Use of the RAI-MDS 2.0 and interRAI LTCF assessment ... · Q-2 Mar 2015 Baseline Sept 2014 Q-1 Dec...

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UseoftheRAI-MDS2.0andinterRAILTCFassessmentsystemstoInformPolicyandImprovePracFceandHealthOutcomesinLTCResidents

JulieWeir,JenniferMajor,KayePhillips,&GeriStLouis

April24,2017

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Othercontributorstothiswork:

JohnHirdes,LoriMitchell,CynthiaSinclair,SelmaDidic

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Disclosure

› WehavenoactualorpotenIalconflictofinterestinrelaIontothistopicorpresentaIon.

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SessionObjecFves

› OverviewofCFHI’sPan-Canadian&NewBrunswickAppropriateUseofAnIpsychoIcCollaboraIveevaluaIon&measurementapproach

› Analysismethods&keyfindings• UseofinterRAI

› DiscusshowthestandardizedinterRAIassessmentsystemis:• asustainableevaluaIontoolforhealthcareorganizaIons• caninformstandards,policy&pracIceacrosscaresectors

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AnIpsychoIcsareprimarilyintendedforthemanagementofpaIentswithschizophreniaorbipolardisorder.1in4LTCresidentsinCanadatakesanIpsychoIcmedicaIonswithoutdiagnosisofpsychosis(CIHI*)

EvidencedemonstratesthatanIpsychoIcmedicaIonsare:§  MinimallyeffecIveinmanagingbehavioralissues

associatedwithdemenIa(Barton,2005)§  AssociatedwithworseningcogniIvefuncIoning(Vigen,

2011),§  Resultinseriousadverseeventswhenusedlongterm,

especiallyintheelderly(Gareri,2014)Non-pharmacological,paIent-centeredcareapproaches,shouldbetriedfirst(Zuidema,2015).

*CanadianInsItuteforHealthInformaIon(CIHI).Retrievedfromhep://yourhealthsystem.cihi.ca/

InnovaFonNeeded!TheOverprescribingofAnFpsychoFcMedicaFonsin

LongTermCare

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MeetCynthia:AnEXTRA-OrdinaryCFHIFellowfromWinnipeg

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SpreadingSuccessAcrossCanada:CFHI’span-CanadianAUACollaboraFves

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ObjecFves:§ ReduceinappropriateuseofanIpsychoIcsinnursinghomes

§ ImprovethequalityandexperienceofdemenIacarefornursinghomeresidents,familiesandstaff§ BuildindividualandorganizaIonalcapacityindesigning,implemenIng,evaluaIng,sustainingandspreadingresident-centredanddata-drivendemenIacareinnovaIons

datasystemusedbyallparIcipaInghomes.

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AUAMeasurementApproach:IdenFfyingTargetResidents

› PriortoAUAimplementaIonteamsaresupportedinidenIfyingresidentswhoarecandidatesforinappropriateanIpsychoIcmedicaIonreducIon

›  TargetResidentshaveaprescrip+onforanan+psycho+cmedica+onbutnodiagnosisofschizophrenia,Hun+ngton’schorea,hallucina+ons,ordelusions,andthosewhoarenotclassifiedasend-ofliferesidents.

›  TeamsfirstidenIfytargetresidentsinthefirstunitwheretheywanttoimplementtheAUAapproach

•  ThisisbestpracIcerecommendaIonforsuccessfulspread.

•  AkersuccessfulimplementaIoninthisfirstunit–selectanotherunit,idenIfyneededchangestotheapproach,selectanewcohortoftargetresidents,andimplementtheAUAapproachthere.

