1. 1 On-Time Quality Improvement for Long-Term Care Using Nursing Home IT for Optimal Care Delivery Presentation to AHRQ Annual Conference Track 1. HIT Improving Quality of Care for Vulnerable Populations Through HIT September 8, 2008 by Susan D. Horn, Ph.D Institute for Clinical Outcomes Research 699 East South Temple, Suite 100 Salt Lake City, Utah 84102 Salt Lake City, Utah 84102 801-466-5595 (V) 801-466-6685 (F) shorn@isisicor.com www.isisicor.com www.isisicor.com

2. 2 AHRQ Transforming Healthcare Quality through Information Technology Findings from 3 Projects 1. Real-Time Optimal Care Plans for Nursing Home QI 2. Nursing Home IT: Optimal Care Delivery 3. On-Time Quality Improvement for Long- Term Care

3. 3 1.Integrate evidence-based research on pressure ulcer prevention into long term care daily practice 2.Implement pre-IT and HIT solutions in long term care to support redesigned processes and improved outcomes 3.Identify HIT implementation best practices Objectives NURSING HOME IT: OPTIMAL CARE DELIVERY

4. 4 Background – Clinical Quality  Pressure ulcer (PrU) rates remain high  Despite guidelines  Despite training  NH staff know how to prevent PrUs  Need to identify high risk residents on weekly basis  Knowledge not integrated into day to day practice  Entire multi-disciplinary team needs to coordinate care better for high risk residents (including CNAs)

5. 5 Background - Operations CNAs document in 7-8 different placesCNAs document in 7-8 different places Communication is fragmentedCommunication is fragmented Difficult to track down information for MDS assessmentsDifficult to track down information for MDS assessments CNA documentation often incomplete and inaccurate, yet they spend the most time with residentsCNA documentation often incomplete and inaccurate, yet they spend the most time with residents

6. 6 Steps to Success 1.Research-based foundation 2.Partnerships; bottom-up approach 3.Standardized comprehensive documentation 4.Timely feedback reports 5.Integrate into daily workflow and care planning 6.Incorporate into IT – explicit link between IT and QI

7. 7 Step 1 – Research Based Foundation National Pressure Ulcer Long-term Care Study (NPULS) 1996-1997 6 long-term care provider organizations 6 long-term care provider organizations 109 facilities; 2,490 residents 109 facilities; 2,490 residents 1,343 residents with pressure ulcer; 1,147 at risk 1,343 residents with pressure ulcer; 1,147 at risk 70% female; Average age = 79.8 years 70% female; Average age = 79.8 years Funded by Ross Products Division, Abbott Laboratories

8. 8 Long Term Care CPI Results Outcome: Develop Pressure Ulcer General Assessment Assessment IncontinenceInterventions Nutrition NutritionInterventionsStaffingInterventions + Age  85 + Male + Severity of Illness + History of PrU + Dependency in >= 7 ADLs >= 7 ADLs + Diabetes + History of tobacco use + Dehydration + Weight loss + Mechanical devices for the containment of urine (catheters) - Disposable briefs - Toileting Program - RN hours per resident day >=0.5 - CNA hours per resident day >= 2.25 Medications - SSRI + Antipsychotic Horn et al, J. Amer Geriatr Soc March 2004; 52(3):359-367 - Fluid Order - Nutritional Supplements standard medical standard medical - Enteral Supplements disease-specific disease-specific high calorie/high high calorie/high protein protein

9. 9 Effects of Nutritional Support in Long Term Care

10. 10 Bladder Incontinence Management in Long Term Care

11. 11 Step 2: Partnerships Empower all members of a facility teamEmpower all members of a facility team Front-line workers actively participate in QI activitiesFront-line workers actively participate in QI activities Share across facilitiesShare across facilities

12. 12 Step 3: Standardized Documentation Redesign work flow – consolidate documentation and eliminate duplicationRedesign work flow – consolidate documentation and eliminate duplication Allow individual facility customizationAllow individual facility customization Encourage inter-facility sharing and observe facilities come to consensus over timeEncourage inter-facility sharing and observe facilities come to consensus over time

13. 13 Redesign Documentation CNA Daily flow sheetDaily flow sheet Single form replaced multiple logs, clipboards, bedside chartsSingle form replaced multiple logs, clipboards, bedside charts Reduced redundant documentation “document one thing, one time, in one place”Reduced redundant documentation “document one thing, one time, in one place” Care Planning Team Nurses, dietitians, wound nurses contribute to care plans Used by multiple members of the care team to plan/implement care

14. 14 Transition from Paper to HIT CNA staff for daily documentationCNA staff for daily documentation Wound nurse for documentation - tracking pressure ulcersWound nurse for documentation - tracking pressure ulcers Nursing Management, charge nurses, and Dietary access on-line reports to support decision-making, care planning, and CQI activitiesNursing Management, charge nurses, and Dietary access on-line reports to support decision-making, care planning, and CQI activities

15. 15 Digital PenDigital Pen » Thin and light device that writes like an ordinary pen » Includes camera that records pen strokes » Used with digitized form, digital pen reads unique pattern of dots to interpret the data Docking StationDocking Station » Battery charging » Uploading data from memory to database via Internet Example Technology #1 Digital Pen & Paper

16. 16 Digital Pen Systems In the absence of existing HIT, the Digital Pen and Paper solution was used because of its: » Ease of use and low cost » Minimal staff training requirements » Minimal set up and support requirements » Minimal impact to existing clinical workflow resulting in rapid staff adoption rates » Rapid report development cycle supports accelerated implementation timeline » The Digital Pen and Paper solution does not interfere with existing facility IT applications.

