Sub Project Aims and Research Questions - Nursing Home Help

1
MOQI Initiative Primary and Secondary Evaluations
Specific Aim Method Evaluation
Decrease avoidable
hospitalizations, ER
visits, observation
stays
Establish
sustainable
INTERACT processes
that use tools in
each facility to
facilitate NF staff
detecting and
managing changes
in residents’
condition within the
NF
Updated 6 27 2013 mr
APRN early illness
recognition
intervention; QI
analysis of each
hospitalization; QI
systems improvement
with NF staff;
feedback reports of
progress
APRNs and IQC work
with nursing home
staff to integrate into
care delivery systems;
QI systems
improvement with NF
staff; family and
resident (and NF
staff) education about
managing changes in
condition within the
NF
PRIMARY
Hospitalizations
are reduced for
all enrollees by
60% per year (as
compared to
baseline of 365
per 1000
residents per
year) (updated
narrative
10/12/12 page
51)
Reduce the
numbers of
inappropriate
family requests
for
hospitalization
(add question to
INTERACT
Hospitalization
QI report the
APRNs are
completing to
also ask if the
hospitalization
was requested by
the family)
Track
participation,
deployment and
utilization of
INTERACT
processes/tools
Track nursing
facility staff level
of confidence in
managing
residents’
changes in
condition within
Data Collection
Activities and
Timeline
1)Measure
hospitalization
rates,
readmission
rates,
emergency room
visits and
transfers
resulting in
observation
stays using CMS
required data
collected
2)Provide
feedback reports
using data from
data base
monthly and
quarterly
3)Analyze and
summarize the
QI
hospitalization
reports from
each home
quarterly
1)Measure
INTERACT use
and diffusion in
each nursing
home using Staff
Survey and staff
confidence in
managing
changes in
condition within
the NF
2)Sample 2 units
per month (6
surveys) per NF
Follow up
needed
Would be good
to have the
actual 2012
numbers for
each of the 16
homes, is that
possible
Discuss with
Pam and Mike
Roth (MR)
Jessica
GRA input
reports into N-5
for serial
analysis (needs
to be done)
Marcia analyze

2
Increase the
numbers of
Advanced
Directives; increase
the specificity of AD;
reduce conflicting
documentation of
AD for participating
residents
CTC provides staff,
resident, family
education about AD;
CTC works with NF
staff and APRNs to
improve discussion
process with
residents and
families;
interdisciplinary team
develops policies and
procedures for
facility’s to adapt for
QI process
improvement
the NF
Conduct resident
and family (and
staff) education
managing
changes in
condition within
the NF;
newsletter
articles about
this for NF
newsletters;
public news
articles and press
releases about
managing
changes in
condition in the
NF and avoiding
hospital is better
care
AD completion
rates in NF are
improved 15-20%
each year (page
20 of updated
narrative)
Track AD rates
and
improvements in
specificity and
conflicting
documentation
News brief
articles about
ADs for NF
monthly
Analyze and
summarize the
surveys from
each home
monthly and
quarterly
2)Staff
attendance in
INTERACT
training in each
home
summarized
monthly and
quarterly
3)Provide
change in
condition
feedback reports
using data from
data base
monthly and
quarterly
4)Prepare news
briefs and press
releases for NF
use about MOQI
and benefits of
managing within
the facility
quarterly
1)Staff
attendance in
AD training in
each home
summarized
monthly and
quarterly
2)Analyze and
summarize
content of ADs
in each NF
during first 6
months then
every 6 months
thereafter
3)Provide
advance
IQC
IQC/Marcia
IQC
Jessica
MR needs to
organize/draft
MR with help
from APRNs and
MOQI ops team
CTC
Julie Starr,
doctoral student
in July for
baseline using
spreadsheet
from AD team;
CTC/CT Lead
thereafter
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3
Increase the use of
technology for the
benefit of NF
residents
Assure appropriate
medication use in
the NF residents
Evaluate and
implement
software/components
to be used in the
technological
solutions to
communication
problems among
nursing homes,
hospitals, health care
providers, and other
service providers in
NFs; ensure
integration and
interoperability of all
aspects of technology
solutions. Train
nursing home staff
regarding use of
technology and
workflow; monitor
usability of systems
including efficiencies
of clinical workflow,
effectiveness of
human computer
interactions, and staff
satisfaction with
systems.