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AUAMeasurementApproach:CoreMeasures›  BeforeimplemenIngtheAUAapproach,teamsassesstheTargetresidentstodeterminebaselinestatusofthecoremeasures:

•  ForanIpsychoIcs:o NumberofprescripIons

o Prescribedpriortoadmission?Yes/no

•  ForotherpsychotropicmedicaIons(anIdepressants,anI-anxieIes,&hypnoIcs):

o CurrentprescripIons(yes/notoalistofdrugs)

o NumberofprescripIons

ThisinformaIonisobtainedthroughpaIentcharts,medicaIonreview,pharmacydata–ofeachoftheresidentswhoarecandidatesforreducIon

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AUAMeasurementApproach:CoreMeasuresconFnued

•  Demographics(language,sex,age,diagnoses)

•  Frequencyofbehavioralsymptoms(verbalabuse,physicalabuse,sociallyinappropriateordisrupIvebehavior,resistancetocare)

•  Useofphysicalrestraints

•  Falls,pain,acIviIesofdailyliving,cogniIveperformance,aggressivebehavior,depression,indexofsocialengagement

ThisinformaIonisobtainedthroughpaIentcharts,medicaIonreview,pharmacydata–ofeachoftheresidentswhoarecandidatesforreducIon

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Directcareteamengagement

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TheAUADesktop:AnOnlineLearningPlaVorm

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TheAUAOutcomes:BeXercare&healthforresidents

222/416 #ofTargetResidentsdisconFnuedorreduced(54%)

41

30

29

58

31

33

20

28

2345

Q-2Mar2015

BaselineSept2014

Q-1Dec2014

Q-3Jun2015

Falls↓

VerbalAbusiveBehaviours↓

AggressiveBehaviour noincrease

ResisIngCare↓

SociallyInappropriateBehaviours↓

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15 teams across 8 PTs

56 LTC facilities

7034 residents ROI:Every1$spentonAUA,saves

4.24$inpreventablehealthcarecosts-RiskAnalyIca

ScalingtheAUAacrossNewBrunswickCFHIandNBANH’sNewBrunswickAppropriateUseofAnFpsychoFcs

(NB-AUA)CollaboraFve[May2016-May2018]

§  PartnershipbetweenCFHI&NBANHtoscalebilingualNBcollaboraIveacrossallNBnursinghomes

§  $600,000fundingcommitmentfromNBgov’t(DepartmentofSocialDevelopment)

§  2-PhasedSpreadApproach:§  Phase1[Feb2016-May2017]:15nursinghomes§  Phase2[Feb2017-May2018]:46homes

§  Thesamegoals,objecIvesanddeliverymethodasthepan-CanadianAUAcollaboraIve

§  AdvisoryCommieee(includingsystemstakeholders)providingcounseltoNB-AUA

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EarlyNB-AUAPhaseIResults

•  PhaseIhomeshavesubmieeddatafor212residentswhotheyhaveidenIfiedascandidatesforinappropriateanIpsychoIcmedicaIonreducIon.

•  ExciIngoutcomesinjust6monthsinclude:

•  35%(75)oftheseresidentshavehadtheiranIpsychoIcmedicaIonsreducedordisconInued•  24%(51)disconInued•  11%(24)onlowereddose

•  Physicallyabusivebehaviourhasdecreasedby38%•  Falls&aggressivebehaviourhasdecreasedby13%•  Physicalrestraintusehasdecreasedby23%

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AUAMeasurementApproach:InSummary

›  ChangesinthebaselinestatusofthecoremeasuresfortargetresidentsaretrackedquarterlythroughassessmentsalignedwithinterRAI™MDS2.0(panCanadian)orLTCFassessments(NB-AUA).

›  ThisenablesteamstoseewhetherimplementaIonoftheAUAApproachishavingthepredictedeffectinimprovingappropriateuseofanIpsychoIcs(withoutincreasesinpossiblenegaIveconsequences,suchasincreasesinbehaviours,restraintuse,orfalls).

›  EachhomewasalreadydoingtheinterRAI™assessments,soaligningcoremeasureswiththisassessmentdatawasasustainablesoluIon.

