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Clinical Practice Improvement

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.com shorn@isisicor.com www.isisicor.comwww.isisicor.com

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AHRQ Transforming AHRQ Transforming Healthcare Quality through Healthcare Quality through

Information Technology Information Technology

NURSING HOME IT: OPTIMAL NURSING HOME IT: OPTIMAL

MEDICATION and CARE DELIVERYMEDICATION and CARE DELIVERY

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Build on ICOR experienceBuild on ICOR experience• NPULS studyNPULS study• AHRQ Partnership for Quality: ‘Real-time Optimal Care Plans for Nursing Home QI’AHRQ Partnership for Quality: ‘Real-time Optimal Care Plans for Nursing Home QI’

Implement HIT solutions in long term care:Implement HIT solutions in long term care:• Electronic CNA documentation Electronic CNA documentation • Clinical decision support focused on incontinence care, nutrition management, skin assessment, Clinical decision support focused on incontinence care, nutrition management, skin assessment,

behavior management, and restorative care best practicesbehavior management, and restorative care best practices• Electronic medication documentation and administration. Electronic medication documentation and administration.

Identify HIT implementation best practices:Identify HIT implementation best practices:• Collaborative, multi-disciplinary partnershipsCollaborative, multi-disciplinary partnerships• Workflow analysis and clinical process redesign efforts throughout each stage of implementationWorkflow analysis and clinical process redesign efforts throughout each stage of implementation• Ongoing assessment of implementation processes and refinement based on evaluation resultsOngoing assessment of implementation processes and refinement based on evaluation results

ObjectivesObjectives

NURSING HOME IT: OPTIMAL NURSING HOME IT: OPTIMAL MEDICATION and CARE DELIVERYMEDICATION and CARE DELIVERY

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ICOR Experience: ResearchICOR Experience: Research

National Pressure Ulcer Long-term care Study (NPULS)National Pressure Ulcer Long-term care Study (NPULS)

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 years

Funded by Ross Products Division, Abbott Laboratories, 1996-97Funded by Ross Products Division, Abbott Laboratories, 1996-97

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NPULS Results: General CareOutcome: Develop Pressure Ulcer

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 7 ADLsADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Mechanical devices for + Mechanical devices for the containment of urine the containment of urine (catheters) (treatment (catheters) (treatment time time 14 days) 14 days)

- Disposable briefs- Disposable briefs (treatment time (treatment time 14 14 days) days)

- Toileting Program - Toileting Program (treatment time (treatment time 21days 21days))

+ Static pressure + Static pressure reduction: protective reduction: protective device (treatment time device (treatment time 14 days) 14 days)

+ Positioning: protective + Positioning: protective

device (treatment time device (treatment time

14 days) (p=.07)14 days) (p=.07)

- RN hours per resident - RN hours per resident per day per day 0 .250 .25

- CNA hours per resident - CNA hours per resident

per day per day 22

- LPN hours per resident - LPN hours per resident

per day per day 0.750.75

MedicationsMedications

- AntidepressantAntidepressant

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NutritionalNutritional AssessmentAssessment

NutritionalNutritionalInterventionsInterventions

+ Dehydration signs and + Dehydration signs and

symptoms: symptoms: low systolic blood low systolic blood

pressure, high temperature, pressure, high temperature,

dysphagia, high BUN, diarrhea, dysphagia, high BUN, diarrhea,

dehydration dehydration

+ Weight Loss: + Weight Loss: 5% in last 30 5% in last 30

days or days or 10% in last 180 days10% in last 180 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

NPULS Results: Nutritional CareNPULS Results: Nutritional CareOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

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NPULS Psychiatric Medications NPULS Psychiatric Medications

Dementia & Agitation n = 803Dementia & Agitation n = 803

No Psych MedsNo Psych Meds 32.5%32.5%Anti-psychoticsAnti-psychotics 31.5%31.5%Anti-depressantsAnti-depressants 34.6%34.6%Anti-anxietyAnti-anxiety 34.9%34.9%

Combinations in 42% of treated residentsCombinations in 42% of treated residents

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Long-Term Care Residents Long-Term Care Residents with Agitation in Dementiawith Agitation in Dementia