APRN and NF staff
medication reviews
with intent to reduce
polypharmacy and
newsletters; AD
public news
articles and press
releases
Usage of HIT
solutions,
including
CareMail will
increase every six
months in the NF
by APRNs and NF
staff.
Improve accurate
real time
communication
flow of health
information
between
hospitals and
NFs; Track # of
connections per
month using
CARE mail, then
clinical viewer;
Track usability of
HIT solutions
implemented in
NF and hospitals;
Track medication
reviews in each
NF
directives
feedback reports
using data from
data base
monthly and
quarterly
4)Prepare news
briefs and press
releases for NF
use about MOQI
and benefits of
managing within
the facility
quarterly
1)Staff
attendance in
CareMail and
other HIT
training in each
home
summarized
monthly and
quarterly
2)Provide Care
Mail usage for
each NF
feedback reports
using data base
from MHC
monthly and
quarterly
3)Analyze and
summarize the
usability surveys
from each home
as conducted
and quarterly
4)Summarize
workflow
improvements in
NF r/t
technology
monthly and
quarterly
1)Provide
medication
review feedback
reports using
Jessica
CTC
HIC
MHC/HIT Lead
HIC/HIT Lead
HIC
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4
Describe the impact
of the MOQI
Initiative on the
QMs and NF costs
each year of
Initiative
Describe the role,
transition,
challenges,
satisfiers, barriers,
etc., of the APRNs in
the MOQI Initiative.
Describe direct care
staff perception of
APRN role in their
nursing home.
Describe the
influence of hospital
admission/discharge
planning structure
and processes on
reducing the
readmission rate of
nursing home
residents
optimum medication
use to improve
resident health status
Analysis of QMs and
annual cost reports
for the NF in Initiative
Blackboard written
descriptions to
questions/topics and
periodic focus groups
(see below)*
Paper/electronic
copies of survey to
direct care staff (see
below)**
Interviews/survey of
hospital staff (see
below)*** to collect
qualitative and other
descriptive data to
compare with the
literature about
transition of care
models
SECONDARY
Track QMs and
annual cost
reports
Content analysis
with trending of
ideas, topics,
insights
Summary of
findings
Content analysis
data from data
base monthly
and quarterly
Obtain the QMs
for each NF
quarterly from
Primaris; obtain
cost reports
from Medicaid
office; prepare
data set for
analysis;
quarterly and
annually
1)Weekly
descriptions by
APRNs of a
success and a
challenge in BB
2)Focus groups
every 6 months
3)Answers to 3
key questions
every 6 months
in BB (see
below)*
1)confidential
survey
completed by NF
direct care staff
at 6 months post
“go-live” and
annually
1)interviews
with data
transcription
Jessica
Jessica prepare
data set; Greg
Petroski
analysis; MOQI
leads and Marcia
review analysis
with Greg P
1)Amy and Lori
monitor BB,
provide
examples for
CMS reports
2)Marcia and
other person
conduct; Marcia
analysis
1,3)GRA enter
data from BB
into N-5 for ongoing
analysis;
1)doctoral
student
distributes,
collects, enters
data into data
base, summarize
GRA working
with CTC and CT
Lead
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5
*APRN Role
Aim: To describe the role, transition, challenges, satisfiers, barriers, etc., of the APRNs in the MOQI
Initiative.
Two methods of data collection will used, Blackboard and periodic focus groups.