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AUAMeasurementApproach:DatasubmissionMethods1.  PanCanadian:viaanexcelspreadsheet

2.  NB-AUAphaseI:viaonlineform3.NB-AUAphaseII:viamomentumsokwaresoluIons,integratedwiththeLTCF

•  Themethodsofdatasubmissionhaveevolved:NB-AUAphaseIIrepresentsthemostsustainable(leastImeintensiveandleasttrainingheavy)soluIon

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PanCanadian

› CFHIprovidedteamswithtrainingonhowtocreatevisualsinexcel

› HomessentdatatoCFHIonaquarterlybasis

AUAMeasurementApproach:DatasubmissionMethods

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NBAUAphaseI

› Providedteamswithaccesstotheirdata&“dashboards”

› ProvidedCFHIwithaccesstotheaggregatedata

AUAMeasurementApproach:DatasubmissionMethods

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NB-AUAMeasurement:interRAILTCFasaSustainableSoluFon› HowtoimplementamoresustainablesoluIon,thatislessImeintensiveforstaffforQImeasurement?

•  UseassessmentsANDdatasubmissionprocessesthatarepartofrouIneclinicalpracIce.

› TheopportunityinNB:

o RolloutoftheinterRAILTCFintheprovincepresentedanopportunitytosimplifythedatasubmissionprocess&addresstheImerestraintchallengeexperiencedbymanyofthepan-Canadianteams

o SingleSokwareSoluIonprovider:Momentum(incontrasttopan-CanadianAUAhomes)

o CollaboraIonwithCIHIassupportfortraininganddevelopmentofthedatacollecIonformontheMomentumsokwaresoluIonplayorm

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NB-AUAMeasurement:interRAILTCFasaSustainableSoluFon§  ForNB-AUAPhaseIIMomentumSokwareSoluIonswas

contractedtodevelop&deployacustomreporIngdataform

§  DataformwithintheLTCFwillautomaIcallyextractdataforAUAcoremeasuresthroughquarterlyLTCFassessments

§  TheNB-AUAdataformwillalsoallow:•  HomestotrackimprovementsinotherqualityimprovementiniIaIves

•  GeneraIonofdataextractstoCFHIforanalysis•  Homestoaccessreports,suchasrunchartsandothervisuals

§  ThishashugeimpacttoensuringsustainabilityforqualityimprovementiniIaIveswithinNewBrunswick.

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› Beforeshowingresultsofalongitudinalanalysis–empoweredbyuseofinterRAIdataacrossCanadianLTChomes,wewillreview:

•  SupportroleCIHIplaysintheAUAcollaboraIves•  interRAI(1)  Whatitis

(2)  Familyofinstruments

(3)  ApplicaIons

(4)  Howitcanbeusedtoinformqualityassessment,policy&pracIcechange

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HowCIHIsupportsnursinghomes

•  EducaIonplanfororientaIontotheinterRAILTCF&RAIMDS2.0§  Codingguidelines§  Useofoutcomescales,CAPsandquality

indicators§  UseofCCRSeReports

•  Supportdatasubmission•  Provideresourcesfortraining,informaIon,

publicaIons,presentaIonsetc.•  Fulfilldatarequests

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CIHI-CFHI-NBANHpartnership

•  CIHIalsoinformedthedevelopmentoftheassessmentguides–quickreferenceguidesthenursinghomescanreferencetocompleteassessmentsrelatedtothecollaboraIvecoremeasures.

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interRAIWho?

•  InternaIonal,not-for-profitnetworkof~100researchersandhealth/socialserviceprofessionals

What?

•  Comprehensiveassessmentofstrengths,preferences,andneedsofvulnerablepopulaIons

How?

•  MulInaIonalcollaboraIveresearchtodevelop,implementandevaluateinstrumentsandtheirrelatedapplicaIons

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interRAIFamilyofInstruments

•  MentalHealth•  InpaIent•  Community•  EmergencyScreener•  Forensic&AddicIonsSupplement•  CorrecIonalFaciliIes•  BriefMentalHealthScreener•  Child&YouthMentalHealth

•  IntellectualDisability

•  SubjecFveQualityofLife•  Longtermcare•  Homeandcommunitycare•  MentalHealth

•  HomeCare•  Adult&pediatricversions•  ContactAssessment

•  ComplexConFnuingCareHospitals,NursingHomes

•  AcuteCare•  EDScreener•  EDContactAssessment

•  PalliaFveCare

•  CommunityHealthAssessment•  FuncIonalsupplement•  MHsupplement•  Dea{lindsupplement

