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Smart Networks are the Future of Post-Acute Care: 3 Ways Providers Can Stay Ahead

As the rest of health has transitioned towards some form of value-based or quality-contingent payment (whether through the Readmissions Reduction Program, Hospital Value-Based Purchasing, Physician Quality Reporting System or Meaningful Use), post-acute care has anxiously waited on the sidelines. No longer. With the passage of the IMPACT Act, the extensive growth of ACOs and Bundled Payment for Care Improvement pilots, and growing sophistication of quality measures and data analytics, post-acute care providers are finding themselves increasingly in the spotlight to prove they can offer higher value outcomes over alternative providers or lower-cost settings.

For the past few years, both healthcare networks and consumers have relied heavily on the CMS Five Star Rating, which, as I and others have written about before, is an imperfect guide to quality. For hospital-led systems, rehospitalization measures are increasingly becoming an important marker of quality. In a recent Mcknight’s article, Steven Littlehale of Pointright describes the challenge of narrow networks based on just a few measures. Instead, he proposes using “smart networks” based on several outcome and process measures. Careport Health, a start-up based in Boston, is attempting to do just that.

With the impending transformation towards value-based payment models and smart referral and partner networks, along with growing sophistication on outcomes and measures, how can post-acute care providers remain competitive? Here are three areas to consider:

1. Build a high-reliability, outcome-based organization.

The days of focusing on RUG rates and pushing length of stay as high as possible are over. The five star rating system, while still important, will no longer be the key to acceptance by partner networks. Providers instead need to develop strong, consistent systems to provide high-quality care as effectively and efficiently as possible. Not only does this require a competent therapy team, but providers must also have engaged staff, from CNAs to housekeeping aides, who all contribute to the well being and satisfaction of guests. The need for resiliency means providers must adopt a holistic view of their operations, rather than relying on a few heroes to steer the ship. Information will need to flow continuously and seamlessly through the organization, enabled by technology but driven (and utilized) by capable employees. A culture of continuous improvement and rigorous root cause analysis is essential, which requires deep organizational investment in learning, problem solving, and engagement.

Investments in culture and institutional capacity will have a rollover effect as well: post-acute care providers  who position themselves as meaningful, exciting and challenging places to work will help stem the tide of turnover that has long plagued the sector, and provide a buffer against the growing shortage of direct care workers.

2. Invest in long-term relationship management.

Providers can no longer forget about guests after a discharge is complete– nor should they wait until admission before forming relationships. Instead, providers need to become sources of information about aging and care options for the entire community. They should also invest in interactive care coordination and follow-up technologies to ensure emergent needs and care challenges can be addressed before they become more costly. From call center-based coordination to remote monitoring technologies, the options are quickly growing.

This change to long-term relationship management is both a new challenge—and new opportunity—for providers. Utilizing their existing social services, recreation and transportation infrastructure, skilled nursing providers can quickly and effectively provide low cost, high value assistance to keep elders in their homes after discharge from a skilled facility.

Providers can also take the lead on facilitating care coordination between a guest’s primary care team and other needed resources, such as social services and supports offered through Area Agencies on Aging. Engaging elders in the community also provides natural referral networks for long-term or community-based care services the organization also provides.

3. Expand service lines to target newly available revenue streams.

Many senior housing providers have long stayed away from Medicare services because of the onerous regulations and increased complexity. Bundled payment and ACO models provide innovative opportunities to partner with or build home health agencies and provide high quality, inclusive rehab services in lower-cost-of-care settings. For senior housing providers, this can open up lucrative revenue streams while also providing needed resources to build clinical care capacity and resident offerings. By contracting directly with innovative ACO programs, providers can also avoid the hassle and uncertainty of Medicare billing, as well.

For hospitals and health networks, partnering with senior housing communities provides an ideal way to support a targeted, high risk population with minimal investment of resources. Using analytics and care coordination services like Care at Hand, Life2 and Caremerge, providers can seamlessly integrate expanded services into existing workflows and structures. Non traditional senior housing providers, such as HUD 202 buildings, can also tap into these new opportunities to expand revenue while reducing overall healthcare costs. For instance, housing organizations are partnering with ACOs to reduce hospitalizations– and capturing a piece of the savings. Senior housing providers are providing home care and meal delivery services to local neighbors– making money and building brand awareness. Assisted living communities are participating in bundled payment initiatives to manage chronic conditions in the community in exchange for health IT investments and care management support.

