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Deciding what you want to change and communicating that intention is the first step of the quality improvement cycle. This page provides a general description of the goal and its benefits to share with your team.

Long-term care residents are often transferred to hospitals when they have an acute change in their clinical condition. Many such changes in condition can be managed safely without transfer, avoiding the trauma and risks associated with hospitalization. In order to achieve this goal, staff must be prepared and have the necessary resources available. Working on this goal will assist staff to safely care for residents on-site using evidence-based and expert recommended tools and practices to reduce rates of hospitalization without compromising residents’ well-being or wishes.

  • How Does Reducing Hospitalizations Benefit Residents?

    Residents receive timely care from staff members who know the resident and who are able to respond to the resident’s individual preferences and needs.

    Residents remain in a familiar environment with their personal possessions and maintain their routines as much as possible.

    Residents avoid an uncomfortable, often traumatic, trip to the hospital, and potentially long delays in the hospital’s emergency room.

    Residents avoid adverse events that can occur due to miscommunication between the hospital and the provider.

    Residents avoid adverse effects that can occur due to a change in their medication regimen.

    Residents avoid acquiring a hospital-related complication.

    Residents are not confused by changes in utilization review or reimbursement procedures.

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  • How Does Reducing Hospitalizations Benefit Long-term Care Staff?

    Staff are more skilled and confident in care delivery and better able to identify changes in condition and learn evidence-based care practices.

    Staff are able to maintain connection with the resident that is often lost once a hospital transfer is made.

    Staff are able to provide continuous support to the resident and family members.

    Staff are able to practice at a level for which they are trained and licensed.

    Staff members are more satisfied and thus more likely to stay.

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  • How Does Reducing Hospitalizations Benefit Long-term Care Providers?

    Communities better maintain census as a result of increased referrals from hospitals due to better resident outcomes.

    Providers have better customer satisfaction and improved community image.

    Providers save time and money because work associated with hospitalizations and readmissions are eliminated.

    Providers will meet the national Partnership for Patients efforts and Quality Assurance Performance Improvement (QAPI) requirements by reducing transfers to the hospital.

    Providers will prepare for payment reform and partnering with hospitals, home health agencies and others in accountable care organizations and other similar initiatives.

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Step 2 – Tracking Tool  >

Tracking Tool

The Campaign Tracking Tools allow you to document your work, monitor outcomes and the processes related to your outcomes. To achieve a data-driven quality improvement project, collect data for several months to establish a solid baseline and set a target for your improvement; then continue collecting data -- charts within the workbooks and trend graphs on the website provide you and your team with the feedback you need to determine if the changes you are making are being fully implemented and if they are having the expected impact on your outcomes. Keep your workbook up-to-date on a daily or weekly basis and look at data often to support a rapid cycle quality improvement project. Download the data tracking tool and collect data for a month or so to determine your starting point.

Questions? Contact the NNHQI Campaign Help Desk:

Before you start, read our Tip Sheet on Testing Change & Starting Small (PDF).

Step 3 – Examine Process  >

Examine Process

This set of probing questions will help you evaluate your current processes and provide guidance for ways to make improvements.

  • What patterns do we see in our hospitalization rates?

    • Is there a particular day that has a high frequency of hospitalizations?
    • What time of day are most of our admissions from the hospital occurring?
    • What time of day are most of our discharges to the hospital occurring?
    • What day of the week are most of our admissions from the hospital occurring?
    • What day of the week are most of our discharges to the hospital occurring?
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  • Which groups are most affected?

    • What proportion of our transfers has dementia?
    • Is there a pattern of clinical causes for transfer to the hospital?
    • Of the individuals that were admitted to the hospital,
      • How many of them died?
      • How soon after the transfer did they die?
    • Is this primarily a problem of:
      • Readmissions to the hospital,
      • Primary hospitalizations, or
      • Both?
    • Are most of the decisions for hospital admission made by the Medical Director, a covering physician, or by the individual’s physician?
    • Is there a particular practitioner that is requesting that his or her patients get admitted to the hospital?
    • Are residents calling 911 because they are worried about their condition?
    • Are we experiencing a spike caused by something like the flu or epidemic diarrhea that is currently going on in our nursing home?
    • How many of our admissions are taking an antipsychotic or psychoactive drug?
    • Has there been an increase in falls with injury?
    • Has the number of other incidents changed?
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  • Processes and Resources to Consider

  • Which groups are most affected?

    • Do we track and analyze admission and transfer data?
    • What is the volume of admissions we get from each hospital? How many residents are transferred back?
    • Do we routinely analyze the causes of all hospital/emergency room transfers?
    • What are nurses and CNAs saying about these hospitalizations? E.g., Do they agree that a resident should have been transferred?
    • Do we get all the information we need from the hospital at admission?
    • What specific data does the hospital have on tracking our readmissions?
    • Do the admissions from the hospital challenge our capacity to care for them?
    • What happens to residents when they are transferred to the hospital?
      • Are they admitted?
      • Are they placed in observation status?
      • Are they seen in the emergency room only and returned to the nursing home?
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  • What is the role of person-centered care and decision-making?

    • Do we have a process in place to assess care preferences and begin care planning prior to the admission?
    • Are we routinely and periodically reviewing resident and family wishes regarding hospitalizations?
    • Are we routinely working with residents and families on their:
      • Goals for care?
      • Advance care planning?
    • How well do our direct caregivers know their residents?
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  • What roles do various staff play in decision-making?

    • How involved is the Medical Director with individual transfer decisions?
    • What is nursing's role when a hospitalization is deemed necessary?
    • Is nursing involved in decision-making?
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  • Are we communicating effectively?

