Marilyn J. Rantz, PhD, RN, FAAN · Recognizing pattern changes Detecting early signs of health...
Transcript of Marilyn J. Rantz, PhD, RN, FAAN · Recognizing pattern changes Detecting early signs of health...
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MarilynJ.Rantz,PhD,RN,FAANCurators’ProfessorEmeritusUniversityofMissouri‐SinclairSchoolofNursingGSAFellowNationalAcademyofMedicineMember
PresentationfortheUniversityofTexasatAustin
NEW SOLUTIONS TO OLD PROBLEMS:PAST,PRESENT,AND FUTURE OF LONGTERM CARE ‐ IN PURSUIT OF QUALITY
NEW SOLUTIONS TO OLD PROBLEMS:PAST,PRESENT,AND FUTURE OF LONGTERM CARE ‐ IN PURSUIT OF QUALITY
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WhereThisReallyAllBegan…
FinishingaMastersinNursing,ChronicIllnessandLeadershipandManagementatMarquetteUniversityHadfinishedaMastersinEducationwithGuidanceandCounselingemphasisandpracticeteachinginNursingtwoyearsearlier
“Here,honey,ajobjustafewmilesfromourhouse!”“Anursinghome?Ihaveneverevenwalkedintoone!”“Aww,you’llbethebestqualifiedcandidatetheyeversaw!”
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ALoveAffairBegins……LAKELANDNURSINGHOME
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NothingLikeRealWorldExperience…
• Meetingandgettingtoknowhundredsofolderpeople,theirfamilies,anddedicatedemployeesprovidingcareandservices
• CommitmenttoQualityImprovement,teamandgroupprocessesfordecision‐making,evidence‐basedpractice,advancedpracticenurses
• Realizingthepopulationexplosionofolderadultsinthenextdecadeswilloverwhelmhealthcareandlongtermcareservices
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IMPENDINGAGINGSOCIETYRESOURCESFORNH ANDPLANNINGFORFUTURE
http://www.aoa.acl.gov/aging_statistics/Profile/2015/4.aspxTotalpopulation2014‐2060319million‐417million
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IMPACTOF SIMILARGRAPHSBY20301‐IN‐5AMERICANSWILLBE65OROLDER
Impact of Silar graphs
https://www.census.gov/prod/1/pop/p25‐1130.pdf
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Needfor MoreEducation ‐NEWTOOLSFOR “OLD”PROBLEMS
• ContinuedworkingasNHAatLakeland• AttendedUWisconsinMilwaukeeforPhDinNursingwithfocusinLongtermcare,publicpolicy,qualitymeasurement,andMDSdata
• MovedtoMissourisohusbandcouldcattleranchfulltime,retiredfrombusinessinWisconsin
• BeganworkingatSinclairSchoolofNursing,UniversityofMissouri,firstacademicjobofcareer(25yearsago,now)
• PicturesLakelandNursingHomeresidentsofficewall‐stilltheretoday!!REMINDSMEWHYIDOWHATIDO!
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LaunchingaResearchTrajectory
Largedatasettrainingandmentoring(NowBigData)Reality!Qualitativemustbeapartofthis!!Excellenttrainingandmentoringinqualitativemethods—Alwaysusesomequalitativemethods
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• MissouriDivisionofAgingandMDSdata,teamforanalysis,feedbackreportstodepartmentandnursinghomesstatewide
• QualityIndicators(MDSdata),comparisonsstatewide• FocusgroupstodevelopVersion1oftheObservableIndicatorsofCareQualityinNursingHomes,latercompletedevelopmentalwork
• Exploratorystudies NHqualityofcare,cost,staffing• Interventionstudies improvecarequality,cost,staffing• AginginPlaceProjectbegins…
LaunchingaResearchTrajectory
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WhatpeopleWANTWhatpeopleNEED
Newsolutionstotheoldproblems ‐justdosomethingDIFFERENT!!
