1. Canadian Health Outcomes for Better Information and Care
C - HOBIC
Canadian Health Outcomes
for
Better Information and Care

2. C-HOBIC Overview Project Background WRHA Implementation
RAI outcome measures
Challenges and Lessons Learned
Discussion.

3. C-HOBIC
Background:
National Research Project in partnership with Canadian Nurses Association
Funded by Canada Health Infoway
Provinces involved: Manitoba, Ontario, Saskatchewan

4. Project Intent
Provide information to Health Care Professionals on clinical outcomes from information based on nurse sensitive indicators
Explore how the outcome information is integrated into the work flow
Utilization of the clinical data available
Describe how managers and front-line health care professionals use the information to further evidence informed practice and care planning for the clients/patients
Creation of reports
In Home Care, the nurse sensitive outcomes were broadened to include other disciplines as well, because the clinicians include not only nurses, but social workers and occupational therapists.

5. Project Deliverables
Development of 3 reports for use by clinicians and managers
Provision of education on access to the reports
Provision of education on integration of the reports into care planning process
Provision of follow-up support to clinicians and managers
Facilitation of the evaluation of the Project in May 2009.

6. Timeline Project Start - Oct 08. Report Requirements – Nov 08.
Report Development – Complete Jan 2009.
Staff Training – Jan 2009.
Implementation – Feb to Mar 09.
Follow-up Training & Support – Ongoing.

7. Participants Six PCHs. Six Home Care Offices. Over 225 nurses.
60 Case Coordinators (professionals in a health related discipline)

8. Participant Recruitment
Provided information on the C-HOBIC project.
Outlined commitment of regional staff to provide education.
Outlined site responsibility to provide ongoing education.

9. Education Plan
Goal: to provide education about the use of reports in the care planning process including various RAI reports and the C-HOBIC report.
Wanted to show the value of the previous work done by staff in the completion of the RAI. They could now get information which would help in the delivery of care.

10. Education
LTC - The Education Plan included a central launch session and two site based sessions.
HC - Staff were trained in small groups or individually.
Two hour PowerPoint presentation with hands on access to CHOBIC report.
Follow-up support.

11. Educational Presentation Outline
C-HOBIC project.
Outcome data: why is it important.
Review of care plan requirements.
Discussion of interdisciplinary team approach to care planning.
Report integration into the care planning process
when, who, how.
Report review and access.
RAI outcome measure reports and C-HOBIC report. 11

12. Resident Assessment Instrument (RAI)
A standardized assessment tool; different versions for home care (HC) and long term care (LTC)
Completed on admission and quarterly in LTC
Completed on admission and annually in HC
Used to collect a minimum data set (MDS) with triggers for further assessment
Completed electronically

13. RAI Outcome Measures
Each Measure evaluates a different aspect of the clinical status of the client.
Each Outcome Measure is based upon carefully selected items in the RAI-HC and RAI-LTC assessment.
Measures leads the clinician through an investigative process when reviewing the assessment, in creating the care plan and evaluating the care plan and client status.
Evaluating the results of the care plan:
Has the client’s status changed,
If yes, ask yourself:
What are the causal factors of the client’s change? E.g. new illness, change in informal or formal supports, etc.
Is a change in care plan needed and are additional/different supports required?
Is the client’s functional decline a factor of the aging process?
Is the client’s functional improvement directly linked to the specific formal/informal supports provided? Eg. Stroke rehab clients; client/caregiver stress reduction service provision.
If no, ask yourself:
Is the care plan maintaining the client as expected? Often when there is no change in client function, we have attained our goal.

14. RAI Outcome Measures IADL Difficulty (RAI-HC)
IADL Involvement (RAI-HC)
Cognitive Performance Scale
Depression Rating Scale
Pain Scale
Index of Social Engagement (RAI-LTC)
ADL Self-Performance Hierarchy Scale
CHESS Scale – Changes in Health, End-stage disease and Signs and Symptoms
MAPLe Score – Method of Assigning Priority Levels (RAI-HC)

15. RAI Outcome Measures IADL Difficulty (RAI-HC)
Captures patterns of difficulty with the tasks of housework, meal preparation, and phone use.
IADL Involvement (RAI-HC)
Measures performance patterns of the tasks of housework, meal preparation, and phone use.
Cognitive Performance Scale
Measures cognitive status using daily decision-making skills, making self understood, short-term recall, and eating.

