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
WhereThisReallyAllBegan…
FinishingaMastersinNursing,ChronicIllnessandLeadershipandManagementatMarquetteUniversityHadfinishedaMastersinEducationwithGuidanceandCounselingemphasisandpracticeteachinginNursingtwoyearsearlier
“Here,honey,ajobjustafewmilesfromourhouse!”“Anursinghome?Ihaveneverevenwalkedintoone!”“Aww,you’llbethebestqualifiedcandidatetheyeversaw!”
ALoveAffairBegins……LAKELANDNURSINGHOME
NothingLikeRealWorldExperience…
• Meetingandgettingtoknowhundredsofolderpeople,theirfamilies,anddedicatedemployeesprovidingcareandservices
• CommitmenttoQualityImprovement,teamandgroupprocessesfordecision‐making,evidence‐basedpractice,advancedpracticenurses
• Realizingthepopulationexplosionofolderadultsinthenextdecadeswilloverwhelmhealthcareandlongtermcareservices
IMPENDINGAGINGSOCIETYRESOURCESFORNH ANDPLANNINGFORFUTURE
http://www.aoa.acl.gov/aging_statistics/Profile/2015/4.aspxTotalpopulation2014‐2060319million‐417million
IMPACTOF SIMILARGRAPHSBY20301‐IN‐5AMERICANSWILLBE65OROLDER
Impact of Silar graphs
https://www.census.gov/prod/1/pop/p25‐1130.pdf
Needfor MoreEducation ‐NEWTOOLSFOR “OLD”PROBLEMS
• ContinuedworkingasNHAatLakeland• AttendedUWisconsinMilwaukeeforPhDinNursingwithfocusinLongtermcare,publicpolicy,qualitymeasurement,andMDSdata
• MovedtoMissourisohusbandcouldcattleranchfulltime,retiredfrombusinessinWisconsin
• BeganworkingatSinclairSchoolofNursing,UniversityofMissouri,firstacademicjobofcareer(25yearsago,now)
• PicturesLakelandNursingHomeresidentsofficewall‐stilltheretoday!!REMINDSMEWHYIDOWHATIDO!
LaunchingaResearchTrajectory
Largedatasettrainingandmentoring(NowBigData)Reality!Qualitativemustbeapartofthis!!Excellenttrainingandmentoringinqualitativemethods—Alwaysusesomequalitativemethods
• MissouriDivisionofAgingandMDSdata,teamforanalysis,feedbackreportstodepartmentandnursinghomesstatewide
• QualityIndicators(MDSdata),comparisonsstatewide• FocusgroupstodevelopVersion1oftheObservableIndicatorsofCareQualityinNursingHomes,latercompletedevelopmentalwork
• Exploratorystudies NHqualityofcare,cost,staffing• Interventionstudies improvecarequality,cost,staffing• AginginPlaceProjectbegins…
LaunchingaResearchTrajectory
WhatpeopleWANTWhatpeopleNEED
Newsolutionstotheoldproblems ‐justdosomethingDIFFERENT!!
ThreeKeysto Always Consider
FoundationalPerspectivesOlderAdultsand LTCOlderadultswanttobeasindependentaspossibleaslongaspossibleTheywanttobelivinginthehomeoftheirchoiceTheyneedtoNOTexperiencemultipletransitionsof“home”asthatincreasesriskofhealthdeclineanddeathTheyneedrelationshipsandengagementwith“living”
TraditionallongtermcaremodelsneedtobechallengedNewmodelsofLTCmustbeevaluatedusingsoundresearchmethodsmeasuringcost,quality,andstaffing
ThosePersistentProblemsofAging!!StillNeedNewSolutions
• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers
ThingsOurTeamsHavePursuedfor Solutions
• MeasuringQualityinLongTermCare ‐ developedandtestedtheObservableIndicatorsofNursingHomeCareQualityInstrument
• Developedandtestedfeedbackreportingmethodstonursinghomesandclinicalconsultationservicetoimprovequalityofcare
• MeasuringLTCNursingCareProcesses,Outcomes,andCost ‐ qualitativelyandquantitativelythenwithaMultidimensionalIntervention
• MeasuringEffectivenessofAdvancedPracticeNursesinLongTermCare ‐ clinicalconsultationservicetoimprovequalityofcareandimplementbestpracticesstatewide(QualityImprovementProgramforMissouri)andMultidimensionalIntervention
• MeasuringEffectivenessandCostEffectivenessofAdvancedPracticeNursesinMOQIInterventiontoReduceAvoidableHospitalizationsofNursingHomeResidents ‐ qualitativelyandquantitativelyin2CMSInnovationCenterInitiatives
ThingsOurTeamsHavePursuedfor Solutions
MOQIModel
MOQIInterventioninSTL
MOQIPrimaryProjectGoalsReduceavoidablehospitaltransfersviafouraspectsofAPRNCareCoordination
1. Conditionmanagement2. Earlyillnessdetection3. INTERACT4. End‐of‐life
ANDhealthinformationtechnology
NowtestingpaymentforacuteillnesscareinNH
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.”
