Improving Clinical Decision Making in Nursing Homes Through HIT Implementation

1. Health IT in LTC: Implementation Focused on Value Nursing Home HIT: Lessons Learned to Improve Clinical Decision Making Susan D. Horn, PhD Institute for Clinical Outcomes Research 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282 801-466-5595 (T) 801-466-6685 (F) shorn@isisicor.com

2. Discussion Objectives • Describe links between translating best practices into daily work and HIT implementation in LTC. • Present updates and lessons learned to date on Transforming Healthcare Quality through Information Technology (THQIT) grant: Nursing Home IT

3. Background National Pressure Ulcer Long Term Care Study • 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 Integrate with HIT Research Implement 1996-97 2003 2004

4. Research Based Best Practices Nursing Home Study (NPULS) 1996-1997 • 6 long-term care provider organizations • 109 facilities • 2,490 residents studied • 1,343 residents with pressure ulcer; 1,147 at risk • 70% female, 30% male • Average age = 79.8 years Funded by Ross Products Division, Abbott Laboratories

5. Background: NPULS 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 years implementing these findings in nursing homes. General Assessment Pressure Relief Interventions Incontinence Interventions Staffing Interventions - RN hours per resident day >=0 .25 - CNA hours per resident day >= 2 -LPN hours per resident day >=0.75 + Age  85 + Male + Severity of Illness + History of PU + Dependency in >= 7 ADLs + Diabetes + History of tobacco use + Mechanical devices for the containment of urine (catheters) - Disposable briefs - Toileting Program +Static pressure reduction: protective device +Positioning: protective device Medications - SSRI + Antipsychotic

6. Background: NPULS Nutritional Care Nutritional Assessment Nutritional Interventions + Dehydration signs and symptoms: low systolic blood pressure, high temperature, dysphagia, high BUN, diarrhea, dehydration + Weight Loss: >=5% in last 30 days or >=10% in last 180 days • - Fluid Order • - Nutritional Supplements • standard medical • - Enteral Supplements • disease-specific • high calorie/high • protein Horn et al, J. Amer Geriatr Soc March 2004

7. Effects of Nutritional Supportin Long Term Care

8. Bladder Incontinence Management in Long Term Care

9. Long-Term Care Residents with Agitation in DementiaRecommended Practice • Use fewest number of medications possible (OBRA 1987) • Minimize use of benzodiazepines • Use atypical over typical antipsychotics • Use SSRIs over tertiary amine antidepressants • Avoid combination therapy

10. Medication % Hospital + ER % Restraints % Pressure Ulcers No Psych Medications 20.0 19.9 37.2 Monotherapy 17.2 24.0 24.0** SSRI + Antipsychotic 9.9** 12.3* 12.6** Medication Use and Outcomes for Elderly with Dementia with Agitation Monotherapy includes antipsychotic only, antidepressant only, or antianxiety only SSRI + antipsychotic medications concurrently. *p<.05**p<.01 Horn, Drug Benefit Trends 2003; 15 (Supplement 1, December): 12-18

11. “Real-Time” Implementation In Daily Work • Establish an implementation team at each facility • Define core data elements & standardize documentation for CNA, care team communication, and Wound RN • Redesign clinical workflow • Integrate feedback reports into care planning • Assess impact: workflow efficiencies & clinical outcomes • Develop plans to sustain through IT

12. CNA Daily flow sheet Single form replaced multiple logs, clipboards, bedside charts Reduced redundant documentation “document one time, in one place” PU Tracking Sheet Wound RN standardized documentation: tracks resident risk and pressure ulcer status Information used to compile summary reports Comprehensive Standardized Documentation

13. Timely Feedback Reports • Access to summarized information for clinical decision-making • Improve response time between identification of resident need and intervention • Identify residents at risk for pressure ulcer development • Transform from paper to data culture • Link reports to documentation elements

14. Nutrition Summary Meal intake for 4 weeks Fluid intake for 4 weeks Diet order Supplement product Weight change since last week Psychiatric medications received Weight Summary Weight 180 days prior Weight 30 days prior Weight for each of past 4 weeks Weight change since last week 5-10% weight loss past 30 days >10% weight loss past 180 days Psychiatric medications received Nutrition Report Stratified by Risk Provide ‘BIG picture’ over time, not just snapshot of one shift or one day

15. Nutrition Report How use the Nutrition Report? • Identify which meals are not being eaten • Promote use of nutritional supplements • Identify need for consistent weights

16. Results • Decrease Pressure Ulcer Development • Increase Adherence to Best Practices • Increase Staff Accountability and Satisfaction • Inclusion of front-line workers in QI efforts • Comprehensive documentation at point of care • Communication among care team improved • Reduce Inefficiencies • # documentation forms for CNAs • CNA time looking for documentation book • Time to compile reports for State Regulators and MDS • Time for Wound RN to summarize and report data • Improve State Survey Process • Establish a foundation for EHR

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

18. Preventing Pressure Ulcers is a Good Business Decision Average savings by pressure ulcer event in FY 05 $, not including hospitalization • Stage 1 - $1,932 • Stage 2 - $7,170 • Stage 3 - $11,534 • Stage 4 - $14,077

19. HIT Implementation Grant Objectives • Implement HIT solutions in long term care to support redesigned processes and improved outcomes • CNA documentation • Wound RN documentation • Timely reports in clinical decision-making • Medication Administration Record • Integrate evidence-based research on pressure ulcer prevention into long term care daily practice • Identify HIT implementation best practices

20. LTC Facilities in HIT Project • Sioux Falls, SD • Mott, ND • Wood River, NE • Pelican Rapids, MN • Hastings, NE • Phoenix, Arizona • Cincinnati, Ohio (4) • Washington, DC • Dover, Ohio • Gahanna, Ohio • Chillicothe, Ohio • Waupun, WI Total of 15 LTC facilities located in 12 cities and 8 states

21. HIT Implementation Scope

22. Noteworthy Results to Date: HIT Implementation • CNA documentation standardized to include best practice elements • Workflow inefficiencies reduced • Communication among care team improved: RN, CNA, Dietary, MDS, Social Services • Front-line satisfaction improved • Time to compile reports for State regulators and MDS reduced • Use of data improved

23. Lessons Learned: Key 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 champions • Dedicate project management resources

24. Lessons LearnedHIT Products for LTC • Current HIT products for LTC require modification to incorporate best practice data elements • Reports often lack clinical decision-making capabilities • Modification to existing products can be costly and time consuming • Few products have mature eMAR application • Facility system selection processes often lack rigorous and systematic approach

25. Areas for Ongoing Collaboration: HIT Implementation and QI in LTC • Integrate research-based specifications, e.g., pressure ulcer healing, falls prevention, pain mgt • Facilitate partnerships across organizations • Standardize data elements documented • Design timely feedback reports • Integrate reports into daily workflow and care planning • Assess impact and identify ‘best practices for IT implementation’