On-Time Prevention Program for Long On-Time Prevention Program for Long Term Care: Clinical Decision SupportTerm Care: Clinical Decision Support

William Spector, Ph.D. William Spector, Ph.D. AHRQAHRQ

Sandra Hudak, MS RN Sandra Hudak, MS RN SLH Clinical ConsultingSLH Clinical Consulting

Presentation at AHIMAPresentation at AHIMAJune 17, 2013June 17, 2013

Baltimore, MDBaltimore, MD

Using HIT for Prevention in Using HIT for Prevention in Nursing HomesNursing Homes

Pressure ulcers, falls, and preventable hospitalizations Pressure ulcers, falls, and preventable hospitalizations happen too often in nursing homes (NHs) despite happen too often in nursing homes (NHs) despite regulatory and market approaches to encourage regulatory and market approaches to encourage prevention and treatmentprevention and treatment

Challenges for managing clinical risk Challenges for managing clinical risk – Residents' changing risk profiles not readily availableResidents' changing risk profiles not readily available

– Daily documentation is fragmented across disciplinesDaily documentation is fragmented across disciplines

– Difficult to assemble & summarize information from multiple Difficult to assemble & summarize information from multiple sources to profile resident’s risksources to profile resident’s risk

– MDS is focused on chronic care not acute changes that increase MDS is focused on chronic care not acute changes that increase risk if not managed risk if not managed

– Most staff not using patient data to track changes and interveneMost staff not using patient data to track changes and intervene

On-Time Program:On-Time Program:ComponentsComponents

Clinical decision support (CDS) tools embedded into HIT, evidence based & usable Clinical decision support (CDS) tools embedded into HIT, evidence based & usable by front-line staffby front-line staff

Strategies to integrate CDS tools into front-line NH practiceStrategies to integrate CDS tools into front-line NH practice Guided facilitation to support adoption of tools & strategiesGuided 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 UlcersPrevent Pressure Ulcers

– Monitor Pressure Ulcer HealingMonitor Pressure Ulcer Healing

– Prevent FallsPrevent Falls

– Reduce Potentially Avoidable Hospitalizations & ED VisitsReduce Potentially Avoidable Hospitalizations & ED Visits

Prerequisites: HIT Vendor, Leadership commitment and multidisciplinary teams, Prerequisites: HIT Vendor, Leadership commitment and multidisciplinary teams, data-driven QIdata-driven QI

On-Time Program: Research Support On-Time Program: Research Support

for Design Strategyfor Design Strategy

Evidence-based risk identification from literatureEvidence-based risk identification from literature Clinical expert panel review of tools and risk criteriaClinical expert panel review of tools and risk criteria Front line staff workgroup for input to tool Front line staff workgroup for input to tool

development & considerations for work flow development & considerations for work flow redesignredesign– Input about NH clinical operationsInput about NH clinical operations

– Clinical expertiseClinical expertise

– Represent chains, for-profits, nonprofits, variety of Represent chains, for-profits, nonprofits, variety of vendors vendors

Pilot test with actual data risk rules & impact to Pilot test with actual data risk rules & impact to work flowwork flow

Identify risk criteriaIdentify risk criteria Identify information needs of all disciplinesIdentify information needs of all disciplines Incorporate data elements into existing clinical documentation (e.g., Incorporate data elements into existing clinical documentation (e.g.,

nurse, dietary & CNA)nurse, dietary & CNA) Create resident risk profile reports, profile changes in riskCreate resident risk profile reports, profile changes in risk

– Incorporate multiple information sources to profile residents at risk Incorporate multiple information sources to profile residents at risk (clinical assessments, MDS assessment, orders)(clinical assessments, MDS assessment, orders)

Design simple weekly reports for front line & promote the use of Design simple weekly reports for front line & promote the use of information to guide decision makinginformation to guide decision making– Focus on weekly changes Focus on weekly changes

– Provide trendsProvide trends

– Patient and unit level informationPatient and unit level information

– Summarize data to support root cause analysis to analyze system causes Summarize data to support root cause analysis to analyze system causes

Provide strategies for integrating tools into practiceProvide strategies for integrating tools into practice Implementation of tool-use led by facilitatorImplementation of tool-use led by facilitator After 6-10 months facilities are independent of facilitatorAfter 6-10 months facilities are independent of facilitator

On-Time Program: On-Time Program: CDS StrategyCDS Strategy

On-Time Program: On-Time Program: Facilitation StrategyFacilitation Strategy

9-12 month implementation period9-12 month implementation period– Biweekly phone calls with each QI teamBiweekly phone calls with each QI team

– Incorporate risk reports with ongoing processes & Incorporate risk reports with ongoing processes & structuresstructures

– Engage front-line staff in workflow redesignEngage front-line staff in workflow redesign Huddles, weekly committee meetings, morning reportsHuddles, weekly committee meetings, morning reports

– Access CDS reports to trigger early risk ID and Access CDS reports to trigger early risk ID and interventionintervention

– Strengthen multi-disciplinary team collaboration, Strengthen multi-disciplinary team collaboration, communication & care coordinationcommunication & care coordination

On-Time Program: On-Time Program: Technology StrategyTechnology Strategy

Leverage EMR use to support QI effortsLeverage EMR use to support QI efforts– Educate front-line staff on information useEducate front-line staff on information use

– Show concrete link between EMR and QI effortsShow concrete link between EMR and QI efforts

Provide functional specifications for any vendorProvide functional specifications for any vendor Use existing vendor software features for Use existing vendor software features for

documentationdocumentation Develop collaborative relationships with EMR vendors Develop collaborative relationships with EMR vendors

in LTCin LTC Partner with NH associations, QIOs and Health Partner with NH associations, QIOs and Health

DepartmentsDepartments Make On-Time available for future effortsMake On-Time available for future efforts

HIT Vendors & On-Time ModulesHIT Vendors & On-Time Modules* planning to add/complete in 2013* 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

✔

On-Time Program:On-Time Program:Evaluation and UpgradesEvaluation and Upgrades

NY PrU EvaluationNY PrU Evaluation– PrU analysis of changes in incidence rates at resident levelPrU analysis of changes in incidence rates at resident level

– Interrupted time-series design with comparison groupInterrupted time-series design with comparison group

– Shows 60% reduction when integrate 3-4 reportsShows 60% reduction when integrate 3-4 reports

California falls evaluationCalifornia falls evaluation– Clustered randomized control study in California NH chain with Clustered randomized control study in California NH chain with

matching (Results in 2014)matching (Results in 2014)

Pilot test design and feasibility for avoidable hospitalization module Pilot test design and feasibility for avoidable hospitalization module (Results are final specs and implementation strategies; Dec. 2013) (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 Road map for each training session

Expand tools to provide appropriate clinical referrals and follow-ups Expand tools to provide appropriate clinical referrals and follow-ups for each identified risk factorfor each identified risk factor

For More InformationFor More Information On-Time MaterialsOn-Time Materials

– http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/index.html

– William.Spector@ahrq.hhs.gov

– SLHudak@SLHclinicalconsulting.comSLHudak@SLHclinicalconsulting.com