Meritus Medical Center in Hagerstown, Md., has done something every hospital in America wants to do.

“We decreased readmissions [from skilled nursing facilities] by 24 percent across the entire county,” says Andrea Horton, director of care management for the community hospital. “Percentage-wise, we dropped our readmission rate from almost 21 percent to 16 percent, which we have sustained.”

In doing so, the hospital saved $1.52 million in a year.

The success came from a collaboration designed to improve the quality of care at nursing homes — and help Meritus succeed in global capitation.

Like most other Maryland hospitals, Meritus operates under Total Patient Revenue, an all-payer capitation system authorized by a waiver from the Centers for Medicare & Medicaid Services. Meritus entered the pay system four years ago.

“We are incentivized to reduce volume to our hospital,” Horton says. “That is why we started reaching out to our skilled nursing home providers and looking at our readmissions.”

She started by identifying the three nursing homes responsible for the most readmissions and invited representatives to participate in a week-long rapid-cycle process improvement event facilitated by Meritus’ operations improvement staff. Leaders from the nursing homes and hospital created a process map from the patient’s perspective, detailing all the steps from admission to the hospital through discharge to a skilled nursing home and readmission.

Then they looked at the map to find problems that needed solutions. The exercise highlighted, for example, that the hospital and nursing homes were exchanging too much information when a patient transferred from one site to the other.

“When you get a medication administration record from a nursing home that is 50 pages long, it’s really hard to weed through in an emergency department setting to know what the patient is taking,” Horton says.

The team developed interventions to address each problem, data tools to monitor progress and a commitment to keep working until sustainable solutions were perfected.

“The nursing homes were auditing us on our performance, we were auditing them, and it was really a collaboration,” she says. “We would all sit down together to do the Plan-Do-Study-Act cycle to learn what was working and what was not and what needed to be tweaked until we had a good system.”

Once a process was perfected, it was introduced to the other seven nursing homes that serve Meritus patients. Horton rejected the idea of working with a limited number of preferred nursing facilities.

“My personal goal is that, no matter which facility has a bed available, our patients are getting the same level and quality of care,” she says. “Because we are the sole community hospital and we have 10 nursing homes in our service area, my goal was to bring everybody along and be included in the work. It helped to foster collaboration.”


A key element of Meritus’ readmissions reduction is the use of Interventions to Reduce Acute Care Transfers, or INTERACT, a publicly available quality improvement program for skilled nursing facilities. Developed with funding from the federal government and other sources, INTERACT is a set of protocols and tools — now in its fourth iteration, called INTERACT Version 4.0 — to mitigate unwarranted hospital admissions from nursing homes. [For more information, go to]

INTERACT tools and protocols are widely used within the skilled nursing facility setting, but Meritus’ rapid-cycle improvement process event revealed that nursing home staff did not always take full advantage of them.

“That was part of the standard process that we created — that INTERACT was used to its full capacity in the nursing homes,” Horton says.

Used in Canada, the United Kingdom, Singapore and across the United States, INTERACT has been evaluated in several multi-institution studies in the past several years. Its success in reducing unnecessary readmissions is associated with the level of engagement at a given nursing home, including executive support, staff training and ongoing management of the quality improvement effort, according to an March 2014 article in the Journal of the American Medical Directors Association.

The INTERACT program is designed to provide early identification and evaluation of changes in a patient’s condition before hospitalization is needed. It identifies the processes necessary to manage common changes, such as shortness of breath or loss of appetite, without hospital admission whenever possible. And it focuses on advance care planning and, if the patient wishes, the use of palliative or hospice care as an alternative to hospitalization near the end of life.

INTERACT tools include:

  • the Stop and Watch early warning tool used by all nursing home staff members to note changes in a patient’s condition such as “ate less” or “talks or communicates less.”
  • the Situation, Background, Assessment and Recommendation, or SBAR, communication technique to improve communication between nursing home nurses and the primary care providers they call to discuss possible patient transfers to a hospital. The form concisely documents the four elements so that the nurse and primary care provider understand one another.
  • clinical decision support tools that provide specific care paths if a patient exhibits symptoms of a particular problem, such as a lower respiratory infection or a urinary tract infection.
  • advance care planning tools.
  • a nursing home capabilities list so that hospital personnel know the clinical services available at a given nursing home. This helps them make decisions about whether a patient whose condition has deteriorated needs to be transferred to the hospital.
  • nursing home to hospital transfer form that provides concise information that ED staff use to evaluate a patient who arrives from a nursing home
  • hospital to post-acute care transfer form that provides concise information needed to facilitate a smooth transition

Complying with the INTERACT program has become standard operating procedure for nursing homes in the Hagerstown area, Horton says.

“Before, there was no standard and nothing that would guide nursing home staff to make sure that they left no stone unturned prior to sending patients to the hospital,” she says. “They would just call the doctor, get the order and out the patients would go, with nobody taking some time to troubleshoot some of the things that could be addressed. That has now been deployed across our county with a lot of success.”

To learn more about how hospitals and nursing homes are collaborating to reduce readmissions, read “Why Nursing Home Quality Matters to Hospitals.”

Lola Butcher is a contributing writer to Trustee.