Long term and post-acute care is experiencing a cataclysmic change in health care delivery attributable to two major market forces:

1. The implementation of regulations aimed at producing outcomes-based, bundled payment structures and increased quality accountability.

The Affordable Care Act (ACA), the emergence of accountable care organizations (ACOs), and the impending implementation of bundled payments and value-based purchasing have affected providers in many ways, including:
■ Increased quality accountability from outside partners;
■ Dependence on partnerships for skilled admissions;
■ Increasing resident acuity; and
■ A need for more clinically competent staff.

2. The exponential increase in the number of seniors needing care, combined with limited availability of licensed clinical care providers.

While the number of Americans over 65 is projected to double in the next 30 years, the number of physicians and registered nurses is predicted to remain relatively flat. This means that long term and post-acute care providers will have to find ways to leverage fewer clinicians in caring for more residents, with higher levels of acuity.

Integrating Research, Records

The aforementioned challenges require a range of solutions; however, there are two common denominators: accountability for quality outcomes and increasing the efficiency of clinicians.

There is little doubt that health information technology is a major component of the solution to address these challenges. The electronic health record (EHR) is now “a need to have rather than a nice to have,” and leaders must view an EHR as a key component of the solution to meet the changing health care demands. That being said, the EHRs of today must evolve to meet the provider needs of tomorrow.

Another common theme of health care today is the requirement to demonstrate the use of evidence-based practices within all care settings.

Historically, providers have implemented evidence-based practices using paper protocols, policies and procedures, and clinical guidelines. As providers move from a paper to an electronic health care world, those former paper practices also need to transition to automated systems that facilitate the capture of data in a way that it can be analyzed.

The volume of medical research continues to grow, especially in the areas of geriatric medicine and wellness, and global access is becoming the norm rather than the exception.

As the amount of research increases and impacts clinical protocols, it becomes more challenging for clinicians to remain current on best practices.

The solution that has been embraced in primary and acute care is the embedding of clinical research within an EHR. This solution is termed “clinical decision support.”

Understanding CDS

Clinical decision support (CDS) is frequently used in conversation by long term and post-acute care providers relative to features that they would like to see in an EHR solution. However, CDS has more comprehensive and complex functionality than is typically discussed within the profession.

For the purposes of this column, CDS is defined as providing clinicians or patients with clinical knowledge and intelligently filtered patient information to enhance patient care.

The research-based clinical knowledge must get the right information, to the right person, in the right CDS intervention format, to the right channel, at the right point in the workflow.

The value of CDS is supported in the literature as enhancing care and quality. However, if the clinical knowledge is not current, interrupts the end user needlessly, or is not patient-specific, utilization declines.

The New Landscape

The primary goals of the ACA are to improve the patient’s experience of care (including quality satisfaction), improve the health of populations, and reduce the per capita cost of health care.

All sectors of health care, including long term and post-acute care, acute-care hospitals, and ACOs, are feeling the impact of this: Residents are being admitted to skilled nursing facilities with high-acuity needs, with the expectation that competent clinical staff will meet these needs and that further rehospitalizations will be avoided.

Additionally, the cost of care while achieving positive outcomes is being monitored and is expected to decrease. To achieve success, clinical care must be delivered and supported by research-based interventions, and in a way that leverages the time and expertise of each and every available clinician.
The era of “this is the way we have always done it” and the use of non-research-tested assessment tools is over. Clinicians need to use recently published, evidence-based guidelines in the delivery of care. The challenge, however, is keeping pace with relevant information and fewer resources for caring for more residents. EHR solutions, with embedded CDS, assist the care provider in choosing the most applicable interventions and in focusing their time on the residents with the most immediate and acute clinical needs.

The Benefits Of CDS

The benefits of CDS include:
■ Results in standardized documentation by using templates, thereby
limiting inconsistent narrative
■ Drives consistency in care decisions as a consequence of implementing evidence-based care guidelines.
■ Enhances credibility in relationships with care providers.
■ Improves confidence in quality outcomes since care is delivered in a consistent manner.
■ Improves quality and safety through alerts and reminders.

What Providers Need To Know

First and foremost, providers should look for a CDS solution that is embedded in their EHR. The mere integration of parallel systems with overlapping clinical workflows is not a viable solution as it introduces the potential for errors in data entry, decreases staff efficiency, and adds unnecessary costs.

Second, the CDS solution should embody the best practices of various industry-accepted guidelines and evidence-based research.

Given the wide range of diagnoses and conditions that need to be addressed in the senior population, and the growing amount of medical research, it is unlikely that any one institution or organization will be the source of all relevant best practices.

Third, the data collected as a function of implementing CDS should be accessible via business intelligence tools to trend and report on clinical outcomes and drive process improvements.
Denise Wassenaar, chief clinical officer of MatrixCare, is an evidence-based practitioner experienced in innovative approaches to the delivery of care, including more than 20 years of clinical leadership experience. Wassenaar is a licensed registered nurse and a nursing home administrator and holds a master’s degree in nursing from Purdue University Calumet. She is a frequent national and regional presenter on current clinical and regulatory topics.