Utuqqanaat Inaat is the Inupiaq name for one of the most unique long term care facilities in the United States. This outstanding facility opened for occupancy in October 2012, in Kotzebue, Alaska, located 32 miles above the Arctic Circle, which makes it the northernmost nursing home in the country.

 

The facility, whose name translates into The House for Elders, serves the entire Northwest Borough of Alaska, an area roughly the size of Indiana. It is part of the vision to provide exceptional care for Native Alaskans by the Maniilaq Association, which is a tribally owned and operated, not-for-profit, health, tribal, and social services organization.

Due to its remoteness and extreme environmental conditions, initial recruitment efforts resulted in staffing that consisted of many temporary employees and new managers who lacked department head experience. Many of the necessary policies and procedures were lacking or had been borrowed from other facilities. With a three- to four-hour time zone difference from the rest of the country, there were limitations to contacting resources in a timely fashion.

Despite sincere efforts, the first Alaska state survey proved to be disastrous, with 21 citations amassed on 110 pages.

Wanting the best care available for their elders (residents), the Maniilaq Association decided to establish a remote-presence knowledge team (virtual team) of long term care experts for the orientation of the managers and to work in collaboration with onsite leaders to institute the changes necessary to ensure compliance of state-required standards of care.

A remote-presence knowledge team, or virtual team, is defined as a small temporary group of geographically, organizationally, and/or time-dispersed knowledge workers who coordinate their work predominately through information and communication technologies in order to accomplish the organizational tasks.

Even under ideal circumstances, virtual teams face frequent challenges due to the following issues:

In addition to these more common challenges, the team encountered overarching problems that were part of the Kotzebue landscape and included the following:

The remote team included a director of nursing, activities leader, dietician, and social worker, all of whom were from various parts of the United States. During the initial site visit, which lasted one week, the focus was on conducting a mock state survey, identifying areas for improvement and developing an action plan that would address potential deficiencies in survey compliance.

The secondary objective for any remote-presence knowledge team is to establish relationships and to develop protocols to ensure clear and predictable communication.

While time differences and isolated locations are common issues for remote knowledge teams, this was not the biggest obstacle. Frequency of turnover and limited Internet bandwidth were two critical variables that required special consideration for the development of successful strategies.

Issues of consistent application of policies and continuity of care were apparent in the electronic health record (EHR) review. There were inconsistent or nonexistent care plans and wide variations in the depth of clinical documentation, as well as unacceptable responses to the same regulated clinical scenarios. These issues were directly attributable to the transient nature and differing backgrounds of the clinical staff.

Also apparent was the varied clinical experience that new staff brought to the facility. Many had no long term care experience and were unaware of the documentation requirements associated with this heavily regulated profession, where care events require specific documentation and actions to meet compliance expectations.

The frequent turnover and lack of long term care management experience affected many team decisions, including the transition from narrative notes to drop boxes and required fields for clinical charting and the rigid nature of managerial instructions.

The second limiting factor was a lack of Internet consistency and strength. Insufficient bandwidth resulted in video communication that demonstrated inconsistent access and extremely slow uploads.

These constraints also excluded remote presence technologies, which would have added a “real time” dimension to support remote team efforts and effectively reduced the communication options to emails, telephone conferencing, and faxes.

Having established the methods of communication, the team proceeded to exchange phone numbers, fax numbers, and email addresses and agreed upon schedules for teleconference calls.

The EHR became the point where care was evaluated and documentation was reviewed. Using a Web-based program eliminated many critical concerns, such as time differences, remoteness, and Internet bandwidth limitations, and allowed the team to be able to review progress notes, assessments, care plans, and Minimum Data Set (MDS) documentation at their convenience.

A careful review of the progress notes disclosed significant clinical events and observations about condition, as well as treatment modalities and care needs. These observations helped to determine the documentation improvements necessary and which documents must be initiated in response to a significant event.

Routine assessments are required on a quarterly and annual basis for most disciplines. These routine requirements were inventoried and completeness determined. A more expert review was necessary to determine the quality of the assessment or care plan content, and this was provided by the respective team members.

With various disciplines identifying needed documentation improvements, an improved tracking method was introduced to manage the flow of requests for changes and the response by the onsite team.

As the remote team identified gaps in documentation, a compliance documentation tracking form was generated outlining the issue/issues and emailed or faxed to the onsite caregivers and their respective managers.

As the needed steps were completed, it was returned to the team member, who reviewed the amended record and made a determination as to its completion. In this way, the onsite team received clear instruction, the manager was aware of the progress, and the remote team could track the disposition of their recommendations.

Questions, concerns, and progress were reviewed biweekly during telephone conferences. In situations where observations indicated that the elder was experiencing a more immediate clinical change in condition, onsite staff were notified immediately via email or telephone. This methodology helped to identify missing documentation in time to make corrections and improve care.

One critical goal in addressing inappropriate or missing documentation was to create a process that presented limited but appropriate charting pathways. These pathways would ensure compliance through EHR enhancements and the development of a manual that outlined situation-specific documentation requirements.

Organized by discipline, the manual provided instruction as to required documentation, as well as who was responsible for completion and under what circumstances the information should be provided. Included in the manual were the governing policies and a sample of the electronic form to be completed.

EHR enhancement also included the building of 44 custom assessment or documentation forms that allowed less narrative, increased use of mandatory fields, checkboxes with limited options, and strategic drop boxes.

The efforts more than met expectations by reducing the number of Alaska State Department of Health citations from 21 in 2012 to two in 2013, with no clinical citations. While the example used was extreme, the same methodology may be applied to any long term care facility. Where better Internet capabilities are available, the process could be enhanced. The same techniques are used to review MDS effectiveness, develop QAPI (Quality Assurance and Performance Improvement) programs, and respond to government audits.