How Trilogy, Aliya Combat Big, Bad 3 Clinical Concerns In Nursing Homes

By Kristin Carroll

More advanced technology, a team-based approach to prevention and care, and concerted efforts to drive vaccination are among the key strategies that can help nursing home providers combat infections, falls and pressure ulcers.

These “big, bad three” clinical challenges are persistent within facilities but providers can “improve them drastically,” Dr. Andrew McNamara, chief medical officer with Trilogy Health Services, said at the recent Skilled Nursing News RETHINK Conference in Chicago.

Trilogy Health Services is based in Louisville, Kentucky, and operates 141 facilities in Indiana, Kentucky, Michigan, Ohio and Wisconsin.

ALIYA Healthcare Chief Medical Officer Dr. Geraldine Luna agreed with McNamara, and both speakers pointed to improvements within their own organizations. For example, ALIYA has introduced hydration clinics that have cut down on the rate of urinary tract infections.

Trilogy is taking on a multi-step approach to fall prevention, starting with a medication review with the agency’s pharmacy partners. The company is also piloting an artificial intelligence-enabled camera to help with wound documentation and treatment, McNamara said.

These types of interventions and innovations are needed because the big, bad three are preventable and yet drive a disproportionate number of hospital readmissions and other outcomes that hurt a provider’s reputation and bring negative financial consequences, while also being “sentinel indicators of inequality, lack of commitment and justice to our patients,” Luna said at RETHINK.

Technology for better prevention

Receiving an early warning that something might be off with a patient can help providers prevent a number of issues. ALIYA has implemented an electronic medical record (EMR) that tracks vitals as providers input them. The EMR can show trends in the patient’s condition, which can point to a developing issue.

“It’s a way that, in real time, you’re having those conversations with the technology that you have in place,” she said. “Our staff is right there, checking on those, informing their doctors, activating their care team. So it’s working well for us.”

Fever is a top indicator of an infection. Trilogy tested a program that monitors and tracks residents’ temperature and sounded an alarm on deviations from the baseline. McNamara said the program, which initially had 25 residents under monitoring, was successful at keeping patients out of hospital.

“Of those, we had four early detections of infections,” he said. “We had two that we caught before they got bad and were able to treat in place with fluids. One was a COPD patient, we made sure they had appropriate respiratory support, so on and so forth, to prevent them from going to the hospital.”

McNamara also highlighted the use of artificial intelligence (AI) in health care, saying it is a support tool for clinicians rather than a wholesale solution.

“It’s not going to solve everything,” he said. “How do we use the data that AI generates to help us improve care and delivery in the areas where we’re trying to improve that?”

ALIYA is also using AI as a support for their staff, Luna said. The system has risk stratification capabilities that can trigger alarms for nurses in terms of where to focus to prevent exacerbations, but Luna said none of the AI systems replace the human expertise of the care team.

“I would highly recommend a lot of judgment when you’re using the tool, but it’s there to support,” she said. “You can’t go wrong if you use it the right way, and the more you use it, the more you get to know about it.”

Vaccination advocacy for respiratory infections

In line with recommendations from the Centers for Disease Control and Prevention (CDC) and Medicare requirements, skilled nursing residents should be offered cold, flu, pneumonia and RSV vaccines each year.

Luna said that in recent years, despite having a strong vaccination program, ALIYA has had difficulties in getting people to accept the shots. Family members can also object to their loved one receiving a vaccine and convince their loved one it’s not needed.

“We’re really having a tough time to keep a preventative [system] in place to decrease hospitalizations this season,” she said. “If there is any population that is vulnerable, it’s the geriatric patients living in a nursing home.”

With the right advocacy in place, ALIYA saw a 40?crease in visits to the emergency room for flu symptom management last year, Luna said.

McNamara agreed and added that Trilogy is working with its pharmacy partners to hold vaccination clinics for RSV and other respiratory illnesses. He said Trilogy has faced challenges creating solid policies as the various states in the company’s footprint have taken different approaches to CDC vaccine and masking recommendations.

“Based on location, how they interpreted some of the vaccines and the stuff that happened during the pandemic, they’re a little jaded. It can be hard to say, ‘Hey, this RSV thing is really important now,’” he said.

A team approach to falls

When a SNF resident does fall, ALIYA calls in the entire care team, including family members, within 24 hours, Luna said.

“We activate the team, and we include the family, and we get real time interventions that are built into their care plan,” she said. That way, needed adjustments in care can be implemented as quickly as possible to disrupt any pattern of hospitalization.

Trilogy has many of the same practices, McNamara said. The company uses the Johns Hopkins fall risk assessment and de-brief tools. He said the company is exploring different technology vendors for in-room sensors and other tools to help assess fall risk and monitor for falls.

For instance, he highlighted a gait analysis tool built by someone who has analyzed Major League Baseball players’ swings, which should help identify and “subtle changes” that can indicate fall risk.

“It looks like Mrs. Smith is just not getting up the way she did or … she couldn’t push off her chair, well, those are all totally predictors of somebody that’s likely to fall, right? So the more you can get ahead of those kinds of things, the better.”

Nurses as frontline pressure ulcer prevention

The first stop for pressure ulcer prevention is the nurses and staff who interact with the patients every day, Luna said. Not only do these workers spot pressure ulcers forming, they can also help patients ambulate as part of prevention, which is the “most important” factor in combating these wounds.

“This is where champions of our routine and our amazing nurses, front liners out there [come in],” she said. “We have CNAs that help out with early detection, but the most important is the preventative part.”

Luna added that pressure ulcer identification can help spot patients who need to be transferred to hospice.

“We’re talking about skin integrity, as any other organ, is failing,” she said, speaking of individuals in the active dying stage. “Identification of those patients, early enrollment not only improves the quality of life, but also saves a lot of the hurdles that we get with reimbursement.”

Trilogy also has a robust wound care program, with wound care-certified nurses and dedicated wound care teams.

“It’s one of those things that we want to try to get to zero to but obviously, we’re not there,” McNamara said. “But we look at it very, very carefully.”

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