Out of the data silo
Hospitals are being forced to evaluate skilled nursing facility readmission rates.
On paper, it sounds like a noble goal: Get healthcare providers to implement IT solutions to improve the resident experience.
In reality, getting providers on the same page with healthcare IT has been a mixed bag. The relatively new world of HIT has been explored somewhat tentatively by long-term care: For the first few years, software programs were relatively siloed, focusing on one aspect of care or compliance.
But as the years go on, the full scope of possibilities is starting to come into focus, and providers are more comfortable using HIT to improve communication, increase compliance and predict patient outcomes — all with an eye toward reducing rehospitalization rates.
Catching the carrot
With the passage of the Protecting Access to Medicare Act of 2014 in April, preventing readmission to hospitals has become an even more pressing concern for long-term care. As part of the law, the Centers for Medicare & Medicaid Services will implement a new reimbursement plan starting in 2018, explains Doc DeVore, Director of Clinical Informatics & Industry Relations with Answers On Demand (AOD) Software.
“A reserve of 2 percent of total payments will be set aside and the top 30 percent of long-term care providers with the lowest re-hospitalization rates will receive a reimbursement from the reserve pool,” he says.
But the government's stick-and-carrot plan may prove to be redundant. That's because low readmission rates are already vital to ensure ongoing hospital referrals and to keep communities financially stable, experts say.
“If a hospital looks at its data and says, ‘My readmission rate from skilled nursing facility A is much lower that it is from skilled nursing facility B,' guess where they're going to refer their patients?” asks Kim Ross, senior director of marketing with MatrixCare.
To benefit from these higher referral rates — and, ultimately, increase revenue — long-term care providers need to have a way to track their progress in avoiding rehospitalizations and share data with accountable care organizations and other stakeholders. Statistics regarding length of stay and even patient satisfaction surveys are important for ACOs, and HIT solutions are more capable of collecting and packaging that information than ever.
“In order to stay ahead of the curve, providers need to look at healthcare information technology solutions that are flexible, scalable and interoperable,” says Dave Wessinger, chief technology officer at PointClickCare.
Preventing readmissions also relies on a rapid transfer of accurate health information, says Keith Speights, president at RosieConnect LLC.
“If you can't make a change quickly enough, that patient will go back to the hospital. If you can intervene, the resident can be taken care of in the skilled nursing facility,” he says. “It's about getting the key clinical information into the hands of the right person.”
While many industry insiders correctly point to financial constraints as a barrier to adoption—“It's not like [providers] are making a ton of money, and government reimbursements aren't setting the world on fire, either,” quips Ross—there are other blockades that may be less obvious but no less of a hindrance.
First and foremost, says Jeremiah Johnson, vice president of business development with VorroHealth, is a lack of strategy. IT needs to support a company's overall goals, not just the specific needs of long-term care.
“As a popular saying goes, ‘Begin with the end in mind,'” he says. “An IT strategy that is well thought out, documented and communicable creates an environment in which barriers can be broken and implementation can survive even when the headwinds arise.”
Hesitancy and skepticism on the part of staff is one major drag on HIT implementation in long-term care. Entrenched physicians and nurses may be reluctant to change. Administrators may worry over security fears and the potential for medical records to be hacked. Many have taken an attitude of, “if it ain't broke, don't fix it” — but just because something isn't broken doesn't mean it's working well.
Overcoming reluctance from the staff can be difficult, but there's a way around, according to Wessinger. “Organizations need to involve everyone in the selection process, determine what will work within the organization's capabilities and train staff accordingly,” he says.
In order to find success with new technology, COMS CEO Edward J. Tromczynski recommends designating a group of champions, headed up by the leadership team, to lead the charge and serve as the cheerleaders for the remainder of the staff.
“‘But we've always done it this way' or ‘I don't trust technology' are often-heard excuses,” he explains. “As such, it's critical to take the time to train your ‘elite' team beyond simply how the software works. Focus on a ‘we is smarter than me' methodology and include regular products review and best practices shared among all members of the team.”
Staff buy-in is only one challenge, as many providers can wince at the cost of new tech systems. But LeRoy Boan, senior sales representative at NTT DATA Long-Term Care Solutions, advises providers to look well beyond the first year, when the costs outweigh the benefits, in order to really see their return on investment.
