Health Care Innovation Awards Round Two: Project Profile


Project Title: "Person Centered Care Connections"
Geographic Reach: Minnesota
Estimated Funding Amount: $3,347,584


The CareChoice Cooperative project will test Person Centered Care Connections, which will build on and expand another successful CareChoice project, Resident Centered Care Connections, in an effort to reduce unnecessary hospitalizations and total cost of care by using four essential care components to address problems and gaps in nursing home post-acute and long term care. These four components are INTERACT (Interventions for Reduce Acute Care Transfers), POLST (Provider Orders for Life Sustaining Treatment), palliative care and enhanced discharge planning. INTERACT is an evidenced-based process for reducing hospitalizations from nursing homes by improving communication among caregivers and between the nurse and medical provider. INTERACT empowers nursing assistants to recognize and report changes in patient and residents' condition and promotes concise and thorough communication between the nurse and medical provider when relaying changes in patient and residents' condition. POLST encourages informed decision-making about goals of care and desired treatments and makes these patient and residents' goals and desires actionable physician orders for care providers. Palliative care is an approach that endeavors to provide care consistent with the patient and residents' defined goals of comfort, pain and symptom relief. It increases quality of life for people with chronic or life-threatening illnesses. The proposed enhanced discharge planning process includes using evidence-based components of Project RED (Re-engineered Discharge) and available technology to create an efficient system for nursing home staff to do the comprehensive education and preparation needed by patients and families to promote a successful patient and residents' transition from care setting to home. Together, these four components of care have proven effective in reducing hospital admissions, enabling patient determined goals of care and improving palliative care for the patient and residents' of CareChoice nursing homes over the past three years.

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