VETERANS HEALTH ADMINISTRATION

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2 Integrating Spinal Cord Injury Outcomes Into Care Bridget Bennett, MD Assistant Chief, SCI Service Jennifer Sippel, PHD Management of Information & Outcomes Coordinator, SCI Service I. Manosha Wickremasinghe, MD Chief, SCI Service Philip Ullrich, PHD Management of Information & Outcomes Director, SCI/D Services

3 Objectives Describe the scope of a new national, validated, risk-adjusted, outcomes-based program Discuss how to implement several leadership strategies in service of integrating outcomes into practice Discuss how to implement several specific outcomes integration strategies Recognize many positive patient care outcomes and experiences resulting from above-mentioned integration

4 Planting Seeds Along the Way Integrity Commitment Advocacy Respect Excellence

5 Background Veterans Administration Spinal Cord Injury/Disorders Service Management of Information & Outcomes (MIO) Initiative Spinal Cord Injury & Disorders Outcomes (SCIDO)

6 Utilization of Outcomes Patient B outcomes Patient A outcomes Patient C outcomes Program Outcomes & Team Utilization

7 MIO Initiative and SCIDO: More accessible caseload management Understanding local caseload characteristics Better managing annual exam participation Enhanced viewing of information related to SCI for each patient Improved registry program information available for all users with clinical access to SCIDO 6

8 Spinal Cord Injury & Disorders Outcomes (SCIDO) National outcomes-based registry live in Dallas: January 2011 Migrated previous registry Opportunity to use it to manage caseload in new ways

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16 Frequency Age of Veterans with SCI/D (n=695) Age Category

17 Frequency Etiology of Veterans with SCI/D (Atraumatic) Atraumatic (n=359)

18 Frequency Etiology of Veterans with SCI/D (Traumatic) Vehicular Fall Violence Sports Other Unknown Traumatic (n=310)

19 Population Characteristics N=669 Non-traumatic, mean age 61.2 (n=359) Traumatic, mean age 58.4 (n=310)

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23 MIO Initiative: Opportunities for Improvement Enhancing team communication Improving the way IDT members view and interpret patients functional status and any changes indicating need for further rehabilitation Facilitating a more intentional and interdisciplinary follow-up point of care (90-day post-rehab) Integrating information to approach patient care from a biopsychosocial perspective Providing more customized/individual care 22

24 MIO Initiative: Enhancing team communication Outlook group NTX SCI REHAB Detailed IDT weekly schedule Protected network shared folder Weekly IDT template / note (updated prior to IDT meeting) FIM scores IDT schedule 90-day post rehab consults order set and note titles. Emerging case manager role 23

25 MIO Initiative: Enhancing team communication 24

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32 MIO Initiative: Inpatient Rehabilitation Outcomes START ASIA FIM Satisfaction with life (SWLS) FINISH ASIA FIM D/C destination 3-Month Follow-up FIM Participation (CHART-SF) SWLS Health Status (SF-8 ) Other information: Age, gender, education, etiology, length of stay Calculated: FIM Gain, FIM Efficiency, Goal attainment, Neurological stability, and more.

33 Pre-SCIDO FIM Documentation 32

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36 Post-SCIDO FIM Documentation 35

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38 Integrating Outcomes on a Patient Level The Interdisciplinary Team administers the Functional Independence Measure (FIM) for start, goal-setting, and finish for inpatient rehabilitation. This is an example of patient growth viewed by the Interdisciplinary Team. 37

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40 Integrating Outcomes on a Patient Level Interdisciplinary team members collaborate by looking at individual patient outcomes information over time. 39

41 Integrating Outcomes on a Patient Level The SCIDO program generates a CPRS progress note. The Interdisciplinary Team (IDT) analyzes the FIM outcome information for each patient during IDT weekly meetings. After 90-day follow-up, the IDT has evidence of patient improvement at home. 40

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44 Interdisciplinary Team Perspective PT/OT/psychology interpret incorporation of 90-day follow-up as positive, resulting in improved communication and patient care Improved ability to analyze and compare start/goal/finish assessments Improved communication with nursing due to increased mindfulness of goals, discharge dates, and training deadlines. With SCIDO, it s helped us to focus on other assessments than the FIM. Like the FAM. OT is working on writing, which is part of the FAM. The FAM helped us focus more on things that mattered to the patient. PT/OT actually started putting FAM into annual exam notes as well as outpatient medical rehabilitation. 43

45 Integrating Outcomes on a Program Level At the same Interdisciplinary Team meetings, providers also utilize patient outcomes on a programmatic level. The outcome information obtained at the point of care for each patient is housed in SCIDO and available programmatically. 44

46 Integrating Outcomes on a Program Level Patient B outcomes Patient A outcomes Patient C outcomes Program Outcomes 45

47 Inpatient Rehabilitation Outcomes

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51 Integrating Outcomes on a Program Level Mindfully integrating outcomes into the care delivery process then makes the programmatic information available automatically and continuously. 50

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53 Inpatient Rehabilitation Outcomes from SCIDO

54 Rehabilitation Stay in DAYS Inpatient Rehabilitation LENGTH OF STAY IN DAYS hi tet lo tet para asia d Fiscal Year

55 FIM Point Gain During Rehab Stay Inpatient Rehabilitation FIM POINT GAIN PER ADMISSION hi tet lo tet para asia d Fiscal Year

56 Rehabilitation Efficiency (FIM gain / LOS) Inpatient Rehabilitation REHABILITATION EFFICIENCY hi tet lo tet para asia d Fiscal Year

57 Rehabilitation Efficiency (FIM gain / LOS) Inpatient Rehabilitation Efficiency Fiscal Year

58 Improvements contributing to efficiency rebound implementing SCIDO during FY2011 strengthening IDT processes around the MIO Initiative and ICARE values during late FY2011 and FY2012 improved formal and informal communication among inpatient rehabilitation team members increasing outpatient medical rehabilitation participation from 2 in FY2010 to 3 in FY2011 to 5 in FY

59 Future directions Staff buy-in continual process of bringing programmatic charts into IDT meetings and staff meetings to create a culture of continuous process improvement ICARE values Incorporate outcomes information into website and other outlets for consumer use empowering the veteran Using the patient-level outcome information tools to present to the veteran and provide more education to the patient so they have a clearer picture of their rehabilitation experience 58

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61 Integrating Spinal Cord Injury Outcomes Into Care QUESTIONS? Bridget Bennett, MD Jennifer Sippel, PHD I. Manosha Wickremasinghe, MD Philip Ullrich, PHD