MarilynJ.Rantz,PhD,RN,FAANCurators’ProfessorEmeritusUniversityofMissouri‐SinclairSchoolofNursingGSAFellowNationalAcademyofMedicineMember

PresentationfortheUniversityofTexasatAustin

NEW SOLUTIONS TO OLD PROBLEMS:PAST,PRESENT,AND FUTURE OF LONGTERM CARE ‐ IN PURSUIT OF QUALITY

NEW SOLUTIONS TO OLD PROBLEMS:PAST,PRESENT,AND FUTURE OF LONGTERM CARE ‐ IN PURSUIT OF QUALITY

WhereThisReallyAllBegan…

FinishingaMastersinNursing,ChronicIllnessandLeadershipandManagementatMarquetteUniversityHadfinishedaMastersinEducationwithGuidanceandCounselingemphasisandpracticeteachinginNursingtwoyearsearlier

“Here,honey,ajobjustafewmilesfromourhouse!”“Anursinghome?Ihaveneverevenwalkedintoone!”“Aww,you’llbethebestqualifiedcandidatetheyeversaw!”

ALoveAffairBegins……LAKELANDNURSINGHOME

NothingLikeRealWorldExperience…

• Meetingandgettingtoknowhundredsofolderpeople,theirfamilies,anddedicatedemployeesprovidingcareandservices

• CommitmenttoQualityImprovement,teamandgroupprocessesfordecision‐making,evidence‐basedpractice,advancedpracticenurses

• Realizingthepopulationexplosionofolderadultsinthenextdecadeswilloverwhelmhealthcareandlongtermcareservices

IMPENDINGAGINGSOCIETYRESOURCESFORNH ANDPLANNINGFORFUTURE

http://www.aoa.acl.gov/aging_statistics/Profile/2015/4.aspxTotalpopulation2014‐2060319million‐417million

IMPACTOF SIMILARGRAPHSBY20301‐IN‐5AMERICANSWILLBE65OROLDER

Impact of Silar graphs

https://www.census.gov/prod/1/pop/p25‐1130.pdf

Needfor MoreEducation ‐NEWTOOLSFOR “OLD”PROBLEMS

• ContinuedworkingasNHAatLakeland• AttendedUWisconsinMilwaukeeforPhDinNursingwithfocusinLongtermcare,publicpolicy,qualitymeasurement,andMDSdata

• MovedtoMissourisohusbandcouldcattleranchfulltime,retiredfrombusinessinWisconsin

• BeganworkingatSinclairSchoolofNursing,UniversityofMissouri,firstacademicjobofcareer(25yearsago,now)

• PicturesLakelandNursingHomeresidentsofficewall‐stilltheretoday!!REMINDSMEWHYIDOWHATIDO!

LaunchingaResearchTrajectory

Largedatasettrainingandmentoring(NowBigData)Reality!Qualitativemustbeapartofthis!!Excellenttrainingandmentoringinqualitativemethods—Alwaysusesomequalitativemethods

• MissouriDivisionofAgingandMDSdata,teamforanalysis,feedbackreportstodepartmentandnursinghomesstatewide

• QualityIndicators(MDSdata),comparisonsstatewide• FocusgroupstodevelopVersion1oftheObservableIndicatorsofCareQualityinNursingHomes,latercompletedevelopmentalwork

• Exploratorystudies NHqualityofcare,cost,staffing• Interventionstudies improvecarequality,cost,staffing• AginginPlaceProjectbegins…

LaunchingaResearchTrajectory

WhatpeopleWANTWhatpeopleNEED

Newsolutionstotheoldproblems ‐justdosomethingDIFFERENT!!

ThreeKeysto Always Consider

FoundationalPerspectivesOlderAdultsand LTCOlderadultswanttobeasindependentaspossibleaslongaspossibleTheywanttobelivinginthehomeoftheirchoiceTheyneedtoNOTexperiencemultipletransitionsof“home”asthatincreasesriskofhealthdeclineanddeathTheyneedrelationshipsandengagementwith“living”

TraditionallongtermcaremodelsneedtobechallengedNewmodelsofLTCmustbeevaluatedusingsoundresearchmethodsmeasuringcost,quality,andstaffing

ThosePersistentProblemsofAging!!StillNeedNewSolutions

• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers

ThingsOurTeamsHavePursuedfor Solutions

• MeasuringQualityinLongTermCare ‐ developedandtestedtheObservableIndicatorsofNursingHomeCareQualityInstrument

• Developedandtestedfeedbackreportingmethodstonursinghomesandclinicalconsultationservicetoimprovequalityofcare

• MeasuringLTCNursingCareProcesses,Outcomes,andCost ‐ qualitativelyandquantitativelythenwithaMultidimensionalIntervention

