Project ID: 2.b.vii
Project Name:
INTERACT in Skilled Nursing Facilities (SNF)/Long-Term Care (LTC)
Project Description:
Implementing the INTERACT project (inpatient transfer avoidance program for SNF)
Project Chairs:
Lisa Betrus, Valley Health Services
Christa Serafin, Sitrin Medical Rehabilitation Center
Objective:
The skilled nursing facilities (SNF) will implement the evidence-based INTERACT program developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Centers for Medicare and Medicaid Services (CMS).
Rationale and Relationship to Other Projects:
INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute changes in a resident’s condition in order to stabilize the patient and avoid transfer to an acute care facility. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. The current version of the INTERACT Program was developed by the INTERACT interdisciplinary team under the leadership of Dr. Ouslander, MD with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by the Commonwealth Fund. There is significant potential to further increase the impact of INTERACT by integrating INTERACT II tools into the SNF health information technology through a standalone or integrated clinical decision support system.
Core Components
The SNF(s) in the PPS will need to undertake the following activities:
- Engagement and education of leadership in the INTERACT principles.
- Identification of a facility champion who can act to engage other staff and serve as a coach.
- Development of care pathways and other clinical tools for the monitoring of chronically ill patients with the goal to early identify potential instability and allow intervention to avoid hospital transfer. Education of all staff on care pathways and INTERACT principles.
- Development of Advance Care Planning tools to assist residents and families in expressing and documenting their wishes for near end of life and end of life care.
- Coaching program to facilitate and support implementation.
- Education of patient and family on the initiative and empowering them to participate in planning of care.
- Establishment of enhanced communication with acute care hospitals, preferably with EHR and HIE connectivity.
- Measurement of outcomes including quality assessment/root cause analysis of transfer to identify interventions.
- Use of INTERACT 3.0 toolkit and other resources available at INTERACT’s website.
- Demonstration of a clear cultural competence and willingness to engage Medicaid members in the design and implementation of system transformation including addressing issues of health disparities.