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Health IT in LTC: Health IT in LTC: Implementation Focused on ValueImplementation Focused on Value

Nursing Home HIT: Lessons Learned to Nursing Home HIT: Lessons Learned to

Improve Clinical Decision MakingImprove Clinical Decision Making

Susan D. Horn, PhDSusan D. Horn, PhDInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

699 E. South Temple, Suite 100 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282Salt Lake City, Utah 84102-1282801-466-5595 (T) 801-466-6685 (F)801-466-5595 (T) 801-466-6685 (F)

shorn@isisicor.comshorn@isisicor.com

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Discussion ObjectivesDiscussion Objectives

Describe links between translating best Describe links between translating best practices into daily work and HIT practices into daily work and HIT implementation in LTC.implementation in LTC.

Present updates and lessons learned to Present updates and lessons learned to date on Transforming Healthcare Quality date on Transforming Healthcare Quality through Information Technology through Information Technology (THQIT) grant: Nursing Home IT(THQIT) grant: Nursing Home IT

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BackgroundBackground

1996-97

2003 2004

AHRQ-funded: “Real-Time Optimal Care Plans” • Translate evidence-based best practices into daily work

AHRQ-funded: “Transforming Healthcare Quality through IT”• Support HIT adoption in LTC• Integrate ‘Real-Time’ knowledge in IT

ResearchIntegrate with HIT

National Pressure Ulcer Long Term Care Study

Implement

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Research Research Based Best Practices Based Best Practices Nursing Home Study (NPULS) 1996-1997Nursing Home Study (NPULS) 1996-1997

• 6 long-term care provider organizations6 long-term care provider organizations

• 109 facilities109 facilities

• 2,490 residents studied2,490 residents studied

• 1,343 residents with pressure ulcer; 1,147 at risk1,343 residents with pressure ulcer; 1,147 at risk

• 70% female, 30% male70% female, 30% male

• Average age = 79.8 yearsAverage age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

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Background: NPULSBackground: NPULS

The project builds on 10 years of research starting with findings from the The project builds on 10 years of research starting with findings from the National Pressure Ulcer Long-term Care Study and successes over the past 5 National Pressure Ulcer Long-term Care Study and successes over the past 5 years implementing these findings in nursing homes. years implementing these findings in nursing homes.

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

Pressure ReliefPressure ReliefInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in >= 7 ADLs>= 7 ADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Mechanical devices + Mechanical devices for the containment of for the containment of urine (catheters) urine (catheters)

- Disposable briefs- Disposable briefs

- Toileting Program- Toileting Program

+Static pressure +Static pressure reduction: protective reduction: protective device device

+Positioning: +Positioning:

protective deviceprotective device

- RN hours per - RN hours per resident day >=0 .25resident day >=0 .25

- CNA hours per - CNA hours per resident day >= 2resident day >= 2

-LPN hours per -LPN hours per resident day >=0.75resident day >=0.75

MedicationsMedications

- SSRI + Antipsychotic

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NutritionalNutritional AssessmentAssessment

NutritionalNutritional InterventionsInterventions

+ Dehydration signs and + Dehydration signs and

symptoms: symptoms: low systolic low systolic

blood pressure, high blood pressure, high

temperature, dysphagia, high temperature, dysphagia, high

BUN, diarrhea, dehydration BUN, diarrhea, dehydration

+ Weight Loss: + Weight Loss: >=5% in >=5% in

last 30 days or >=10% in last last 30 days or >=10% in last

180 days180 days

- Fluid Order- Fluid Order

- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements

• disease-specificdisease-specific• high calorie/high high calorie/high protein protein

Nutritional CareNutritional Care

Horn et al, Horn et al, J. Amer Geriatr SocJ. Amer Geriatr Soc March 2004 March 2004

Background: NPULSBackground: NPULS

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Effects of Nutritional SupportEffects of Nutritional Supportin Long Term Carein Long Term Care

