Reducing Veterans Hospitalizations From Community Living Centers

Study Overview
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Brief Summary
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The goal of the project was to implement and evaluate the intervention, Interventions to Reduce Acute Care Transfers (INTERACT) in VHA CLCs, which is designed to improve the care of Veterans using CLCs who experience acute changes in their condition and at the same time reduce their rate of hospitalization.

Detailed Description
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The project was designed to show that engagement by frontline CLC staff, in using the INTERACT (VA version of INTERACT) program will identify Veterans' clinical problems earlier, help evaluate and safely initiate management of acute changes in conditions in the CLC, communicate more effectively with physicians about Veterans' conditions, thereby avoiding unnecessary hospitalizations, and provide more emergent hospitalizations when necessary. The project planned to implement the INTERACT quality improvement program as the intervention in up to 15 randomly selected, pair matched CLCs for a 6 month intensive training period and an additional 12-18 month ongoing follow-up monitoring period. Additionally, a quantitative and qualitative evaluation of the implementation of the INTERACT intervention was done to characterize the fidelity with which CLCs in the intervention pairs participated in training, engaged in regular conference calls, undertook root cause analyses identifying why hospitalizations occurred and used the tools in which they were trained. The program's effect is based on three core strategies: 1) enabling front-line NH staff to identify acute conditions early in their course, thereby helping to prevent them from becoming severe enough to require acute hospitalization; 2) providing communication and decision support tools that assist with the safe and effective management of certain conditions in the Community Living Center (CLC) without transfer to the acute hospital; and 3) educating CLC staff in advance care planning and discussions about end-of-life and comfort care plans, and thus increasing the use of advance directives, comfort care measures, and palliative and hospice care as an alternative to hospitalization when appropriate.

Official Title
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Implementing and Evaluating INTERACT in VA CLCs

Conditions
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Quality Improvement

Intervention / Treatment
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* Other: Interventions to Reduce Acute Care Transfers


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Veterans in experimental and control CLCs during 18 months during which the INTERAC intervention was implemented. Exclusion Criteria: Veterans not in participating CLCs

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Pair matched cluster randomized trial; randomization at the provider level.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Experimental VA Community Living Centers<br>Eight VA CLCs selected to receive the INTERACT intervention | Other: Interventions to Reduce Acute Care Transfers<br>* Experimental CLCs were trained in INTERACT QI Intervention, containing tools, strategies and educational resources designed to catch and manage acute changes in conditions early that a Veteran may be experiencing, leading to a potential reduction in preventable hospital transfers from CLCs.<br>* Other names: INTERACT;|
| No Intervention: Control VA Community Living Centers<br>Eight CLCs, matched to experiment CLCs, based on size, location to VAMC, and hospitalization rates, did not receive the intervention and continued care as usual | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Admissions Per Person Year Alive Measured at the Facility Month Level | hospital admissions from nursing home per person year at risk of being hospitalized calculated for each of the 16 facilities per month of observation during the 18 months of the active study and 18 months preceding introduction of the intervention in the experimental facilities. This measure is constructed from EMR data and not from a scale. | 36 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Potentially Avoidable Hospitalizations | Potentially avoidable hospitalization per person year alive aggregated to the facility level. These hospitalizations are a sub-set of all hospitalizations based upon an AHRQ algorithm frequently referenced in the literature. | 18 months followup during observation period. |