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c"i-fcass.ca@c"i_fcass
UseoftheRAI-MDS2.0andinterRAILTCFassessmentsystemstoInformPolicyandImprovePracFceandHealthOutcomesinLTCResidents
JulieWeir,JenniferMajor,KayePhillips,&GeriStLouis
April24,2017
c"i-fcass.ca@c"i_fcass
Othercontributorstothiswork:
JohnHirdes,LoriMitchell,CynthiaSinclair,SelmaDidic
c"i-fcass.ca@c"i_fcass
Disclosure
› WehavenoactualorpotenIalconflictofinterestinrelaIontothistopicorpresentaIon.
c"i-fcass.ca@c"i_fcass
SessionObjecFves
› OverviewofCFHI’sPan-Canadian&NewBrunswickAppropriateUseofAnIpsychoIcCollaboraIveevaluaIon&measurementapproach
› Analysismethods&keyfindings• UseofinterRAI
› DiscusshowthestandardizedinterRAIassessmentsystemis:• asustainableevaluaIontoolforhealthcareorganizaIons• caninformstandards,policy&pracIceacrosscaresectors
c"i-fcass.ca@c"i_fcass
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
c"i-fcass.ca@c"i_fcass
MeetCynthia:AnEXTRA-OrdinaryCFHIFellowfromWinnipeg
8
SpreadingSuccessAcrossCanada:CFHI’span-CanadianAUACollaboraFves
9
ObjecFves:§ ReduceinappropriateuseofanIpsychoIcsinnursinghomes
§ ImprovethequalityandexperienceofdemenIacarefornursinghomeresidents,familiesandstaff§ BuildindividualandorganizaIonalcapacityindesigning,implemenIng,evaluaIng,sustainingandspreadingresident-centredanddata-drivendemenIacareinnovaIons
datasystemusedbyallparIcipaInghomes.
9
c"i-fcass.ca@c"i_fcass
AUAMeasurementApproach:IdenFfyingTargetResidents
› PriortoAUAimplementaIonteamsaresupportedinidenIfyingresidentswhoarecandidatesforinappropriateanIpsychoIcmedicaIonreducIon
› TargetResidentshaveaprescrip+onforanan+psycho+cmedica+onbutnodiagnosisofschizophrenia,Hun+ngton’schorea,hallucina+ons,ordelusions,andthosewhoarenotclassifiedasend-ofliferesidents.
› TeamsfirstidenIfytargetresidentsinthefirstunitwheretheywanttoimplementtheAUAapproach
• ThisisbestpracIcerecommendaIonforsuccessfulspread.
• AkersuccessfulimplementaIoninthisfirstunit–selectanotherunit,idenIfyneededchangestotheapproach,selectanewcohortoftargetresidents,andimplementtheAUAapproachthere.
11
c"i-fcass.ca@c"i_fcass
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
12
c"i-fcass.ca@c"i_fcass
AUAMeasurementApproach:CoreMeasuresconFnued
• Demographics(language,sex,age,diagnoses)
• Frequencyofbehavioralsymptoms(verbalabuse,physicalabuse,sociallyinappropriateordisrupIvebehavior,resistancetocare)
• Useofphysicalrestraints
• Falls,pain,acIviIesofdailyliving,cogniIveperformance,aggressivebehavior,depression,indexofsocialengagement
ThisinformaIonisobtainedthroughpaIentcharts,medicaIonreview,pharmacydata–ofeachoftheresidentswhoarecandidatesforreducIon
13
c"i-fcass.ca@c"i_fcass
14
Directcareteamengagement
c"i-fcass.ca@c"i_fcass
TheAUADesktop:AnOnlineLearningPlaVorm
15
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↓
16
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
17
EarlyNB-AUAPhaseIResults
• PhaseIhomeshavesubmieeddatafor212residentswhotheyhaveidenIfiedascandidatesforinappropriateanIpsychoIcmedicaIonreducIon.
• ExciIngoutcomesinjust6monthsinclude:
• 35%(75)oftheseresidentshavehadtheiranIpsychoIcmedicaIonsreducedordisconInued• 24%(51)disconInued• 11%(24)onlowereddose
• Physicallyabusivebehaviourhasdecreasedby38%• Falls&aggressivebehaviourhasdecreasedby13%• Physicalrestraintusehasdecreasedby23%
1818
c"i-fcass.ca@c"i_fcass
AUAMeasurementApproach:InSummary
› ChangesinthebaselinestatusofthecoremeasuresfortargetresidentsaretrackedquarterlythroughassessmentsalignedwithinterRAI™MDS2.0(panCanadian)orLTCFassessments(NB-AUA).
› ThisenablesteamstoseewhetherimplementaIonoftheAUAApproachishavingthepredictedeffectinimprovingappropriateuseofanIpsychoIcs(withoutincreasesinpossiblenegaIveconsequences,suchasincreasesinbehaviours,restraintuse,orfalls).
› EachhomewasalreadydoingtheinterRAI™assessments,soaligningcoremeasureswiththisassessmentdatawasasustainablesoluIon.
