In your community, how often does this scenario occur?
You arrive in the morning and see that a recently admitted resident was sent to the hospital overnight with increased confusion and fever. In hindsight, you learn that the resident was not themselves, was restless and was assisted to the bathroom multiple times the night before last. The resident dozed yesterday and did not go to the Dining Room for any of their meals and ate little in their room. You review the documentation, track down the Nurse Assistant who cared for the resident yesterday who reports that the resident was “not herself, but I knew she was up most of the night. I reported it to the nurse.”
You speak to the nurse who has a vague memory of this conversation, and he says that the resident was dozing but cooperative. No assessment was done, no physician was notified and no notation appeared on the 24 Hour Report. Your conclusion was that the Nurse Assistant and Nurse from at least two shifts did not adequately assess and follow through when the resident showed signs of a developing problem!
Prospective and current residents, families, and referring providers evaluate the quality of your organization when choosing a post-acute or long-term care provider. Your team is trying to provide top quality resident-centered care. One aspect of the quality of the care provided by your facility that is being scrutinized by your local hospitals, Accountable Care Organizations, referring providers, and CMS is your readmission rates. On the November 13, 2014 CMS Long Term Care Open Door Forum, the Centers for Medicare and Medicaid Services (CMS) indicated that there will probably be further quality measures added including a re-hospitalization measure in the next year or two.
Optimus EMR can assist with this challenge to manage your readmission rate! Our innovative Clinical Decision Support (CDS) Tools provide answers to assist your team in early identification and prevention of resident transfer to the hospital. The information guides the team to evaluate residents in a timely manner and enhances communication within the team and with the MD/NP/PA. Designed to optimize communication, automation, and integration with clinical documentation and the Electronic Control Center dashboard, the CDS Tools include:
Interact III: Interventions to Reduce Acute Care Transfers Tools
- Stop and Watch Early Warning Tool for the Nurse Assistants and other staff to document and communicate resident changes to the charge nurse for follow-up
- SBAR Communication Form and Progress Note is used by licensed nursing staff and guides resident evaluation and communication of acute changes of condition to MD, NP, and PA
- Change in Condition Cards: Symptoms and when to report to the MD/NP/PA
- Care Paths references for conditions commonly causing readmission
- Advance Care Planning Progress Note
- Comfort Care Plan template which may be customized for individual resident needs
AHRQ (Agency for Healthcare Research and Quality) On-Time Quality Improvement for Long Term Care (On Time) Avoidable Transfers Toolkit Reports
Reports used to assist with identification and prevention of avoidable transfers to the Hospital and Emergency Department (AHED). These reports use specific resident information including age, DNR status, recent ED and hospital information, high risk diagnoses, current clinical conditions contributing to transfer risk, polypharmacy, and high risk change in condition information to identify residents at risk for transfer. This information enables your team to care plan to monitor the resident to prevent readmission.
24 Hour Report
Our automated, real-time 24 Hour Report used for shift to shift and 24 Hour Report. Information on the report automatically flows to the report from admission and discharge information, clinical documentation, orders, and vital signs. You customize the report based on your needs with more than 50 criteria to choose from. Staff can add notes and issues to communicate as well.
Quality Performance Metrics Dashboard Report
Allows you to analyze data on admissions, discharges and destinations, readmission information, staffing, and quality measures.
Now, let’s go back and re-write the opening story with the Optimus EMR Clinical Decision Support Tools.
The Nurse Manager noted that the resident was at medium risk for transfer to the hospital based on the AHRQ Transfer Risk report and noted this on the Care Plan. She created Nurse Orders for the Nurse and CNA to monitor this resident. The Nurse Assistant on midnights who knew the resident was at risk noted the resident change and documented an Interact Stop and Watch Early Warning Tool and communicated this to the nurse. The nurse followed up with a resident assessment and completed an Interact SBAR Communication form.
The automated change in condition functionality instructed the nurse to notify the physician immediately based on the resident status. The nurse discussed the change in condition with the physician and all pertinent information was available from the Interact SBAR Communication Form. The physician ordered applicable diagnostic tests, monitoring and resident orders to address the problem. The resident information including the Stop and Watch Early Warning Tool, fever and new antibiotic automatically displayed on the 24 Hour report.
You come to work in the morning and see that a recently admitted resident had a problem monitored, identified, communicated and addressed in a timely manner and is now resting comfortably and being monitored by the staff. No resident transfer and readmission was needed thanks to the team use of the Optimus EMR Clinical Decision Support Tools!