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

Slide Presentation

On June 17, 2013, William Spector and Sandra Hudak made a presentation at the American Health Information Management Association (AHIMA) Long-Term and Post-Acute Care (LTPAC) Health IT (HIT) Summit. This is the text version of their slide presentation.

Slide 1

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

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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

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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

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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*
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

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  • 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

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Return to Pressure Ulcer Prevention

Page last reviewed December 2017
Page originally created August 2014
Internet Citation: On-Time Prevention Program for Long Term Care: Clinical Decision Support. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/spectorhudaktxt.html