Nutritional Treatment Strategies

N Pressure

Ulcer Develop Rate

Oral Supplement / Standard Medical Nutritional

134 21.6%

Enteral Formula 210 23.8%

Fluid Order 396 25.0%

Snacks, House Shakes 403 27.3%

No Nutritional Risk -- No Nutritional Treatment

195 27.2%

At Nutritional Risk -- No Nutritional Support

323 35.6%

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Bladder Incontinence Management Bladder Incontinence Management in Long Term Carein Long Term Care

Treatments N PU Develop Rate

Incontinent-Use one or more of following treatments: 1,441 34.2% - Briefs, disposable 501 23.6% - Toileting program 549 23.9% - Briefs, reusable 118 26.3% - Topical Treatment 1,159 29.1% - Bed pads, disposable 193 29.5% - Bed pads, reusable 221 32.1% - Use of catheter 195 51.3% Continent-No incontinence treatment 209 26.3%

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Long-Term Care Residents with Agitation in DementiaLong-Term Care Residents with Agitation in DementiaRecommended PracticeRecommended Practice

Use fewest number of medications possible Use fewest number of medications possible (OBRA 1987)(OBRA 1987)

Minimize use of benzodiazepinesMinimize use of benzodiazepines

Use atypical over typical antipsychoticsUse atypical over typical antipsychotics

Use SSRIs over tertiary amine Use SSRIs over tertiary amine antidepressantsantidepressants

Avoid combination therapyAvoid combination therapy

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Medication Use and Outcomes for Elderly Medication Use and Outcomes for Elderly with Dementia with Agitationwith Dementia with Agitation

12.6**12.6** 12.3*12.3* 9.9**9.9**SSRI + AntipsychoticSSRI + Antipsychotic

24.0**24.0** 24.024.017.217.2MonotherapyMonotherapy

37.237.219.919.920.020.0No Psych MedicationsNo Psych Medications

% Pressure % Pressure UlcersUlcers

% % RestraintsRestraints

% Hospital % Hospital + ER+ ER

Medication Medication

Monotherapy includes antipsychotic only, antidepressant only, or antianxiety onlyMonotherapy includes antipsychotic only, antidepressant only, or antianxiety onlySSRI + antipsychotic medications concurrently. SSRI + antipsychotic medications concurrently. *p*p<<.05.05 **p**p<<.01.01

Horn, Drug Benefit Trends 2003; 15 (Supplement 1, December): 12-18Horn, Drug Benefit Trends 2003; 15 (Supplement 1, December): 12-18

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Implementation Implementation In Daily WorkIn Daily Work

Establish an implementation team at each Establish an implementation team at each facilityfacility

Define core data elements & standardize Define core data elements & standardize documentation for CNA, care team documentation for CNA, care team communication, and Wound RNcommunication, and Wound RN

Redesign clinical workflowRedesign clinical workflowIntegrate feedback reports into care planningIntegrate feedback reports into care planningAssess impact: workflow efficiencies & Assess impact: workflow efficiencies &

clinical outcomesclinical outcomesDevelop plans to sustain through ITDevelop plans to sustain through IT

““Real-Time”Real-Time”

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Comprehensive Standardized Comprehensive Standardized DocumentationDocumentation

CNACNA

• Daily flow sheet Daily flow sheet

• Single form replaced Single form replaced multiple logs, multiple logs, clipboards, bedside clipboards, bedside chartscharts

• Reduced redundant Reduced redundant documentation documentation “document one time, “document one time, in one place”in one place”

PU Tracking SheetPU Tracking Sheet

• Wound RN Wound RN standardized standardized documentation: tracks documentation: tracks resident risk and resident risk and pressure ulcer status pressure ulcer status

• Information used to Information used to compile summary compile summary reportsreports

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Timely Feedback ReportsTimely Feedback Reports

Access to summarized information for Access to summarized information for clinical decision-makingclinical decision-making

