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On-Time Quality Improvement On-Time Quality Improvement for Long-Term Carefor Long-Term Care

Using Nursing Home IT Using Nursing Home IT for Optimal Care Deliveryfor Optimal Care Delivery

Presentation to AHRQ Annual Conference Track 1. HITPresentation to AHRQ Annual Conference Track 1. HIT

Improving Quality of Care for Vulnerable Populations Through HITImproving Quality of Care for Vulnerable Populations Through HIT

September 8, 2008September 8, 2008

byby

Susan D. Horn, Ph.DSusan D. Horn, Ph.DInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

699 East South Temple, Suite 100 699 East South Temple, Suite 100 Salt Lake City, Utah 84102Salt Lake City, Utah 84102

801-466-5595 (V) 801-466-6685 (F)801-466-5595 (V) 801-466-6685 (F)shorn@isisicor.com shorn@isisicor.com www.isisicor.comwww.isisicor.com

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AHRQ Transforming Healthcare Quality AHRQ Transforming Healthcare Quality

through Information Technologythrough Information Technology

Findings from 3 ProjectsFindings from 3 Projects

1. Real-Time Optimal Care Plans for Nursing 1. Real-Time Optimal Care Plans for Nursing Home QIHome QI

2. Nursing Home IT: Optimal Care Delivery2. Nursing Home IT: Optimal Care Delivery

3. On-Time Quality Improvement for Long-3. On-Time Quality Improvement for Long-Term CareTerm Care

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

2.2. Implement pre-IT and HIT solutions in long Implement pre-IT and HIT solutions in long term care to support redesigned processes term care to support redesigned processes and improved outcomesand improved outcomes

3.3. Identify HIT implementation best practicesIdentify HIT implementation best practices

ObjectivesObjectives

NURSING HOME IT: NURSING HOME IT: OPTIMAL CARE DELIVERYOPTIMAL CARE DELIVERY

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Background – Clinical QualityBackground – Clinical Quality

Pressure ulcer (PrU) rates remain high Pressure ulcer (PrU) rates remain high Despite guidelinesDespite guidelines Despite trainingDespite training

NH staff know how to prevent PrUsNH staff know how to prevent PrUs

Need to identify high risk residents on weekly basisNeed to identify high risk residents on weekly basis

Knowledge not integrated into day to day practice Knowledge not integrated into day to day practice

Entire multi-disciplinary team needs to coordinate Entire multi-disciplinary team needs to coordinate care better for high risk residents (including CNAs)care better for high risk residents (including CNAs)

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Background - OperationsBackground - 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 Difficult to track down information for MDS assessmentsMDS assessments

• CNA documentation often incomplete CNA documentation often incomplete and inaccurate, yet they spend the most and inaccurate, yet they spend the most time with residents time with residents

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Steps to SuccessSteps to Success

1.1. Research-based foundationResearch-based foundation

2.2. Partnerships; bottom-up approachPartnerships; bottom-up approach

3.3. Standardized comprehensive documentationStandardized comprehensive documentation

4.4. Timely feedback reportsTimely feedback reports

5.5. Integrate into daily workflow and care Integrate into daily workflow and care planningplanning

6.6. Incorporate into IT – explicit link between Incorporate into IT – explicit link between IT and QIIT and QI

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Step 1 – Research Based FoundationStep 1 – Research Based Foundation

National Pressure Ulcer Long-term Care National Pressure Ulcer Long-term Care

Study (NPULS) 1996-1997Study (NPULS) 1996-1997

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

• 109 facilities; 2,490 residents 109 facilities; 2,490 residents

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

riskrisk

• 70% female; Average age = 79.8 years70% female; Average age = 79.8 yearsFunded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

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Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

NutritionNutritionInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PrU+ History of PrU

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

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Dehydration+ Dehydration

+ Weight loss+ Weight loss

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

- - Disposable briefsDisposable briefs

- Toileting Program- Toileting Program

- RN hours per - RN hours per resident day >=0 .5resident day >=0 .5

- CNA hours per - CNA hours per resident day >= 2.25resident day >= 2.25

MedicationsMedications

- SSRI + Antipsychotic

Horn et al, Horn et al, J. Amer Geriatr SocJ. Amer Geriatr Soc March 2004; 52(3):359-367 March 2004; 52(3):359-367