Focus group questions include:
Many of you have never worked in LTC before,
Tell us about how this transition has been for you What things have surprised you about your
work in the nursing home
During the first 6 months in your role as APRN in your nursing home, tell us about a situation
when you were about to prevent a hospitalizations. What did you do that helped prevent that
hospitalization for a resident Why did that work
Tell us about a situation where the INTERACT processes/tools worked well Why/how did that
work well in that situation
Tell us what you find most satisfying about working in your nursing home as an APRN
If you were going to recruit nurses to work in LTC, what would you use to help explain why they
should consider working in this setting
What could we have done as a support team during the first 6 months to help you achieve a
good start to attain the Initiative goals in your home
What do we need to do as a support team the next 6 months to help you make good progress to
attain the Initiative goals in your home
For BlackBoard questions for them to answer every 6 months:
Goals of the project include:
· Reduce the frequency of avoidable hospital admissions and readmissions;
· Improve resident health outcomes;
· Improve the process of transitioning between inpatient hospitals and nursing facilities; and
· Reduce overall health care spending without restricting access to care or choice of providers.
1. What are the key things you have done in your nursing home to achieve the Initiative goal of
reducing avoidable hospital admissions and readmissions of long stay nursing home residents
2. What parts of your APRN role have been essential in helping to achieve improved health
outcomes for the residents in your nursing home
3. In what ways have policies and routine care practices about advanced directives changed in your
facility since the Initiative began
**Staff Perception of the APRN role
Aim: To describe direct care staff perception of APRN role in their nursing home.
What are direct care staff perceptions about the APRN in their nursing home
What do staff describe as most helpful about the APRN role in their nursing home
What do staff describe as most challenging about the APRN role in their nursing home
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6
Data collection plan:
Doctoral student distribute paper/electronic copies of survey to direct care staff working in
eligible nursing homes (NH at 6 months post implementation) (questionnaire below)
Invite direct care RN, LPN, CNA and CMT staff to participate
Collect completed surveys in a secured way to assure confidentiality (placed in sealed envelope).
Student to enter data from paper copy into an electronic data base (e.g., Survey Monkey or
Qualtrics)
***Hospital admission/discharge planning processes
Aim: To describe the influence of hospital admission/discharge planning structure and processes on
reducing the readmission rate of nursing home residents.
Is the organizational structure of the hospital, specifically admission/discharge planning, significant in
reducing the readmission rate of nursing home patients
What are the discharge planning/transitional care models in place in the hospitals serving the nursing
homes in the MOQI Initiative
What are the characteristics of hospital to nursing home transfers: liaison, communication, structure
(personnel, ownership), readmission rates to specific hospitals, reimbursement
What are the organizational characteristics of each of the hospitals
Are there some common organizational structures of some hospitals used by them that indicate some
models may be more efficient in facilitating transfers
Are there methods of communication between nursing homes and hospitals ie: admission nurse/social
worker etc.,that facilitate accurate information flow and efficient transfers
What are the processes used in each hospital to facilitate transfers
Are there some common care transition models used by some hospitals that indicate some models may
be more efficient in facilitating transfers
Data will be collected by interviews and survey methods. Data will be analyzed to look specifically for
transition of care models supported by the National Transitions of Care Coalition (NTOCC)
www.NTOCC.org/Comendium. Care Transitions Interventions (CTI) patient works with transitions coach
to learn transition specific self-management skills. Transitional Care Model (TCM) multidisciplinary team
led by a masters prepared care transitional care nurse to treat chronically ill high-risk older patients
before, during and after discharge. The Guided Care Model. Guided care nurse (GCN) coordinates care
for chronically ill patients. Project Re-Engineered Discharge (RED) standardized discharge process.
Project BOOST (Better Outcomes for Older Adults through Safe Transitions) St. Louis, MO Society of
Hospital Medicine provides hospitals with tools and mentoring to improve discharge and readmission
process.
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Questionnaires:
Staff Perception of the APRN role
Draft questions below, also need demographic items added.