ComplexAdaptiveSystemsComponents
Relationships amongstaffInterconnectionsCommunication
CognitivediversityLeadstoSelf‐Organization
“Stone Soup”
FinalResultsPhase1‐ Effecton ProbabilityofAnyPotentiallyAvoidableHospitalization
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.
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
OtherThingsOurTeamsHavePursuedfor Solutions
AgingInPlaceProject ‐ firstincommunity,thenatTigerPlace
TechnologytoEnableAginginPlace‐ TheElderTech InterdisciplinaryResearchTeam ‐collaborationwithEngineeringtodevelopandtesttechnologiesforeldersandrehabilitation
AGINGINPLACE‐ CommunityDemonstrationand TigerPlace
• Foundation‐ RNCareCoordination,gettingrightservicesatrighttimetomaximizeregaining/maintaininghealthandINDEPENDENCE
• CMSgrant1999‐2003‐ wellnesscenterfocused,licensedhomehealthagencyforMedicare,Medicaid,privateinsurance,privatepay,servedoverahundredmonthly2006
• Legislationin1999and2001enabledTigerPlacetobebuiltandevaluationofAIPinidealhousingwherepeoplecanlivethroughtheendoflifeintheirownprivateapartment/home
• TigerPlaceopened2004,expandedin2009and2011,serving65dailyinhousing;now85inrehabilitationandtraditionalskilledcare
KeyClinicaland FinancialOutcomesof AIPResearch
RNcarecoordinationreducesadversehealthevents,improvescareoutcomes,nursinghomeutilization,andcostsless
Clinicaloutcomesbetter(ADLperformance,lessdepressedandbettercognition,continence,pain,andshortnessofbreath)
Costsavings$1,591permonth(nursinghomecomparison)$483(communitycomparison)
KeyClinicaland FinancialOutcomesof AIPResearch RNcarecoordinationatTigerPlaceincreasesLOSbyayear
CostsforanyatTigerPlacenursinghomeeligibleparticipanthasneverapproachedorexceedednursinghomecare
Inafouryearanalysis(2009‐2012)theaverageannualcostforthosenursinghomeeligiblewas$20,000lessperyearthannursinghomecare
TigerPlacewas Developedbythe UniversityofMissouriin Affiliationwith AmericareSystems,Inc.
ResidentsliveinindependentapartmentwithbasicservicesprovidedbyAmericare(housekeeping,transportation,2mealsperday,socialactivities)
HealthpromotionactivitiesbySinclairHomeCareoftheSchoolofNursing(exerciseclasses,on‐goingnursinghealthassessment,wellnesscenteropendaily,RNcarecoordination,privatenursingservicesaffordablypackagedwhenneeded)
Designedtomaximizeindependence(builttonursinghomestandards,licensedasanintermediatecarefacility,operatedasindependenthousingwithservices)NOTRANSITIONSREQUIREDthroughtheendoflife
TigerPlaceCareModel
TheChallenge
GiveustechnologyforTigerPlacethatwillhelpolderadultsstayasactiveandfunctionallyindependentaspossible.
