Over a decade ago, Dr. Joe Ouslander and others developed the INTERACT (Interventions to Reduce Acute Care Transfers) program to help facilities recognize early clinical changes of condition that could then be managed in their facilities. 

Since INTERACT was introduced, a new payment system in SNFs for post-acute rehabilitation was introduced in 2019 called PDPM (Patient Derived Payment Method), which focuses on patient characteristics to determine payment. Using this data, acute hospitals can now compare the outcomes of patients they refer to different SNFs based on their patients’ PDPM severity of illness score. The Providence Hospital System has partnered with CMS as a full-risk ACO for its Medicare patients. In my county, all 18 SNFs receive monthly report cards on their performance regarding LOS (length of stay), 30-day readmission rates, and average PDPM severity of illness score. Recently, facilities, whose performance was in the bottom 25%, received requests to schedule a POC (Plan of Correction) meeting with the hospital SNF care transition specialist, with future rehabilitation referrals at risk. If you received one of these emails, what would you do?  

Traditionally, I have tended to blame acute hospitals for many of the resident relapses based on inadequate hospital communication of patient needs and incomplete transfer orders and discharge summaries. However, if the PDPM severity of illness score is close to accurate and your relapse rate is in the bottom 25%, how are other facilities doing better than yours?

INTERACT developed tools to help facilities address this question. I have attached some of these free tools at the bottom of this article. The Root Cause Analysis Tool is a good place to start with each unplanned transfer, which should be a sentinel event to be completed within 48 hours. This process should not only focus on the patient’s condition at the time of transfer, but also on potential missed opportunities in the days prior to transfer. CNA’s may miss or not report Early warning signs to licensed nurses, which is the purpose of the STOP and Watch tool. In addition, licensed nurses are more focused on medication passes and skilled care, so they may not recognize serious illness until it is too late, when a patient can no longer be safely managed in the facility. To help nurses assess these changes in condition, INTERACT developed the Change in Condition File Card Tool and the SBAR Communication Tool; Dr. Albert Lam, Past-President of CALTCM, developed CALTCM SNF 2.0® a program that supports nursing homes to incorporate INTERACT tools. The SBAR Communication tool prepares the assessing nurse for sharing their comprehensive assessment with the physician, which focuses on the “Care that Matters” to this patient. Since the care capacities of facilities vary, NP’s and Physicians should receive written information regarding what is in the Medication E-Kit, the IV fluids available, RN’s available 24/7, and stat lab capacity. When a patient is transferred, the Acute Care Transfer Document Checklist includes Face Sheet, MAR, SBAR, ACP documents, and appropriate clinical care documents to accompany this resident. At the end of each month, the facility QI champion should review the care gaps from each root cause analysis in a systematic way using the QAPI process to propose SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) changes at the monthly QI interdisciplinary meeting. The Quality Improvement Summary Worksheet provides a nice summary of the findings and potential recommendations. 

I hope you will not wait for the ACO’s economic nudge to improve. Our patients deserve our best possible care. 

Link to Pathway INTERACT webpage. 

Downloadable INTERACT tools and resources are available for free through the Pathway INTERACT webpage, link provided below. Users will be prompted to create a free account. (Please note there are organizations who are licensed to sell pre-printed forms for a fee, but all the tools are available for free online.) Some EHRs have INTERACT tool packages which can be purchased.

https://pathway-interact.com/interact-tools/interact-tools-library/