In your most recent experience with contacting the APRN about a resident in your nursing home, how did you contact him or
her
In person
By telephone
Other
Did the APRN ... (Select all that apply)
Quickly identify the problem
Appear very knowledgeable and confident
Help us understand the causes and solution to the problem
Handle problems with courtesy and professionalism
About how long did it take to get the resident's problem resolved
Immediate resolution
Less than one day
Between two and three days
Between three and five days
More than one week
The problem is still not resolved
How many times did you have to contact the APRN before the problem was corrected
Once
Twice
Three times
More than three times
The problem is still not resolved
Overall, how satisfied are you with your experience working with the APRN
Totally
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Very Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Very Dissatisfied
If you were less than totally satisfied, what could have been done to improve your experience
What is most helpful about having the APRN available in your nursing home
What would you describe as the biggest challenge to working with the APRN in your nursing home
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4. My gut says we should not have more than 5 nurses on any one mailbox for the DG homes. Do
you have a guess how many nurses might be included per home for access to CareMail so I know
how many extra mailboxes we might need
5. Of the referred to hospitals, would there be multiple individuals at each hospital who would
need CareMail mailboxes
APRN Questions Asked Via Blackboard
1) Weekly documentation of how the intervention is progressing
a. Please share one example from the past week when you made a positive difference in resident
care and/or prevented a hospitalization; what did you do that helped prevent the hospitalization
or made a positive difference How was that accomplished
b. If you have an example of how the nursing staff prevented a hospitalization when you were not
there, please share that, too. How was that accomplished
c. If you have an example of how the INTERACT processes or tools worked well in a situation,
please share that. How/why did it work in that situation
2) Feedback about technology (one time request June 4, 2013)
a. Do you have access to a printer
b. If so, can you print what you need easily
c. Do you have Internet access for tablet and/or other internet-based devices necessary to do
your job
d. What are issues you having with Care mail
e. What prevents Care mail from working in your nursing home
f. Where is the scanner located
g. Can you access the scanner
h. Are there other issues related to technology that you would like to be addressed
3) INTERACT Training was not recorded in BB, it was primarily discussed via Live Collaborate. During
each session we asked APRNs to share both facilitators and barriers to implementing INTERACT in
their nursing homes. These examples were often shared by individual APRNS in the weekly
successes and challenges postings.
4) Orientation questions asked of APRNs about their nursing home environment and work flow
(requested from APRN when within first 2-3 wks of being on-site in their nursing home). Goal to
immerse them in the NH environment and establish baseline about certain processes specific to the
project (e.g., INTERACT use, advanced care planning, etc.)
A. Overview of unit organization
1. Do some units seem more organized than others
2. Are there better working relationships on one unit than another
3. Are there gaps that you observe in their clinical processes
4. Why do you think these differences exist
B. Preadmission Process
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1. Meet with Admissions Coordinator/SW/SSD to discuss resident pre-admission process
(observe family meetings, hospital visits (if applicable), and other processes in place
prior to admission.
2. Observe Advance Directive discussions with resident/family as performed by Admissions
Coordinator/SW/SSD or other assigned staff. Shadow social service staff for 1 day
3. Complete Nursing Home Capabilities Check List from INTERACT (Form located in
INTERACT book or download from INTERACT website)
(http://interact2.net/docs/INTERACT%20Version%203.0%20Tools/Communication%20T
ools/Communication%20Between%20the%20Nursing%20Home%20and%20Hospital/IN
TERACT%20Nursing%20Home%20Capabilities%20List%20Dec%2029%202012.pdf)
C. Admission
1. Observe admission assessment of a resident
2. Observe the physician order entry process for a new admission
3. Observe what/how physician communication takes place during a new admission
4. Observe if medication reconciliation takes place on new admission, and describe how it
occurs; include what staff performs the process; are physicians/pharmacists/other staff
consulted about medication orders that require clarification
D. Resident Management
1. Attend MDS/Care planning meeting; observe interactions of those present. Specifically
identify who attends (RN, SWD, CNAs, therapists, resident, and family) and their
contribution to the meeting.
2. Attend change of shift report (night shift to day shift and day shift to evening shift).
a) Who attends this meeting
b) What is their role and/or discipline
c) What type of information is exchanged
d) How is F/U communicated (e.g., waiting for physician to return a call, pending lab)
3. Shadow/observe charge nurse for 1 day.
a. What are the main responsibilities of the charge nurse role
b. Who is performing the role (RN or LPN)
c. What clinical interpretation occurs and how often
d. Do they plan their day
4. Shadow/observe CNA staff for 1 day.
a. What is the workload of the CNA
b. Do they have adequate information about their assigned residents
c. Observe the type of relationships they have with residents.
