Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home (Massachusetts)

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Summary:

This project developed and evaluated a medication reconciliation intervention for medication monitoring and followup of elderly patients discharged from a skilled nursing facility (SNF), with a goal of reducing the incidence of drug-induced injury. The research team evaluated the intervention through a time-series assessment to measure the efficacy of communicating key health information and alerts to outpatient primary care physicians and visiting nurses. Therapeutic monitoring guidelines were developed and integrated into the ambulatory electronic medical record (EMR) used at the Fallon Clinic. A range of outcomes were evaluated including the rate of followup office visits, the rate of appropriate monitoring for high-risk medications, the rate of hospital readmission and emergency department (ED) visits, and the incidence of adverse drug events (ADEs). In addition an analysis was completed on the development and implementation costs. 

The specific aims of the project were to:

  • Evaluate the impact of automated scheduling alerts on the rate of followup office visits with an outpatient physician within 21 days of discharge from sub-acute care. 
  • Evaluate the impact of automated monitoring alerts on the rate of appropriate monitoring for selected high-risk medications within 30 days of discharge from sub-acute care. 
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of ADEs within 45 days after discharge from sub-acute care. 
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of hospital readmission and emergency department visits within 30 days of discharge from sub-acute care. 

The study team did not find significant improvements in visits to outpatient providers following discharge from a SNF, laboratory monitoring in response to alerts, ADE rates, or rehospitalization rates relating to the intervention. However, ED visits were significantly lower during the intervention period. The development costs for establishing the automated system were estimated at $76,314 with the major costs and time contributions from physicians to develop content, provide overall project management, and review alerts during the test period.

The study identified several additional important issues, including that older adults discharged from SNFs to home are a highly vulnerable population. They have high rates of medical conditions, including traditionally considered comorbidities as well as serious depression and sensory impairments. Many of them were transferred to a SNF for continued in-patient care after a hospitalization triggered by an ED visit, frequently including trauma. Thirty percent were re-hospitalized within 30 days of the SNF discharge and 30 percent had an ADE within 45 days.  

For this vulnerable group, there was a lack of information in the EMR for two thirds of the discharges identified in the claims data. This suggests the possibility of a serious lack of information flowing to primary care physicians. This is reinforced by the low rates of office visits to primary care physicians, even among this better documented group. Although there were high rates of office visits to other providers, the potential lack of continuity of care would be a source of further medical difficulties for this group of patients.

Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities to Home - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017817
  • Project Period: 
    September 2008 – September 2012
  • AHRQ Funding Amount: 
    $1,188,157
  • PDF Version: 
    (PDF, 291.47 KB)

Summary: The purpose of this project was to develop and evaluate a medication reconciliation intervention for medication monitoring and followup of elderly patients discharged from a skilled nursing facility (SNF), with a goal of reducing the incidence of drug-induced injury. The research team evaluated the intervention through a time-series assessment to measure the efficacy of communicating key health information and alerts to outpatient primary care physicians and visiting nurses. Therapeutic monitoring guidelines were developed and integrated into the ambulatory electronic medical record (EMR) used at the Fallon Clinic. Dr. Field and her team measured a range of outcomes to determine whether the intervention facilitates high-quality transitions, including the rate of followup office visits, the rate of appropriate monitoring for high-risk medications, the rate of hospital readmission and emergency department (ED) visits, and the incidence of adverse drug events (ADEs). In addition an analysis was completed on the development and implementation costs.

Specific Aims:

  • Evaluate the impact of automated scheduling alerts on the rate of followup office visits with an outpatient physician within 21 days of discharge from sub-acute care. (Achieved)
  • Evaluate the impact of automated monitoring alerts on the rate of appropriate monitoring for selected high-risk medications within 30 days of discharge from sub-acute care. (Achieved)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of ADEs within 45 days after discharge from sub-acute care. (Achieved)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of hospital readmission and emergency department visits within 30 days of discharge from sub-acute care. (Achieved)

2012 Activities: Due to earlier delays of programming, refinement, and testing of the clinical alerts and messages in the EMR, the intervention was initiated in July 2011 and ended in July 2012. Because the team was identifying an average of only 10 discharges per month, they were concerned that they would not have time to accumulate a large enough sample size to run statistical analyses. As a result, the study team modified their implementation to remove randomization and provide the information and alerts for all discharges. Outcomes were analyzed with a time-series assessment using 2 years of data from the period prior to the intervention as the comparison period.

A manuscript describing the process, required resources, and personnel costs of developing and implementing the transition intervention was published in Informatics in Primary Care: Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home. In addition, Dr. Field presented at the AHRQ Annual Conference in September 2012.

