As a result of lessons learned in the three-year DHS PIPP project Resident Centered Care Connections (RCCC), the following best practices are recommended:
Best Practice: INTERACT
INTERACT is an evidence-based quality improvement program to reduce avoidable hospitalizations from nursing homes. The INTERACT website provides program information, forms and instructions which can be downloaded and used without charge. Key components of INTERACT used in RCCC include SBAR, QI audit tool, Acute Change in Condition Card Files and care paths. Care paths are educational tools and reference for guiding evaluation of specific symptoms that commonly cause acute care transfers. These currently include:
Acute Mental Status Change
Change in Behavior: New or Worsening Behavioral Symptoms
GI Symptoms – Nausea, Vomiting, Diarrhea
Shortness of Breath
Symptoms of CHF
Symptoms of Lower Respiratory Illness
Symptoms of UTI
Best Practice: Hospital to ER Transfer Form
This ER transfer form is intended to facilitate communication between nursing home and emergency room staff. by presenting necessary information in quick read format. The form was developed during the implementation of DHS PIPP- RCCC program with input from ER personnel and the Metro Alliance of Geriatric Primary Care Providers. The Metro Alliance has representatives from all of the major Minneapolis/St Paul primary care organizations and its purpose is to create common evidence-based approaches to care. The transfer form is intended to enhance communication between the nursing home and hospital emergency room by presenting key information in a readily available format appropriate for emergent care.
Best Practice: Provider Orders for Life Sustaining Treatment (POLST)
The POLST is a form that makes a patient/resident’s wishes for Advanced Directives and end-of-life care into actionable physician orders. The POLST process begins with conversations between patients, loved ones, and health care professionals and is designed to ensure that seriously ill or frail patients can choose the treatments they want or do not want and that their wishes are documented and honored. It is completed at admission to the nursing home, signed by the patient and the medical provider and reviewed routinely and when there are changes in condition. The Minnesota POLST form is endorsed by the MMA and the Emergency Medical Services Regulatory Board and is available here.
Best Practice: Palliative Care
Palliative Care is a philosophy of care particularly appropriate for those with advanced chronic disease for which there is no cure and for those who choose comfort and quality of life as their most important goal of care. Palliative care strives to provide optimal pain and symptom management while focusing on the psychosocial and spiritual needs of the individual. Key components of palliative care include pain and symptom management as well as spiritual and psychosocial care. Palliative care differs from hospice in that it can include curative interventions and does not require a six-month prognosis. CareChoice endorses the provision of palliative care for those for whom it is appropriate. Palliative care includes but is not limited to hospice care and comfort care. Comfort care is a term sometimes used to direct care orders when a resident is nearing end of life. Comfort care may also be specified by the physician on the POLST.
PowerPoint presentations were developed to teach components of INTERACT, pain management, POLST and palliative care. Most are available by contacting CareChoice.
Best Practice: Pain Management
The Pain Management Program is a comprehensive approach to interdisciplinary identification and treatment of pain in both the short and long term care population. The components of the program were developed in 2009 when 18 member nursing homes participated in Resident Centered Pain Care, a successful year long project to reduce the incidence of moderate to severe pain in patients and residents of these homes. The Pain Identification/Review form is intended to be used routinely to detect indications of pain. The Pain Assessment provides a framework for a thorough assessment of pain in both cognitively intact and impaired individuals. The pain program included extensive staff education on pain management including both medication and non-medication interventions.
As a result of this program, CC participating facilities collectively reduced the incidence of moderate to severe pain by more than 10% as measured by CMS Quality Measures/Indicators: