On-Time Prevention Program for Long Term Care: Clinical Decision Support
Slide Presentation
Slide 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
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 8
HIT Vendors & On-Time Modules
Vendor | Pressure Ulcer Prevention | Pressure Ulcer Healing | Falls Prevention | Avoidable Transfers |
---|---|---|---|---|
Answers on Demand | X* | X* | ||
American Data / ECS | X | X | X* | X |
eHealth / SigmaCare | X | X* | ||
Healthcare Systems Connection | X | |||
HealthMEDX / Vision | X | X* | X* | |
LINTECH EMR | X | X | ||
Optimus EMR | X | X* | ||
Point Click Care | X | |||
Resource Systems / CareTracker | X |
* planning to add/complete in 2013.
Slide 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.
Slide 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