Change is quickly coming to the post-acute care space. This includes not only traditional providers, like skilled nursing facilities, but also assisted living and senior housing communities, home health and home care agencies, and ancillary service providers. Organizations should position themselves now to be an integral value-based partner with these new opportunities or risk being left with outdated service offerings— and empty buildings.

You can learn more about how eSSee Consulting helps providers and Health IT companies capture these new opportunities by visiting our Solutions.

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Harness the Power of Information with Governance

“[Information governance is] an organization’s coordinated, inter-disciplinary approach to satisfying information compliance requirements and managing information risks while optimizing information value” – The Sedona Conference Commentary on Information Governance

Governance is the practice of aligning an organization’s values and goals with its operations and structures. Like other crucial resources in healthcare, information is a high level asset that requires management and oversight to ensure it can be used effectively. Information governance, a rapidly growing concept in healthcare, allows an organization to create reliable structures and processes to manage, maintain and act upon information in a way that supports organizational goals and ensures compliance with applicable rules and responsibilities.

Most, if not all, healthcare organizations have at least a simple governance structure in place around privacy and security of health information, driven by the requirements of HIPAA. But information governance is a much deeper concept, addressing not only security but also the quality of information and how effectively it can be used and shared (when necessary). As the use of information in and across healthcare organizations grows, the quality, reliability and availability of that information will become almost as important as actual care routines. For long-term and post-acute care organizations, now is the ideal time to think hard about information governance structures.

AHIMA (The American Health Information Management Association) provides a wealth of resources on information governance (http://www.ahima.org/topics/infogovernance), including an excellent primer on the eight principles of information governance. These eight principles (depicted below) offer a framework to understand the full cycle of information use within an organization.

In a 2014 survey of healthcare organizations, AHIMA found a wide range of organizational approaches to information governance:

Tellingly, 34% of organizations either didn’t think there was any need for governance or didn’t know their organization’s position, while another 22% have not started any program. As this survey represented a wide range of healthcare providers, long-term and post-acute care providers can be expected to fall disproportionately in these underdeveloped camps.

An information governance program should begin at the Board level, typically in the form of a Board oversight committee. In smaller organizations, information governance may be adequately situated within the corporate compliance and risk management program. A cross-functional team should be comprised of Board representatives, the CIO, the IT Director, clinical and administrative leadership, and other relevant stakeholders. Once organized, the information governance committee can develop an organizational information governance strategy and structure to address several components:

  • Key roles and responsibilities
    • Who is responsible for program development and oversight?
    • Who will manage training? Auditing? Communication?
    • How will oversight and accountability survive turnover and succession?
  • Information standards, definitions and expectations
    • How will information be used and what requirements are necessary for these uses?
    • What dimensions govern the acceptability of information?
  • Policies and procedures that govern information management
  • An audit and oversight program
    • How will the organization ensure compliance and identify opportunities for improvement?
  • Workforce training
    • How will employees in all job functions and at all levels contribute to the overall governance program?

Given the central place of health information and its importance to operations, the principle of information integrity oftentimes occupies the majority of a governance program’s ongoing work. A large part of information integrity involves ensuring data quality through the dimensions of accuracy, completeness, validity, timeliness and accessibility.

  • Accuracy: Is the information correct?
  • Completeness: Are all required elements present?
  • Validity: Does the information match the rules?
  • Timeliness: Is the information present when needed?
  • Accessibility: Is the information available?

To manage these dimensions, a governance committee should develop standards for each element, training to teach staff how to prepare and store information correctly, and audit mechanisms to verify data quality and identify problems.

As information needs become more complex, the role for information governance will only grow. Organizations should lay the foundation for a strong information governance program now or risk not having the infrastructure required to compete in the future healthcare marketplace. Begin by setting the governance structure, define roles and responsibilities, train all stakeholders, and sustain through oversight and continuous improvement.