• MeasuringEffectivenessofAdvancedPracticeNursesinLongTermCare ‐ clinicalconsultationservicetoimprovequalityofcareandimplementbestpracticesstatewide(QualityImprovementProgramforMissouri)andMultidimensionalIntervention

• MeasuringEffectivenessandCostEffectivenessofAdvancedPracticeNursesinMOQIInterventiontoReduceAvoidableHospitalizationsofNursingHomeResidents ‐ qualitativelyandquantitativelyin2CMSInnovationCenterInitiatives

ThingsOurTeamsHavePursuedfor Solutions

MOQIModel

MOQIInterventioninSTL

MOQIPrimaryProjectGoalsReduceavoidablehospitaltransfersviafouraspectsofAPRNCareCoordination

1. Conditionmanagement2. Earlyillnessdetection3. INTERACT4. End‐of‐life

ANDhealthinformationtechnology

NowtestingpaymentforacuteillnesscareinNH

ComplexityScience

Preparing Nursing Homes and Hospitals for the Future of Health Information ExchangePreparing Nursing Homes and Hospitals for the Future of Health Information Exchangeand Hospitals for the Future of Health

Information ExchangePreparing Nursing Homes and Hospitals for the Future of Health Information Exchange

t

“Traditionalbureaucraticapproachestomanagement[inLTC],imposebarrierstothefreedomofinteractionneededforeffectiveself‐organization.”

ComplexAdaptiveSystemsComponents

Relationships amongstaffInterconnectionsCommunication

CognitivediversityLeadstoSelf‐Organization

“Stone Soup”

FinalResultsPhase1‐ Effecton ProbabilityofAnyPotentiallyAvoidableHospitalization

KeyResultswith RTI‐SelectedComparisonGroup 40%reductioninall‐causehospitalizationsand 57.7%potentiallyavoidablehospitalizationsreduced(p=.001); 54.1% allcauseEDvisitsreductionand 65.3%potentiallyavoidableEDvisitsreduced(p=.001).

33.6%Medicareexpendituresinall‐causereducedand 45.2%inpotentiallyavoidablehospitalizations(p=.001); 50.2%Medicareexpendituresinall‐causeEDvisitsreducedand 59.7%potentiallyavoidableEDvisitsreduced(p=.001).

Ingber,MJ,Feng,Z,Khatutsky,G,etal.Evaluationoftheinitiativetoreduceavoidablehospitalizationsamongnursingfacilityresidents:Annualreportprojectyear4,February,2017.Availableat:https://innovation.cms.gov/Files/reports/irahnfr‐finalyrfourevalrpt.pdf.AccessedApril14,2017.CentersforMedicareandMedicaidServices.MedicareHospitalQuality.

The Keyto Success‐ FinalResultsAPRNs(AdvancePracticeRegisteredNurses)

1. Majorfocusisnotp r ima r y c a r e (MOregulations)2. Rolemodele v i d en c e ‐ b a s ed c a r e tofacilitynursingstaff

foreffectiverecognition,assessment,andcommunicationaboutresidents’changeinconditiontoPrimaryCareProviders

3. APRNssupporttheuseofI NTERACT andqu a l i t y imp rov emen t toreduceunnecessaryhospitaltransfers

4. Promotemed i c a t i o n r e v i ew ,e nd ‐ o f ‐ l i f e p l a nn i n g ,c ommun i c a t i o n ,andH IT u s e

5. SupportedbyMOQ I T e am (HIT,QI,SW,MedDirector)andf e edba c k r e po r t s

OtherThingsOurTeamsHavePursuedfor Solutions

AgingInPlaceProject ‐ firstincommunity,thenatTigerPlace

TechnologytoEnableAginginPlace‐ TheElderTech InterdisciplinaryResearchTeam ‐collaborationwithEngineeringtodevelopandtesttechnologiesforeldersandrehabilitation

AGINGINPLACE‐ CommunityDemonstrationand TigerPlace

• Foundation‐ RNCareCoordination,gettingrightservicesatrighttimetomaximizeregaining/maintaininghealthandINDEPENDENCE

• CMSgrant1999‐2003‐ wellnesscenterfocused,licensedhomehealthagencyforMedicare,Medicaid,privateinsurance,privatepay,servedoverahundredmonthly2006

• Legislationin1999and2001enabledTigerPlacetobebuiltandevaluationofAIPinidealhousingwherepeoplecanlivethroughtheendoflifeintheirownprivateapartment/home

• TigerPlaceopened2004,expandedin2009and2011,serving65dailyinhousing;now85inrehabilitationandtraditionalskilledcare

KeyClinicaland FinancialOutcomesof AIPResearch

RNcarecoordinationreducesadversehealthevents,improvescareoutcomes,nursinghomeutilization,andcostsless

Clinicaloutcomesbetter(ADLperformance,lessdepressedandbettercognition,continence,pain,andshortnessofbreath)

Costsavings$1,591permonth(nursinghomecomparison)$483(communitycomparison)

KeyClinicaland FinancialOutcomesof AIPResearch RNcarecoordinationatTigerPlaceincreasesLOSbyayear

CostsforanyatTigerPlacenursinghomeeligibleparticipanthasneverapproachedorexceedednursinghomecare

Inafouryearanalysis(2009‐2012)theaverageannualcostforthosenursinghomeeligiblewas$20,000lessperyearthannursinghomecare

TigerPlacewas Developedbythe UniversityofMissouriin Affiliationwith AmericareSystems,Inc.

