action The reports generated from QI review tools, as well as reports that could be shared based on completion of SBAR or Stop and Watch data provide patterns and help to identify fundamental, systemic issues throughout the facility such as failures in communication, weak teamwork, inadequate documentation, delays in relaying critical information across departments, etc. Networking with cross-continuum teams and hospital partners supports enhanced and seamless care across transitions and provider types that consider the nursing home part of the larger health care system.

Principles in the Advance Care Planning tools support patient and family engagement, person-centered care and a focus on patient self-determination of their goals of care. Consistent implementation of those tools represents systemic action throughout the facility. Conclusion INTERACT is a publicly available quality improvement program that focuses on improving the identification, evaluation, and management of acute changes in condition of nursing home residents. Figure 3. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication.

References 1. Health Aff. J Am Geriatr Soc. Ouslander JG, Maslow K.