Effects of an Intervention to Reduce Hospitalizations From Nursing Homes

Abstract

IMPORTANCE Medicare payment initiatives are spurring efforts to reduce potentially avoidable hospitalizations. OBJECTIVE To determine whether training and support for implementation of a nursing home (NH) quality improvement program (Interventions to Reduce Acute Care Transfers [INTERACT]) reduced hospital admissions and emergency department (ED) visits. DESIGN, SETTING, AND PARTICIPANTS This analysis compared changes in hospitalization and ED visit rates between the preintervention and postintervention periods for NHs randomly assigned to receive training and implementation support on INTERACT to changes in control NHs. The analysis focused on 85 NHs (36 717 NH residents) that reported no use of INTERACT during the preintervention period. INTERVENTIONS The study team provided training and support for implementing INTERACT, which included tools that help NH staff identify and evaluate acute changes in NH resident condition and document communication between physicians; care paths to avoid hospitalization when safe and feasible; and advance care planning and quality improvement tools.MAIN OUTCOMES AND MEASURES All-cause hospitalizations, hospitalizations considered potentially avoidable, 30-day hospital readmissions, and ED visits without admission. All-cause hospitalization rates were calculated for all resident-days, high-risk days (0-30 days after NH admission), and lower-risk days (Ն31 days after NH admission). RESULTSWe found that of 85 NHs, those that received implementation training and support exhibited statistically nonsignificant reductions in hospitalization rates compared with control NHs (net difference, −0.13 per 1000 resident-days; P = .25), hospitalizations during the first 30 days after NH admission (net difference, −0.37 per 1000 resident-days; P = .48), hospitalizations during periods more than 30 days after NH admission (net difference, −0.09 per 1000 resident-days; P = .39), 30-day readmission rates (net change in rate among hospital discharges, −0.01; P = .36), and ED visits without admission (net difference, 0.02 per 1000 resident-days; P = .83). Intervention NHs exhibited a reduction in potentially avoidable hospitalizations overall (net difference, −0.18 per 1000 resident-days, P = .01); however, this effect was not robust to a Bonferroni correction for multiple comparisons. CONCLUSIONS AND RELEVANCETraining and support for INTERACT implementation as carried out in this study had no effect on hospitalization or ED visit rates in the overall population of residents in participating NHs. The results have several important implications for implementing quality improvement initiatives in NHs. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02177058

Quality measurement and nursing homes: measuring what matters

“…For example, a recent trial of INTERACT, an intervention designed to reduce hospitalisations of nursing home residents, showed no apparent benefit 30. The authors contend this null result could reflect the challenges of implementing a complex, resource-intensive intervention in the nursing home setting, something noted in pre-trial studies where drop-out of nursing homes was a concern 31.…”

Degree of Implementation of the Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement Program Associated with Number of Hospitalizations

“…Because no effects were seen in the intention‐to‐treat analyses, analyses were conducted on a subset of 85 of these SNFs that reported no use of INTERACT before the trial was initiated (33 intervention, 52 control), with the hypotheses that these SNFs would be more likely to show an effect. These analyses demonstrated a significant effect on 1 of the 5 outcomes (PAHs using CMS definitions), but this finding did not remain robust to a Bonferroni correction …”

The effect of assigning dedicated general practitioners to nursing homes

“…Finally, although we measured the impact of the program for 15 months, the long‐term effect could differ. An important future research project would be to randomly assign GPs and nursing homes to a program such as was implemented in Denmark, especially because Kane et al found less promising results with INTERACT when homes were randomly assigned vs when they volunteered.…”

“…Ouslander et al and Ingber et al found that nursing homes that volunteered to implement the program experienced reductions in hospitalizations, with reductions in preventable admissions also occurring in the latter study † . In a recent study where 85 nursing homes were randomly assigned to receive training and implementation support for INTERACT, however, there was no impact on hospitalizations, readmissions, or preventable hospitalizations …”

“…In the United States, an estimated 25 percent of long‐stay nursing home residents are hospitalized, annually and between 20 and 25 percent of these people are readmitted to a hospital within a month . Many of these admissions are preventable, with recent estimates ranging from 40 percent to 47 percent .…”