This article is sponsored by Real Time Medical Systems (Real Time). In this Voices interview, Skilled Nursing News sits down with Real Time’s Vice President Clinical Operations, Cindy Kreider (RN, BC RAC-CT) to learn how Real Time is helping SNFs through Advance Care Planning or ACP. Kreider relays how ACP helps SNFs with their value-based care goals and shares why in skilled nursing, 2022 will be the year of getting back to the basics.
Skilled Nursing News: Cindy, what career experiences do you most draw from in your role today with Real Time?
Cindy Kreider: I’ve had the privilege to serve in a variety of roles in the acute and post-acute environments, where countless experiences served me well in my role with Real Time. From my 30-plus years of working in various facility, regional and corporate roles, I am able to impart best practices to enable SNFs to navigate their daily challenges with staffing, the vast regulatory requirements, the care complexity, multiple co-morbidities of the patient population and numerous areas of risk to improve patient care.
To that end, my career experiences have allowed me to provide clinical input into Real Time’s Interventional Analytics solutions to ease the burden, by providing staff a solution that offers real-time clinical alerts, quality measures, patient care detail, documentation accuracy, and more. This allows them to intervene early in the care of the patient, which improves care outcomes, saves staff time and can assist in mitigating risk.
Real Time stresses the importance of Advance Care Planning (ACP) for SNFs. What is ACP and why is it important for post-acute facilities?
Kreider: Advance Care Planning is a process that enables individuals to make plans about their future and supports adults at any age or stage of health in understanding and sharing their personal values, preferences and life goals, regarding future medical care. Therefore, the goal of ACP is to help people receive medical care that is consistent with their preferences, values and goals.
The timing and nature of ACP may vary depending on the clinical status of the person, but regardless of the clinical status, ACP should be proactive, appropriately timed and integrated into routine care. It is also a good practice to revisit ACP each time a person’s medical condition changes to ensure patient-centered care is always met.
Value-based care (VBC) continues to be a prevalent topic within the health care industry, and post-acute care facilities are no exception. Within the VBC model, it is important for post-acute settings to have an appropriate balance of the patient’s goals, while ensuring the care provided is meeting the patient needs.
As more and more patients are discharged to post-acute facilities with a multitude of chronic medical issues and co-morbidities, the information within the advance care plan initiative helps to guide the clinical teams to ensure that patients receive timely medical care that is consistent with their values, goals and preferences while also aligning with VBC outcomes.
Let’s expand on that. How does ACP relate back to value-based care?
Kreider: ACP is an integral aspect of the facility’s comprehensive care planning process and assures re-evaluation of the patient’s desires on a routine basis. When there is a significant or progressive change or decline in the patient’s condition, the process helps the patient, family and interdisciplinary teams prepare for the time when a patient becomes unable to make those decisions, ensuring that their wishes are honored.
Understanding the patient’s specific end-of-life care needs reduces unnecessary medical expense and is in keeping with the goals of patient-centered and patient-driven care decisions.
Under ACP, post-acute facilities receive what’s called an ACP score. How does Real Time calculate the scores, and what do the scores mean?
Kreider: The ACP score is modeled after the PSI, or Personal Severity Index, and is based on a predictive score calculated using either clinical data from the electronic health record on new patients or on MDS 3.0 items once an MDS assessment is completed. A score of nine or greater helps providers identify patients who may be moving through a different stage in the life cycle or who may require changes to their current care plans and advanced directives. The information allows providers to initiate discussions with the patient and/or family, including a review of the code status and quality of life decisions.
What is the Real Time ACP alert, and what are the key benefits for post-acute facilities?
Kreider: Once an MDS assessment is complete with Real Time’s ACP Alert, a measurable score utilizing clinical data is assigned to the patient, as well as risk factors modeled after PSI. As facilities are often tasked with attending to a variety of patients, the interventional capabilities embedded within that ACP score enable them to prioritize care for patients who have a score of nine or greater.
In addition, they can obtain information explaining what is triggering that score. The score includes metrics relating to ADL functionality, as well as clinical and mood status. This compilation aids facilities to provide the patient with the best quality of life care, while the interventional scorecard enables the care teams to discuss and respect the patient’s choices while they’re of sound mind.
As far as the benefits of the alert, knowing a patient’s ACP score is a big advantage. It enables providers to honor family and patient expectations and avert the emotional decision-making that often leads to inappropriate or unwanted care. Clinical staff can accurately assess the care the patient is receiving and ensure there is an appropriate emphasis on areas inclusive of things like pain management, depression management, and what is most important to the patient in supporting their quality of life.
What benefits can post-acute facilities recognize by embracing a VBC approach?
Kreider: VBC improves quality outcomes for patients and reduces the overall cost of care by improving overall wellness and preventative treatments. Through collaboration, post-acute facilities can implement value-based care goals while not sacrificing the patient’s care or their end-of-life decisions.
All in all, there are various benefits in utilizing ACP analytics. One of these benefits is the opportunity for productive conversations relating to palliative or end-of-life care with patients and their families. By adding value to these discussions, care providers can maximize quality of care while simultaneously taking patient choice into consideration and reducing unnecessary medical costs.
The integration of that information from the ACP analysis continually helps facilities not only provide VBC, but also helps them maximize efficiency when caring for patients with differing ACP scores and prioritizing accordingly. Therefore, this may require changes to current care plans, as well as advanced directives.
Ultimately, this provides post-acute facilities the opportunity to initiate discussions, as well as giving the patient and their loved ones what’s important around advanced directives and the associated decision-making processes. It is important to keep in mind, although the ACP is a predictive tool, patients may still require further clinical investigation before reaching a proper diagnosis.
Finish this sentence, “In skilled nursing, 2022 will be the year of…”?
Kreider: I would say that in skilled nursing, 2022 will be the year of moving beyond COVID and getting back to the basics while keeping the patient at the center, with a focus on meeting quality of care. Also, implementing new staffing strategies for the best operational performance, seeing VBC providers growing exponentially, and the use of interventional analytics and software solutions to assist in narrowing the gap and improving care and operational outcomes.
You may view this article on the Skilled Nursing News website, here.