- Fluid Order- Fluid Order

- - Nutritional SupplementsNutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements

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

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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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Step 2: PartnershipsStep 2: Partnerships

• Empower all members of a facility teamEmpower all members of a facility team

• Front-line workers actively participate Front-line workers actively participate in QI activitiesin QI activities

• Share across facilitiesShare across facilities

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Step 3: Standardized DocumentationStep 3: Standardized Documentation

• Redesign work flow – consolidate Redesign work flow – consolidate documentation and eliminate duplicationdocumentation and eliminate duplication

• Allow individual facility customizationAllow individual facility customization

• Encourage inter-facility sharing and Encourage inter-facility sharing and observe facilities come to consensus over observe facilities come to consensus over timetime

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Redesign DocumentationRedesign Documentation

CNACNA

• Daily flow sheet Daily flow sheet

• Single form replaced Single form replaced multiple logs, clipboards, multiple logs, clipboards, bedside chartsbedside charts

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

Care Planning TeamCare Planning Team• Nurses, dietitians, wound Nurses, dietitians, wound

nurses contribute to care nurses contribute to care plans plans

• Used by multiple members Used by multiple members of the care team to of the care team to plan/implement care plan/implement care

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Transition from Paper to HITTransition from Paper to HIT

• CNA staff for daily documentationCNA staff for daily documentation

• Wound nurse for documentation - Wound nurse for documentation - tracking pressure ulcerstracking pressure ulcers

• Nursing Management, charge nurses, Nursing Management, charge nurses, and Dietary access on-line reports to and Dietary access on-line reports to support decision-making, care planning, support decision-making, care planning, and CQI activitiesand CQI activities

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•Digital PenDigital Pen» Thin and light device that writes like an Thin and light device that writes like an

ordinary penordinary pen» Includes camera that records pen strokesIncludes camera that records pen strokes» Used with digitized form, digital pen Used with digitized form, digital pen

reads unique pattern of dots to interpret reads unique pattern of dots to interpret the datathe data

•Docking StationDocking Station » Battery chargingBattery charging» Uploading data from memory to Uploading data from memory to

database via Internetdatabase via Internet

Example Technology #1Example Technology #1 Digital Pen & Paper Digital Pen & Paper

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Digital Pen SystemsDigital Pen Systems

In the absence of existing HIT, the Digital Pen and In the absence of existing HIT, the Digital Pen and Paper solution was used because of its:Paper solution was used because of its:

» Ease of use and low costEase of use and low cost» Minimal staff training requirements Minimal staff training requirements » Minimal set up and support requirements Minimal set up and support requirements » Minimal impact to existing clinical workflow resulting in Minimal impact to existing clinical workflow resulting in

rapid staff adoption ratesrapid staff adoption rates» Rapid report development cycle supports accelerated Rapid report development cycle supports accelerated

implementation timelineimplementation timeline» The Digital Pen and Paper solution does not interfere with The Digital Pen and Paper solution does not interfere with

existing facility IT applications. existing facility IT applications.

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Ex: CNA DocumentationEx: CNA Documentation

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Example technology #2 Example technology #2 Electronic Medical RecordElectronic Medical Record

ProfileProfile:: Add CNA standardized documentation data elements into Add CNA standardized documentation data elements into

EMREMR Add Wound RN standardized documentation data elements Add Wound RN standardized documentation data elements

into EMRinto EMR

Project RequirementsProject Requirements:: Incorporate standardized data elements, including best Incorporate standardized data elements, including best

practices, into applicationpractices, into application Produce On-Time reportsProduce On-Time reports

Vendors to dateVendors to date Optimus EMR, Lintech, CareTracker, eHealth, ReliableOptimus EMR, Lintech, CareTracker, eHealth, Reliable

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Step 4: Timely FeedbackStep 4: Timely Feedback

• Use comprehensive standardized documentation Use comprehensive standardized documentation datadata

• 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 Summarize clinical information in variety of formats for use by RNs, MDS coordinators, formats for use by RNs, MDS coordinators, dieticians, CNAs, etc.dieticians, CNAs, etc.