ThreeKeysto Always Consider
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FoundationalPerspectivesOlderAdultsand LTCOlderadultswanttobeasindependentaspossibleaslongaspossibleTheywanttobelivinginthehomeoftheirchoiceTheyneedtoNOTexperiencemultipletransitionsof“home”asthatincreasesriskofhealthdeclineanddeathTheyneedrelationshipsandengagementwith“living”
TraditionallongtermcaremodelsneedtobechallengedNewmodelsofLTCmustbeevaluatedusingsoundresearchmethodsmeasuringcost,quality,andstaffing
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ThosePersistentProblemsofAging!!StillNeedNewSolutions
• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers
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ThingsOurTeamsHavePursuedfor Solutions
• MeasuringQualityinLongTermCare ‐ developedandtestedtheObservableIndicatorsofNursingHomeCareQualityInstrument
• Developedandtestedfeedbackreportingmethodstonursinghomesandclinicalconsultationservicetoimprovequalityofcare
• MeasuringLTCNursingCareProcesses,Outcomes,andCost ‐ qualitativelyandquantitativelythenwithaMultidimensionalIntervention
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• MeasuringEffectivenessofAdvancedPracticeNursesinLongTermCare ‐ clinicalconsultationservicetoimprovequalityofcareandimplementbestpracticesstatewide(QualityImprovementProgramforMissouri)andMultidimensionalIntervention
• MeasuringEffectivenessandCostEffectivenessofAdvancedPracticeNursesinMOQIInterventiontoReduceAvoidableHospitalizationsofNursingHomeResidents ‐ qualitativelyandquantitativelyin2CMSInnovationCenterInitiatives
ThingsOurTeamsHavePursuedfor Solutions
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MOQIModel
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MOQIInterventioninSTL
MOQIPrimaryProjectGoalsReduceavoidablehospitaltransfersviafouraspectsofAPRNCareCoordination
1. Conditionmanagement2. Earlyillnessdetection3. INTERACT4. End‐of‐life
ANDhealthinformationtechnology
NowtestingpaymentforacuteillnesscareinNH
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ComplexityScience
Preparing Nursing Homes and Hospitals for the Future of Health Information ExchangePreparing Nursing Homes and Hospitals for the Future of Health Information Exchangeand Hospitals for the Future of Health
Information ExchangePreparing Nursing Homes and Hospitals for the Future of Health Information Exchange
t
“Traditionalbureaucraticapproachestomanagement[inLTC],imposebarrierstothefreedomofinteractionneededforeffectiveself‐organization.”
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ComplexAdaptiveSystemsComponents
Relationships amongstaffInterconnectionsCommunication
CognitivediversityLeadstoSelf‐Organization
“Stone Soup”
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FinalResultsPhase1‐ Effecton ProbabilityofAnyPotentiallyAvoidableHospitalization
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KeyResultswith RTI‐SelectedComparisonGroup 40%reductioninall‐causehospitalizationsand 57.7%potentiallyavoidablehospitalizationsreduced(p=.001); 54.1% allcauseEDvisitsreductionand 65.3%potentiallyavoidableEDvisitsreduced(p=.001).
33.6%Medicareexpendituresinall‐causereducedand 45.2%inpotentiallyavoidablehospitalizations(p=.001); 50.2%Medicareexpendituresinall‐causeEDvisitsreducedand 59.7%potentiallyavoidableEDvisitsreduced(p=.001).
Ingber,MJ,Feng,Z,Khatutsky,G,etal.Evaluationoftheinitiativetoreduceavoidablehospitalizationsamongnursingfacilityresidents:Annualreportprojectyear4,February,2017.Availableat:https://innovation.cms.gov/Files/reports/irahnfr‐finalyrfourevalrpt.pdf.AccessedApril14,2017.CentersforMedicareandMedicaidServices.MedicareHospitalQuality.
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The Keyto Success‐ FinalResultsAPRNs(AdvancePracticeRegisteredNurses)
1. Majorfocusisnotp r ima r y c a r e (MOregulations)2. Rolemodele v i d en c e ‐ b a s ed c a r e tofacilitynursingstaff
foreffectiverecognition,assessment,andcommunicationaboutresidents’changeinconditiontoPrimaryCareProviders
3. APRNssupporttheuseofI NTERACT andqu a l i t y imp rov emen t toreduceunnecessaryhospitaltransfers
4. Promotemed i c a t i o n r e v i ew ,e nd ‐ o f ‐ l i f e p l a nn i n g ,c ommun i c a t i o n ,andH IT u s e
5. SupportedbyMOQ I T e am (HIT,QI,SW,MedDirector)andf e edba c k r e po r t s
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OtherThingsOurTeamsHavePursuedfor Solutions
AgingInPlaceProject ‐ firstincommunity,thenatTigerPlace
TechnologytoEnableAginginPlace‐ TheElderTech InterdisciplinaryResearchTeam ‐collaborationwithEngineeringtodevelopandtesttechnologiesforeldersandrehabilitation
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AGINGINPLACE‐ CommunityDemonstrationand TigerPlace
• Foundation‐ RNCareCoordination,gettingrightservicesatrighttimetomaximizeregaining/maintaininghealthandINDEPENDENCE
• CMSgrant1999‐2003‐ wellnesscenterfocused,licensedhomehealthagencyforMedicare,Medicaid,privateinsurance,privatepay,servedoverahundredmonthly2006
• Legislationin1999and2001enabledTigerPlacetobebuiltandevaluationofAIPinidealhousingwherepeoplecanlivethroughtheendoflifeintheirownprivateapartment/home
• TigerPlaceopened2004,expandedin2009and2011,serving65dailyinhousing;now85inrehabilitationandtraditionalskilledcare
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KeyClinicaland FinancialOutcomesof AIPResearch
RNcarecoordinationreducesadversehealthevents,improvescareoutcomes,nursinghomeutilization,andcostsless
Clinicaloutcomesbetter(ADLperformance,lessdepressedandbettercognition,continence,pain,andshortnessofbreath)
Costsavings$1,591permonth(nursinghomecomparison)$483(communitycomparison)
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KeyClinicaland FinancialOutcomesof AIPResearch RNcarecoordinationatTigerPlaceincreasesLOSbyayear
CostsforanyatTigerPlacenursinghomeeligibleparticipanthasneverapproachedorexceedednursinghomecare
Inafouryearanalysis(2009‐2012)theaverageannualcostforthosenursinghomeeligiblewas$20,000lessperyearthannursinghomecare
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TigerPlacewas Developedbythe UniversityofMissouriin Affiliationwith AmericareSystems,Inc.
