Hospital readmission from nursing homes is one area of healthcare that can be improved upon.  Across the United States, an average of 15% of patients admitted to a Skilled Nursing Facility (SNF) are re-admitted to the hospital within 30 days.  Not only is this taxing and possibly detrimental to the resident but it also carries a heavy price tag. Each time a resident is discharged and readmitted to a hospital they are uprooted from their familiar home environment and susceptible to the following:

  • altered mental states
  • increased confusion
  • delirium and disorientation
  • falls and secondary injuries
  • hospital acquired infections
  • catheter placement
  • development of pressure ulcers
  • generalized deconditioning

These are only a few issues residents may face.   To ensure their health and well-being, hospitalizations should be avoided whenever possible.

Skilled Nursing Facilities employ doctors, nurses, certified nursing assistants, rehabilitation therapists, dieticians, activity coordinators, social workers, and more.  These professionals have the opportunity to interact with the nursing home residents on a daily basis.  They get to know a resident’s personality and behaviors, as well as become familiar with their daily routines and preferences.  This deep understanding of the resident’s behavior, medical history, and mannerisms sets the stage for the perfect environment to identify and manage the worsening of a chronic condition.

The INTERACT Program is an evidence-based quality assurance program that focuses on improving the care of nursing home residents with acute changes in condition.  The program is comprised of procedures, protocol, and tools to increase staff communication, decision making, family and resident interaction, and quality improvement.  The INTERACT program’s primary tenant is the early identification and evaluation of changes in resident condition.  Often, slight changes in a person’s behavior or body functions are signs that there may be a change in their medical condition.  By using the INTERACT program, SNF staff would be able to recognize a subtle change in condition, promptly evaluate and treat the condition, and maintain a resident’s health and well-being at the facility, without requiring an unnecessary trip to the hospital.

The INTERACT Program wasn’t created to prevent all transfers to the hospital from the skilled nursing setting.  There are many instances when a transferring a patient to the hospital is the right thing to do. Instead, INTERACT is empowering staff members who work with the patients each day to significantly decrease preventable and avoidable hospital admissions.  The INTERACT Program also has a large Advanced Care Planning component to assist in the creation of a plan for those patients who do not want excessive measures taken to prolong their life.

There are over 50 Skilled Nursing Facilities in Millennium’s provider network working together to implement this program. With continued collaboration and utilization, there will a profound impact on patient quality of care and everyday life.

If you have any further comments or questions regarding this project, please feel free to contact Saralin Tiedeman, Project Manager at (716)898-6425, or e-mail at


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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

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