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Christian Home and Rehabilitation Center, a skilled nursing facility in rural Wisconsin, implemented findings from an AHRQ-funded project that focused on integrating health information technology into nursing homes and long-term care facilities.

The AHRQ-funded project, "Real-time Optimal Care Plans for Nursing Home Quality Improvement," sought to build partnerships for implementing quality improvement activities in long-term care facilities. Incorporating evidence-based best practices into everyday workflow and facilitating clinical process redesign, the project demonstrated the value of integrating standardized documentation and timely feedback reports in this environment.

The research was conducted by Susan Horn, PhD, Senior Scientist at the Institute for Clinical Outcomes Research and Vice President for Research, International Severity Information Systems, Inc.

Key to the success of program implementation at Christian Home and Rehabilitation Center has been involvement of those who are actually taking care of the patients. Certified Nursing Assistants (CNAs), RNs/LPNs, nutritionists, physical and occupational therapists, and even equipment vendors are all part of resident care teams.

Becky Wilson, restorative nursing coordinator at the facility, says the involvement of frontline staff transformed the work culture. "The CNAs were very involved in developing the standardized flow sheets used for charting purposes. Their suggestions were incorporated into the design of the forms. Participation in the project has improved job satisfaction for them. It amazes me how free the CNAs feel to come to the leadership and suggest something new to try. And the leadership listens to them and shares their concerns and needs."

Wilson's facility reduced the number of forms used to document care by at least half (in some cases by as much as 70 percent), simplifying them as well. While the documentation process is more involved than it was prior to the "Real-time" implementation, the CNAs appreciate that they now have a place to report experiences actually encountered in the process of meeting residents' needs. CNAs are able to document care and changes that may occur during the course of the day, which then influence the resident's care plan.

Prior to the standardized charting, multiple log books were kept that recorded information. Each log book focused on one aspect of the patient, such as diet, urinary continence, meal intake, or weight. The redesigned workflow consolidated these multiple log books into one document that was scanned to a database. Resident information related to activities of daily living—such as bathing, eating, toileting, incontinence episodes, and dressing, as well as behaviors and weight loss—is located in one place and used to generate reports that are provided to the caregivers each week.

The reports have been instrumental in improving communication, generating enthusiasm among staff for health information technology, and creating what Horn calls a "data culture," where the staff focus on information needed for resident care versus the completion of forms.

"Real-time" reports alert staff to changes in conditions that may otherwise be missed. Clinical decisions can be made based on what is happening over a period of time and not on what is seen on a particular shift or by one staff member. In the long run, the data are used to make cost-effective decisions that are more appropriate for individual residents.

The incontinence reports also led to increased savings at Christian Home. These reports allowed staff to monitor toileting programs and products more closely. By reviewing the reports, urinary tract infections were caught before they became medical issues, and appropriate diaper product use has resulted in cost reductions.

The facility demonstrated a savings from decreased pressure ulcer development of 22 percent in treatment costs, which translated to approximately $26,000 in the first year of full implementation. Generally, treatment costs—not including hospitalization—range from about $2,000 to $14,000, depending on the severity of the wound.

"Real-time" reports are beneficial to management staff reviewing charting for Medicare and Medicaid purposes or for those who need to compile information from different areas to develop a complete assessment of a particular resident.

"Staff in long-term care facilities see the data, the reports based on the data they document, the positive changes, and their input all coming together to create a better system," says Horn. "They tell us their work is so much more meaningful because they can see outcomes."