The INTERACT Quality Improvement (QI) program emerged from research funded by the Center for Medicaid and Medicare Services. INTERACT was designed to improve care of CLC residents experiencing acute changes in conditon thereby preventing avoidable hospitalizations. INTERACT was initially tested in a non-experimental implementation trial that found among those nursing homes (NH) that implemented the program, the rate of hospitalizations fell substantially. Avoiding preventable hospitalizations for NH residents reduces further complications associated with hospitalizations including: distress/discomfort; delirium; poly-pharmacy; falls; incontinence/catheter use; hospital acquired infection; poor nutrition; immobility; deconditioning; and pressure ulcers. The HSR&D project, Implementing and Evaluating INTERACT in VA CLCs, implemented and evaluated the QI program in VA Community Living Centers (CLCs) using a pair matched cluster randomized experimental design.
Aim 1: Characterize VA CLCs in terms of alternate measures of hospitalization and examined variations from 2007-2012.
Aim 2: Implement INTERACT in 8 CLCs pair-matched with 8 control CLCs for a 6 month training period and an additional 12 month follow-up monitoring period. INTERACT trains staff to identify Veterans' changes in condition earlier, communicate more effectively to clinicians, and evaluate and safely manage acute changes in the CLC when feasible, thereby avoiding unnecessary hospitalizations.
Aim 3: Evaluate the implementation of INTERACT by: documenting variation in the implementation of INTERACT across CLCs and over time; determining the impact of INTERACT on hospitalization rates using an 'intent to treat' as well as an 'as treated' analysis; and using the Consolidated Framework for Implementation Research (CFIR) to identify factors contributing to the adoption and implementation of INTERACT.
Aim 4: Examine the impact of INTERACT on the 'appropriateness' of hospitalizations before and after its introduction in the 8 intervention CLCs using clinician reviews that followed a Structured Implicit Review (SIR) process.
Aim 5: Determine the budget impact analysis to be immaterial in this circumstance. No additional staff or resources were added to necessitate the need for this analysis at this time.
A quantitative and qualitative evaluation of the implementation of the INTERACT QI program characterized the fidelity with which CLCs participated in training, engaged in regular conference calls, undertook root cause analyses identifying why hospitalizations occurred and used the INTERACT tools in which they were trained. 8 CLCs participated, identifying Champions responsible for implementation of INTERACT as a QI project. Champions encouraged staff to engage in web-based training and regular conference calls and supported engagement in INTERACT throughout the 6 month training and 12 month follow-up monitoring period.
The experimental design was a pair matched, cluster randomized trial in which CLCs with similar patient mix, hospitalization rates and size were matched and then randomly assigned to intervention and control conditions. The primary outcome was the change in the rate of hospital transfers from the 8 intervention and 8 control CLCs before and after the introduction of INTERACT in the intervention CLCs.
CFIR was applied to the qualitative data assembled about INTERACT implementation in order to identify factors contributing, either negatively or positively, to adoption of the intervention in CLCs. Within the VA CLC setting, it is evident that the innovation characteristics of INTERACT as well as the inner setting or culture of the CLC, had an impact on the implementation. Future efforts to implement similar QI initiatives within VA CLCs should be informed by these findings.
One INTERACT tool used by CLC nurses was the SBAR designed to document a patient's change in clinical condition and what that change was and how it was managed. This tool was integrated into CPRS in each CLC allowing us to characterize implementation of this aspect of the intervention. We found dramatic differences in the use of SBARs across CLCs and within CLCs over time. We also found that the lack of advance care planning and prevalent use of "full code" status was a frequent contributing factor in many cases when care may have been rendered more appropriately in the CLC.
IMPACT OF INTERACT ON HOSPITALIZATIONS
Hospitalizations from CLC (to the local VMAC or via fee basis payment to a community hospital) for intervention and control CLCs were counted per facility per month and for the 18 months prior to introducing INTERACT and the rates were standardized across the two groups of facilities. Differences in the change in rate were compared during the 18 months of the INTERACT intervention. While the intervention CLCs hospitalization rates declined slightly relative to those of controls, this difference was small and not statistically or clinically significant.
The transfer cases considered by the reviewers as avoidable were rated as having poor quality of care requiring a higher level of care. There was no difference between pre and post intervention transfer cases in the proportion of avoidable hospitalizations nor the proportion of cases where transfer was attributable to poor quality. Using the established AHRQ diagnosis based algorithm used to identify avoidable hospitalizations, there were
only 12% found to be avoidable but using this definition of "avoidable" found very little overlap. There was only an overlap with the reviewer determined avoidable cases of 7%. A much lower rate of avoidable hospitalizations was identified by the clinician reviews as well as by the AHRQ than expected based on past literature.
The underlying intent of the intervention was to decrease avoidable transfers by early identification and management of acute changes in the CLCs when safe and feasible. Implementing INTERACT in VA CLCs aligned with the VA strategic goals to enhance care and corresponds directly with specific goals related to the Strategic Analytics for Improvement and Learning (SAIL), VHA Blueprint of Excellence, and GEC's Strategic Plan. Based upon our analyses, rates of avoidable hospitalizations from CLC, whether using the AHRQ algorithm or clinicians' judgment, were much lower than previously reported in the literature suggesting that the relatively high rate of hospitalization from CLC are warranted due to case mix severity.
- Mochel AL, Henry ND, Saliba D, Phibbs CS, Ouslander JG, Mor V. INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies. Geriatric nursing (New York, N.Y.). 2018 Mar 1; 39(2):212-218.
- Mor V. INTERACT (Interventions to Reduce Acute Care Transfers) VA CLC Version 1.0. Providence, RI: Providence COIN; 2017 Oct 1.
- Mor V. INTERACT (Interventions to Reduce Acute Care Transfers) Tool: Stop & Watch Early Warning Tool. Providence, RI: Providence COIN; 2017 Oct 1.
- Mor V. Implementation of the SBAR (Situation, Background, Assessment and Request) Tool Into CPRS. Providence, RI: Providence COIN; 2017 Oct 1.
- Mor V. INTERACT (Interventions to Reduce Acute Care Transfers) Care Path Poster. 2017 Oct 1.
- Allen SM, Cote DL, Wysoki A, Thomas K, Intrator O, Youssef R, Kinosian B, Phibbs CS, Mor V. A National Profile of Change in VA Community Living Centers 2004-2011. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Yano EM, Mor V. Using Partnered Research to Accelerate HSR&D Impacts: Lessons from the CREATE Initiative. Invited Plenary Panel. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Thomas K, Cote DL, Intrator O, Kinosian B, Mor V, Phibbs CS, Wysocki A, Makineni R, Youssef R, Allen SM. Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.