Due to the significant time and resources necessary to develop, program, and refine the alerts and messages and program them into the EMR system, Dr. Field used a 1-year no-cost extension to complete the study, data collection, and the subsequent analyses. As last reported in the AHRQ Research Reporting System, project progress was on track and budget spending was on target. The project ended in September 2012.

Impact and Findings: The study team did not find significant improvements in visits to outpatient providers following discharge from an SNF, laboratory monitoring in response to alerts, ADE rates, or rehospitalization rates relating to the intervention. However, emergency department visits were significantly lower during the intervention period. The development costs for establishing the automated system were estimated at $76,314 with the major costs and time contributions from physicians to develop content, provide overall project management, and review alerts during the test period.

The study identified several additional important issues, including that older adults discharged from SNFs to home are a highly vulnerable population. They have high rates of medical conditions, including traditionally considered comorbidities as well as serious depression and sensory impairments. Many of them were transferred to a SNF for continued in-patient care after a hospitalization triggered by an ED visit, frequently involving trauma. Thirty percent were re-hospitalized within 30 days of the SNF discharge and 30 percent had an ADE within 45 days.

For this vulnerable group, there was a lack of information in the EMR for two-thirds of the discharges identified in the claims data. This suggests the possibility of a serious lack of information flowing to primary care physicians. This is reinforced by the low rates of office visits to primary care physicians, even among this better documented group. Although there were high rates of office visits to other providers, the potential lack of continuity of care would be a source of further medical difficulties for this group of patients.

Target Population: Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*This target population is one of AHRQ's priority populations.

Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017817
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,188,157
  • PDF Version: 
    (PDF, 202.02 KB)

Summary: This project developed and is evaluating a transitional care intervention: an electronic medical record (EMR)-based medication reconciliation system for medication monitoring and followup of elderly patients discharged from a skilled nursing facility (SNF) to ambulatory settings with the goal to reduce the incidence of drug-induced injury. The research team will evaluate the intervention through a time- series assessment to measure the efficacy of communicating key health information and alerts to outpatient primary care physicians and visiting nurses. Therapeutic monitoring guidelines have been developed and integrated into EpicCare, an ambulatory EMR used at the Fallon Clinic. Dr. Field and her team are measuring a range of outcomes to determine whether the intervention facilitates high-quality transitions, including the rate of followup office visits, the rate of appropriate monitoring for high-risk medications, and the incidence of adverse drug events (ADEs). Finally, they are analyzing the costs of developing and implementing the intervention. The results from this study will provide important insights into the effective use of clinical alerts and coordinated delivery of actionable information to improve the quality of care delivered to elderly patients transitioning from sub-acute care to the ambulatory setting.

Specific Aims:

  • Evaluate the impact of automated scheduling alerts on the rate of followup office visits with an outpatient physician within 21 days of discharge from sub-acute care. (Ongoing)
  • Evaluate the impact of automated monitoring alerts on the rate of appropriate monitoring for selected high-risk medications within 30 days of discharge from sub-acute care. (Ongoing)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of ADEs within 45 days after discharge from sub-acute care. (Ongoing)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of hospital readmission and emergency department visits within 30 days of discharge from sub-acute care. (Ongoing)

2011 Activities: During the first part of 2011, the team completed final programming, refinement, and testing of the clinical alerts and messages in the EMR. The intervention went live in July 2011. Because of delays, the team will only have 15 months of data collection. In addition, because they are identifying an average of only 10 discharges per month, they were concerned that they will not have time to accumulate a large enough sample size to run statistical analyses. As a result, the study team modified their implementation to remove randomization and provide the information and alerts for all discharges.

Analysis will now be based on a time-series assessment using 2 years of data from the period prior to the intervention as the comparison period.

Dr. Field and the team continued to develop manuscripts and disseminate the early work of this project on the development of the guidelines and the baseline results, including a manuscript, Baseline and follow-up laboratory monitoring of cardiovascular medications, published in the September volume of Annals of Pharmacotherapy. A manuscript describing the process, required resources, and personnel costs of developing and implementing the transition intervention has been accepted for publication in Informatics in Primary Care. In addition, Dr. Field presented at the AHRQ Annual Conference in September.

Due to the significant time and resources necessary to develop, program, and refine the alerts and messages and program them into the EMR system, Dr. Field is using a 1-year no-cost extension to conduct the study and complete the analyses.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track according to the revised timeline, and project budget spending is on target.

Preliminary Impact and Findings: This project has no findings to date. Results will be available at the conclusion of the time-series assessment.