ResidentsliveinindependentapartmentwithbasicservicesprovidedbyAmericare(housekeeping,transportation,2mealsperday,socialactivities)

HealthpromotionactivitiesbySinclairHomeCareoftheSchoolofNursing(exerciseclasses,on‐goingnursinghealthassessment,wellnesscenteropendaily,RNcarecoordination,privatenursingservicesaffordablypackagedwhenneeded)

Designedtomaximizeindependence(builttonursinghomestandards,licensedasanintermediatecarefacility,operatedasindependenthousingwithservices)NOTRANSITIONSREQUIREDthroughtheendoflife

TigerPlaceCareModel

TheChallenge

GiveustechnologyforTigerPlacethatwillhelpolderadultsstayasactiveandfunctionallyindependentaspossible.

Squaringthe LifeCurve

Reducefunctionaldeclineby Assessingbehaviorpatterns Assessinggait&activitylevel Recognizingpatternchanges Detectingearlysignsofhealthdecline(socanintervenebeforethingsbecomemajorevents)

Detectingfalls InformingRNCareCoordinationCurrenttrend

Withproactivecare

FunctionalDecline

Time

Proactivehealthmanagementthroughintegrationofsensordataandhealthdata

Rantz,Marek,Aud,Tyrer,Skubic,Demiris,&Hussam,NursingOutlook,2005.

TechnologyResearchFunding EvaluationoftheUseofBedsideTechnologytoImproveQuality

ofCareinNursingFacilities,CMS,2003‐2006 TechnologytoEnhanceAginginPlaceatTigerPlace,

AdministrationonAging,2005‐2009 TechnologytoAutomaticallyDetectFallsandAssessFallRiskin

SeniorHousing,AHRQ,2009‐2013 TechnologytoAutomaticallyDetectEarlySignsofIllnessin

SeniorHousing,NINR,2009‐2012 IntelligentSensorSystemforEarlyIllnessAlertsinSenior

Housing,NINR,2013‐2016 SeveralNSFandotherengineeringgrants

SensorsHydraulicbedsensorunderthemattresscapturesquantitativepulse,respiration&restlessness

Gaitparameters&fallsarecapturedusingdepthimages

Sensors

Webportal

& Mobiledevices

Integration&

Data Storage

Detection of Health

Change or Functional

Decline

AlertManager

SensorNetworkforHealthAlertsclinicaldecisionsupportsystem

Clinical Care Coordinator

Alert Feedback

Health changeemail alert

Skubic et al., Technology & Health Care, 2009; ICOST 2012, IEEE JTEHM (in press)Rantz et al., Journal of Gerontological Nursing, 2010

EHR

SensorData

MotionSensorDensityMap

midnight

7am

11pm

Feb1 Mar14

BLACK=timeawayfromhome

HEALTHY,ACTIVE RESIDENT

Wang&Skubic,IE,2008;Wang,Skubic,&Zhu,EMBC,2009,TITB 2012.

OtherLifestylePatterns

HighactivityIrregularpatternCognitiveimpairment

LowactivitySedentarylifestyle

Depression

Changein BathroomActivityat Night

midnight

7am

11pm

BedSensorDataChanges

ERvisitHospitalization

Increasinglowpulseevents

Changeinbedrestlessness

Rantz,etal.,ICOST,2008;CIN,2010.

ERvisitHospitalization

EarlyIllnessAlert26daysbeforeER40daysbeforeER

BedSensorDataChanges

MUHydraulicBedSensorPlacedUnderthe Mattress

15 units deployed

10Secondsfrom BedSensor

RawSignal

Pulsefrombedsensor

Pulsefromfingersensor

Heiseetal.,EMBC,2010,2011;Rosalesetal.,2012.

NOW!!Technologyto AutomaticallyDetectHealthChanges

Environmentallyembedded(non‐wearable)sensorsmonitornew‘vitalsigns’

Continuouslymeasurefunctionalstatus,detectpotentialchangesinhealthorfunctionalstatus,andalertforearlyrecognitionandtreatment

Algorithms,onaverage,detecthealthchanges10daysto2weeksbeforethepersonisawareofsymptomsofimpendinghealthproblems

RantzMJ,SkubicM,KoopmanRJ,AlexanderG,PhillipsL,MustermanKI,BackJR,Aud MA,GalambosC,GuevaraRD,MillerSJ:Automatedtechnologytospeedrecognitionofsignsofillnessinolderadults.JGerontol Nurs 2012;38:18–23.

