1. On-Time Prevention Program for Long Term Care: Clinical Decision Support On-Time Prevention Program for Long Term Care: Clinical Decision Support William Spector, Ph.D. AHRQ Sandra Hudak, MS RN SLH Clinical Consulting Presentation at AHIMA June 17, 2013 Baltimore, MD

2. Using HIT for Prevention in Nursing Homes Pressure ulcers, falls, and preventable hospitalizations happen too often in nursing homes (NHs) despite regulatory and market approaches to encourage prevention and treatment Pressure ulcers, falls, and preventable hospitalizations happen too often in nursing homes (NHs) despite regulatory and market approaches to encourage prevention and treatment Challenges for managing clinical risk Challenges for managing clinical risk – Residents' changing risk profiles not readily available – Daily documentation is fragmented across disciplines – Difficult to assemble & summarize information from multiple sources to profile resident’s risk – MDS is focused on chronic care not acute changes that increase risk if not managed – Most staff not using patient data to track changes and intervene

3. On-Time Program: Components Clinical decision support (CDS) tools embedded into HIT, evidence based & usable by front-line staff Clinical decision support (CDS) tools embedded into HIT, evidence based & usable by front-line staff Strategies to integrate CDS tools into front-line NH practice Strategies to integrate CDS tools into front-line NH practice Guided facilitation to support adoption of tools & strategies Guided facilitation to support adoption of tools & strategies Focus on identifying & managing high risk residents to: Focus on identifying & managing high risk residents to: – Prevent Pressure Ulcers – Monitor Pressure Ulcer Healing – Prevent Falls – Reduce Potentially Avoidable Hospitalizations & ED Visits Prerequisites: HIT Vendor, Leadership commitment and multidisciplinary teams, data-driven QI Prerequisites: HIT Vendor, Leadership commitment and multidisciplinary teams, data-driven QI

4. On-Time Program: Research Support for Design Strategy Evidence-based risk identification from literature Evidence-based risk identification from literature Clinical expert panel review of tools and risk criteria Clinical expert panel review of tools and risk criteria Front line staff workgroup for input to tool development & considerations for work flow redesign Front line staff workgroup for input to tool development & considerations for work flow redesign – Input about NH clinical operations – Clinical expertise – Represent chains, for-profits, nonprofits, variety of vendors Pilot test with actual data risk rules & impact to work flow Pilot test with actual data risk rules & impact to work flow

5. Identify risk criteria Identify risk criteria Identify information needs of all disciplines Identify information needs of all disciplines Incorporate data elements into existing clinical documentation (e.g., nurse, dietary & CNA) Incorporate data elements into existing clinical documentation (e.g., nurse, dietary & CNA) Create resident risk profile reports, profile changes in risk Create resident risk profile reports, profile changes in risk – Incorporate multiple information sources to profile residents at risk (clinical assessments, MDS assessment, orders) Design simple weekly reports for front line & promote the use of information to guide decision making Design simple weekly reports for front line & promote the use of information to guide decision making – Focus on weekly changes – Provide trends – Patient and unit level information – Summarize data to support root cause analysis to analyze system causes Provide strategies for integrating tools into practice Provide strategies for integrating tools into practice Implementation of tool-use led by facilitator Implementation of tool-use led by facilitator After 6-10 months facilities are independent of facilitator After 6-10 months facilities are independent of facilitator On-Time Program: CDS Strategy

6. On-Time Program: Facilitation Strategy 9-12 month implementation period 9-12 month implementation period – Biweekly phone calls with each QI team – Incorporate risk reports with ongoing processes & structures – Engage front-line staff in workflow redesign Huddles, weekly committee meetings, morning reports Huddles, weekly committee meetings, morning reports – Access CDS reports to trigger early risk ID and intervention – Strengthen multi-disciplinary team collaboration, communication & care coordination

7. On-Time Program: Technology Strategy Leverage EMR use to support QI efforts Leverage EMR use to support QI efforts – Educate front-line staff on information use – Show concrete link between EMR and QI efforts Provide functional specifications for any vendor Provide functional specifications for any vendor Use existing vendor software features for documentation Use existing vendor software features for documentation Develop collaborative relationships with EMR vendors in LTC Develop collaborative relationships with EMR vendors in LTC Partner with NH associations, QIOs and Health Departments Partner with NH associations, QIOs and Health Departments Make On-Time available for future efforts Make On-Time available for future efforts

8. HIT Vendors & On-Time Modules * planning to add/complete in 2013 Vendor Pressure Ulcer Prevention Pressure Ulcer Healing Falls Prevention Avoidable Transfers Answers on Demand ✔*✔* ✔*✔* American Data/ECS ✔✔✔*✔* ✔ eHealth/ SigmaCare ✔✔*✔* Healthcare Systems Connection ✔ HealthMEDX/Vision ✔✔*✔* ✔*✔* LINTECH EMR ✔✔ Optimus EMR ✔✔*✔* Point Click Care ✔ Resource Systems/ CareTracker ✔

9. On-Time Program: Evaluation and Upgrades NY PrU Evaluation NY PrU Evaluation – PrU analysis of changes in incidence rates at resident level – Interrupted time-series design with comparison group – Shows 60% reduction when integrate 3-4 reports California falls evaluation California falls evaluation – Clustered randomized control study in California NH chain with matching (Results in 2014) Pilot test design and feasibility for avoidable hospitalization module (Results are final specs and implementation strategies; Dec. 2013) Pilot test design and feasibility for avoidable hospitalization module (Results are final specs and implementation strategies; Dec. 2013) Enhance training program for On-Time facilitators Enhance training program for On-Time facilitators – Road map for each training session Expand tools to provide appropriate clinical referrals and follow-ups for each identified risk factor Expand tools to provide appropriate clinical referrals and follow-ups for each identified risk factor

10. For More Information On-Time Materials On-Time Materials – http://www.ahrq.gov/professionals/systems/long-term- care/resources/ontime/index.html http://www.ahrq.gov/professionals/systems/long-term- care/resources/ontime/index.html http://www.ahrq.gov/professionals/systems/long-term- care/resources/ontime/index.html – William.Spector@ahrq.hhs.gov William.Spector@ahrq.hhs.gov – SLHudak@SLHclinicalconsulting.com