• Reports contribute to care planning processesReports contribute to care planning processes

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Integrate Research-Based Specifications Integrate Research-Based Specifications into Timely Reportsinto Timely Reports

Weekly ReportsWeekly Reports Nutrition Report / Weight SummaryNutrition Report / Weight Summary

Incontinence ReportIncontinence Report

Behavior ReportBehavior Report

Pressure Ulcer ReportPressure Ulcer Report

QI “Trigger Report”QI “Trigger Report”

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• Nutrition SummaryNutrition Summary» Low meal intake flagLow meal intake flag» Average meal intake for 4 Average meal intake for 4

weeksweeks» Tube feeding indicatorTube feeding indicator» Dietary consult dateDietary consult date» Weight change Weight change » Existing pressure ulcerExisting pressure ulcer» History of resolved ulcerHistory of resolved ulcer

• Weight SummaryWeight Summary» Weight 180 days priorWeight 180 days prior» Weight 30 days priorWeight 30 days prior» Weight trendsWeight trends» Recent weight changeRecent weight change» 5-10% weight loss past 30 5-10% weight loss past 30

daysdays» >10% weight loss past 180 >10% weight loss past 180

daysdays

Example: Nutrition ReportExample: Nutrition Report

Stratified by RiskStratified by RiskProvide ‘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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Step 5: Integrate Reports into Step 5: Integrate Reports into Care Planning ProcessesCare Planning Processes

Support clinical team in understanding Support clinical team in understanding reportsreports– Education in use of reportsEducation in use of reports

Facilitate use of reports in team processesFacilitate use of reports in team processes– Multi-disciplinary team processes for care Multi-disciplinary team processes for care

planningplanning– Accountability for best practice Accountability for best practice

implementation and resident outcomes implementation and resident outcomes monitoringmonitoring

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Prevention Reports

Standardized CNA documentation

QI Team

Access timely information

Reduce redundancy

Consolidate documentationFront-line team members use reports in daily work

Identify high-risk residents

Information TechnologyStep 1

Step 2 Step 3

Step 4

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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

es

ide

nts

Facilities Average National Norm

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

Q4 03 – Q3 05 % Change = - 33%

Impact On Pressure Ulcer QMs Impact On Pressure Ulcer QMs Study Facilities CombinedStudy Facilities Combined

Source: CMS Nursing Home Compare; Facility QM data Source: CMS Nursing Home Compare; Facility QM data reportsreports

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On-Time Quality Improvement On-Time Quality Improvement for Long-Term Carefor Long-Term Care

On-Time QI in Long Term CareHigh Risk Pressure Ulcer Quality Measure

(17 facilities - Implementation Start Q2-Q4 2006 *)

0

2

4

6

8

10

12

14

16

18

20

% H

RP

U Q

M

High Implementers (n=7) combined QM

Mod/Low Implementers (n=10) combined QM

All On-Time facilities

Natonal

High Implementers (n=7) combined QM

11.1 11.0 10.2 13.1 13.0 10.7 9.8 7.0 9.1

Mod/Low Implementers(n=10) combined QM

17.3 14.6 13.3 12.9 13.3 12.8 14.5 13.9 14.4

All On-Time facilities 14.2 12.8 11.9 12.1 13.2 10.9 10.7 10.2 10.6

Natonal 13.7 13.1 12.9 12 12.8 12.5 12.5 12.8 12.5

QM 05 Q2

QM 05 Q3

QM 05 Q4

QM 06 Q1

QM 06 Q2

QM 06 Q3

QM 06 Q4

QM 07 Q1

QM 07 Q2

Percent change in QM Q1 06 to Q2 07High implementers: - 30.7%Low implementers: + 11.5%All On-Time facilities: -12.9%National: +4.2%

Start Implementation

Note: 4 facilities implementing Q2-Q4 '06 (high level implementation) did not have reported QM data

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On-Time Quality Improvement On-Time Quality Improvement for Long-Term Carefor Long-Term Care

On-Time QI in Long Term CareWeight Loss Quality Measure

(17 facilities - Implementation Start Q2-Q4 2006)