16. RAI Outcome Measures Depression Rating Scale Pain Scale
Score of 3 or more suggests possible depression; based on Section E, Questions 1a – g.
Pain Scale
Score based on two questions: pain frequency and pain intensity
Index of Social Engagement (RAI-LTC)
Measure of level of participation in social activities
Score 0-6; higher score identifies increase in social activity
ADL Self-Performance Hierarchy
Measures activities of daily living performance according to early, middle, and late stages of loss.
Depression Questions: Section E.
1a. client’s negative statements
1b. persistent anger
1c. expressions of unrealistic fears
1d. repetitive health complaints
1f. sad or worried expression
1g. Tearfulness
Pain
There is a quality initiative looking into pain and how we identify it, and how to care plan around it.
ADL Self-performance Hierarchy
Early loss – personal hygiene
Middle loss – toilet use/locomotion
Late loss – eating

17. RAI Outcome Measures CHESS
Changes in Health and End-Stage Signs and Symptoms
Measures medical complexity and health instability.
Higher scores are associated with higher mortality, use of acute hospital services, pain, receipt of specialized treatments, and poor health outcomes.
Score is based on:
Vomiting
Dehydration
Leaving uneaten food
Weight loss,
SOB
Edema,
End-stage Disease
Decline in cognition
ADL

18. RAI Outcome Measures MAPLe (RAI-HC)
Method of Assigning Priority Levels
Predictive of facility admission, caregiver stress, or a feeling by family or client that the client would be better off elsewhere.
Those clients in the Very High level are 10 times more likely to be admitted to a long term care facility within 3 months.
Score is based upon:
Cognition
ADL function and/or
Behaviour disturbances including wandering.
Show handout – MAPLe decision tree

19. C-HOBIC Outcome Measures
Included in the WRHA Project:
ADL – Activities of Daily Living
Bladder Continence
Pain
Falls
Pressure Ulcers
IADL – Instrumental Activities of Daily Living (Home Care)
Not Included in the Project:
Fatigue, Dyspnea, Nausea, Therapeutic Self-care
The data for the outcome measures was derived from the RAI-HC and RAI-LTC; those measures not included from the original project were those that could not be derived from the available assessment instruments presently utilized within the region.
The Project focuses on more specific areas within the RAI-HC and the RAI-LTC assessment to give the clinician a more detailed analysis of the client’s/patient’s functional abilities in certain areas.

20. C-HOBIC Individual Outcome Measure Report
Provides a detailed analysis of each client’s/patient’s outcome data for the specified indicators
Measures are intended to lead the clinician through an investigative process when reviewing the assessment, in creating the care plan, and evaluating the results of the care plan and client status.

21. LTC - Individual Report
Show results for four quarters..most recent to remote (will be changing that)
ADL…includes all of items in G section to show progress or decline over time as well as the ADL long form which is just a summary of a,b,e,g,h,i,j
Bladder continence, pain freq and intensity, falls, and skin ulcers is simply pulling forward values you entered in the last four quarters so you can easily compare
Remember under skin ulcers MDS is asking for all types of wounds to be captured here (M1)..not just pressure ulcers ; have also included data from M2a…which was not indicated as required in the CHOBIC measures document
Can look to the quality indicator report to see how many pressure ulcers
DEMO OF SOFTWARE AT THIS POINT IN PRESENTATION 21

22. HC - Individual Summary Report
Provides a detailed analysis of the individual client’s functional status in the specific areas. The data is taken from the most recent four completed, locked RAI-HC assessments. 22

23. C-HOBIC Management Outcome Measure Report - Detailed
Provides a detailed analysis of a specified caseload or office in Home Care or a specified unit within a facility or a facility in LTC with respect to the outcome data for the specified indicators
I.e. These values identify the number of clients who have scored in each level of dependence in a particular quarter.

24. Management Outcome Measure Report - Detailed
The data are collected from the total number of assessments completed in each specific category from each yearly quarter (Q)
Q1 = April, May, June
Q2 = July, Aug, Sept
Q3 = Oct, Nov, Dec
Q4 = Jan, Feb, Mar

25. LTC - Management Detailed Report
Indicates it is number of clients….actually number of assessments completed and signed off in the quarter 25

26. HC - Management Detailed Report
Note: total number of clients may not equal the breakdown within each outcome measure, as there may have been 2 or more assessments done on the same client(s) during the one quarter. 26

27. C-HOBIC Management Outcome Measure Report - Summary
Provides average values of the outcome data within the specific community area for Home Care and for the unit and facility for Long Term Care

28. LTC - Management Summary Report28

29. HC -Management Summary Report
The report can be run by CC Caseload or Office 29

30. Lessons Learned
Need to meet face to face with participants early on to ensure understanding of commitment and specific learning needs.
Need to check and verify technology at each site before education begins.
Investigate current technology solutions in use by clinical staff and define impact on the project.
Not being able to access the reports directly from the RAI has been a significant issue for clinicians. 30