Care transitions, when patients are transferred from one care provider to another or from one care setting to another, have been associated with high rates of adverse events and a 20% re-hospitalization rate within 30 days of transfer. Improving care transitions is a key strategic priority of the Mass Senior Care Foundation, which is leading the way or participating in the following initiatives:
The Care Transitions Education Project
In August 2011, Mass Senior Care Foundation received a Robert Wood Johnson Foundation and Northwest Health Foundation Partners Investing in Nursing's Future grant for the Care Transitions Education Project. This exciting three year initiative will prepare and empower more nurses to lead effective care transitions, and complement regional and state efforts to reduce avoidable readmissions, and improve quality care while reducing costs. Click here for more information.
Massachusetts Skilled Nursing Facilities Leading the Nation with the INTERACT Quality Improvement Program (www.interact2.net)
INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The program in includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
The INTERACT Quality Improvement Program was initially developed by Dr. Joseph Ouslander and colleagues as part of a CMS special study in Georgia from 2006-2008. Massachusetts nursing facilities became involved in a follow up project funded by the Commonwealth Fund in 2009.
Ten Massachusetts facilities participated in a 6 month collaborative project with ten facilities in NY and ten in FL that evaluated the INTERACT II toolkit. Participating sites were asked to provide feedback on the content and format of the toolkit and the feasibility of implementing it. Feedback from this collaborative led to several revisions to the toolkit and a change in focus from calling INTERACT II a toolkit to a Quality Improvement Program. Massachusetts facilities were instrumental in these revisions.
Transfers to the acute care hospital were reduced by 17% overall among the participating facilities. Engaged facilities (those who had good attendance on collaborative calls and regular submission of data and highly motivated project leaders) demonstrated a 24% reduction in transfers.
Some of the best results were in MA facilities with one facility reporting a reduction of more than 70% in acute care transfers during the project period.
This initial work has sparked incredible interest statewide from all sectors of health care. Additional funding from the Practice Change Fellowship allowed more than 100 additional sites to receive training on the INTERACT toolkit in 2010-2011. We estimate that 225 Massachusetts skilled nursing facilities have received training and have either implemented or are in the process of implementing the INTERACT Quality Improvement Program.
Facilities that have implemented the INTERACT Quality Improvement Program have brought valuable resources and strategies to STAAR Cross Continuum teams and have been identified as ideal pilot sites for other statewide projects including the MOLST pilot and demonstration project, the IMPACT project (development of an electronic universal transfer form), and as Community Based Care Transitions Grant partners.
Cross continuum partners including acute care hospitals, physician practices, and Aging Service Access Points have been actively seeking information about and training on the INTERACT Quality Improvement Program. Recent training sessions have included cross continuum partners coming together to begin working on reducing readmissions together.
For more information on the INTERACT Quality Improvement Program, contact Laurie Herndon, MSN, GNP-BC, Director of Clinical Quality @firstname.lastname@example.org
STAAR (State Action on Avoidable Re-hospitalizations Initiative)
Recently, the Institute for Healthcare Improvement (IHI) launched the State Action on Avoidable Re-hospitalizations (STAAR) initiative — a multi-state, multi-stakeholder approach to dramatically improve the delivery of effective care at a regional scale. This initiative aims to reduce re-hospitalizations by working across organizational boundaries in three states, Massachusetts, Michigan, and Washington — by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces. Through supporting the strategy and leadership of state-level Steering Committees in the three states, IHI aims to help states reduce state-wide 30-day re-hospitalization rates by 30 percent and to increase patient and family satisfaction with transitions in care and with coordination of care.
The engagement with cross-continuum partners is integral to the core principle of co-creating the ideal communication processes between “senders” and “receivers” across care settings. The second phase of this work will consist of a collaborative learning network to improve the “reception” into the post-acute setting of care: the medical home and/or the skilled nursing facility. Many MA skilled nursing facilities are currently participating on these cross continuum care teams. For more information on this project, please contact our Director of Clinical Quality, Laurie Herndon.
Care Transitions Forum
While the Centers for Medicare and Medicaid Services, the National Quality Forum and other national organizations have undertaken major efforts to reduce re-hospitalizations due to poor care transitions from hospital to home, little attention has been paid to care transitions from hospital to nursing facility and nursing facility to home.
To help fill this void, the Massachusetts Senior Care Foundation formed a Care Transitions Task Force focused specifically on issues that occur during transfers. Later joined by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Health Data Consortium, the task force has now grown to include nearly 70 member organizations and has changed its name to the Care Transitions Forum.
In 2008, the Care Transitions Forum was asked to lead a work group on care transitions for the Massachusetts Health Care Quality and Cost Council, the entity mandated under the state’s health care reform law to forge quality and cost effective improvements across the health care system.
The work began in 2008 and includes the design and implementation of a statewide strategic plan for care transitions, participation in new demonstration projects led by partners such as the Institute for Healthcare Improvement, Partners HealthCare, Commonwealth Medicine, and others. The Care Transitions Forum also sponsors seminars on care transitions for health and informatics professionals.
Efforts to prevent the negative consequences associated with poor care transitions involve improving communication among providers, creating standardized tools and processes, encouraging patients and families to be more involved in and educated about their own health care, and measuring results.
More information on improving care transitions is available from the National Transitions of Care Coalition, and the Care Transitions Program.
If you would like more information about the Massachusetts Care Transitions Forum, please contact Laurie Herndon.
Resources for preventing re-hospitalization