The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care

Abstract

Interventions to Reduce Acute Care Transfers (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. Effective implementation has been associated with substantial reductions in hospitalization of nursing home residents. Familiarity with and support of program implementation by medical directors and primary care clinicians in the nursing home setting are essential to effectiveness and sustainability of the program over time. In addition to helping nursing homes prevent unnecessary hospitalizations and their related complications and costs, and thereby continuing to be or becoming attractive partners for hospitals, health care systems, managed care plans, and accountable care organizations, effective INTERACT implementation will assist nursing homes in meeting the new requirement for a robust quality assurance performance improvement program, which is being rolled out by the federal government over the next year.

Keywords: Hospital readmissions; quality improvement programs.

Figure 1. Overview of the INTERACT Program in Every Day Care

This overview illustrates the use of the INTERACT Program in every day care in the nursing home, from the time of admission, to identifying a change in condition, and communicating and documenting relevant information; as well the quality improvement components of the program at the bottom of the figure.

Figure 2. Example of an INTERACT Quality Improvement Dashboard

This is one example of the type of quality improvement data that can be generated from the INTERACT program. Figure 2a illustrates how 30-day readmission rates can be tracked, trended over time, and benchmarked against another group of nursing homes. Figure 2b illustrates how data from the root cause analyses of transfers using the INTERACT Quality Improvement Tool can be summarized to highlight areas for education and care process improvements. In this example summarizing over 1000 transfers, the most common changes in condition associated with transfers were abnormal vital signs, altered mental status, uncontrolled pain, and shortness of breath; about two-thirds were handled by telephone only; one-third occurred during evening or night shifts; about one-quarter occurred on a weekend; and one in five were rated as potentially preventable.

Figure 2. Example of an INTERACT Quality Improvement Dashboard

This is one example of the type of quality improvement data that can be generated from the INTERACT program. Figure 2a illustrates how 30-day readmission rates can be tracked, trended over time, and benchmarked against another group of nursing homes. Figure 2b illustrates how data from the root cause analyses of transfers using the INTERACT Quality Improvement Tool can be summarized to highlight areas for education and care process improvements. In this example summarizing over 1000 transfers, the most common changes in condition associated with transfers were abnormal vital signs, altered mental status, uncontrolled pain, and shortness of breath; about two-thirds were handled by telephone only; one-third occurred during evening or night shifts; about one-quarter occurred on a weekend; and one in five were rated as potentially preventable.

Figure 2. Example of an INTERACT Quality Improvement Dashboard

This is one example of the type of quality improvement data that can be generated from the INTERACT program. Figure 2a illustrates how 30-day readmission rates can be tracked, trended over time, and benchmarked against another group of nursing homes. Figure 2b illustrates how data from the root cause analyses of transfers using the INTERACT Quality Improvement Tool can be summarized to highlight areas for education and care process improvements. In this example summarizing over 1000 transfers, the most common changes in condition associated with transfers were abnormal vital signs, altered mental status, uncontrolled pain, and shortness of breath; about two-thirds were handled by telephone only; one-third occurred during evening or night shifts; about one-quarter occurred on a weekend; and one in five were rated as potentially preventable.

Figure 3. Example of an INTERACT Care Path

The INTERACT care path for Symptoms of Lower Respiratory Illness is one of nine that provide guidance on evaluation and management of common conditions precipitating hospital transfers. 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.