Geriatrics as a Team Sport: Grantee Wins CMS Innovation Award for Cost-Saving Senior Care Program

Expansion of a time-tested initiative may save millions, while protecting the health of older Americans.

    • September 14, 2012

Repeated, often unnecessary, hospitalizations of older adults living in skilled nursing or assisted living facilities are not only traumatic for patients and their loved ones, but also extremely costly for the health care system.  Among Medicare patients admitted to skilled nursing care from the hospital, one in four are returned to the hospital within 30 days.

The problem also extends to the growing number of seniors who are in assisted living or growing older at home. For these reasons, the $7.3 million Brookdale Senior Living (BSL) Transitions of Care Program is a quality improvement initiative designed to greatly reduce unnecessary hospitalizations among seniors in independent living, assisted living, and dementia-specific facilities, as well as community dwelling older adults receiving home health care services. The program is a partnership between the University of North Texas Health Science Center (UNTHSC), Brookdale Senior Living, Florida Atlantic University, Loopback Analytics, the University of South Florida, the American Association of Colleges of Nursing and Florida Medical Quality Assurance, Inc.

“To accomplish this, we are taking an established program—INTERACT II (Interventions to Reduce Acute Care Transfers) that is currently only being used in skilled nursing facilities, and adapting it to these new environments,” explains José A. Pagán, PhD, professor and chair of the department of Health Management and Policy at the UNTHSC School of Public Health, principal investigator for the Transitions of Care Program and a former Robert Wood Johnson Foundation (RWJF) Health & Society Scholar (2003-2005).

Common Sense Care

“Focusing on clinical nurse leaders to coordinate care, we are applying the tools outlined in INTERACT II to get everyone in a care facility or home care environment to work together to identify how people are doing on a daily basis and what they need to stay healthy and out of the hospital,” says Pagán, an economist who was also a 2006 RWJF Investigator in Health Policy Research. “We will also gather data on what leads to hospitalizations, working with institutions in several states, over three years.”   

INTERACT II provides four types of tools for health care teams: communications modules;   care path instructions; advance care planning information; and quality improvement measures.

“Some of the clinical content is not unique in medicine,” says Joseph Ouslander, MD, the creator of INTERACT II and a professor of geriatrics at the Charles E. Schmidt College of Medicine.  “These are just principles of good quality geriatric care, organized and put into a form that people can use.”

The Stop & Watch tool (part of the INTERACT II communications module), for example, helps providers and caregivers identify often small, but significant shifts in a person’s condition that may be a sign of the increasing severity of an illness, such as changes in activity, appetite or mood.

The SBAR (Situation Background Assessment Request) procedure is a structured communication tool for nurses to guide them through recognizing and responding to certain symptoms, before they call a physician. “It can greatly improve physician/nurse communication about the patient,” Ouslander says.

Key Role for Nurses

“INTERACT II really allows us to make everyone in the older person’s community part of the care team,” explains Rita Vann, RN, vice president of clinical services at Brookdale and an expert in quality improvement in skilled nursing. “That’s particularly important now because we are seeing a level of acuity in assisted living that we have never seen before.  People are living longer and aging in place at home or in assisted living facilities, as their illnesses become more severe.”

As a link between older adults, their caregivers and physicians, “nurses are the lynchpin in the communications team.  The resident physicians for assisted living facilities, for example, are not on the premises.  Often, when the facility calls a physician, he or she may choose to send the older patient to the hospital simply because there’s not enough information for the physician to determine the severity of their condition,” Vann says. 

But by using SBAR, “the nurse can provide the physician with better, more consistent information, so that they may avoid sending someone to the hospital for something like a urinary tract infection [very common among older adults] that can be treated in the assisted living environment,” she adds.

The other critical piece of INTERACT II programming is teaching nurses, physicians and other health care workers how to address end-of-life care issues. “The advance directive communication tool allows us to help families understand the end-of-life process, so that they have an idea of what to expect and how to plan,” Vann says. “Overall, the INTERACT II tool makes things happen consistently and that’s really the key to quality health care.”

Even though INTERACT II focuses on nurses, “I teach that geriatrics is a team sport,” Ouslander adds. “Nurse practitioners, physician assistants, nutritionists, everyone should be involved.  By helping all of these caregivers to do their jobs better, INTERACT II aims to improve care for patients, make things easier for families and save billions of health care dollars over the next several years.”

Importance of Interdisciplinary Collaboration

Pagán adds that the lessons learned as a scholar contributed to his ability to work on the Brookdale/Transitions program.  “As an RWJF Health & Society Scholar, I learned to work with people from across the health professions.  The program teaches you to think about the big picture, learn about leadership and determine how to bring all of these players together to accomplish a goal. That experience, in part, prepared me for the Brookdale project and helped me shape the ideas that are part of the program.  I hope it will have a great impact on reducing costs and improving care.”


The Robert Wood Johnson Foundation Health & Society Scholars program is based on the principle that progress in the field of population health depends upon multidisciplinary collaboration and exchange. The program is intended to produce leaders who will change the questions asked, the methods employed to analyze problems, and the range of solutions to reduce population health disparities.

The Robert Wood Johnson Foundation’s Investigator Awards in Health Policy Research program provides funding to highly qualified individuals undertaking broad studies of the most challenging health, health care and health policy issues facing America.

Learn more about the RWJF Investigator Awards.

Learn more about the RWJF Health & Society Scholars Program.

▪ For an overview of RWJF scholar and fellow opportunities, visit RWJFLeaders.org