For more information on setting up an information governance program, visit AHIMA’s website: www.ahima.org/topics/infogovernance

I will also be speaking about the important of information governance, along with EHR adoption and succession planning at the Long-Term Post Acute Care Heath IT Summit in Baltimore June 21st-23rd. This is a fantastic learning conference for all those involved in long-term and post-acute care operations. Learn more at: ltpachealthit.org/content/annual-ltpac-health-it-summit

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EHR Implementation Guide: Part Two – Implementation and Optimization

Build and Implementation

Build

Depending on the system and vendor, the build phase can take anywhere from weeks to months. During the process, you may find yourself discovering better ways to accomplish a process halfway through the build. Don’t be afraid to rebuild modules when this occurs—a little extra time spent now can save considerable time over and over again down the road. It’s a good idea to talk with colleagues who have already implemented the system to learn from their challenges and experience.

Data Governance

As part of the build phase, spend time to develop a data governance structure. This entails a written plan of who is accountable for information integrity and security, processes for managing data quality, and auditing systems for HIPAA compliance, security, and accuracy. The structure should involve oversight from the corporate or board-level.

Training

Vendors typically recommend a slew of webinar-based training modules for all staff. The idea is to gather a group of staff and watch someone demonstrate the EHR functions step by step. Not only is this training style time-consuming and expensive, it is ineffective at building proficiency in users. Why is proficiency important to think about? Research has shown that adults learn much better when concepts are tied to the work they are expected to do. In the case of EHRs, the goal should be to have proficient users– in other words, that staff are able to use the application effectively to do their job– as opposed to knowing a complex set of modules and screens.

By listening to and/ or watching a remote user walk through screens and screens of capabilities, staff are likely to retain very little once the training is completed. Instead, training should be developed and deployed around workflow and roles, using a well-designed simulation environment that closely matches the new system. In other words, staff members should have access to a computer and be able to complete the step by step activities at the same time as the trainer. The savings in reduced training time and increased proficiency from this approach alone can make retaining an external, experienced EHR consulting firm cost-effective.

Go-Live

Go-Live is the big day to switch the new EHR system on. If you have invested the time and resources in your journey so far, Go-Live should be simply another step in the process. Make sure you have extra staff available to ease the transition. Management staff should also spend time in crucial operational areas to demonstrate commitment and provide support as needed.

Implementation Project Closure/ Transfer to Optimization Structure

The optimization phase of an EHR project should be built long before go-live day. After the implementation phase ends, usually 90 days or so after go-live, return to the established goals for the system and compare to the results achieved so far. Begin implementing a long-term strategy to understand how the EHR is integrating into workflows and make adjusts to the system when necessary. In addition, consider the following tips:

  • Develop strong training programs that can be consistently provided to new staff. A reliance on web-based training modules leads to poor proficiency and increased variation in usage and data entry, as does training provided solely as part of a traditional floor orientation program. Instead, take the time to develop (and keep updated) a training program that includes simulation, facility-specific guides, and leadership oversight to ensure continuity of information and practices.
  • Commit to one place for data. Many organizations are loathe to give up their trusted Excel-based census tracking worksheets and paper-based incident tracking systems. Resist the urge to keep data in different places. To fully capitalize on the business intelligence and analytic features of EHRs, you need to have all the data in one place to properly guide future decision-making. Data analytics is quickly reshaping all of healthcare. For LTPAC providers, this means you must have accurate data on rehab outcomes, rehospitalization statistics, and efficiency of operations. If your EHR solution is a barrier, press your vendor for added functionality. Chances are good they either have a solution from another provider, or, more likely, other providers are struggling with and clamoring for the same solution.
  • Ask staff probing questions. It’s not enough to ask, “Is everything okay?” At one organization where I served as administrator, I discovered months after implementation that some of our med aides were not following the proper procedures to chart their med pass. In researching why the staff had not mentioned the deviation before, I discovered that they had never been able to follow the process as described, but quickly found a workaround that seemed to work. When I would ask if everything was okay in the months after go-live, naturally and honestly they answered, “Sure!” Ask staff directly if things are working as expected. Ask regularly if staff are finding different ways to accomplish tasks. Encourage your superusers to report common questions and issues so you can examine whether there are organization-wide trends.