    • Do we use a structured communication tool?
    • How do we share information:
      • Among ourselves (between nursing home staff members)?
      • Between our staff and our physicians?
      • Between our nursing home and the hospital?
      • Between our nursing home and diagnostic services?
      • Between staff and resident/family?
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  • What other process improvements should we consider?

    • Do we look at the list of medications at the time the resident is admitted to the nursing home? Do we routinely do medication reconciliation?
    • Are we using the "Stop and Watch" INTERACT III tool or another process to ensure we capture small changes in condition early?
    • Can we get diagnostic testing done easily and in a timely way?
    • Do we have after-hours physician consultation? How effective are our current arrangements for after-hours access to physicians?
    • What access to medications is typically needed to manage acute changes in condition – such as narcotics and antibiotics?
    • Do we have on-site oxygen?
    • Is the acuity level of the residents higher than we are able to manage? If so, why?
    • Are we staffed to be able to care for residents who are experiencing an acute change in condition?
    • Does the hospital we are transferring to have a special service that we are not able to provide?
    • Would it be possible for us to add some services that would reduce our need to send residents to the hospital to get them, such as, IV’s, X-rays?
    • Who have we engaged in process improvement? Who else needs to be engaged to support success?
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Step 4 – Create Improvement  >

Create Improvement

The Science of Change

  • The Circle of Success is a quality improvement framework and a guide to finding the resources you need on the website.
  • Quality Improvement Methods are evidence-based approaches for creating systemic change. This collection includes quick-start instructions, templates, and mini-videos.
Website INTERACT Stop and Watch Early Warning Tool
INTERACT Stop and Watch, designed for use by all staff and family members provides a way recognize early warning signs of changes in resident condition that need clinical follow-up.
Website INTERACT Care Paths and Change in Condition File Cards
INTERACT Care Paths and Change in Condition File Cards assist nurses in making judgments about changes in resident condition and what issues need immediate and non-immediate intervention by the physician.
Adobe PDF AMDA's Clinical Practice Guideline for Acute Change in Condition
Clinical Practice Guideline developed by AMDA that discusses Acute Change of Condition in the Long Term Care Setting and provides tips on assessment and monitoring.
Website INTERACT Acute Care Transfer Document Checklist
INTERACT Acute Care Document Checklist identifies and organizes the information that needs to be sent to the hospital when a hospital transfer is needed.
Adobe PDF Pioneer Network Shift Huddle Tip Sheet
Pioneer Network Shift Huddle Tip Sheet describes how to set-up and conduct Shift Huddles to communicate change in condition information across shifts.
Adobe PDF CHATS - Communicating Health Assessment by Telephone | CHATs Progress Note
CHATs – Communicating Health Assessment by Telephone are tools consisting of 16 common problems found in long term care settings. Tools are used by clinical staff in reporting change in condition.
Adobe PDF Research study of implementation of CHATs in LTC Facility
Detailed description of Duke University and Durham VA Extended Care & Rehabilitation Center project improving nurse/physician communications using CHATs.
Advanced Care Planning
Website INTERACT Advanced Care Planning Tools
INTERACT tools to help manage residents at or near end-of-life. Tools include: Advance Care Planning Communication Guide; Identifying Residents Who May be Appropriate for Hospice or Palliative/Comfort Care Orders; Comfort Care Order Set; Deciding About Going to the Hospital.
Adobe PDF LTC Professional Leadership Council Care Delivery Process (2008)
LTC Professional Leadership Council describes the universally acknowledge method to identify and address complex issues to enable individualized care plans and interventions.
Care Transitions
Adobe PDF AMDA's Clinical Practice Guideline for Transitions of Care in the Long Term Care Continuum
Clinical Practice Guideline developed by AMDA that addresses Transitions of Care in the Long Term Care settings. Discusses planned and unplanned transfers.
Website Project RED (Re-Engineered Discharge) Training Program
Project Red – Re-Engineered Discharge is a patient-centered intervention and standardized approach to discharge planning to improve self-care and reduce preventable readmissions. The training developed for hospitals can be adapted for LTC use.
Website Project Boost
Project Boost offers resources and tools to improve care during transfers to the community. Tools focus on identifying high-risk individuals and improving information flow. Developed for hospitals, but can be adapted for LTC use.

Step 5 – Engage  >


Engaging stakeholders creates a robust and successful quality improvement project. Use these fact sheets to start the conversation and encourage everyone to be involved. A story board is a wonderful, visual way to engage your community in the project, keep everyone in the know about new changes that are being tested, and share your challenges and successes along the way.

Story Board Guide
Adobe PDF Storyboard guide from QAPI
Use this guide to create a compelling poster to keep your community engaged in your project, monitor your progress, and celebrate your success. Print outcome trend graphs from your Campaign account to document your change!
Hospitalizations Fact Sheets
Adobe PDF Leadership Fact Sheet
Adobe PDF Staff Fact Sheet
For Consumers:
Adobe PDF Health-Related Services
Adobe PDF Hospitalization Costs
Adobe PDF Consumers Fact Sheet

Step 6 – Monitor & Sustain  >

Monitor & Sustain

Once you make a change or an improvement, it’s important that you continue to collect and submit your data to ensure your improvements are working.

Step 7 – Celebrate Success  >

Celebrate Success

Too often we let accomplishments pass by without notice because we are already moving on to the next step. But, it's important to take a moment to celebrate accomplishments, big and small.

A celebration program can create a spirit of community in your nursing home. Use visible awards such as certificates, plaques and other tangible rewards that can be proudly displayed. Try giving a spontaneous award from time to time to acknowledge people who are going the extra mile.

More resources on their way. Please check back soon.

Back to Goals  >

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