Quality Improvement
Conditions
Brief summary
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
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.
Interventions
OTHERInterventions to Reduce Acute Care Transfers
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.
Sponsors
Providence VA Medical Center
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Masking description
Intervention implemented in providers assigned to experimental condition, so all knew they were in a study. Control facilities did not know there was a study underway.
Intervention model description
Pair matched cluster randomized trial; randomization at the provider level.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
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
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hospital Admissions Per Person Year Alive Measured at the Facility Month Level | 36 months | 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. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Potentially Avoidable Hospitalizations | 18 months followup during observation period. | 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. |
Countries
United States
Participant flow
Recruitment details
All Veterans admitted to any of the eight experimental and eight control facilities (VA Community Living Centers) during the study timeframe, January 2016 - December 2017.
Participants by arm
| Arm | Count |
|---|---|
| Experimental VA Community Living Centers Eight VA CLCs selected to receive the INTERACT intervention
Interventions to Reduce Acute Care Transfers: 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. | 3,205 |
| Control VA Community Living Centers 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 | 3,338 |
| Total | 6,543 |
Baseline characteristics
| Characteristic | Experimental VA Community Living Centers | Control VA Community Living Centers | Total |
|---|---|---|---|
| Age, Customized <55 | 121 Participants | 141 Participants | 262 Participants |
| Age, Customized 55-64 | 542 Participants | 583 Participants | 1125 Participants |
| Age, Customized 65-74 | 1187 Participants | 1150 Participants | 2337 Participants |
| Age, Customized 75-84 | 673 Participants | 656 Participants | 1329 Participants |
| Age, Customized 85+ | 682 Participants | 808 Participants | 1490 Participants |
| Race/Ethnicity, Customized Black | 788 Participants | 816 Participants | 1604 Participants |
| Race/Ethnicity, Customized Hispanic | 47 Participants | 79 Participants | 126 Participants |
| Race/Ethnicity, Customized Other | 28 Participants | 39 Participants | 67 Participants |
| Race/Ethnicity, Customized Unknown | 34 Participants | 30 Participants | 64 Participants |
| Race/Ethnicity, Customized White, non-Hispanic | 2308 Participants | 2374 Participants | 4682 Participants |
| Region of Enrollment United States | 3205 Participants | 3338 Participants | 6543 Participants |
| Sex: Female, Male Female | 110 Participants | 84 Participants | 194 Participants |
| Sex: Female, Male Male | 3095 Participants | 3254 Participants | 6349 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 3,205 | 0 / 3,338 |
| other Total, other adverse events | 0 / 3,205 | 0 / 3,338 |
| serious Total, serious adverse events | 0 / 3,205 | 0 / 3,338 |
Outcome results
Primary
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.
Time frame: 36 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Experimental VA Community Living Centers | Hospital Admissions Per Person Year Alive Measured at the Facility Month Level | 5.5 hospitalizations per person year alive | Standard Error 2.5 |
| Control VA Community Living Centers | Hospital Admissions Per Person Year Alive Measured at the Facility Month Level | 5.8 hospitalizations per person year alive | Standard Error 2.5 |
Comparison: We assumed the average monthly pre-intervention hospitalization rates of intervention and control CLCs were equal, so only average monthly post-intervention hospitalization rates might diverge. Each CLC had its own start month and contributed 18 months pre-intervention and 18 months post-intervention. Hospitalizations rates were modeled using a multilevel negative-binomial regression because it allows for over-dispersion, which is commonly observed with medical events such as a count.p-value: <0.05negative-binomial regression coefficient
Secondary
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.
Time frame: 18 months followup during observation period.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Experimental VA Community Living Centers | Potentially Avoidable Hospitalizations | .3 hospitalizations per person year alive |
| Control VA Community Living Centers | Potentially Avoidable Hospitalizations | .2 hospitalizations per person year alive |