AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
The Agency for Healthcare Research and Quality developed On-Time Preventable Hospital and Emergency Department Visits for nursing homes with an electronic medical record (EMR). The tools are designed to help a multidisciplinary nursing home team prevent hospital and emergency department (ED) visits that can be avoided with good preventive care. They include five reports (one with two versions) that are produced weekly and populated with clinical information from the EMR.
Some of the reports provide clinical information on at-risk residents and recent changes in health and function that help staff make timely care plan adjustments to avoid hospitalizations. These reports use evidence-based rules to provide a priority list of high-risk residents who populate the reports.
Additional reports identify residents who have had a recent preventable hospital visit to help staff evaluate why these transfers occurred so that the nursing home can make system changes and prevent future transfers. Some of these reports provide facility or unit-level information that leadership can use to monitor trends in factors frequently leading to preventable transfers.
Development of On-Time Preventable Hospital and Emergency Department Visits began with a review of the literature and available clinical guidelines, including the Interventions to Reduce Acute Care Transfers (INTERACT) Care Pathways,i and incorporated input from a technical advisory panel of clinical and research experts. In addition, a group of nursing home nurses reviewed and provided input on report details and format. Finally, the high-risk rules were guided by results from analyses of the Nursing Home Stay File reported by Spector, et al., that combined nursing home stay data with inpatient claims.ii
Data used to populate certain components of the electronic reports come from a standard set of documentation elements used to record information on transfers between the nursing home and the hospital or ED. Facilities that do not use the Transfer Note or Intake Note may generate the reports as long as the required data elements are available in the EMR from other documentation sources.
The electronic reports assume the availability of nursing home intake and transfer information. These reports are intended for inclusion in the EMR system. Technical specifications are available for EMR vendor programmers to develop the reports as designed. Nursing homes will need to work with their vendor to determine the availability of data elements required for each report. They also need to verify that staff are collecting accurate data to populate the needed data elements and collecting information needed for the reports.
Each report is described in detail in the Electronic Reports section. If a nursing home uses a less comprehensive assessment, the reports will need to be adjusted to account for the missing information.
In addition to the five electronic reports, implementation tools are provided to help staff decide which reports they want to use and in which meetings or huddles they will use the reports. All implementation materials are intended to be used by staff with the help of an On-Time facilitator. Training materials are provided on the Web site for facilitators.
Implementation materials include the Hospital Transfer Self-Assessment Worksheet, which guides staff in a review of current practices for recognizing residents at high risk for transfer. The self-assessment will help facilities planning to implement On-Time Preventable Hospital and ED Visits to identify areas with potential for improvement as they work toward On-Time implementation.
A menu of implementation strategies is another component of the On-Time program’s implementation materials. The implementation strategies menu offers a set of choices for reviewing report information in existing or new meetings or huddles and suggests attendees for these meetings.
Providing a variety of strategies for using one report or a combination of reports allows the facility team to consider alternative uses that may fit within its current workflow and meet the unique needs of their facility, avoiding a “one size fits all” approach. Table 1 lists reports and implementation materials for pressure ulcer healing.
|Transfer Risk Report – High Risk|
|Transfer Risk Report – Medium Risk|
|ED Treat and Release Report|
|Monthly Summary of Transfers by Facility or Nursing Unit|
|Monthly Summary of Transfers by Provider|
|Key Metrics Trend Report|
|Hospital Transfer Self-Assessment Worksheet|
|Menu of Implementation Strategies|
|Implementation Steps and Timeline|
i Available at Pathway Health (http://www.pathway-interact.com/).
ii Spector WD, Limcangco R, Williams C, et al. Potentially avoidable hospitalizations for elderly long-stay residents in nursing homes. Med Care 2013;50(8):673-81. PMID:23703648.