Improve response time between Improve response time between identification of resident need and identification of resident need and interventionintervention» Identify residents at risk for pressure ulcer Identify residents at risk for pressure ulcer

developmentdevelopment

Transform from paper to data cultureTransform from paper to data culture» Link reports to documentation elementsLink reports to documentation elements

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• Nutrition SummaryNutrition Summary» Meal intake for 4 weeksMeal intake for 4 weeks» Fluid intake for 4 weeksFluid intake for 4 weeks» Diet orderDiet order» Supplement product Supplement product » Weight change since last weekWeight change since last week» Psychiatric medications Psychiatric medications

receivedreceived

• Weight SummaryWeight Summary» Weight 180 days priorWeight 180 days prior» Weight 30 days priorWeight 30 days prior» Weight for each of past 4 weeksWeight for each of past 4 weeks» Weight change since last week Weight change since last week » 5-10% weight loss past 30 days5-10% weight loss past 30 days» >10% weight loss past 180 days>10% weight loss past 180 days» Psychiatric medications receivedPsychiatric medications received

Nutrition ReportNutrition Report

Stratified by RiskStratified by Risk

Provide ‘BIG picture’ over time, not just snapshot of one shift or one dayProvide ‘BIG picture’ over time, not just snapshot of one shift or one day

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Nutrition ReportNutrition Report

How use the Nutrition Report?How use the Nutrition Report?

• Identify which meals are not being eatenIdentify which meals are not being eaten

• Promote use of nutritional supplementsPromote use of nutritional supplements

• Identify need for consistent weightsIdentify need for consistent weights

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ResultsResults

Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development

Increase Adherence to Best PracticesIncrease Adherence to Best Practices

Increase Staff Accountability and SatisfactionIncrease Staff Accountability and Satisfaction– Inclusion of front-line workers in QI effortsInclusion of front-line workers in QI efforts– Comprehensive documentation at point of careComprehensive documentation at point of care– Communication among care team improvedCommunication among care team improved

Reduce InefficienciesReduce Inefficiencies– # documentation forms for CNAs# documentation forms for CNAs– CNA time looking for documentation bookCNA time looking for documentation book– Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS – Time for Wound RN to summarize and report dataTime for Wound RN to summarize and report data

Improve State Survey ProcessImprove State Survey Process Establish a foundation for EHREstablish a foundation for EHR

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Q4 03 (Pre-Implementation) to Q3 05 (Post-Intervention Review) Combined Facilities Average

0.0

5.0

10.0

15.0

20.0

% H

igh

Ris

k R

esid

ents

Facilities Average 14.0 13.0 12.9 10.6 9.6 9.4 12.0 9.1 8.7

National Norm 14.0 14.0 14.0 13.0 13.0 13.0 14.0 14.0 13.0

Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05

Background: Background: Impact On Pressure Ulcer QMsImpact On Pressure Ulcer QMs

Source: CMS Nursing Home Compare; Facility QM data reports

The combined facilities’ average shows an overall reduction of 33% in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods

Combined Facilities

National Norm

Q4 03 – Q3 05% Change = - 33%

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Preventing Pressure Ulcers is a Preventing Pressure Ulcers is a Good Business DecisionGood Business Decision

Average savings by pressure ulcer event in FY 05 Average savings by pressure ulcer event in FY 05 $, not including hospitalization$, not including hospitalization

Stage 1 - $1,932Stage 1 - $1,932

Stage 2 - $7,170Stage 2 - $7,170

Stage 3 - $11,534Stage 3 - $11,534

Stage 4 - $14,077Stage 4 - $14,077

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1.1. Implement HIT solutions in long term care to Implement HIT solutions in long term care to support redesigned processes and improved support redesigned processes and improved outcomesoutcomes

CNA documentationCNA documentation Wound RN documentationWound RN documentation Timely reports in clinical decision-makingTimely reports in clinical decision-making Medication Administration RecordMedication Administration Record