d. Does the CNA have consistent assignment with a group of residents
5. Shadow/observe MDS Coordinator for 1 day.
a. What is the job of the MDS coordinator
b. How many assessments are they expected to complete; what is the care planning
process; how do they interact with residents/families/other team members; how do
they obtain information about the resident
c. Do they talk with staff, look at the chart, and talk with resident/families
d. While shadowing staff, start to understand the work roles of nursing and nonnursing
staff.
e. How do people communicate with each other How are residents greeted
f. Are they given a choice about which activities they are involved in, choices of about
care and treatment
E. Medication Management
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11
1. Review medication orders.
a. Review Medication Administration Sheet (MAR); is it automated or handwritten
b. How are new medication orders managed in off hours
c. How does staff obtain new medicines for residents
d. How long does it take to obtain new medications from the pharmacy (turnaround
time)
2. Are monitoring parameters put in place If so, by whom and how it is communicated
3. Shadow/observe CMT for one medication pass. Notice how many times CMT is
interrupted.
4. Identify how monitoring of medication therapy occurs (e.g., assessment of PRN
medications; monitoring of labs, vital signs, other physical parameters in relation to
medications)
5. Meet with consulting pharmacist during monthly visit. How does pharmacist
communicate recommended medication adjustments to attending physicians
6. Observe whether staff are using INTERACT condition alert tools: Stop & watch, SBAR.
What does staff do when they notice a condition change
F. Change of Condition
1. When a resident has a change in condition note the following:
a. Who takes charge of the situation
b. Do nurses consult with each other when there is condition change
c. If LPNs are involved, do they consult with the RN staff
d. Does staff check if resident has Advance Directive that provides guidance about
what care they want
2. Observe/evaluate assessment skills of staff
a. Observe nurse to nurse communication; look at formal versus informal methods.
b. Observe Nurse to CNA communication; look at formal versus informal methods. Do
nurses thank CNAs for their input
3. Observe Physician communication about condition change.
a. a. How does physician communication occur (via phone, fax, in person during
rounds)
b. b. What type of clinical information is shared Is the SBAR tool used
4. Who contacts the family about the condition change
G. Transfer of Residents to Hospitals
1. When a resident has been transferred to the hospital.
a. Was a resident physical assessment appropriate to the condition change performed
adequately
b. Did staff review the resident record and identify relevant medical information prior
to contacting the physician
2. How does communication with physician, hospital or ER, and family take place
3. Review transfer documents.
a. What documents are used
b. Were these documents facility created
c. If not, what organization created the documents
H. Committee Structure/Meetings
1. Determine what type of committees the home has. What is the purpose of each
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12
2. Attend as many of the clinical/staff meetings as possible as an observer (e.g., care plan
meeting, department head meeting, high risk team meeting, stand-up meeting).
Evaluate whether action takes place at meeting that will impact clinical outcomes, or if
they just report data at meeting. Note the following:
a. Do people come to meeting prepared
b. Does the leader run an effective meeting
c. Are follow-up duties assigned to staff How does leader facilitate discussion among
staff
d. How are problems managed
3. Specifically attend Quality Assurance/Performance Improvement (QAPI) meeting; will
the decisions made in this meeting result in activity or actions that impact clinical
outcomes, or is the meeting a forum to report data
a. Do people come to meeting prepared
b. Does the leader run an effective meeting
c. Are follow-up duties assigned to staff
I. Physicians and Other Providers
1. Find out when the Medical Director is in the home and introduce yourself. Be prepared
to speak about the project (they’ve already received communication in various forms
about it).
2. Introduce yourself and the project to any physicians, NPs, or PAs you see in the home.
3. Observe how the staff interacts with providers during their visits to the home.
a. How is information about residents communicated
b. Do they round with the providers
b. What evidence of collaboration do you observe
c. How do nurses describe their relationship with providers
ARTICLES to WRITE
Role Transition of the APRNs to LTC (Geriatric Nursing target)
Successes and challenges with implementation of HIE in LTC
Care Mail and Medical Directors and other LTC staff (JAMDA target)
Challenges of Advanced Directives in LTC, issues of discussions, planning, conversations, videos that
others have done Do we need to do one (JAMDA target)
Updated 6 27 2013 mr