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ApplicaIonsofinterRAIAssessmentSystem:Oneassessment…mulIpleapplicaIons

Assessment

CarePlan

OutcomeMeasures QualityIndicators

ResourceAllocaFon

BalanceincenFvesEvaluaFon

BestPracFcesRiskManagement

Case-mixSinglePointEntry

PaFentSafetyQualityImprovementPublicAccountability

AccreditaFon

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interRAIdataasabasisforchangingpolicy&pracFce

› UsedinCanadaforregulatory&qualitymonitoringpurposes-publicreporIngandnursinghomeinspecIon

›  CanbeusedtoidenIfyinstancesofgoodorbadqualityordifferencesincarepracIcewhichcaninformpolicy&pracIcechangetoimprovequality.Forexample:

•  Coststructure:policiestoreduceduplicaIvecare(idenIfiedthroughinterRAIcomparisons)havesavedstateofMichiganUSD1Billiondollars

•  Changingservicecapsforhomecare,prioriIzingaccesstoservices,andinclusionofcasemixinfundingformulashavealsobeenjusIfiedthroughuseofinterRAIdata

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•  RestraintuseemergedasanimportantqualityindicatorinCanadainthe1990’swheninternaIonalcomparisonsofinterRAIdatashowedaboveaverageusein

•  StudybyPublicHealth

AgencyofCanadashowreducedratesinmostprovinces(exceptSK)

•  AccesstolongitudinaldatafromrouIneinterRAIassessmentmakesitpossibletomonitorqualityofcare&evaluateimpactofpolicydecisionsonqualityofcare.

Sourceofgraph:CanadianDatasetavailablefrominterRAI.org,ascitedinCarpenter&Hirdes,2013in“AGoodLifeinOldAge:Monitoring&ImprovingQualityinLongTermCare

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› AligningoutcomemeasureswithinterRAIenablesustoexaminetheimpactoftheAUAcollaboraIvethroughcomparinginterRAIqualityindicatorsinCFHIhomesvs.non-CFHIhomes

› Thiscanprovidepolicy-makerswithevidencetomovetosimilarmodelsofcare

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interRAIOutcomeEvaluaFon

interRAIlongitudinalcomparaFveanalysis:ParFcipaFngandnon-parFcipaFngLTChomes[Apr-14-Jun-15]

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interRAIOutcomeEvaluaFonofCFHI’sAUAinLTCCollaboraFve

5quartersofRAI2.0assessmentdata:Apr-14toJun-151.Nursinghomelevelanalyses:Examinedratesof13Qualityindicators

•  ComparedCFHIanIpsychoIcmedicaIonintervenIonLTCfaciliIes(“CFHIFaciliIes”)toallotherfaciliIesusingtheinterRAIassessment(“OtherCCRSFaciliIes”)

2.Residentlevelanalyses:MulI-levellongitudinalmodelsoftransiIonstonon-useofanIpsychoIcs

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CFHIcollaboraFvehomesvs.non-CFHIcollaboraFvehomes

•  Nosignificantdifferencesinage,gender,ordiagnosesdistribu=onbyhome’spar=cipa=oninCFHIInterven=on,Q12014.

0

20

40

60

<65 65-74 75-84 85+

%

AgeGroupCFHI Other

050100

Male Female

%

Gender

CFHI Other

0

20

40

60

80

%

CFHI

DistribuFonofDiagnoses

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NursingHomeLevelAnalysesBoxPlotsofRiskAdjustedQualityIndicators

OverTime

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DRG01 - Percent of residents on an4psycho4cs without a diagnosis of psychosis: CFHI facili+es vs. Other CCRS LTC Facili+es

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0

0.1

0.2

0.3

0.4

0.5

2014Q1 2014Q2 2014Q3 2014Q4 2015Q1

Adjusted

QIR

ate

DRG01MedianAdjustedQIRates

Median(CFHI) Median(otherCCRS)

AnotherWaytoLookattheQIChanges

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PercenFle FirstQuarter LastQuarter Difference

CFHI Others CFHI Others CFHI Others

20thpercenIle

23.9 19.1 11.5 12.4 -12.4 -6.7

Median(50th)