“Adding [HIT solutions] may not show savings immediately,” he says, “but they will as soon as nurses eliminate things like medication notebooks and monthly recaps from their routines. The nursing hours saved on this alone would pay for the software.”
Communicating for success
Interoperability is the ability for an organization's systems to share critical information with other providers across the senior care continuum, Wessinger explains—and it's the name of the game for many in the healthcare IT field.
“Interoperability with health systems and other acute care settings is at a crucial level for long-term and post-acute care providers,” says Chris Dollar, chief operating officer at HealthMEDX. “We are reaching a tipping point where providers will not be able to successfully run their businesses without the benefits that the right electronic medical record can provide.”
Providers don't need to look to the distant future to see certain trends taking shape.
“[Acute care providers are] under pressure to shorten length of stay,” notes Jim Hoey, president and CEO of Prime Care Technologies, and skilled nursing centers are receiving increasingly fragile residents.
With residents with such complex needs, the receiving facility needs instant access to information, from medications and physician orders to diagnoses, potential complications and allergies.
“All care settings need to receive accurate and pertinent information in a timely fashion to ensure a good transition,” says Maria Arellano, RN, MS, clinical product manager at American HealthTech. “We have to share what we've learned about the patient with their next caregiver, otherwise they have to start all over again which takes time and resources. A vulnerable patient doesn't have the time for the new setting to figure it out all over again.”
An increased focus on care coordination means providers must use electronic health records systems not only to create better reimbursement, but to provide a better resident experience, says Steve Pacicco, CEO at SigmaCare.
“EHRs allow clinicians to leverage predicative analytics, data trending and clinical decision support tools to identify residents at risk for rehospitalizations or changes in condition which mitigate unnecessary readmissions,” he says. But analytics alone are not enough, he warns.
“Historically, analytics have not been actionable because data has been incomplete or siloed,” Pacicco says. “Interoperability with local healthcare providers (via HIEs or Direct Messaging) and third-party vendors (such as the pharmacy, laboratory and diagnostic provider) is needed to make sure this critical data is available to the care team and exchanged between care settings in order to make informed care decisions.”
Care for the future
In the face of rising demand for healthcare and long-term care services from an aging population, providers are searching for ways to sustain and improve the level of care they provide. Fortunately, says Johnson, technology firms are starting to address this growing need.
“We will start to see IT solutions that will not only allow providers a look upstream using predictive analytics, modeling and trending of information,” he says, “but also the interactive ability to immediately alert providers and intervene to create more appropriate care paths.”
While there are still some paper note takers, these systems make it harder to pull out patient data and looking for trends that could affect care decisions, according to Debi Damas, RN, senior care product manager with Relias Learning.
“IT allows providers to track better,” she says. “When you're doing the documentation, you can see problems coming before you actually have a problem.”
By finding problems early, patients can often be treated in the facility, without requiring a return trip to the hospital. Predictive analytics can help reduce costs and improve care by identifying when an individual is approaching the end of life.
“At least 30 percent of all Medicare expenditures are attributed to the 5 percent of beneficiaries that die each year, with one-third of that cost occurring in the last month of life,” according to Janine Savage, RN, national account manager at PointRight.
“Several reputable studies have shown that when life expectancy is limited, hospitalization and aggressive medical treatment may not only be futile and costly, but quality of life is often sacrificed and patients experience a ‘worse' dying process,” she says.
Social safety net
Clinical data mining and communication between providers are unquestionably vital when it comes to reducing rehospitalization. However, according to Richard Juknavorian, senior director of product management at PointRight, there's another factor in preventing return trips to the hospital, and it's something that HIT will start to use more.
Getting providers to more strongly consider socioeconomic status and psychosocial factors is as close to a silver bullet for preventing rehospitalization as it gets, Juknavorian says.
A 2012 study in the journal Circulation, for example, found readmission rates following heart procedures were significantly higher when psychosocial and socioeconomic factors interfered with a patient's ability to follow medication orders, self-monitor health or schedule follow-ups after leaving the hospital or post-acute care facility. Countless other studies have linked rehospitalization to factors like depression.
Including this information along with clinical data, claims information, MDS, and the other HIT metrics can help providers determine which residents are at a high risk for rehospitalization.
“Care plans and interventions should be tailored to the specific profile of a patient, as much as possible, and derived from benchmarks on outcomes of how similarly profiled patients performed,” he observes. “There is no one-size-fits-all model.”