Hospitalizations of frail nursing home residents can result in higher costs, complications and death. According to the “Revolving Door of Rehospitalization from Skilled Nursing Facilities,” a paper published in the January 2010 issue of Health Affairs, 23.5 percent of Medicare beneficiaries discharged from the hospital to a skilled nursing facility (SNF) were readmitted to the hospital within 30 days at a cost to Medicare of $4.34 billion in 2006. These rehospitalizations are frequent and costly. Research suggests that a substantial amount of these hospitalizations may be preventable.
A low-cost, yet high-impact quality improvement program designed by researchers in the Charles E. Schmidt College of Medicine and the Christine E. Lynn College of Nursing at Florida Atlantic University can play a critical role in assisting nursing home staff to improve quality of care, and reduce morbidity and expense of unnecessary hospitalizations. Interventions to Reduce Acute Care Transfers (INTERACT) is a quality improvement program that includes tools that assist nursing home staff in three strategies that can reduce preventable hospitalizations: 1) identifying, assessing and managing conditions to prevent them from becoming severe enough to require hospitalization; 2) managing selected conditions, such as respiratory and urinary tract infections in the nursing home without hospital transfer when safe and feasible; and 3) improving advance care planning and developing palliative care plans as an alternative to acute hospitalization for residents at the end of life when the risks of hospitalization may outweigh the benefits.
The INTERACT quality improvement projects are directed by Joseph Ouslander, M.D., senior associate dean for geriatric programs in the Charles E. Schmidt College of Medicine at Florida Atlantic University. The most recent evaluation, supported by a grant from The Commonwealth Fund, was implemented at 25 community-based nursing homes in Florida, Massachusetts and New York over a six-month period. The results of the evaluation in these 25 nursing homes were recently published in the April 2011 Journal of the American Geriatrics Society.“The effects of the intervention were substantial,” said Ouslander. “The most significant finding from this collaborative quality improvement project was a 17 percent reduction in hospital admissions among the residents. The reduction was even greater in homes that were more engaged in implementing the INTERACT intervention.”
Among the key findings of the study include:
– The 25 nursing homes that completed the program experienced a 17 percent reduction in hospitalization rates compared with the same six-month period in the previous year.
– Of the 25 nursing homes, 17 were characterized as "moderately or highly engaged" in the initiative. This group had a 24 percent reduction in hospitalizations, compared with a six percent reduction in the group of eight facilities rated as "minimally or not engaged" and a three percent reduction in a comparison group of 11 nursing homes.
– The average cost of the six-month intervention was $7,700 per nursing home.
– The projected Medicare savings in a 100-bed nursing home were about $125,000 per year, enough to support a full-time advance practice nurse or physician assistant in the nursing home or other care improvements in the nursing home, as well as the costs of implementing the intervention.
“If implemented widely, the program could result in fewer complications, lower morbidity from hospitalizations and reductions in Medicare costs. Some of the savings could be used to support improved care in U.S. nursing homes,” said Ouslander.
INTERACT is now recommended by the Center for Medicare and Medicaid Services (CMS) as an intervention to improve patient safety and transitions between care settings (http://www.cfmc.org/caretransitions/provider_resources.htm). Programs such as INTERACT are highly relevant to health care reform and the sustainability of Medicare by helping to achieve the CMS “triple aim” of improved care, improved health and reduced cost.
The INTERACT program and INTERACT II tools and resources are available at http://interact2.net. Ouslander and his colleagues have also developed a curriculum that can help nursing homes implement the INTERACT program.