Did you know that in 2016, 20% of Medicare residents are hospitalized within 30 days of discharge? Nearly 90% of these hospitalizations were classified as unplanned. Early identification of a resident’s change in condition is paramount to managing and preventing unnecessary transfers. The eINTERACT™ program is a PointClickCare^® module that was developed to help decrease hospital readmissions and improve quality of care. It consists of several parts including:

• eINTERACT Stop and Watch Tool: This is used by nursing assistants or other staff members who are in a position to observe the resident and identify early changes in their condition that need to be reported to licensed nursing staff.
  • PointClickCare has incorporated the Stop and Watch content into the PointClickCare Point of Care (POC) application.
  • eINTERACT Stop and Watch Alerts are available in the Standard Alert Library for the direct care staff to utilize to notify nursing staff about a resident’s change in condition.

• eINTERACT Transfer Form: This form has been incorporated into the Assessments/Evaluations tab of the resident’s chart and is to be used at the time a resident is being transferred to the hospital.
  • This form is automatically triggered when the nurse discharges or transfers the resident to an acute care hospital.
  • It helps providers clearly communicate high-quality information that is critical for emergency room and other hospital staff to care for the resident.
  • It also helps reduce documentation time and reduce risk for transcription errors—and it improves efficiencies at the time of transfer.
• eINTERACT™ Change in Condition Form: This has been incorporated into the Assessments/Evaluations tab of the resident’s chart to be used at the time a resident has a change in condition. The nurse will complete the form prior to calling the MD/NP/PA. Completing the form prior to calling allows the nurse to have all of the necessary information available in order to make the best decision for the resident.

As part of the eINTERACT initiative, PointClickCare has included the functions of the eINTERACT Hospital Trend Tracker into the PointClickCare EHR. The data required to track rehospitalization rates is automatically pulled into the EHR at the time of an admission and/or transfer. This information is then available for trackable analysis and key indicators, to view and/or to export to reports including:

• Admission Log: This provides a view of all residents who are within 30 days of their admission to the skilled nursing facility, as well as residents who have been discharged and/or transferred to a hospital within the first 30 days of admission.

• Transfer Log: This provides a view of all resident transfers to the hospital including name, date, reason for transfer and outcome.
• Hospitalization Rates Tracking: This offers a view of all outcomes for 30-day readmission rate, transfers resulting in admission, transfers resulting in emergency department (ED) only and transfers resulting in observation stay only.
• Trend Tracking: This provides various trends for pattern identification including admissions/transfers by hospital, practitioner, outcome, reason, day of week and time of day. All transfers that occur within the 30-day period after admission are automatically logged for the quality improvement team or for committee review. Such reviews are needed to drive changes in the care delivery processes with the goal to further reduce acute care transfers.

The eINTERACT Hospital Transfer Quality Improvement Review Tool is designed to help with the analysis of any hospital transfers and identify opportunities to prevent transfers. The eINTERACT Quality Improvement Worksheet for Review of Acute Care Transfers is intended to be completed for individual hospital transfers or for a representative sample in order to conduct a root cause analysis and identify common reasons for transfers. This form includes:

• Resident Characteristics: Users can view transfers grouped by age, conditions, increasing risk of re-hospitalization, other hospitalizations and transfers to the emergency department without admission to hospital.
• Changes in Condition: This allows you to view transfer data for the length of time between identification of change of condition and transfer to hospital, new or worsening signs and symptoms, abnormal findings from the lab and by diagnosis or presumed diagnosis.
• Actions Taken: This allows you to view data from QI reviews indicating trends on tools used to evaluate change in condition, medical evaluations, types of diagnostic testing used pre-transfer, medical and nursing interventions, advanced care planning tools and types of directives in place.
• Hospital Transfer Data: This allows you to view data grouped by LOS prior to transfer, transferring clinician, day of week, time of day and outcomes including resident death and receiving institution.
• Improvement Opportunities: This allows you to view improvement opportunities, transfers rated as preventable, the resources needed to improve and determines whether the transfer should have occurred sooner in the process.
  • Examining trends in these data sets with the eINTERACT QI Analysis Tool can help you focus educational and care process improvement activities throughout the care continuum to prevent unnecessary transfers or expedite a transfer when it is appropriate.

Having the eINTERACT™ program will ultimately benefit your organization by:

• Improving resident safety, helping your team ensure that potential changes in condition are captured and documented in a timely fashion. This enables licensed staff to proactively address any actual changes in condition. If a transfer is necessary, all critical resident information can be provided to the hospital to ensure a smooth transition of care.
• Saving time and money through elimination of manual admission/transfer logs and manual readmission rate calculations using a national standard for rate calculation. Additionally, required information is automatically captured by the system during the admission and transfer process without disrupting staff workflow.
• Ensuring compliance with easy access to accurate and complete transfer information for all residents. Nationally accepted standards and documentation policies are built into the system. Plus, alerts are provided to monitor compliance throughout. As information seamlessly flows within the PointClickCare EHR platform, resident data continually remains current, enabling your staff to reduce the potential of hospital readmissions.

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