30.4 27.3 20.1 20.3 -10.3 -7.0

80thpercenIle

41.4 35.4 25.5 30.0 -15.9 -5.4

BEHD4-PercentofresidentswhosebehavioursymptomsdeclinedCFHIfaciliFesvs.OtherCCRSLTCFaciliFes

40

0

0.05

0.1

0.15

0.2

0.25

2014Q1 2014Q2 2014Q3 2014Q4 2015Q1

Adjusted

QIR

ate

BEHD4MedianAdjustedQIRates

Median(CFHI) Median(otherCCRS)

Person-LevelAnalysesMulI-levellongitudinalmodelsoftransiIonsoutof

anIpsychoIcuse

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Whydomodellingattheindividuallevel?

•  QIstelluswhetherthehomehaschangedatthepopulaIonlevel•  Butwealsowanttounderstandwhathappenedattheresidentlevel•  ComposiIonofhomechangesoverIme• WanttobesurethatindividualresidentsbenefitfromQIefforts•  ProvincesalsohadtheirowniniIaIvestoreduceanIpsychoIcuse•  ConsiderfactorsnotinQIriskadjustmenttobroadencovariates

•  AscertainmentbiasmaymeanthatsomefaciliIesaremoreorlesslikelytoidenIfyclinicalissues(e.g.,behaviourproblems)

•  NewstaIsIcalmodelsavailabletoexaminelongitudinalchangewhilecontrollingforeffectsatfacilitylevels•  Challenge:Availabledatasettoolargeforsomeofthemostadvancedmodels

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AdjustedoddsraFo*foreffectofCFHIintervenFonbystartFmeforfollow-upperiod,allparFcipaFngprovinces

00.20.40.60.81

1.21.41.61.82

Allavailableyears 01-Jan-14 01-Sep-14Adjusted

Odd

sRaI

oforrem

ainingonAP

StartTimeforObservaIonPeriod

*Adjustedforprovinceonly.Excludespersonswithschizophrenia,HunIngton’s,delusions,hallucinaIons

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AdjustedoddsraFo*foreffectofCFHIintervenFonbyprovincebasedonJan1,2014startFme,allparFcipaFngprovinces

00.20.40.60.81

1.21.41.61.82

AllProvinces BC AB SK ON NL

Adjusted

Odd

sRaI

oforrem

aining

onAP

StartTimeforObservaIonPeriod

*Adjustedforage,gender,CPS,ABS.Excludespersonswithschizophrenia,HunIngton’s,delusions,hallucinaIons

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ConcludingCommentsThereisstrongevidencethathomesintheCFHIiniIaIveimprovedtheirpaeernsofanIpsychoIcuseoverIme•  Beeerimprovementthaninnon-CFHIhomes•  Riskadjusted,sonotconfoundedbychangeinpaIentpopulaIons

AtthesameIme,therewasnoappreciablechangeinotherQIs•  ParIcularlyimportantthatbehaviouralandrestraintusedidnotrisenotablyakertheanIpsychoIcreducIonstartedto“kickin”

EvidenceatthefacilitylevelissubstanIatedbyperson-levelmulIlevelmodels•  Butneedfurtheranalysestofinalizethemodels-resultsvarydependingonmodelassumpIons

ConInuedResearch:•  ConInuethelongitudinalresearchonpanCanadianCFHIhomesvs.non-CFHIhomes–willtheresultssustain?•  LongitudinalresearchontheNB-AUAhomes• WhatfactorsaremostpredicIveofimprovement?

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TheCanadianFounda+onforHealthcareImprovementisanot-for-profitorganiza+onfundedbyHealthCanada.TheviewsexpressedhereindonotnecessarilyrepresenttheviewsofHealthCanada.LaFonda+oncanadiennepourl’améliora+ondesservicesdesantéestunorganismesansbutlucra+ffinancéparSantéCanada.Lesopinions

expriméesdansceUepublica+onnereflètentpasnécessairementcellesdeSantéCanada.

Thankyou

Jennifer.Major@c�i-fcass.caJweir@nbanh.comGStLouis@cihi.caKaye.Phillips@c�i-fcass.ca