19
AUAMeasurementApproach:DatasubmissionMethods1. PanCanadian:viaanexcelspreadsheet
2. NB-AUAphaseI:viaonlineform3.NB-AUAphaseII:viamomentumsokwaresoluIons,integratedwiththeLTCF
• Themethodsofdatasubmissionhaveevolved:NB-AUAphaseIIrepresentsthemostsustainable(leastImeintensiveandleasttrainingheavy)soluIon
20
c"i-fcass.ca@c"i_fcass
PanCanadian
› CFHIprovidedteamswithtrainingonhowtocreatevisualsinexcel
› HomessentdatatoCFHIonaquarterlybasis
AUAMeasurementApproach:DatasubmissionMethods
21
c"i-fcass.ca@c"i_fcass
NBAUAphaseI
› Providedteamswithaccesstotheirdata&“dashboards”
› ProvidedCFHIwithaccesstotheaggregatedata
AUAMeasurementApproach:DatasubmissionMethods
22
c"i-fcass.ca@c"i_fcass
NB-AUAMeasurement:interRAILTCFasaSustainableSoluFon› HowtoimplementamoresustainablesoluIon,thatislessImeintensiveforstaffforQImeasurement?
• UseassessmentsANDdatasubmissionprocessesthatarepartofrouIneclinicalpracIce.
› TheopportunityinNB:
o RolloutoftheinterRAILTCFintheprovincepresentedanopportunitytosimplifythedatasubmissionprocess&addresstheImerestraintchallengeexperiencedbymanyofthepan-Canadianteams
o SingleSokwareSoluIonprovider:Momentum(incontrasttopan-CanadianAUAhomes)
o CollaboraIonwithCIHIassupportfortraininganddevelopmentofthedatacollecIonformontheMomentumsokwaresoluIonplayorm
23
NB-AUAMeasurement:interRAILTCFasaSustainableSoluFon§ ForNB-AUAPhaseIIMomentumSokwareSoluIonswas
contractedtodevelop&deployacustomreporIngdataform
§ DataformwithintheLTCFwillautomaIcallyextractdataforAUAcoremeasuresthroughquarterlyLTCFassessments
§ TheNB-AUAdataformwillalsoallow:• HomestotrackimprovementsinotherqualityimprovementiniIaIves
• GeneraIonofdataextractstoCFHIforanalysis• Homestoaccessreports,suchasrunchartsandothervisuals
§ ThishashugeimpacttoensuringsustainabilityforqualityimprovementiniIaIveswithinNewBrunswick.
cfhi-fcass.ca @CFHI_FCAS
S 24
c"i-fcass.ca@c"i_fcass
› Beforeshowingresultsofalongitudinalanalysis–empoweredbyuseofinterRAIdataacrossCanadianLTChomes,wewillreview:
• SupportroleCIHIplaysintheAUAcollaboraIves• interRAI(1) Whatitis
(2) Familyofinstruments
(3) ApplicaIons
(4) Howitcanbeusedtoinformqualityassessment,policy&pracIcechange
25
26
HowCIHIsupportsnursinghomes
• EducaIonplanfororientaIontotheinterRAILTCF&RAIMDS2.0§ Codingguidelines§ Useofoutcomescales,CAPsandquality
indicators§ UseofCCRSeReports
• Supportdatasubmission• Provideresourcesfortraining,informaIon,
publicaIons,presentaIonsetc.• Fulfilldatarequests
27
CIHI-CFHI-NBANHpartnership
• CIHIalsoinformedthedevelopmentoftheassessmentguides–quickreferenceguidesthenursinghomescanreferencetocompleteassessmentsrelatedtothecollaboraIvecoremeasures.
28
interRAIWho?
• InternaIonal,not-for-profitnetworkof~100researchersandhealth/socialserviceprofessionals
What?
• Comprehensiveassessmentofstrengths,preferences,andneedsofvulnerablepopulaIons
How?
• MulInaIonalcollaboraIveresearchtodevelop,implementandevaluateinstrumentsandtheirrelatedapplicaIons
35
cfhi-fcass.ca @CFHI_FCAS
S
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
29
cfhi-fcass.ca @CFHI_FCAS
S
ApplicaIonsofinterRAIAssessmentSystem:Oneassessment…mulIpleapplicaIons
Assessment
CarePlan
OutcomeMeasures QualityIndicators
ResourceAllocaFon
BalanceincenFvesEvaluaFon
BestPracFcesRiskManagement
Case-mixSinglePointEntry
PaFentSafetyQualityImprovementPublicAccountability
AccreditaFon
30
cfhi-fcass.ca @CFHI_FCAS
S
c"i-fcass.ca@c"i_fcass
interRAIdataasabasisforchangingpolicy&pracFce
› UsedinCanadaforregulatory&qualitymonitoringpurposes-publicreporIngandnursinghomeinspecIon
› CanbeusedtoidenIfyinstancesofgoodorbadqualityordifferencesincarepracIcewhichcaninformpolicy&pracIcechangetoimprovequality.Forexample:
• Coststructure:policiestoreduceduplicaIvecare(idenIfiedthroughinterRAIcomparisons)havesavedstateofMichiganUSD1Billiondollars
• Changingservicecapsforhomecare,prioriIzingaccesstoservices,andinclusionofcasemixinfundingformulashavealsobeenjusIfiedthroughuseofinterRAIdata
31
c"i-fcass.ca@c"i_fcass
• RestraintuseemergedasanimportantqualityindicatorinCanadainthe1990’swheninternaIonalcomparisonsofinterRAIdatashowedaboveaverageusein
• StudybyPublicHealth
AgencyofCanadashowreducedratesinmostprovinces(exceptSK)
• AccesstolongitudinaldatafromrouIneinterRAIassessmentmakesitpossibletomonitorqualityofcare&evaluateimpactofpolicydecisionsonqualityofcare.