Recommended PracticeRecommended Practice• Use fewest number of medications possible (Omnibus Reconciliation Use fewest number of medications possible (Omnibus Reconciliation

Act 1987)Act 1987)

• Minimize use of benzodiazepinesMinimize use of benzodiazepines

• Use atypical over typical antipsychoticsUse atypical over typical antipsychotics

• Use SSRIs over tertiary amine antidepressantsUse SSRIs over tertiary amine antidepressants

• Avoid combination therapyAvoid combination therapy

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NPULS Results: Medication Use NPULS Results: Medication Use with Dementia with Agitationwith Dementia with Agitation

Outcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

12.6**12.6** 12.3*12.3* 9.9**9.9**SSRI + SSRI +

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 + ERER

Medication Medication

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

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Integrate sustainable quality improvement into daily operationsIntegrate sustainable quality improvement into daily operations

• Incorporate evidence-based practices for pressure ulcer prevention Incorporate evidence-based practices for pressure ulcer prevention

• Integrate into daily work versus ‘add-on’ projectIntegrate into daily work versus ‘add-on’ project

Focus on critical data elements and information flowFocus on critical data elements and information flow

• Eliminate redundant documentationEliminate redundant documentation

• Reduce paperwork and streamline documentationReduce paperwork and streamline documentation

• Improve accuracy of informationImprove accuracy of information

• Improve communication among multi-disciplinary care teamsImprove communication among multi-disciplinary care teams

Translate documentation into data & data into multi-disciplinary clinical reportsTranslate documentation into data & data into multi-disciplinary clinical reports

Establish pre-IT foundationEstablish pre-IT foundation

AHRQ Partnership for QualityAHRQ Partnership for QualityReal-time Optimal Care Plans for Nursing Home QIReal-time Optimal Care Plans for Nursing Home QI

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Workflow Redesign Target AreasWorkflow Redesign Target Areas

• CNA Daily WorkflowCNA Daily Workflow» Documentation flow sheetsDocumentation flow sheets» Communication with clinical teamCommunication with clinical team

• Nursing Daily WorkflowNursing Daily Workflow» Wound Nurse documentation and reportingWound Nurse documentation and reporting» Care Plan documentation and communicationCare Plan documentation and communication

• Care Planning ProcessesCare Planning Processes» Identify residents at risk for pressure ulcer developmentIdentify residents at risk for pressure ulcer development» Reports used in clinical decision-makingReports used in clinical decision-making» Response between identification of resident need and interventionResponse between identification of resident need and intervention» Monitoring of resident outcomesMonitoring of resident outcomes

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Results to Date• Workflow inefficiencies reduced:Workflow inefficiencies reduced:

– # 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

• Communication among care team improvedCommunication among care team improved

• Pressure ulcer development reducedPressure ulcer development reduced– Decreased approximately 25% in one yearDecreased approximately 25% in one year– Average of $1,885 per pressure ulcer event in FY 04 Average of $1,885 per pressure ulcer event in FY 04

• Front-line satisfaction improvedFront-line satisfaction improved

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Medication Findings Replicated in Medication Findings Replicated in PracticePractice

• Benefits of Combination Psychiatric Medication TherapyBenefits of Combination Psychiatric Medication Therapy

» 23 residents in one facility with weight loss 23 residents in one facility with weight loss (5-10% in <=30 days, >10% in <=180 days)(5-10% in <=30 days, >10% in <=180 days)

• 3 (13%)residents treated with combination 3 (13%)residents treated with combination therapytherapy

• 12 (52%) residents treated with mono-therapy12 (52%) residents treated with mono-therapy• 8 (35%) residents received no psych meds8 (35%) residents received no psych meds

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Impact On # CNA Documenation Forms

0

2

4

6

8

10

Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Site 7 Site 8 Site 9

# d

ocu

men

tati

on

fo

rms

Pre

Post

Impact Workflow Efficiency: Impact Workflow Efficiency: CNA CNA DocumentationDocumentation

Standardization of CNA documentation streamlined documentation processes for staff and Standardization of CNA documentation streamlined documentation processes for staff and resulted in consolidation of forms.resulted in consolidation of forms.