17. 17 Ex: CNA Documentation

18. 18 Example technology #2 Electronic Medical Record Profile:  Add CNA standardized documentation data elements into EMR  Add Wound RN standardized documentation data elements into EMR Project Requirements:  Incorporate standardized data elements, including best practices, into application  Produce On-Time reports Vendors to date  Optimus EMR, Lintech, CareTracker, eHealth, Reliable

19. 19 Step 4: Timely Feedback Use comprehensive standardized documentation dataUse comprehensive standardized documentation data First reports provide feedback on completenessFirst reports provide feedback on completeness Other reports target specific components of careOther reports target specific components of care Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, etc.Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, etc. Reports contribute to care planning processesReports contribute to care planning processes

20. 20 Integrate Research-Based Specifications into Timely Reports Weekly Reports  Nutrition Report / Weight Summary  Incontinence Report  Behavior Report  Pressure Ulcer Report  QI “Trigger Report”

21. 21 Nutrition SummaryNutrition Summary » Low meal intake flag » Average meal intake for 4 weeks » Tube feeding indicator » Dietary consult date » Weight change » Existing pressure ulcer » History of resolved ulcer Weight Summary » Weight 180 days prior » Weight 30 days prior » Weight trends » Recent weight change » 5-10% weight loss past 30 days » >10% weight loss past 180 days Example: Nutrition Report Stratified by Risk Provide ‘BIG picture’ over time, not just snapshot of one shift or one day

22. 22 Step 5: Integrate Reports into Care Planning Processes  Support clinical team in understanding reports – Education in use of reports  Facilitate use of reports in team processes – Multi-disciplinary team processes for care planning – Accountability for best practice implementation and resident outcomes monitoring

23. 23 Prevention Reports Standardized CNA documentation QI Team Access timely information Reduce redundancy Consolidate documentation Front-line team members use reports in daily work Identify high-risk residents Information Technology Step 1 Step 2Step 3 Step 4

24. 24 Q4 03 – Q3 05 % Change = - 33% Impact On Pressure Ulcer QMs Study Facilities Combined Source: CMS Nursing Home Compare; Facility QM data reports

25. 25 On-Time Quality Improvement for Long-Term Care

26. 26 On-Time Quality Improvement for Long-Term Care

27. 27 On-Time Quality Improvement for Long-Term Care

28. 28 On-Time Quality Improvement for Long-Term Care Area of ImpactImpact Summary (Dec 2007) CNA documentation Improvements in CNA documentation completeness reported (DON, DSD, Dietary, and MDS nurses) Improvements in CNA documentation accuracy reported (Dietary and MDS nurses) Workflow efficiencies Improvements in identifying residents at risk and communications among team members reported (facility feedback) Reduced time gathering information (Dietary and MDS nurses up to 30 min per review) CNA satisfaction Improvements in CNA satisfaction reported (facility feedback)

29. 29 Lessons Learned Focus HIT implementation as a tool to sustain process redesign Identify inefficient and efficient steps in existing workflow to focus HIT implementation

30. 30  Standardize data focusing on critical data elements  Reduce documentation duplication  Streamline processes  Front-line driven; include all caregivers in redesign of workflow and documentation Standardize data elements and redesign workflow prior to HIT implementation Lessons Learned

31. 31  HIT development challenges  Resistance to changing documentation  Staff turnover and/or Administrator and DON turnover  Resistance to adopt reports and redesign processes to use reports  Resistance to delegate to team members  IT knowledge deficit in nursing homes Obstacles to Improvement

32. 32Summary  Start with automating CNA documentation  Monitoring compliance is on-going  Training needs are on-going  HIT by itself does not lead to QI  Plan for how information will be used by clinical team  Assign a consistent dedicated person or team of resources to manage the HIT implementation

33. 33 On-Time Prevention of Pressure Ulcers 55 Nursing Homes in California, New York, Idaho, Maryland, Arizona, North Carolina, Washington, DC Funded by AHRQ, CHCF Partners: NY State Health Dept, Delmarva Foundation On-Time has been expanded to

34. 34 Available On-Time Tools  CNA documentation  http://ahrq.gov/research/ltc/pucnaform.pdf  On-Time Reports  http://ahrq.gov/research/ltc/pusamplerep.pdf  Video and other resources  http://ahrq.gov/research/puwebcast.htm