Squaringthe LifeCurve
Reducefunctionaldeclineby Assessingbehaviorpatterns Assessinggait&activitylevel Recognizingpatternchanges Detectingearlysignsofhealthdecline(socanintervenebeforethingsbecomemajorevents)
Detectingfalls InformingRNCareCoordinationCurrenttrend
Withproactivecare
FunctionalDecline
Time
Proactivehealthmanagementthroughintegrationofsensordataandhealthdata
Rantz,Marek,Aud,Tyrer,Skubic,Demiris,&Hussam,NursingOutlook,2005.
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
SensorsHydraulicbedsensorunderthemattresscapturesquantitativepulse,respiration&restlessness
Gaitparameters&fallsarecapturedusingdepthimages
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
MotionSensorDensityMap
midnight
7am
11pm
Feb1 Mar14
BLACK=timeawayfromhome
HEALTHY,ACTIVE RESIDENT
Wang&Skubic,IE,2008;Wang,Skubic,&Zhu,EMBC,2009,TITB 2012.
OtherLifestylePatterns
HighactivityIrregularpatternCognitiveimpairment
LowactivitySedentarylifestyle
Depression
Changein BathroomActivityat Night
midnight
7am
11pm
BedSensorDataChanges
ERvisitHospitalization
Increasinglowpulseevents
Changeinbedrestlessness
Rantz,etal.,ICOST,2008;CIN,2010.
ERvisitHospitalization
EarlyIllnessAlert26daysbeforeER40daysbeforeER
BedSensorDataChanges
MUHydraulicBedSensorPlacedUnderthe Mattress
15 units deployed
10Secondsfrom BedSensor
RawSignal
Pulsefrombedsensor
Pulsefromfingersensor
Heiseetal.,EMBC,2010,2011;Rosalesetal.,2012.
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.
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.*
WhataboutFallsandFallRiskAssessment?Severalnon‐wearable sensorstestedatTigerPlace
Walkingfrom RadarSensor
0 1 2 3 4 5 6 7 8-0.1
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Raw signal of RCR A Spectrogram of RCR A
time(second)
frequ
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(Hz)
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Yardibi,Cuddihy,Genc,Bufi,Skubic,Rantz,Liu,&Phillips,SmartE,2011;EMBC2012.
Fallfrom RadarSensor
0 0.5 1 1.5 2 2.5 3 3.5 4-3
-2.5
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Raw signal of RCR A Spectrogram of RCR A
time(second)
frequ
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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.
CapturingGaitinthe Homewith Kinect
Two clusters for two residents
Grandchildren
Stone & Skubic, EMBC 2012; TBE 2013; EMBC 2014.
KinectSDKisnotusedSegmentpersonindepthimage
Projectto3D,segment,andtrackLog:walkingspeed,height,stridetime&stridelength
In‐HomeGaitAnalysiswith Kinect
Stone & Skubic, JAISE 2011
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)
Future‐ Backto Graphs
http://www.census‐charts.com/Population/pop‐us‐1790‐2000.html
Future‐ Growthof ForeignBorn‐???Howto Plan??
http://www.census.gov/content/dam/Census/library/publications/2015/demo/p25‐1143.pdf?
ThosePersistentProblemsofAging!!StillNeedNewSolutions
• Stayingstrongandindependent• Minimizingfunctionaldecline• Avoidingcognitivedecline• Managingmultiplechronicillnesses• Maintainingnutritionandhydration• Fallsandfallrisk,amongothers
Stillconsider!WhatPeopleWANT/NEED/COST
• Stilllikelytowantindependence‐butdothequalitativeworkfornewandchangingperspectives
• Challengeoldmodels!!• Seeknewsolutionstotheold
problems‐ justdosomethingDIFFERENT!!
Changingthe Practice
OurMission:KeepingOlderAdultsFunctionallyActive!
AdditionalInformationand Papers
AGING IN PLACEwww.agingmo.com
CENTER FOR ELDERCARE AND REHABILITATION TECHNOLOGYwww.eldertech.missouri.edu
NURSING HOME QUALITY,QIPMO,AND MOQIwww.nursinghomehelp.org