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ResidentsliveinindependentapartmentwithbasicservicesprovidedbyAmericare(housekeeping,transportation,2mealsperday,socialactivities)
HealthpromotionactivitiesbySinclairHomeCareoftheSchoolofNursing(exerciseclasses,on‐goingnursinghealthassessment,wellnesscenteropendaily,RNcarecoordination,privatenursingservicesaffordablypackagedwhenneeded)
Designedtomaximizeindependence(builttonursinghomestandards,licensedasanintermediatecarefacility,operatedasindependenthousingwithservices)NOTRANSITIONSREQUIREDthroughtheendoflife
TigerPlaceCareModel
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TheChallenge
GiveustechnologyforTigerPlacethatwillhelpolderadultsstayasactiveandfunctionallyindependentaspossible.
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Squaringthe LifeCurve
Reducefunctionaldeclineby Assessingbehaviorpatterns Assessinggait&activitylevel Recognizingpatternchanges Detectingearlysignsofhealthdecline(socanintervenebeforethingsbecomemajorevents)
Detectingfalls InformingRNCareCoordinationCurrenttrend
Withproactivecare
FunctionalDecline
Time
Proactivehealthmanagementthroughintegrationofsensordataandhealthdata
Rantz,Marek,Aud,Tyrer,Skubic,Demiris,&Hussam,NursingOutlook,2005.
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TechnologyResearchFunding EvaluationoftheUseofBedsideTechnologytoImproveQuality
ofCareinNursingFacilities,CMS,2003‐2006 TechnologytoEnhanceAginginPlaceatTigerPlace,
AdministrationonAging,2005‐2009 TechnologytoAutomaticallyDetectFallsandAssessFallRiskin
SeniorHousing,AHRQ,2009‐2013 TechnologytoAutomaticallyDetectEarlySignsofIllnessin
SeniorHousing,NINR,2009‐2012 IntelligentSensorSystemforEarlyIllnessAlertsinSenior
Housing,NINR,2013‐2016 SeveralNSFandotherengineeringgrants
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SensorsHydraulicbedsensorunderthemattresscapturesquantitativepulse,respiration&restlessness
Gaitparameters&fallsarecapturedusingdepthimages
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Sensors
Webportal
& Mobiledevices
Integration&
Data Storage
Detection of Health
Change or Functional
Decline
AlertManager
SensorNetworkforHealthAlertsclinicaldecisionsupportsystem
Clinical Care Coordinator
Alert Feedback
Health changeemail alert
Skubic et al., Technology & Health Care, 2009; ICOST 2012, IEEE JTEHM (in press)Rantz et al., Journal of Gerontological Nursing, 2010
EHR
SensorData
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MotionSensorDensityMap
midnight
7am
11pm
Feb1 Mar14
BLACK=timeawayfromhome
HEALTHY,ACTIVE RESIDENT
Wang&Skubic,IE,2008;Wang,Skubic,&Zhu,EMBC,2009,TITB 2012.
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OtherLifestylePatterns
HighactivityIrregularpatternCognitiveimpairment
LowactivitySedentarylifestyle
Depression
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Changein BathroomActivityat Night
midnight
7am
11pm
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BedSensorDataChanges
ERvisitHospitalization
Increasinglowpulseevents
Changeinbedrestlessness
Rantz,etal.,ICOST,2008;CIN,2010.
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ERvisitHospitalization
EarlyIllnessAlert26daysbeforeER40daysbeforeER
BedSensorDataChanges
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MUHydraulicBedSensorPlacedUnderthe Mattress
15 units deployed
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10Secondsfrom BedSensor
RawSignal
Pulsefrombedsensor
Pulsefromfingersensor
Heiseetal.,EMBC,2010,2011;Rosalesetal.,2012.