Target Population: Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017817
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,188,157
  • PDF Version: 
    (PDF, 313.91 KB)


Target Population: Elderly*

Summary: The incidence of drug-induced injury is high in the ambulatory geriatric population, especially when people with complex health care needs make high-risk transitions to ambulatory settings. This project developed and will evaluate a transitional care intervention: an electronic medical record (EMR)-based medication reconciliation system for medication monitoring and followup of elderly patients discharged from a skilled nursing facility (SNF) to ambulatory settings. The intervention will be evaluated by a three-arm randomized control trial to measure the efficacy of communicating key health information and alerts to outpatient primary care physicians and visiting nurses. Therapeutic monitoring guidelines have been developed and integrated into EpicCare, a Commission for Health Information Technology-certified ambulatory EMR used at the Fallon Clinic. Dr. Field and her team will measure a range of outcomes to determine if the intervention facilitates high quality transitions, including the rate of followup office visits, the rate of appropriate monitoring for high-risk medications, and the incidence of adverse drug events (ADEs). Finally, they will analyze the costs of developing and implementing the intervention. The results from this study will provide important insights into the effective use of clinical alerts and coordinated delivery of actionable information to improve the quality of care delivered to elderly patients transitioning from sub-acute care to the ambulatory setting.

Specific Aims:
  • Evaluate the impact of automated scheduling alerts on the rate of followup office visits with an outpatient physician within 21 days of discharge from subacute care. (Ongoing)
  • Evaluate the impact of automated monitoring alerts on the rate of appropriate monitoring for selected high-risk medications within 30 days of discharge from subacute care. (Ongoing)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of ADEs within 45 days after discharge from subacute care. (Ongoing)
  • Evaluate the impact of a health information technology-based transitional care intervention on the incidence of hospital readmission and emergency department visits within 30 days of discharge from subacute care. (Ongoing)

2010 Activities: A significant amount of time in 2010 was dedicated to developing, programming, and refining the clinical alerts and messages in the EMR. While this took longer than anticipated, the added time allowed the investigators to add a clinical pilot review of the alerts and messages. All of the content sent each day to primary care physicians on discharged patients was e-mailed to one of the project investigators. The team held multiple meetings with clinicians to review and revise the content of the messages and alerts. This process helped ensure that the frequency and content of the alerts and messages are appropriate to lessen alert fatigue and convey clinically useful information. In addition, Dr. Field and the project team completed a review of each discharge to ensure that the programming has correctly captured all relevant information. This helped the team find multiple critical problems that required additional editing to the program. For example, they found specific problems in identifying newly prescribed antibiotics for patients taking warfarin and special medication interactions with diuretics. By fall 2010, programming and revisions were complete; however, the intervention start date was further delayed by the Fallon Clinic’s EMR software upgrade. Now that the upgrade is finished, the team is currently testing each component of the intervention and working with the SNFs and the geriatricians to begin the intervention in early 2011.

During the year, the project team prepared for the evaluation by designing and testing procedures to identify the primary outcomes. Ambulatory visits, hospital readmissions, emergency department visits, and followup laboratory testing will be tracked through transfers of electronic data from Fallon Clinic and Fallon Community Health Plan. The team determined all of the codes and date requirements that will be used for this portion of the study. In addition, the programmers developed and tested a notification system for informing the project’s pharmacist investigators that an eligible patient has been discharged from a SNF and providing them with a flow sheet containing critical information about each discharged patient to guide record review. The pharmacist investigators will be reviewing each discharged patient’s medical records to search for possible ADEs during the period immediately following SNF discharge and presenting them to pairs of physician investigators to determine if the event was an ADE and if it was preventable. The project team has developed and tested all of the procedures and forms for accomplishing this aspect of the project, including signals of possible adverse events based on their previous work and reports in the literature.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is on track in some respects but not others, mainly due to the significant time and resources necessary to develop, program, and refine the alerts and messages and program them into the EMR system. However, by the end of the year, the programming is complete and the intervention is expected to be initiated in early 2011. Spending is roughly on target.

Preliminary Impact and Findings: There are no findings at this time.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home - Final Report

Citation:
Field T. Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home - Final Report. (Prepared by the University of Massachusetts Medical School under Grant No. R18 HS017817). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 218.24 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Population: 

Managing Patient Care Transitions: How Health IT can reduce unnecessary re-hospitalizations.

Citation:
Jencks S, Jack B, Field T. Managing Patient Care Transitions: How Health IT can reduce unnecessary re-hospitalizations. Webinar presentation sponsored by the AHRQ National Resource Center for Health IT. 2010 February. (PDF, 1.16 MB)
Population: 
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