2.2. Integrate evidence-based research on pressure Integrate evidence-based research on pressure ulcer prevention into long term care daily practiceulcer prevention into long term care daily practice

3.3. Identify HIT implementation best practicesIdentify HIT implementation best practices

ObjectivesObjectives

HITHIT Implementation Grant Implementation Grant

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LTC Facilities in HIT ProjectLTC Facilities in HIT Project

• Sioux Falls, SD Sioux Falls, SD • Mott, NDMott, ND• Wood River, NEWood River, NE• Pelican Rapids, MNPelican Rapids, MN• Hastings, NEHastings, NE• Phoenix, Arizona Phoenix, Arizona • Cincinnati, Ohio (4)Cincinnati, Ohio (4)• Washington, DCWashington, DC• Dover, OhioDover, Ohio• Gahanna, Gahanna, OhioOhio         • Chillicothe, Chillicothe, OhioOhio         • Waupun, WI Waupun, WI

Total of 15 LTC Total of 15 LTC facilities located in facilities located in 12 cities and 12 cities and

8 states8 states

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HIT Implementation ScopeHIT Implementation Scope

Year 1

Clinical documentation (CNA and Wound RN )

Clinical decision-making reports

Year 2

Clinical documentation (RN assessments )

eMAR – medication administration (RN)

Increased number and use of clinical decision-making reports

Year 3

Care plan documentation (Multi-disciplinary team )

Expanded implementation of EMR system functionality: to include other disciplines, e.g., restorative, dietary, MDs

Increased number and use of clinical decision-making reports

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Noteworthy Results to Date: Noteworthy Results to Date: HIT ImplementationHIT Implementation

CNA documentation standardized to include CNA documentation standardized to include best practice elementsbest practice elements

Workflow inefficiencies reducedWorkflow inefficiencies reduced

Communication among care team improved: Communication among care team improved: RN, CNA, Dietary, MDS, Social ServicesRN, CNA, Dietary, MDS, Social Services

Front-line satisfaction improvedFront-line satisfaction improved

Time to compile reports for State regulators and Time to compile reports for State regulators and MDS reducedMDS reduced

Use of data improvedUse of data improved

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Lessons Learned: Lessons Learned: Key Success Factors for ImplementationKey Success Factors for Implementation

Focus use of HIT as a tool to sustain quality and operational improvement

Redesign workflow PRIOR to HIT implementation

Standardize data elements and use of redesigned forms facilitate CNA adoption of HIT

Demonstrate value of data culture Establish partnerships and local championsDedicate project management resources

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Lessons LearnedLessons LearnedHIT Products for LTCHIT Products for LTC

Current HIT products for LTC require modification Current HIT products for LTC require modification to incorporate best practice data elements to incorporate best practice data elements

Reports often lack clinical decision-making Reports often lack clinical decision-making capabilitiescapabilities

Modification to existing products can be costly and Modification to existing products can be costly and time consumingtime consuming

Few products have mature eMAR applicationFew products have mature eMAR application

Facility system selection processes often lack Facility system selection processes often lack rigorous and systematic approachrigorous and systematic approach

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Areas for Ongoing Collaboration: Areas for Ongoing Collaboration: HIT Implementation and QI in LTCHIT Implementation and QI in LTC

1.1. Integrate research-based specifications, e.g., Integrate research-based specifications, e.g., pressure ulcer healing, falls prevention, pain mgt pressure ulcer healing, falls prevention, pain mgt

2.2. Facilitate partnerships across organizations Facilitate partnerships across organizations

3.3. Standardize data elements documentedStandardize data elements documented

4.4. Design timely feedback reportsDesign timely feedback reports

5.5. Integrate reports into daily workflow and care planningIntegrate reports into daily workflow and care planning

6.6. Assess impact and identify ‘best practices for IT Assess impact and identify ‘best practices for IT implementation’implementation’