It’s also crucial to note, you must approach problems with usage of the EHR with a “just” mindset. This means if staff are not following established protocols, it’s crucial to understand why in a way that doesn’t place blame on individuals when the problems are system-induced. (And in our experience, virtually all problems with EHR usage are system-induced.)

  • Stay curious. EHRs vendors are quick to promise their system will do everything under the sun. It won’t, trust us. EHRs currently on the market are clunky adaptations of LTPAC operations. For some processes, you will ask how to do something and receive an answer of either the EHR can’t do that, or it can, but requires a complex set of steps. Push your vendor to simplify steps and improve workflows. What EHR vendors lack in user experience design and functionality, they more than make up in attention to customer needs. So be vocal about what you need and what you’d like to see. Remember Robert Kennedy: “Some [people] see things as they are and ask why—I dream things that never were, and ask why not?” Ask why not. Often.
  • If something doesn’t work, don’t give up on it. This part is a little shocking to us, but we find many organizations that, after struggling to adopt a certain feature or workflow, simply decide an EHR can’t support this part of their business and drop it. One time, we worked with a client that had paid for the billing/ finance module of an EHR, but had completely abandoned it in favor of staying with Quickbooks because they weren’t able to get the system to bill correctly for their independent residents. Resist the temptation. If a billing module doesn’t support your CCRC model, talk openly with your vendor about what you are trying to accomplish. Take a look at your internal process, as well, and be open to reconceptualization of your processes. While current EHRs are clunky, they are hardly impotent. Don’t give up on such a big investment.
  • Be open to—brace yourself—replacing your shiny new EHR. Most vendors work hard to ensure client satisfaction, but if you find yourself with a vendor who refuses to work with your struggles and challenges, go back to your shortlist and reexamine other vendors. The cost to replace a system is truly less than continuing to use a beast that doesn’t actually improve your operations and ability to care for your residents.

Final Thoughts

Current EHR systems on the market are valuable tools to manage data more effectively and streamline some of the labor-intensive parts of LTPAC operations. At the same time, they are not perfect solutions, and unfortunately reflect too much history as revenue cycle agents and not enough experience in day-to-day operations. Most systems are just now integrating workflow engines into the design, and it will be years before useful workflow and clinical decision support tools are available.  Worse, all complete EHR systems currently on the market suffer from a deep bias of paper-centric thinking, which hampers the ability of much of the healthcare industry to leverage technology in the same way that other industries have done (think Apple, Amazon, Google, and Netflix). This means that we likely will see tremendous innovation moving forward, and some of the giants today will struggle or fall away in the near future. Staying on top of technology solutions, rather than clinging tight to a trusted vendor, will require LTPAC organizations to think differently than they have in the past and embrace change much more quickly and tentatively.

EHR Implementation Guide: Part One – Project Management and Vendor Selection

 

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

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Embracing an Adoption Model for EHRs

While aging services providers slowly move forward in implementing electronic health records, a lack of workflow redesign and adoption practices continue to hamper providers’ efforts to realize the full potential of these computerized systems. Chief among the challenges are 1) inconsistent and poorly designed training programs, 2) disconnects between old workflow patterns and new opportunities, 3) a lack of data governance structures,  and 4) failure to embrace optimization opportunities.

1) Inconsistant and Poorly Designed Training Programs

Providers and vendors continue to waste significant resources during training and implementation phases by blasting webinar-based training to classrooms full of staff. Not only is this training style time-consuming and expensive, it is ineffective at building proficiency in users. Why is this important? Research has shown that adults learn much better when concepts are tied to the work they are expected to do. In the case of EHRs, the goal should be to have proficient users– in other words, staff are able to use the application effectively to do their job– as opposed to knowing a complex set of modules and screens.

