Implementing INTERACT in Veterans Health Administration Community Living Centers: A pragmatic randomized trial

Vincent Mor^{1

2}, Debra Saliba^{3

4}, Orna Intrator^{5

6}, Roee Gutman⁷, Amy L Mochel², Margaret Peg Baumann^{8

9}, Rebecca Boxer¹⁰, Heather D'Adamo¹¹, Hiroshi Gotanda¹², Kim W House^{13

14}, Seema Joshi¹⁵, Linda Sohn¹¹, Arti Tayade¹⁶, Kisa A Hilliard⁴, Sarah Tubbesing¹⁷, Ciaran S Phibbs¹⁸, Joseph G Ouslander¹⁹

Affiliations

¹ Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.
² Center of Innovation, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA.
³ GRECC and HS&D Center of Innovation, Los Angeles Veterans Administration Health System, Los Angeles, California, USA.
⁴ Borun Center, Geffen School of Medicine, UCLA, Los Angeles, California, USA.
⁵ Department of Health Services Research, University of Rochester Medical School, Rochester, New York, USA.
⁶ Canandaigua Veterans Administration Hospital, Canandaigua, New York, USA.
⁷ Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA.
⁸ Chicago VA Medical Center, Geriatrics and Extended Care, Jesse Brown VA (Chicago) Geriatrics & Extended Care, Chicago, Illinois, USA.
⁹ Department of Medicine, University of Illinois (Chicago), Chicago, Illinois, USA.
¹⁰ Department of Medicine, University of California Davis, Davis, California, USA.
¹¹ Geriatrics and Extended Care, Department of Veterans Affairs Greater Los Angeles Healthcare System a Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
¹² Department of General Internal Medicine, Cedars-Sinai Medical Center, Atlanta Veterans Administration Medical Center, Decatur, Georgia, USA.
¹³ Atlanta, VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁴ Department of Medicine, Emory University School of Medicine, Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas, USA.
¹⁵ VA Puget Sound Health Care System, University of Washington, St. Louis, Missouri, USA.
¹⁶ Palo Alto Veterans Administration Medical Center, Palo Alto, California, USA.
¹⁷ VA Medical Center, Greater Los Angeles, Office of Geriatrics and Extended Care, Los Angeles, California, USA.
¹⁸ Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.
¹⁹ Professor of Geriatric Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.

PMID: 39630636
DOI: 10.1111/jgs.19301

Randomized Controlled Trial

Implementing INTERACT in Veterans Health Administration Community Living Centers: A pragmatic randomized trial

Vincent Mor et al. J Am Geriatr Soc. 2025 Mar.

. 2025 Mar;73(3):771-781.

doi: 10.1111/jgs.19301. Epub 2024 Dec 4.

Authors

Affiliations

¹ Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.
² Center of Innovation, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA.
³ GRECC and HS&D Center of Innovation, Los Angeles Veterans Administration Health System, Los Angeles, California, USA.
⁴ Borun Center, Geffen School of Medicine, UCLA, Los Angeles, California, USA.
⁵ Department of Health Services Research, University of Rochester Medical School, Rochester, New York, USA.
⁶ Canandaigua Veterans Administration Hospital, Canandaigua, New York, USA.
⁷ Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA.
⁸ Chicago VA Medical Center, Geriatrics and Extended Care, Jesse Brown VA (Chicago) Geriatrics & Extended Care, Chicago, Illinois, USA.
⁹ Department of Medicine, University of Illinois (Chicago), Chicago, Illinois, USA.
¹⁰ Department of Medicine, University of California Davis, Davis, California, USA.
¹¹ Geriatrics and Extended Care, Department of Veterans Affairs Greater Los Angeles Healthcare System a Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
¹² Department of General Internal Medicine, Cedars-Sinai Medical Center, Atlanta Veterans Administration Medical Center, Decatur, Georgia, USA.
¹³ Atlanta, VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁴ Department of Medicine, Emory University School of Medicine, Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas, USA.
¹⁵ VA Puget Sound Health Care System, University of Washington, St. Louis, Missouri, USA.
¹⁶ Palo Alto Veterans Administration Medical Center, Palo Alto, California, USA.
¹⁷ VA Medical Center, Greater Los Angeles, Office of Geriatrics and Extended Care, Los Angeles, California, USA.
¹⁸ Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.
¹⁹ Professor of Geriatric Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA.

PMID: 39630636
DOI: 10.1111/jgs.19301

Abstract

Background: Hospital transfers from VA Community Living Centers (CLCs) are common. The objective of this study was to evaluate the effect of introducing the Intervention to Reduce Acute Care Transfers (INTERACT) program into VA CLCs.

Methods: Cluster randomized trial involving 16 pair-matched VA CLCs.

Interventions: Intervention CLC nursing staff were trained in the use of INTERACT tools designed to identify early signs of a clinical change in condition and improve communication and documentation. One tool was embedded into the VA Electronic Medical Record. Intervention staff were supported by bi-weekly calls over 18 months to reinforce INTERACT tool use.

Measurements: The primary outcome for intent-to-treat analyses was the rate of all-cause hospitalizations per 1000 person days. Secondary outcomes, assessed through structured record reviews and algorithms, were intervention CLCs change in 1) potentially inappropriate transfer decisions and 2) potentially preventable transfers. CLC staff implementation and engagement in INTERACT were documented.

Results: Only five of the eight intervention CLCs substantially engaged in the intervention. Using a negative-binomial regression with random effects, adjusting for month, intervention, and the interaction of time and the intervention, we observed no statistically significant difference between intervention and control facilities in all-cause hospitalizations. This was confirmed with matched resident-level, as-treated, analyses among residents in the five engaged CLCs and their matched controls. Structured implicit review of intervention CLC's medical records revealed low rates of inappropriate transfer decisions both before and after the intervention.

Conclusions: Introducing INTERACT into volunteer VA CLCs did not reduce the rates of all-cause hospitalizations. In both the pre- and post-intervention periods, all-cause hospitalization rates were relatively higher, and inappropriate transfers lower in VA CLCs than commonly observed in community NHs. Low rates of potentially inappropriate transfers and higher nurse and physician staffing in CLCs may explain why INTERACT was not implemented as fully as planned.

Keywords: INTERACT; VA Community Living Centers; all‐cause hospitalizations.

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References

REFERENCES

1. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2011;59(4):745‐753.
1. Lamb G, Tappen R, Diaz S, Herndon L, Ouslander JG. Avoidability of hospital transfers of nursing home residents: perspectives of frontline staff. J Am Geriatr Soc. 2011;59(9):1665‐1672.
1. Handler SM, Sharkey SS, Hudak S, Ouslander JG. Incorporating INTERACT II clinical decision support tools into nursing home health information technology. Ann Longterm Care. 2011;19(11):23‐26.
1. Bonner A, Tappen R, Herndon L, Ouslander J. The INTERACT institute: observations on dissemination of the INTERACT quality improvement program using certified INTERACT trainers. Gerontologist. 2015;55(6):1050‐1057.
1. Ouslander JG, Naharci I, Engstrom G, et al. Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned for reducing unnecessary hospitalizations. J Am Med Dir Assoc. 2016;17(3):256‐262. doi:10.1016/j.jamda.2015.11.018

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Implementing INTERACT in Veterans Health Administration Community Living Centers: A pragmatic randomized trial

Affiliations

Implementing INTERACT in Veterans Health Administration Community Living Centers: A pragmatic randomized trial

Authors

Affiliations

Abstract

References

REFERENCES

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources