Creating Connections: Use of HIT to Link Nursing Homes into the Care Continuum Mary Jane Koren, M.D., M.P.H. Vice President, Delivery System Reform The Commonwealth Fund Grantmakers in Aging Annual Conference Kansas City, MO October 17, 2013
NH market consists of two distinct patient populations Post-acute, short-stay residents financed by Medicare Expectation is for return to the community Reality is many will go back to the hospital With a prequalifying hospitaliza100-day benefit Chronically ill, long-stay (>100 days) residents, financed by Medicaid and out-of-pocket payments Frequent admissions and readmissions 2
Short-stay SNF rehospitalizations are frequent and increasing over time 18.2% 23.5% 2000-2006: 29% increase in 30-day SNF rehospitalizations 3
Long-stay NH hospitalizations are frequent and increasing over time Annual Hospitalization Rate: NY State, 1999-2003 35% 30% 25% 24.2% 25.4% 26.9% 27.8% 28.8% 20% 15% 10% 10.0% 10.5% 10.9% 11.1% 11.4% 5% 0% 1999 2000 2001 2002 2003 Total ACS 4
NH hospitalizations also vary by state Short-stay Long-stay 1 Louisiana 26.8% Louisiana 31.4% 2 Arkansas 25.7% Mississippi 29.9% 3 New Jersey 25.0% Arkansas 27.2% 4 Oklahoma 24.6% New Jersey 26.7% 45 South Dakota 15.2% Utah 9.7% 46 Idaho 14.6% Oregon 8.9% 47 Vermont 14.3% Arizona 8.5% 48 Utah 13.2% Minnesota 6.9% 5 Source: 2006 data, CMWF Scorecard, Brown University
Eric Coleman 6
Helping NHs enter the age of electronic information: 4 CMWF projects NYS NH EHR Demonstration: impact on residents and staff and the business case Evaluating the Potential of Telemedicine to Reduce Hospitalizations of Nursing Home Residents INTERACT: Intervention to Reduce Acute Care Transfers Advancing Excellence: The Nursing Home Quality Campaign 7
NYS NH EHR Demonstration: Study of 20 NHs and 6 control facilities by 3 research teams Clinical impact (Dr. Karl Pillemer, Cornell) : No statistically significant impact was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. A reduction in observed medical errors and near misses Residents subjective assessment of the HIT intervention generally positive. Effect on staff (Dr. David Lipsky, Cornell): optimal use of an EHR is largely a function of leadership and management strategy No change in turnover/retention but enhanced ability attract new employees Higher level of reported communication between employees and supervisors Many frontline staff experienced time savings from their use of the EMR Statistically and significantly lower level of workplace conflict Business case (Dr. Lorin Hitt, Wharton) Neutral or weakly positive productivity effects (most not statistically significant) Results are consistent with role of organizational factors in promoting/ inhibiting adoption and performance: Command? Efficiency? Empowerment? 8
Evaluating the Potential of Telemedicine to Reduce Hospitalizations of Nursing Home Residents: Dr. David Grabowski, Harvard A pre/post randomized study of telemedicine in a Mass. nursing home chain Each treatment nursing home generated $82,000 annually in Medicare savings from prevented transfers Telemedicine service cost the NH $30,000/yr 0% -5% -10% Telemedicine and Hosptial Transfers -15% Treatment (N=6) Control (N=5) 9
INTERACT: Intervention to Reduce Acute Care Transfers Dr. Joseph Ouslander, FAU The goal of INTERACT is to improve care, not to prevent all hospital transfers In fact, INTERACT can help with more rapid transfer of residents who need hospital care Pillars of the INTERACT Program Communication among staff, with physicians, with hospitals Decision support tools Advance care planning asking what residents wantand honoring it! 0% -2% -4% -6% -8% -10% -12% -14% -16% -18% -20% INTERACT and Hosptial Transfers INTERACT (N=25) Control (N=11) Pre-Post Evaluation of 25 treatment and 11 control nursing homes in FL, MA, NY 10
Advancing Excellence: The NH Quality Campaign Residents who Were Physically Restrained (%) AE is an ongoing voluntary campaign to help NHs become high performance organizations Voluntary (>9,578 NHs joined) Recognizes staff and consumers as important and valued partners Based on measureable improvement of 9 meaningful goals Staff stability Consistent Assignment Person-Centered Care Safely Reducing Hospitalizations Medications Infections Mobility Pain Pressure Ulcers 13.6 6.2 Arkansas Restraint Rate 2005 Q3 through 2009 Q3 3.3 2.6 11 2010 Q3
Example Reports Produced 12
Example Reports Produced 100% Primary Clinical Reasons for Transfers 80% 60% 40% 20% 0% 13
Example Reports Produced 100% Primary Contributing Reasons for Transfers 80% 60% 40% 20% 0% 14
Final thoughts: The importance of using IT and collecting data for the purpose of QI and communication is a tough sell for NH owners there is, at present a weak business case Improving transitions or preventing transfers saves money for Medicare but costs the NH in terms of infrastructure enhancement It takes a tremendous effort to get staff comfortable with data collection tools and the idea of analysis so that data becomes information With the advent of ACOs and emphasis on integrated delivery systems, the value of data will increase: hospitals will want to select high-performing NHs for preferred provider agreements 15
THANK YOU 16