By listening to and/ or watching a remote user walk through screens and screens of capabilities, staff are likely to retain very little once the training is completed. Instead, training should be developed and deployed around workflow and roles, using a well-designed simulation environment that closely matches the new system. The savings from this approach alone can make retaining an external, experienced EHR consulting firm cost-effective.

Once systems are implemented, providers should develop strong training programs that can be consistently provided to new staff. A reliance on web-based training modules leads to poor proficiency and increased variation in usage and data entry, as does training provided solely as part of a traditional floor orientation program. Instead, providers should take the time to develop (and keep updated) a training program that includes simulation, facility-specific guides, and leadership oversight to ensure continuity of information and practices.

2) Workflow Challenges

EHRs offer a tremendous opportunity to remove significant waste from operations. From hunting down charts to keeping documentation in one place, an EHR can bring order to chaotic paper charts. Because of this, new workflows oftentimes need to be developed to take advantage of these opportunities. Role for medical records, MDS nurses, billing staff and floor nurses all need to be examined to determine the most effective mechanisms for entering and maintain data in an EHR. The challenge is that even during an EHR build and design phase, paper-centric thinking reigns. This creates a bias towards old systems that leaves most implementations under-powered and underutilized.

Charting and review systems need to be assessed, as EHRs typically provide visibility into areas that previously required redundant systems to manage. Any parallel information systems being used after implementing an EHR should be carefully examined to ensure there isn’t a duplication of data or efforts occurring. Without direct assessment and action, it’s not uncommon for providers to waste 10-15% of their resources maintaining outdated or redundant systems and databases.

3) A Lack of Data Governance Structures

Very little literature has been written or developed regarding data governance in long-term care, and it’s likely that most providers do not have a formalized process for managing the integrity of data entered into an EHR, resulting in unnecessary variation, lowered resident outcomes, and less useful analytics and performance measures. To remedy this, providers need to develop a model for data governance and create processes to define and manage the information entered into the EHR. This means defining roles and responsibilities around the data that is entered, and developing systems and practices to standardize and sustain the data. Compliance should be measured on an ongoing basis, and frequent adjustments should be implemented as new needs are identified.

4) Failure to Embrace Optimization Opportunities

Optimization is the ongoing process of evaluating, improving, and sustaining an EHR over the product life-cycle. For many providers, however, an EHR simply becomes part of the background infrastructure after implementation is complete. For workflows that were not redesigned during implementation, extra or unneeded work often continues indefinitely. Workarounds to problematic features are typically developed and shared by floor staff, which can circumvent opportunities for useful analytics and reporting. In addition, new features developed by vendors are sometimes under- or un-utilized as they are typically buried in pages of product announcements and updates that are rarely viewed. In fact, it is not uncommon for legacy users– those who have had systems the longest– to be among the vendors’ lowest utilizers.

Providers should develop an ongoing optimization strategy that includes frequent observations of staff usage, regular discussions with the EHR vendor on new and planned enhancements, and collaboration with other users to discuss issues, workarounds, and innovative practices.

Have a little more time? Check out this excellent webinar from HIStalk on adoption success factors.

Have a little more time? Watch this excellent HIStalk webinar on long-term adoption.

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

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3 Implementation Challenges that EHR Vendors Should Address Now

EHR projects are challenging for any healthcare organization, but especially so for LTPAC providers, who typically lack IT resources, capital infrastructure, and the staff stability that is crucial to implementing any large technological and process change. The result of this is many providers struggle with poorly implemented, un-optimized systems that don’t deliver the full transformative power of the technology. On top of the internal and systemic challenges facing providers, EHR vendors have been slow to develop workflow-based EHR solutions, adopt adult-learning-based implementation models, and truly partner to help solve the most challenging quality and service-related issues in the industry.

