InteractJewish Home is implementing the INTERACT quality improvement program with a goal of reducing rehospitalization rates by 10%.  INTERACT, an acronym for “Interventions to Reduce Acute Care Transfers” is designed to improve the identification, evaluation, and communication about changes in resident status – steps that have been shown to help reduce the need for patients to return to the hospital.

Transfers to the hospital can be emotionally and physically difficult for residents, and result in numerous complications of hospitalization.  Yet, the national statistics are alarming: 1 of 4 Medicare patients admitted to skilled nursing facilities from hospitals is readmitted to the hospital within 30 days.  Medicare is planning to address this situation with financial incentives to reduce potentially avoidable hospital transfers through pay-for-performance, bundled payments, and other strategies.

In January, Continuing Care Leadership Coalition (CCLC) brought the INTERACT program designers to New York for a full day seminar attended by leadership teams from participating nursing homes. The cross-disciplinary team meets regularly to monitor the program implementation and to discuss post acute challenges.  Extensive data is being collected to enable the team to drill down and analyze current practice and common situations to enable useful recommendations.  Each participating nursing home will also receive support from CCLC throughout the year.

At the core of the program is what Dr. Simon Kassabian calls a “protocol of tools,” which enhance the staff’s ability to observe and address the conditions that most often lead to hospitalization before they become too acute.  These tools fall into three categories: Communication tools; Care Paths or Clinical tools; and Advance Care Planning tools.

The “Early Warning Tool” includes approaches for staff to “Stop and Watch” and record their observations on a pocket card and report.  The “SBAR” tool (Situation-Background-Assessment-Recommendation) provides a framework for communication between members of the health care team.

The care paths for specific conditions are designed to be an educational tool and reference for guiding evaluation of specific symptoms that commonly cause acute care transfers.  Conditions include mental status change, Lower Respiratory Infection, Chronic Heart Failure and Dehydration.

Advance Care Planning is the third component of the program.  There are tools for all staff which provide guidance on how to identify residents who may be appropriate for a palliative care or hospice care, as well as a communications guide for primary care providers, social workers and nurse practitioners with input on how to communicate about advance planning options with residents and family members.

The INTERACT program at Jewish Home should serve to improve the quality of life and level of care by reducing the need for frequent transfers to the hospital.

More information on the INTERACT program can be found here: