Module 2 Tracking Hospital Transfers and Performing Root Cause Analyses Using the

1. Module 2 Tracking Hospital Transfers and Performing Root Cause Analyses Using the INTERACT Quality Improvement Review Tool • This session is designed for: • The INTERACT champion and co-champion • DON, RNs, LPNs • Medical directors • Primary care MDs, and NPs/Pas • Administrators The development and evaluation of the INTERACT quality improvement program and curriculum have been supported by grants from The Commonwealth Fund and the Retirement Research Foundation.

2. Overview of the INTERACT Program • The INTERACT Interdisciplinary Team • Joseph Ouslander, MD Florida Atlantic University • Ruth Tappen, EdD, RN, FAAN Florida Atlantic University • Jill Shutes, GNP Florida Atlantic University • Nancy Henry, PhD, GNP Florida Atlantic University • Maria Rojido, MD Florida Atlantic University • Sanya Diaz, MD Florida Atlantic University • Laurie Herndon, MSN, GNP-BC Mass Senior Care Foundation • Jo Taylor, RN, MPH The Carolinas Center for Medical Excellence • Gerri Lamb, PhD, RN, FAAN Arizona State University • Annie Rahman, PhD, MSW USC Davis School of Gerontology • Dan Osterweil, MD California Association of Long Term Care Medicine • Mary Perloe, GNP Georgia Medical Care Foundation • John Schnelle, PhD Vanderbilt University • Sandra Simmons, PhD Vanderbilt University • Alice Bonner, PhD, GNP Center for Medicare and Medicaid Services In collaboration with participating nursing homes

3. Tracking Hospital Transfers and the Quality Improvement Review Tool What This Session Will Cover • Tracking hospital transfers – rationale, definitions, and methods • Key factors involved in hospital transfers • Performing root cause analyses on transfers using the Quality Improvement (QI) Review Tool • Using the data to improve care

4. Overview of the INTERACT Program • (“Interventions to Reduce Acute Care Transfers”) • Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition

5. Overview of the INTERACT Program • The goal of INTERACT is to improve care, notto prevent all hospital transfers • In fact, INTERACT can help with more rapid transfer of residents who need hospital care • The goal of INTERACT is to improve the management of residents with a change in condition

6. INTERACT and the New QAPI Requirement • The health care reform law also mandates that each facility have a Quality Assurance and Performance Improvement program (“QAPI”) • The regulation and related surveyor guidance are being written • Improving the management of acute change in condition and reducing unnecessary hospital transfers through the use of INTERACT is one potential focus of your QAPI work • In addition, “Reducing Hospitalizations Safely” is a new goal for the Advancing Excellence in America’s Nursing Homes campaign • (see http://www.nhqualitycampaign.org)

7. Tracking Hospital Transfers and The Quality Improvement Review Tool Why Track Transfers and Complete QI Review Tools? • INTERACT is an overall quality improvement program, not a tool or set of tools • In order to implement any quality improvement program, you must: • Define measures • Track them over time, looking for trends • Compare or benchmark them to your previous performance as well as other facilities and goals based on corporate, state, or federal data • Perform root cause analyses to learn, implement changes based on what you learn in order to continue to improve

8. Tracking Hospital Transfers and The Quality Improvement Review Tool Why Track Transfers and Complete QI Review Tools? • Another major reason to track transfer rates is that hospitals are starting to look at them carefully in order to select partners for integrated care systems who can manage sicker people without hospital transfer. • This goes beyond just the 30-day readmission rate, especially in hospitals that are forming or affiliating with Accountable Care Organizations, or considering bundled payment options • In ACO’s and bundled payment models, all acute care transfers and related costs, not just those of 30-day readmissions are important

9. What Measures Should You Track? Maslow, K and , Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the Long Term Quality Alliance, 2012. (Available at:http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf)

10. What Measures Should You Track? There are four basic measures that can be calculated – all are important to both quality of care and costs • All cause unplanned hospitalization rate • This is a simple frequency of all unplanned hospitalizations from the entire facility which is adjusted for census or days at risk of hospitalization. A simple and relatively standard method is to calculate the rate per 1000 resident days [Interactive Question]

11. What Measures Should You Track? • Readmission rates (30 day) • This is a subset of the all cause admissions • In order to calculate this rate, each admission has to be followed for 30 days. The denominator is the number of admissions from the hospital during the measurement time period. The numerator is hospitalizations. The 30-day readmission rate is a simple percentage of admissions from the hospital who are readmitted as inpatients within 30 days • There are some complicated issues related to this measure • CMS is currently developing a precise definition [Interactive Questions]

12. What Measures Should You Track? • Emergency Room visits only • This is a simple frequency of all-cause ER visits that do not result in hospital admission or an observation stay, and has to be adjusted for census or days at risk of hospitalization as in #1 above. • Residents transferred to the ER who die before hospital admission could be included in this definition.