As they push forward the technology of their systems, EHR vendors would be wise to look at three key pitfalls in current implementation approaches:

1) Training content cannot be delivered effectively through multi-hour webinars. These webinars are nearly a complete waste of staff time and training resources, yet are still the most common method for delivering implementation training. The most efficient and effective approach to training staff is to combine lecture and live-practice at the same time. The more you separate these two integrated activities, the less staff will retain (and the more resources you’ll waste in additional training and practice). In addition, the training schedule should match the clinical workflow, rather than teaching modules in an architecture-based way. What does this mean? Don’t train based on how the EHR has divided up the work in modules (orders, events, progress notes, ADT, etc.)– train based on the user’s workflow; the quicker the training matches known work, the quicker staff will be able to apply the learning to their own internal reference points. And yes, this means training should be customized by facility and by role– a cookie-cutter approach

Most vendors have begun offering a variety of webinar-based, interactive web-based, pre-recorded content and user help guides. These items are an improvement over materials of the past, but are still nowhere near an optimized learning suite. The biggest barrier? Implementation and training costs are billed out to providers as a separate cost, and there is little incentive for vendors to optimize this process. In addition, vendors have little incentive to ensure systems are actually adopted, as the replacement cost for an EHR is beyond what most providers will consider.

2) Sandboxes are confusing as much as they are helpful. I’ll be honest– this has been one of the most surprising learnings I’ve had myself. A sandbox allows the learner to practice working in the EHR environment by utilizing a test facility with made-up residents. This model works really well for conceptual learners (such as myself)– but is challenging for those who are not (such as many, if not most, nursing home staff). Instead of being helpful, by and large, nursing home staff are confused by the sandbox approach and struggle initially to apply the conceptual lessons (adding an order to Susie the test case, for instance) to their own future workflow (adding an order to Susie the resident). In addition, sandboxes often become littered with examples of every variable possible within the EHR– but in places you typically wouldn’t find them. On a recent installation, for example, the sandbox contained a PRN order for NovoLog that required charting on pain level and blood pressure. The order was used to demonstrate a PRN order, and show how you could require certain charting to be completed before administering the medication. The trainees, however, struggled to get beyond the fact that you would never chart for pain level and blood pressure before administering NovoLog (an insulin).

Sandboxes serve a purpose– letting users practice outside of the actual medical records– but they should be crafted to match the implementing facility as much as possible. Once the initial data entry (or a portion, even) is completed, vendors should replicate the database to use as the sandbox. Using familiar residents, assessments, and orders can significantly improve the retention of training.

3) Listen to users, but don’t rely on self-reported user suggestions and improvements as the whole story. When EHRs first came to the market, they presented a variety of solutions that barely resembled long-term care workflows. This is understandable, since they were primarily designed to automate MDS data collection and submission (an entirely different and problematic topic). Over time, as providers shared frustrations and challenges with the software, vendors responded not only by making improvements to the software, but also creating user groups and councils to directly solicit feedback from users. This is a great step forward, and in line with many of the vendors’ switch towards agile-style development.

The new challenge, however, is that facility staff generally don’t understand the EHR architecture, and the vendor product owners don’t understand facility workflows and, more importantly, facility care and service goals. This lack of understanding on both ends of the development process inhibits EHRs from being transformative in practice, and instead we are getting slightly less clunky applications still driven by paper-centric thinking. To get ahead, vendors need to rethink their development process, gathering not only ideas but also goals and desired outcomes from providers. (Think of it as a root cause analysis process.) The development challenge then is to design the best, most efficient way to accomplish those outcomes and goals (instead of the current approach of simply adding functionality)—which will generally require re-engineering the workflow itself. Thus, the vendor development team should include not only software development and subject matter experts, but also workflow analysis and design experts. By doing so, they’ll develop a product that can be much more easily implemented and adopted.

 

For providers, the good news is that the intense competition in the EHR market, combined with a rapidly pivoting payment landscape, is thrusting the need for an optimized and adoptable EHR solution to the forefront. Many of the legacy vendors are committing significant resources to redevelopment and a renewed emphasis on user adoption, while a few newcomers to the space (I’m particularly intrigued by LG CNS for the integrated market and Medtelligent for the AL space) are making surprisingly strong inroads.

For those that are unhappy with their current systems, this is a great time to start looking at replacement options. For the few providers who are still relying on paper workflows, this is an ideal time to make the transition.

 

 

Considering an Electronic Health Record system for your nursing home or assisted living community? Looking to optimize a current installation? Learn how we can help with our EHR Consulting Services.

Ready to get started? So are we!