Elizabeth Newman

If INTERACT used to be the Tom Cruise of the long-term care world, then RAFT is Chris Hemsworth.

Reducing Avoidable Facility Transfers (RAFT), like the actor who plays Thor in the Marvel Cinematic Universe, may have been originally dismissed as just another pretty face. But a new study shows that it, like Hemsworth, has real chops.  

Dartmouth researchers used the RAFT model among residents at three rural skilled nursing facilities between January 1, 2016, and June 30, 2017. They found that average monthly department transfers and hospitalizations decreased by 35.8% and 30.5%, respectively. The reductions were the greatest among long-term care residents.

Results appeared in the August issue of the Journal of the American Medical Directors Association (JAMDA). 

Notably, while INTERACT demonstrated a 17% reduction in hospital admissions, RAFT showed a 29% reduction in the first year and a 35% reduction in the second. 

This significant achievement can be broken down many ways. What’s perhaps most intriguing is what the facilities didn’t do, as much as what they did.

To start, RAFT involves a small team of providers who manage longitudinal care and after-hours calls, of which three were physicians certified in geriatrics. Next, it made filling out advance care plans and Provider Orders for Life Sustaining Treatment forms a standard practice at the SNF. Providers were asked to prioritize the need for goals of care meetings as high, medium or low, with higher priority assigned to residents deemed to have a poorer understanding of their condition or a higher risk of an acute decline.

Notably, they formalized the option of “do not hospitalize — treat in place” and said it was “critical” to success. By the end of the study, only 14% of directives listed unlimited life-prolonging interventions.

However, the researchers noted that many families were not comfortable or ready for pure palliative care.

“They wanted some interventions taken to prolong life, particularly if those interventions offered limited risk of distress,” the researchers wrote. 

That’s why the option of “limited interventions — treat in place” was attractive. That matched the values of 32% of long-term care patients. 

Next, providers were encouraged to speak directly to family members rather than through nurses.

“Prior to RAFT, clinicians often received calls stating, ‘The family wants the patient sent to the ED,’” the researchers wrote.

If I had a nickel for every time I heard a long-term care nurse use that exact phrase about families, I’d be a millionaire. But it’s not the nurses’ fault — I recognize that many families may be far more likely to listen to the doctor. The most charitable explanation of that is that we’re not too far removed from a time when the doctor was considered the voice of a higher power. Getting them on the phone with the family is a way to allow everyone to feel OK about the choice.

But more can be done. The researchers said bluntly that scheduling a meeting after SNF admission — when the risk of rehospitalizations is highest — was often not feasible. Earlier conversations likely could reduce risk and identify high-risk patients even more, they said. 

More studies are needed, they wrote, as the population studied was ethnically homogenous and many areas may not have physicians with as much expertise in geriatrics. 

Ultimately, INTERACT and RAFT likely have value in skilled care. It’s worth finding out, even if it means a few bumps in the road or less-than-glamorous finding.

After all, Tom Cruise has had plenty of misses along with his hits. There’s always time for another big hit, though. Do you know what’s being released in 2020? “Top Gun 2,” a movie everyone in our office has been talking about since the trailer recently was released. 

It’s been a good reminder that sometimes an old favorite still can wow you.

Follow Deputy Editor Elizabeth Newman @TigerELN.