13. What Measures Should You Track? • Transfers resulting in Observation Stays • This is a simple frequency of transfers that result in observation stays. This measure also has to be adjusted for census or days at risk of hospitalization • Admission status (observation vs. inpatient) and whether the resident is initially admitted on observation and then changed to inpatient may be difficult to track • In this situation, they could be counted as “admission, status uncertain”

14. What Measures Should You Track? • Many sub-analyses that can be done • Each of these measures can be tracked by short-stay (e.g. while on the Medicare Part A benefit and/or managed care) vs. long stay • Frequencies of reasons for transfers can also be recorded and trended

15. How Do You Track these Measures? • Some facilities or their corporations already have tracking systems in place • The calculations may or may not be accurate and consistent with evolving CMS measure definition • INTERACT has a paper and pencil tracking tool • The Advancing Excellence Campaign has developed an Excel tool that automatically calculates the measures (a version of this tool is available on the INTERACT website)

16. Tracking Hospital Transfers and the Quality Improvement Review Tool How Do You Track these Measures?

17. How Do You Track these Measures? Original tool can be located at: http://www.nhqualitycampaign.org

18. How Do You Track these Measures? Original tool can be located at: http://www.nhqualitycampaign.org

19. The Quality Improvement Review Toolis meant to identify opportunities to improve management of changes in condition

20. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Designed to guide you through review situations that commonly result in transfers in your facility through systematic root cause analysis, learn, and further improve care The Quality Improvement Review Tool

21. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool • Integrate into your facility’s regular quality and educational processes • Avoid blaming individuals • Look for common situations that you can learn from and improve • Conduct educational activities on related topics The Quality Improvement Review Tool

22. Tracking Hospital Transfers and the Quality Improvement Review Tool • Retrospective – but should be done soon after transfer • Reviews can be done on all or a sample of transfers – but avoid bias if selecting a sample • Consider also reviewing situations in which there was a change in condition, but your staff’s actions prevented a transfer The Quality Improvement Review Tool

23. Tracking Hospital Transfers and the Quality Improvement Review Tool

24. Tracking Hospital Transfers and the Quality Improvement Review Tool • Background Information • Change in Condition • Evaluation and Management • Transfer Information • Opportunities for Improvement The QI Review Tool: 5 Sections

25. Tracking Hospital Transfers and the Quality Improvement Review Tool Section 1: Background Info

26. Tracking Hospital Transfers and the Quality Improvement Review Tool Section 2: Change in Condition

27. Tracking Hospital Transfers and the Quality Improvement Review Tool Section 3: Evaluation and Management

28. Tracking Hospital Transfers and the Quality Improvement Review Tool Section 4: Transfer Information

29. Tracking Hospital Transfers and the Quality Improvement Review Tool Section 5: Opportunities for Improvement

30. Decisions to transfer residents are complicated • Many factors may be involved: • Severity of the resident’s clinical condition • Staff and services available in the nursing home to manage changes in condition • Availability of and staff communication with primary care physicians, NPs, PAs • Advance directives of lack of advance care planning • Resident and/or family preferences • Others The Quality Improvement Review Tool

31. Getting Started: Tracking Hospital Transfers and The Quality Improvement Review Tool “ There’s been a culture change here. We started out thinking if they’re sent to the hospital, it’s not avoidable. Now we recognize we missed early warning signs.” An INTERACT Champion

32. Key Points from Module 2 • INTERACT is an overall quality improvement program that can help your facility meet the new federal QAPI requirement • Tracking, trending, and benchmarking clearly and consistently defined measures, and performing root cause analyses are fundamental to any quality improvement program • There are several ways that tracking hospitalization data can be accomplished

33. Key Points from Module 2 • There are many factors, including clinical, nursing home staffing and capabilities, and resident and family preferences that influence the decision about hospital transfers • The INTERACT QI Review and Transfer Tracking Tools are designed to help you and your facility identify patterns that will guide your future educational and quality improvement activities

34. Quiz and Evaluation • Please complete the Quiz and Evaluation • If you do not complete them: • You will not receive continuing education credit • If your facility is tracking who completes specific modules, you will not be counted