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

1. 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 • 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 • Strategies to integrate CDS tools into front-line NH practice • Guided facilitation to support adoption of tools & strategies • 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

4. On-Time Program: Research Support for Design Strategy • Evidence-based risk identification from literature • Clinical expert panel review of tools and risk criteria • 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

5. On-Time Program: CDS Strategy • Identify risk criteria • Identify information needs of all disciplines • Incorporate data elements into existing clinical documentation (e.g., nurse, dietary & CNA) • 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 • 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 • Implementation of tool-use led by facilitator • After 6-10 months facilities are independent of facilitator

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

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

9. On-Time Program:Evaluation and Upgrades • 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 • 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) • 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

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