Nursing Home and Health Plan Partnership Project

Nursing Home and Health Plan Partnership:

Reducing Readmissions & Honoring Wishes

The California Association of Long Term Care Medicine (CALTCM) is dedicated to improving quality patient care in California. This project is supported by the California HealthCare Foundation (CHCF) based in Oakland, California


In Partnership with three California Health Plans, CALTCM will implement the Interventions to Reduce Acute Care Transfers (INTERACT) program in up to 36 nursing homes, reduce avoidable hospital transfers and align care with residents' wishes.

CALTCM will host three trainings in California in 2016

  • February 2, 2016: Inland Empire Health Plan in Rancho Cucamonga
  • June 15, 2016: Santa Clara, California at Justin's in Santa Clara
  • October 5, 2016: Southern California at UC Riverside

Project Details

Training & Implementation Goals

  • Train 30-36 California Nursing Homes in the Interventions to Reduce Acute Care Transfers (INTERACT)
  • Reduce avoidable hospital transfers
  • Align care with residents’ wishes

Facilitate the Sustainability of Quality Improvement Efforts

  • Develop interventions and relationships with Health Plans, Hospitals, Medical Groups and Nursing Homes

Nursing Home to Hospital Readmissions


  • 66% of 2013 CA NH discharges went to Hospitals
  • Close to 20% of NH admissions are readmitted to Hospitals within 30 days


  • Readmissions are expensive: $15,000 - Average cost per NH readmission in CA (average per CA QIO: Health Services Advisory Group)

High Readmission Rates Represent Poor Care

  • Worsens confusion/delirium, weakness & insomnia
  • Increases risk for new infections, depression & falls
  • Unpleasant patient and family experience


  • Up to 2/3 of rehospitalizations may be preventable with appropriate and timely interventions


Increase patient satisfaction.  Here is a sample of patients reporting overall “Very Good” or “Excellent” care:
  • Pre-training: 70%
  • Post-training: 90%
Additional staff benefits:
  • Improve communication between clinicians
  • Increase nurse competency & confidence
  • Improve patient experience
  • Improve quality of care

Target Audience:  Nursing Home Leadership Team

  • Medical Director
  • Director of Nurses
  • Administrator
  • DSD

Improve Collaboration Between:

  • Hospitals
  • Health Plans
  • Medical Providers
  • Nursing Homes