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Q4 03 (Pre-Implementation) to Q4 04 (Post-Intervention Initial Review) Combined Facilities Average

0.0%

10.0%

20.0%

30.0%

% H

igh

Ris

k R

esid

en

ts

Average 14.0% 13.0% 12.9% 10.6% 9.6% 5.6%

National Norm 14% 14% 14% 13% 13%

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

Impact On Pressure Ulcer QMs Impact On Pressure Ulcer QMs

Source: CMS Nursing Home Compare; Facility QM data reportsSource: CMS Nursing Home Compare; Facility QM data reports

The combined facilities’ average (includes 7 facilities that implemented in Apr ’04) shows an overall reduction in the QM % of The combined facilities’ average (includes 7 facilities that implemented in Apr ’04) shows an overall reduction in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods. high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods.

Note that 4 of the 11 participating facilities are not reported: 2 implemented in Q1 05, 1 does not report QM data, 1 was not Note that 4 of the 11 participating facilities are not reported: 2 implemented in Q1 05, 1 does not report QM data, 1 was not reported in Nursing Home Compare database.reported in Nursing Home Compare database.

Q4 03 – Q3 04Q4 03 – Q3 04 % Change = -26.4% % Change = -26.4%

Q4 03 – Q4 04: % Change = - 56.9%Q4 03 – Q4 04: % Change = - 56.9%

Combined FacilitiesCombined Facilities

National NormNational Norm

CMS data through Q3 04CMS data through Q3 043 Sites 3 Sites provided data provided data Q4 04Q4 04

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AHRQ Transforming Healthcare Quality AHRQ Transforming Healthcare Quality through Information Technologythrough Information Technology

NURSING HOME IT: OPTIMAL MEDICATION NURSING HOME IT: OPTIMAL MEDICATION and CARE DELIVERYand CARE DELIVERY

Implement HIT solutions in long term care:Implement HIT solutions in long term care:• Electronic CNA documentation Electronic CNA documentation • Clinical decision support Clinical decision support • Electronic medication documentation and administrationElectronic medication documentation and administration

Identify HIT implementation best practices:Identify HIT implementation best practices:• Collaborative, multi-disciplinary partnershipsCollaborative, multi-disciplinary partnerships• Workflow analysis and clinical process redesign Workflow analysis and clinical process redesign • Ongoing assessment and refinement of implementation processesOngoing assessment and refinement of implementation processes

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Workflow Redesign Target Areas:Workflow Redesign Target Areas: Clinical Documentation Clinical Documentation

• Clinical documentation and reporting: Clinical documentation and reporting: » CNA - daily flow sheets CNA - daily flow sheets » Care team documentationCare team documentation

– Resident care planResident care plan– Diet ordersDiet orders– Restorative careRestorative care– Skin assessmentsSkin assessments– Pressure ulcer documentation Pressure ulcer documentation

» Feedback reporting to improve resident careFeedback reporting to improve resident care– MDS informationMDS information– Federal and State survey informationFederal and State survey information– Care plan informationCare plan information

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Workflow Redesign Target Areas:Workflow Redesign Target Areas: Medication Administration ProcessMedication Administration Process

• Entering MD ordersEntering MD orders» RN enters into MD order moduleRN enters into MD order module

• Communicating with pharmacyCommunicating with pharmacy» Order verification Order verification

• MedPassMedPass» Eliminate time wasters: new medication look-upEliminate time wasters: new medication look-up» Bar code scanning of medicationsBar code scanning of medications» Verify that the “five rights” have been met – right Verify that the “five rights” have been met – right

patient, medication, dose, time, route.patient, medication, dose, time, route.