NOW!!Technologyto AutomaticallyDetectHealthChanges

Livingwithsensortechnologywithhealthalertsaddsanaverageof1.7yearstolengthofstay(LOS)inindependentseniorhousing

WhencombinedwithRNcarecoordination,sensortechnologywithhealthalertsincreasesLOS2.5yearsfrom1.8to4.3years

CostestimatescomparingcostoflivingatTigerPlacewithsensortechnologyvs.nursinghomerevealpotentialsavingofabout$30,000perperson

PotentialcostsavingstoMedicaidfundednursinghome(assumingthetechnologyandcarecoordinationwerereimbursed)estimatedtobeabout$87,000perperson

Rantz,M.J.,Lane,K.R.,Phillips,L.J.,Despins,L.A.,Galambos,C.,Alexander,G.L.,Koopman,R.J.,Skubic,M.,&Miller,S.J.(2015).EnhancedRNcarecoordinationwithsensortechnology:impactonlengthofstayandcostinAginginPlacehousing.NursingOutlook,63,650‐655.*

WhataboutFallsandFallRiskAssessment?Severalnon‐wearable sensorstestedatTigerPlace

Walkingfrom RadarSensor

0 1 2 3 4 5 6 7 8-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.06

0.08

0.1

time(second)

volta

ge(V

)

Raw signal of RCR A Spectrogram of RCR A

time(second)

frequ

ency

(Hz)

0 2 4 6 80

20

40

60

80

100

120

140

160

180

200

-100

-90

-80

-70

-60

-50

-40

Yardibi,Cuddihy,Genc,Bufi,Skubic,Rantz,Liu,&Phillips,SmartE,2011;EMBC2012.

Fallfrom RadarSensor

0 0.5 1 1.5 2 2.5 3 3.5 4-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

1.5

time(second)

volta

ge(V

)

Raw signal of RCR A Spectrogram of RCR A

time(second)

frequ

ency

(Hz)

0 0.5 1 1.5 2 2.5 3 3.50

50

100

150

200

250

300

-70

-60

-50

-40

-30

-20

-10

Liu,Popescu,Skubic,Rantz,Yardibi,&Cuddihy,PCTH,2011;EMBC2012.

CapturingGaitinthe Homewith Kinect

Two clusters for two residents

Grandchildren

Stone & Skubic, EMBC 2012; TBE 2013; EMBC 2014.

KinectSDKisnotusedSegmentpersonindepthimage

Projectto3D,segment,andtrackLog:walkingspeed,height,stridetime&stridelength

In‐HomeGaitAnalysiswith Kinect

Stone & Skubic, JAISE 2011

NOW!!Technologyto AutomaticallyDetectIncreasingFallRiskand Falls

Alertsforincreasingfallriskusingthefallsensortechnologyalertsimpendingfalls‐ 3weeksbeforefalleventsareverylikelytohappen‐ sopreventativestepscanbetakentopreventthefall(Phillipsetal.,2016;Stoneetal.,2015;Rantz,Skubic,Abbottetal.,2015;Rantz,Skubicetal.,2013)

Sensortechnologyalertsemergencysituationssuchasfallswithinjuriessothatresponsetimecanbereducedreducingmorbidityandmortality(Rantz,Skubicetal.,2015;Rantz,M.,Banerjeeetal.,2014;Rantz,M.,Skubic,M.,Popescuetal.,2015).

NowcommercializedbyForesiteHealthcare,St.Louis,andinhospitals(MO),assistedliving(MO),CCRC(IA)

Future‐ Backto Graphs

http://www.census‐charts.com/Population/pop‐us‐1790‐2000.html

Future‐ Growthof ForeignBorn‐???Howto Plan??

http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25‐1143.pdf?

ThosePersistentProblemsofAging!!StillNeedNewSolutions

• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers

Stillconsider!WhatPeopleWANT/NEED/COST

• Stilllikelytowantindependence‐butdothequalitativeworkfornewandchangingperspectives

• Challengeoldmodels!!• Seeknewsolutionstotheold

problems‐ justdosomethingDIFFERENT!!

Changingthe Practice

OurMission:KeepingOlderAdultsFunctionallyActive!

AdditionalInformationand Papers

AGING IN PLACEwww.agingmo.com

CENTER FOR ELDERCARE AND REHABILITATION TECHNOLOGYwww.eldertech.missouri.edu

NURSING HOME QUALITY,QIPMO,AND MOQIwww.nursinghomehelp.org