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NOW!!Technologyto AutomaticallyDetectHealthChanges
Environmentallyembedded(non‐wearable)sensorsmonitornew‘vitalsigns’
Continuouslymeasurefunctionalstatus,detectpotentialchangesinhealthorfunctionalstatus,andalertforearlyrecognitionandtreatment
Algorithms,onaverage,detecthealthchanges10daysto2weeksbeforethepersonisawareofsymptomsofimpendinghealthproblems
RantzMJ,SkubicM,KoopmanRJ,AlexanderG,PhillipsL,MustermanKI,BackJR,Aud MA,GalambosC,GuevaraRD,MillerSJ:Automatedtechnologytospeedrecognitionofsignsofillnessinolderadults.JGerontol Nurs 2012;38:18–23.
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NOW!!Technologyto AutomaticallyDetectHealthChanges
Livingwithsensortechnologywithhealthalertsaddsanaverageof1.7yearstolengthofstay(LOS)inindependentseniorhousing
WhencombinedwithRNcarecoordination,sensortechnologywithhealthalertsincreasesLOS2.5yearsfrom1.8to4.3years
CostestimatescomparingcostoflivingatTigerPlacewithsensortechnologyvs.nursinghomerevealpotentialsavingofabout$30,000perperson
PotentialcostsavingstoMedicaidfundednursinghome(assumingthetechnologyandcarecoordinationwerereimbursed)estimatedtobeabout$87,000perperson
Rantz,M.J.,Lane,K.R.,Phillips,L.J.,Despins,L.A.,Galambos,C.,Alexander,G.L.,Koopman,R.J.,Skubic,M.,&Miller,S.J.(2015).EnhancedRNcarecoordinationwithsensortechnology:impactonlengthofstayandcostinAginginPlacehousing.NursingOutlook,63,650‐655.*
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WhataboutFallsandFallRiskAssessment?Severalnon‐wearable sensorstestedatTigerPlace
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Walkingfrom RadarSensor
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Yardibi,Cuddihy,Genc,Bufi,Skubic,Rantz,Liu,&Phillips,SmartE,2011;EMBC2012.
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Fallfrom RadarSensor
0 0.5 1 1.5 2 2.5 3 3.5 4-3
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time(second)
volta
ge(V
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Raw signal of RCR A Spectrogram of RCR A
time(second)
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(Hz)
0 0.5 1 1.5 2 2.5 3 3.50
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Liu,Popescu,Skubic,Rantz,Yardibi,&Cuddihy,PCTH,2011;EMBC2012.
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CapturingGaitinthe Homewith Kinect
Two clusters for two residents
Grandchildren
Stone & Skubic, EMBC 2012; TBE 2013; EMBC 2014.
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KinectSDKisnotusedSegmentpersonindepthimage
Projectto3D,segment,andtrackLog:walkingspeed,height,stridetime&stridelength
In‐HomeGaitAnalysiswith Kinect
Stone & Skubic, JAISE 2011
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NOW!!Technologyto AutomaticallyDetectIncreasingFallRiskand Falls
Alertsforincreasingfallriskusingthefallsensortechnologyalertsimpendingfalls‐ 3weeksbeforefalleventsareverylikelytohappen‐ sopreventativestepscanbetakentopreventthefall(Phillipsetal.,2016;Stoneetal.,2015;Rantz,Skubic,Abbottetal.,2015;Rantz,Skubicetal.,2013)
Sensortechnologyalertsemergencysituationssuchasfallswithinjuriessothatresponsetimecanbereducedreducingmorbidityandmortality(Rantz,Skubicetal.,2015;Rantz,M.,Banerjeeetal.,2014;Rantz,M.,Skubic,M.,Popescuetal.,2015).
NowcommercializedbyForesiteHealthcare,St.Louis,andinhospitals(MO),assistedliving(MO),CCRC(IA)
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Future‐ Backto Graphs
http://www.census‐charts.com/Population/pop‐us‐1790‐2000.html
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Future‐ Growthof ForeignBorn‐???Howto Plan??
http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25‐1143.pdf?
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ThosePersistentProblemsofAging!!StillNeedNewSolutions
• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers
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Stillconsider!WhatPeopleWANT/NEED/COST
• Stilllikelytowantindependence‐butdothequalitativeworkfornewandchangingperspectives
• Challengeoldmodels!!• Seeknewsolutionstotheold
problems‐ justdosomethingDIFFERENT!!
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Changingthe Practice
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OurMission:KeepingOlderAdultsFunctionallyActive!
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AdditionalInformationand Papers
AGING IN PLACEwww.agingmo.com
CENTER FOR ELDERCARE AND REHABILITATION TECHNOLOGYwww.eldertech.missouri.edu
NURSING HOME QUALITY,QIPMO,AND MOQIwww.nursinghomehelp.org
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