LESSONS LEARNED IN DATA COLLECTION.

This facility has worked hard to meet the new information management demands of Medicare and managed care

Even though managed care growth in long-term care has slowed, the managed care method of reimbursement is growing rapidly. There is, after all, the fixed payment approach of the Medicare Prospective Payment System (PPS). In any case, high-tech information management has taken on a new importance. We at Judson Retirement Community have tried to respond appropriately.

Managed care organizations want understandable, reliable information to help them decide which long-term care facility is best able to provide cost-effective care, and the facility wants to be able to profit from the contract. Meanwhile, with PPS, Medicare wants to know specially what it is paying for, and why Errors can result in a facility losing money or, worse, being prosecuted for fraud.

In confronting these challenges, we have learned that, without a doubt, the best information system for long-term care is an integrated system that supports the entire process. An integrated system contains different modules for finance, marketing, clinical, etc., but the modules all share some common data elements. This makes an integrated information system effective for a couple of reasons: First no one has to take the time to enter data repeatedly into each module. Data are collected up front and they feed to the other modules, saving staff time. Secondly, the "reportwriter" for the common database tends to be more reliable. Numerous individuals don't interpret and reinterpret the data while they enter it manually.

Unfortunately, in the past there weren't a lot of integrated information systems available to the long-term care industry. That is just now being to change. Even without an integrated information system, other types of information management systems still offer facilities many advantages.

By far the most important is a clinical information system, which typically revolves around the Minimum Data Set (MDS). The benefits of such a system are many. For one, it works to facilitate compliance with regulatory and external accrediting agencies. By previewing quality indicators, the facility can ensure that appropriate processes of care are in place to identify and address concerns. A clinical information system helps strengthen clinical documentation and communication within the care planning team. It can be used to schedule follow-up assessments. It is also useful in reinforcing quality initiatives by identifying concerns regarding care practices.

Information systems help a facility develop resident profiles. Basically then are two types. The first--and the one Judson currently uses--is a "cornerstone" system, which collects and analyzes data related to admission, discharge, transfer, preadmission and clinical outcomes. The more advanced systems tie these cornerstone data to ancillaries such as physical therapy, pharmacy, radiology, lab and materials management. These systems can be cost prohibitive at the moment and, for Judson, the cornerstone does suffice.

Facilities capable of developing resident profiles can more effectively communicate with managed care organizations concerning the outcomes data in which they are interested: length of stay, rehospitalizations, resident satisfaction and clinical outcomes. Managed care organizations (as do state surveyors) also look for unexpected clinical outcomes, such as infection or injuries from a fall.

Judson has just finished an in-depth strategic planning process. One strategic goal is to provide a continuous flow of information among the various levels of care in our continuum. This is most important for efficient operations, but also for continuing to provide managed care organizations with required data. Our plan for the next five years contains a significant information systems upgrade.

As noted, because of PPS and much of managed care, skilled care in nursing homes operates under a fixed per-diem fee. It is therefore important for long-term care facilities to track costs on a real-time basis, and information systems can help. Managing and capturing the actual cost of caring for the resident on a real-time basis allows the facility to internally manage cost and quality daily. If a sudden rise in cost is spotted, it can be caught more effectively than on a weekly or monthly time frame.

It is also important for long-term care facilities to predict the cost of providing care to potential residents. If a facility can develop a profile of a typical managed care resident from the data it has collected, that facility will be able to determine a typical case mix for a particular managed care organization. From this, the facility will be able to predict the cost associated with that case mix. With this understanding of cost, the facility can sit down with the payer at the time it negotiates a contract and make sure its costs are covered when a per-diem amount is accepted.

Judson has developed a detailed budget documenting cash flow. We analyze costs on a monthly, quarterly, semiannual and annual basis. If a significant deviation is noted--e.g., residents with serious infections requiring expensive antibiotics--then these issues are examined. During the next negotiation process, we can determine what should have been excluded from an all-inclusive rate. It is important to correlate trends and costs.

