Edition: March 2012 - Vol 20 Number 03
Article#: 3938
Author: Repertoire

Long-term-care? Short-term care is more like it. The industry is changing, note experts, and it’s becoming increasingly necessary for skilled nursing facilities to care for sicker patients, and to do so quickly and efficiently. Yet providers recognize that it’s not always in patients’ best interest to be transferred to a hospital every time they develop an infection. Doing right by nursing home residents requires balance, they say, and it calls for continual patient assessment and strong communication within and across organizations.

“The industry is in a [state] of change,” says Terry Donovan, director of nursing at Welch Healthcare and Retirement Group (Norwell, Mass.). “Skilled nursing facilities can take care of sicker people earlier on.” In 2011 alone, Donovan oversaw 710 admissions roll through her 142-bed facility. It helps that she has a dependable, longtime staff of certified nurses and nurse assistants, she points out. It also helps that her organization has adopted a set of patient assessment and communication tools called Interventions to Reduce Acute Care Transfers (INTERACT), designed to help reduce unnecessary transfers of nursing home patients to hospitals. Today, Donovan’s facility boasts a low rate of patient re-hospitalization – just under 13 percent.


In many cases, very ill nursing home patients do, indeed, require transfer to acute settings. However, “transfers to hospitals can be emotionally and physically difficult for residents,” according to the INTERACT website http://interact2.net/about.html. In addition, they can be expensive. Hence, INTERACT was developed to help reduce the number of transfers by providing nursing home nurses, clinicians and staff with appropriate communication, clinical and advance care planning tools. Originally part of a project supported by the Centers for Medicare and Medicaid Services (CMS), the INTERACT pilot has been supported by a grant from the Commonwealth Fund and currently involves 150 nursing homes across the country that are piloting an online curriculum.

“Re-hospitalizations [of nursing home patients] are key to think about,” says INTERACT senior project coordinator Laurie Herndon, gerontological nurse practitioner at Fallon Clinic (Worcester, Mass.) and director for clinical quality at Massachusetts Senior Care Foundation. “On the provider side, they need to recognize that unnecessary hospitalizations are not good for the patient’s quality of health. On the policy side, they can be expensive.” Now more than ever before, long-term-care organizations and hospitals need to partner to ensure the best solutions for patients, she notes. That said, the goal should be to reduce unnecessary transfers to hospitals – not all transfers, she points out.

“INTERACT was developed specifically for skilled nursing facilities to help them provide good care and to be part of a [quality improvement] solution,” she continues. “I think the general public really believes we do a better job of communicating with hospitals than we do.” And, while the emergence of accountable care organizations and healthcare reform has facilitated such communication, platforms such as INTERACT can help bring it to the next level, she says. In time, “families will get the sense that there is more communication involved with INTERACT, and they’ll develop greater confidence in nursing homes.”

In recent years, many long-term-care facilities have assumed a greater role in providing sub-acute care, notes Herndon. “Ten years ago, they would have transferred [more] patients to hospitals,” she says. “Now our goal is for [caregivers and clinicians] to recognize subtle changes in patients immediately.” The goal is to achieve early recognition – and comprehensive assessment – of changes, she adds. If a patient’s blood work is off, it may be necessary to transfer him or her to the hospital. “But, in the case of simple urinary infection, we can keep patients in the nursing home.”

The nuts and bolts of INTERACT

Key to INTERACT is the ability of nurses and staff to recognize changes in the status of their residents’ health, to communicate those changes with each other and attending physicians, and then follow appropriate care paths. Part of the process involves knowing if and when it is time to transfer a patient to an acute care setting.

Nurses, assistants and other caregivers are provided with specific tools and protocols in the INTERACT process, including the following:

  • Communication tools.

    1. Early warning tool for certified nursing assistants. These are designed to help certified nurses regularly evaluate and recognize changes in residents and their care, and then report changes to licensed nurses on staff.

    2. SBAR (Situation-Background-Assessment-Recommendation) communication tool and progress note for licensed nursing staff, designed to help them evaluate and communicate acute changes to the physician, nurse practitioner or physician assistant on staff, as well as document all evaluations and communications.

    3. Change-in-condition file cards for licensed nursing staff. A quick reference guide, these are to be made available at the nursing station to provide guidance when nurses communicate acute changes in patient status to the physician, nurse practitioner or physician assistant.

    4. Resident transfer form for licensed nursing staff and emergency room staff to fill out when transferring a resident to a hospital.

    5. Acute care transfer envelope with checklist for all nursing home staff to fill out at the time of patient transfer.

    6. Quality improvement tool for review of acute care transfers to help all staff evaluate the patient’s need for transfer and to potentially reduce the number of future transfers.

  • Care paths. All nursing home licensed nurses, administrative nurses, medical directors, primary care physicians, nurse practitioners and physician assistants follow specific protocols for addressing patients who develop a change in mental status; fever; symptoms of lower respiratory infection, congestive heart failure or urinary tract infection; dehydration.

  • Advance-care planning tools.

    1. Tools for identifying residents to consider for palliative care and hospice. These are designed to help all nursing home staff.

    2. Advance-care planning communication guide for social workers, licensed nurses, physicians, nurse practitioners and physician assistants on how to communicate with residents and their family members about palliative or hospice care.

    3. Comfort care order set for all primary care physicians, nurse practitioners, physician assistants and licensed nurses, which provide examples of orders on palliative/comfort care plans.

    4. Education materials for caregivers to share with residents and their families.

The tools are designed to help facilitate early discussion among nursing home staff, as well as between staff and residents/family. The intention is that, by taking early action and following through with each resident and his/her family members, fewer residents will need to be transferred to a hospital setting – and those who are transferred will truly require it.

What’s the incentive?

Currently, financial incentives are lacking to encourage nursing homes to avoid sending residents to the hospital, says Herndon. In fact, patients transferred from a nursing home to an acute care setting and then back to the nursing home do so with Medicare funding. “So there’s really no incentive to prevent this transfer,” she explains.

Herndon and her INTERACT colleagues would like to see financial incentives based “not on numbers, but on participation in INTERACT. We don’t want to see unintended consequences, for example, retaining patients in the nursing home when they require hospitalization.” Instead, incentives would be based on the nursing home meeting Quality Assurance Performance Measures set forth by the Centers for Medicare & Medicaid Services, she says. “And, we would like to see the financial savings (from avoiding hospitalizations of nursing home residents) re-invested in nursing home staffing and infrastructure needs.”

EMR more important than ever

From the sales rep’s standpoint, INTERACT won’t necessarily impact the types of products nursing homes require, according to Herndon. “What we’ve heard is that facilities will treat more of what they normally treat,” she says. So they’ll need more of everything – especially IV solutions and sets and oxygen, she notes. “The other thing we have heard is that many facilities are targeting chronic obstructive pulmonary disease (COPD) patients. In one case, a facility hired a respiratory therapist. This is one example of how long-term-care facilities will target certain patient profiles and add resources to care for them.”

While INTERACT will be accessible without implementing electronic medical record systems, nursing homes will come to depend on EMRs as they partner with hospitals, she points out. “Long-term-care facilities will want to upload their patients’ medical records into their systems, [in order to] better communicate with hospitals. Yes, implementing EMR always involves an upfront cost, but the training process “should be no different than it would be in any other healthcare setting.”

Nevertheless, “EMR will present a big issue for nursing homes,” says Herndon. “The long-term-care industry has been behind the curve on this for years due to its lack of resources. But the current healthcare environment will require EMRs. It will become crucial.” Distributor sales reps can do their part by educating their customers on the basics of EMRs and directing them to helpful resources, she adds.