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Factors for Successful HITFactors for Successful HIT

• Effective Project Management Team ApproachEffective Project Management Team Approach» Facility Implementation TeamFacility Implementation Team

– representatives of all clinical staffrepresentatives of all clinical staff

» Regular conference calls Regular conference calls – Forum for sharing perspectives and learning across facilitiesForum for sharing perspectives and learning across facilities– Identify next stepsIdentify next steps– Written minutesWritten minutes

» Staged Approach with Clear Incremental ObjectivesStaged Approach with Clear Incremental Objectives– Each phase has defined scopeEach phase has defined scope– Facilities make investments incrementally Facilities make investments incrementally – Identify incremental milestonesIdentify incremental milestones

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Factors for Successful HITFactors for Successful HIT

• Focus on Workflow Redesign as Initial StepFocus on Workflow Redesign as Initial Step» Redesign daily workflow versus add-on project workRedesign daily workflow versus add-on project work» Emphasize CNA involvement and feedbackEmphasize CNA involvement and feedback

• Streamline Documentation and Information FlowStreamline Documentation and Information Flow» Focus on critical data elementsFocus on critical data elements» Reduce redundant documentation Reduce redundant documentation » Improve accuracy of documentationImprove accuracy of documentation» Improve communication among multi-disciplinary care Improve communication among multi-disciplinary care

teamsteams

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Factors for Successful HITFactors for Successful HIT

• Translate Documentation into DataTranslate Documentation into Data» Migrate from paper environment toward a data culture Migrate from paper environment toward a data culture

environmentenvironment

• Translate Data into Multi-disciplinary ReportsTranslate Data into Multi-disciplinary Reports» Migrate from a culture of using quarterly reports for Migrate from a culture of using quarterly reports for

retrospective analysisretrospective analysis

TOTO

» Culture that uses weekly reports for timely resident care Culture that uses weekly reports for timely resident care planning planning

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Unanticipated Changes Unanticipated Changes to Project Plans in Year 1to Project Plans in Year 1

• Additional HIT vendors Additional HIT vendors » eMAR offerings for long term care are new and untested eMAR offerings for long term care are new and untested » HIT vendor product development schedule is not predictableHIT vendor product development schedule is not predictable

• Time associated with evaluating and selecting HITTime associated with evaluating and selecting HIT» Vendors reluctant to acknowledge product limitations Vendors reluctant to acknowledge product limitations » Product demonstrations do not always reflect system Product demonstrations do not always reflect system

capabilitiescapabilities» Vendors reluctant to interface with other systemsVendors reluctant to interface with other systems

• Expanded number of participating facilities Expanded number of participating facilities

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LearningLearning

• Long term care facilities are eager to proceed with HIT Long term care facilities are eager to proceed with HIT implementationimplementation

• Assistance is needed to:Assistance is needed to:» Standardize data elements that incorporate requirements Standardize data elements that incorporate requirements

for best practices and quality for best practices and quality » Share information and learning across facilities Share information and learning across facilities » Redesign daily processes Redesign daily processes » Educate staff to use timely feedback reports Educate staff to use timely feedback reports

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Opportunities to Improve Medication DeliveryOpportunities to Improve Medication Delivery

• Accuracy of MARAccuracy of MAR» Transcription of initial medication order to MARTranscription of initial medication order to MAR» Monthly ‘change over’ process: transcribing Monthly ‘change over’ process: transcribing

medications for all residents each month medications for all residents each month • EfficiencyEfficiency

» Time to enter new ordersTime to enter new orders» Time to complete monthly ‘change over’Time to complete monthly ‘change over’» Time from MD order to RN verification to pharmacy Time from MD order to RN verification to pharmacy

• MedPassMedPass» Time to completeTime to complete» # delays due to searching for information# delays due to searching for information

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Impact On Outcomes & SafetyImpact On Outcomes & Safety

• Decrease Pressure Ulcer DevelopmentDecrease Pressure Ulcer Development» Optimize nutrition and incontinence treatmentsOptimize nutrition and incontinence treatments

• Decrease Medication ErrorsDecrease Medication Errors» Wrong resident, wrong drug, wrong dose, wrong timing, or Wrong resident, wrong drug, wrong dose, wrong timing, or

omissionomission

• Increase Adherence to Best PracticesIncrease Adherence to Best Practices» Right interventions for Right resident at Right timeRight interventions for Right resident at Right time

• 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