0

2

4

6

8

10

12

%W

T L

os

s Q

M High Implementers (n=9) combined QM

Low Implementers (n=8) combined QM

All On-Time Facilities

Natonal

High Implementers (n=9) combined QM

6.4 8.6 7.1 9.2 9.1 8.4 6.2 6.0 5.8

Low Implementers (n=8) combined QM

7.5 9.5 7.9 6.5 8.7 8.6 7.6 7.6 8.1

All On-Time Facilities 7.0 9.1 7.5 7.7 8.9 8.5 7.0 6.9 7.1

Natonal 9.2 8.6 8.5 9 8.7 8.5 8.4 9.1 8.8

QM 05 Q2

QM 05 Q3

QM 05 Q4

QM 06 Q1

QM 06 Q2

QM 06 Q3

QM 06 Q4

QM 07 Q1

QM 07 Q2

Percent change in QM Q1 06 to Q2 07High implementers: -37.2%Low implementers: + 24.3%All On-Time Facilities: -8.2%National: -2.2%

Start Implementation

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On-Time Quality Improvement On-Time Quality Improvement for Long-Term Carefor Long-Term Care

On-Time QI in Long Term Care

Quarterly Pressure Ulcer Incidence Rates (acquired in-house)

8 facilities (900 beds) - high level implementation

0%

2%

4%

6%

8%

10%

High implementers - Combinedrate

4.0% 4.5% 3.6% 4.1% 2.7% 2.6% 2.3%

06Q1 06Q2 06Q3 06Q4 07Q1 07Q2 07Q3

Implementation period

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On-Time Quality Improvement On-Time Quality Improvement for Long-Term Carefor Long-Term Care

Area of Impact Impact 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)

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Lessons LearnedLessons Learned

Focus HIT implementation as a tool to Focus HIT implementation as a tool to sustain process redesign sustain process redesign

• Identify inefficient and efficient steps in existing workflow to focus HIT implementation

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Standardize data focusing on critical data Standardize data focusing on critical data elements elements

Reduce documentation duplicationReduce documentation duplication

Streamline processesStreamline processes

Front-line driven; include all caregivers in Front-line driven; include all caregivers in redesign of workflow and documentationredesign of workflow and documentation

Standardize data elements and redesign Standardize data elements and redesign workflow workflow prior prior to HIT implementationto HIT implementation

Lessons LearnedLessons Learned

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HIT development challengesHIT development challenges

Resistance to changing documentationResistance to changing documentation

Staff turnoverStaff turnover and/or and/or Administrator and DON turnoverAdministrator and DON turnover

Resistance to adopt reports and redesign processes to use Resistance to adopt reports and redesign processes to use reportsreports

Resistance to delegate to team membersResistance to delegate to team members

IT knowledge deficit in nursing homesIT knowledge deficit in nursing homes

Obstacles to ImprovementObstacles to Improvement

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SummarySummary

Start with automating CNA documentationStart with automating CNA documentation

Monitoring compliance is on-going Monitoring compliance is on-going

Training needs are on-going Training needs are on-going

HIT by itself does not lead to QI HIT by itself does not lead to QI

Plan for how information will be used by Plan for how information will be used by clinical teamclinical team

Assign a consistent dedicated person or Assign a consistent dedicated person or team of resources to manage the HIT team of resources to manage the HIT implementationimplementation

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On-Time Prevention of On-Time Prevention of Pressure Ulcers Pressure Ulcers

55 Nursing Homes in55 Nursing Homes in California, New York, Idaho, California, New York, Idaho,

Maryland, Arizona, North Carolina, Maryland, Arizona, North Carolina, Washington, DCWashington, DC

Funded by AHRQ, CHCF Funded by AHRQ, CHCF

Partners: NY State Health Dept, Partners: NY State Health Dept, Delmarva FoundationDelmarva Foundation

On-Time has been expanded toOn-Time has been expanded to

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Available On-Time ToolsAvailable On-Time Tools

CNA documentationCNA documentation http://ahrq.gov/research/ltc/pucnaform.pdfhttp://ahrq.gov/research/ltc/pucnaform.pdf

On-Time ReportsOn-Time Reports http://ahrq.gov/research/ltc/pusamplerep.pdfhttp://ahrq.gov/research/ltc/pusamplerep.pdf

Video and other resourcesVideo and other resources

http://ahrq.gov/research/puwebcast.htmhttp://ahrq.gov/research/puwebcast.htm