Sourceofgraph:CanadianDatasetavailablefrominterRAI.org,ascitedinCarpenter&Hirdes,2013in“AGoodLifeinOldAge:Monitoring&ImprovingQualityinLongTermCare
32
c"i-fcass.ca@c"i_fcass
› AligningoutcomemeasureswithinterRAIenablesustoexaminetheimpactoftheAUAcollaboraIvethroughcomparinginterRAIqualityindicatorsinCFHIhomesvs.non-CFHIhomes
› Thiscanprovidepolicy-makerswithevidencetomovetosimilarmodelsofcare
34
interRAIOutcomeEvaluaFon
interRAIlongitudinalcomparaFveanalysis:ParFcipaFngandnon-parFcipaFngLTChomes[Apr-14-Jun-15]
34
interRAIOutcomeEvaluaFonofCFHI’sAUAinLTCCollaboraFve
5quartersofRAI2.0assessmentdata:Apr-14toJun-151.Nursinghomelevelanalyses:Examinedratesof13Qualityindicators
• ComparedCFHIanIpsychoIcmedicaIonintervenIonLTCfaciliIes(“CFHIFaciliIes”)toallotherfaciliIesusingtheinterRAIassessment(“OtherCCRSFaciliIes”)
2.Residentlevelanalyses:MulI-levellongitudinalmodelsoftransiIonstonon-useofanIpsychoIcs
35
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
36
NursingHomeLevelAnalysesBoxPlotsofRiskAdjustedQualityIndicators
OverTime
37
DRG01 - Percent of residents on an4psycho4cs without a diagnosis of psychosis: CFHI facili+es vs. Other CCRS LTC Facili+es
38
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
39
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
41
Whydomodellingattheindividuallevel?
• QIstelluswhetherthehomehaschangedatthepopulaIonlevel• Butwealsowanttounderstandwhathappenedattheresidentlevel• ComposiIonofhomechangesoverIme• WanttobesurethatindividualresidentsbenefitfromQIefforts• ProvincesalsohadtheirowniniIaIvestoreduceanIpsychoIcuse• ConsiderfactorsnotinQIriskadjustmenttobroadencovariates
• AscertainmentbiasmaymeanthatsomefaciliIesaremoreorlesslikelytoidenIfyclinicalissues(e.g.,behaviourproblems)
• NewstaIsIcalmodelsavailabletoexaminelongitudinalchangewhilecontrollingforeffectsatfacilitylevels• Challenge:Availabledatasettoolargeforsomeofthemostadvancedmodels
42
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
43
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
44
ConcludingCommentsThereisstrongevidencethathomesintheCFHIiniIaIveimprovedtheirpaeernsofanIpsychoIcuseoverIme• Beeerimprovementthaninnon-CFHIhomes• Riskadjusted,sonotconfoundedbychangeinpaIentpopulaIons
AtthesameIme,therewasnoappreciablechangeinotherQIs• ParIcularlyimportantthatbehaviouralandrestraintusedidnotrisenotablyakertheanIpsychoIcreducIonstartedto“kickin”
EvidenceatthefacilitylevelissubstanIatedbyperson-levelmulIlevelmodels• Butneedfurtheranalysestofinalizethemodels-resultsvarydependingonmodelassumpIons
ConInuedResearch:• ConInuethelongitudinalresearchonpanCanadianCFHIhomesvs.non-CFHIhomes–willtheresultssustain?• LongitudinalresearchontheNB-AUAhomes• WhatfactorsaremostpredicIveofimprovement?
45
c�i-fcass.ca@c�i_fcass
TheCanadianFounda+onforHealthcareImprovementisanot-for-profitorganiza+onfundedbyHealthCanada.TheviewsexpressedhereindonotnecessarilyrepresenttheviewsofHealthCanada.LaFonda+oncanadiennepourl’améliora+ondesservicesdesantéestunorganismesansbutlucra+ffinancéparSantéCanada.Lesopinions
expriméesdansceUepublica+onnereflètentpasnécessairementcellesdeSantéCanada.
Thankyou
Jennifer.Major@c�[email protected]@cihi.caKaye.Phillips@c�i-fcass.ca