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INTERACT: Reducing Avoidable Hospitalizations for Nursing Home Residents

The Georgia Medical Care Foundation conducted a special study, supported by CMS, to develop and implement strategies and tools that would reduce potentially avoidable acute care transfers (ACT) from nursing homes.

The INTERACT TOOL KIT (Interventions to reduce Acute Care Transfers) was developed and implemented using a Collaborative Framework similar to the model developed by IHI. The tool kit was designed based on an extensive review of research on ACT, review of medical records for 200 ACT from Georgia nursing homes, 80 nursing home/hospital staff interviews, and input from an expert panel composed of experienced long-term care clinicians and administrators from Georgia and across the nation. The tool kit focuses on communication about residents with acute changes in condition among staff at the nursing home as well as between the nursing homes and hospital, care paths for common acute conditions and advance care planning to assist in reducing potentially avoidable acute care transfers of residents who are terminally ill and/or on a palliative care plan.

The Interact Team is sharing these tools with the nationwide Care Transitions project, and we encourage you to use these tools as appropriate to support your interventions.

INTERACT II - Working Together to Improve Care, Communication, and Continuity for our Residents