Information systems can also support informed decision making, as well as increase the operational efficiency of a long-term care facility. A marketing information system is most helpful in supporting decision making by tracking inquiries, actual admissions and discharges, and donors who support the facility. A facility can also use those data for trending, attempting to pinpoint the appropriate market area and customer profile. Judson has a marketing information system that tracks inquiries, prospective residents, admissions and discharges. It also helps correlate data from marketing activities to create customer profiles, allowing us to capitalize on our marketing dollar.

We are now installing a new clinical Windows-based system for the MDS and associated processes. The system is capable of case mix calculations, performance measures, preadmission costing and validation of case mix. This new system is user-friendly, can be customized and saves staff time from doing manual scheduling and reports.

Another program currently in use at Judson is a scheduling/staffing system that is linked to the payroll system. Employee schedules are computerized. Employees swipe the time clock with their badges, enabling the system to allocate benefits and generate payroll.

Another innovative clinical system that Judson has added combines fall prevention with monitoring incontinence. The system is an ultrathin sensor that is placed in a brief worn by the resident, so that when the resident becomes incontinent, it detects the wetness. The sensor sends a signal to a beeper that the resident assistant carries. We tie this into a fall prevention program, since data show that residents often fall because they either have to go to the bathroom or they are already wet and trying to escape the wetness. The system also tracks the incontinence data and creates a graph tracking when the resident is incontinent, so that we can determine a pattern and develop toileting programs.

Judson has also added a bar-coding system. All resident equipment and supplies are swiped by a hand-held scanner. The equipment used for a resident goes directly to that resident's bill. We will use this system for inventory.

Collecting and analyzing outcomes for managed care can be efficient and effective with or without a complex information system. We have learned over the years, for instance, that the resident's MDS is an absolute wealth of information; we have used these data for quality improvement initiatives, as well as for discussions with managed care. Most facilities, however, have not used these data to the fullest extent. Now with the Health Care Financing Administration (HCFA) requiring the use of quality indicators and the fact that these data are used in surveys, everyone is getting smarter about the MDS.

We have found it helpful to sit down with managed care organizations and share what these data mean for them. Both they and HCFA are talking about the same processes of care. If a facility has an incontinence program, a fall prevention program and is receiving good quality indicators results in other areas, this will support the facility's argument for the quality of its programming.

Facilities sometimes overlook a second great opportunity for obtaining outcomes data: to work with vendors. Facilities might be surprised by the kinds of useful data vendors are collecting, e.g., therapy tracking gains made in ADLs at discharge.

Facilities might also look into the possibilities of networking with other facilities for a cost-effective way to accomplish data collection. An example of this is in the area of resident satisfaction. For a facility to develop, test, collect and analyze resident satisfaction data is a huge undertaking. A larger facility might have a researcher on hand or might have a reliable tool for measuring resident satisfaction. Smaller facilities might purchase the tool or hire the larger facility's researcher to analyze the data for a certain price. There are facilities in the Cleveland, Ohio, area that have a research-oriented business focus with resources that smaller facilities tap. Depending on the services requested, the cost might run $200 to $300 semiannually.

Finally, there is benchmarking. Success with benchmarking for the long-term care industry is now being achieved and is attributable to HCFA's quality indicators project, which became available several months ago on an Intranet system. Facilities are able to submit MDS data electronically and, in 24 to 48 hours, receive state comparative data. Benchmarking has also moved forward in the Cleveland area in the last few years with the growth of an alliance of 25 not-for-profit organizations with 33 facilities throughout northeast Ohio. These 33 facilities meet on a quarterly basis to discuss quality indicators and semiannually for resident satisfaction reviews. We look at data, discuss best practices and, if applicable, take these best practices back to our own organizations.

In sum, we've learned at Judson to follow the changing information demands of the field and try to adapt our information management systems accordingly. It is a never-ending and imperfect process, but one that has taught us a great deal about long-term care management as it is practiced at the turn of the 21St century.

Christina H. Szatala is assistant administrator for Judson Retirement Community in Cleveland, Ohio. For further Information, phone [phone] or fax [phone].