Driving High-Value Care via Clinical Pathways. Andrew Buchert, MD Gabriella Butler, MSN, RN

Transcription

1 Driving High-Value Care via Clinical Pathways Andrew Buchert, MD Gabriella Butler, MSN, RN 1

2 Andrew Buchert, MD Medical Director, Clinical Resource Management Children s Hospital of Pittsburgh of UPMC Assistant Professor of Pediatrics University of Pittsburgh School of Medicine Gabriella Butler, MSN, RN Manager, Clinical Resource Management, Clinical Analytics, and Data Science Children s Hospital of Pittsburgh of UPMC 2

3 Disclosures We have no financial conflicts of interest to disclose. UPMC utilizes Cerner, Epic, and Qlik software. 3

4 Goals of this session: Implement clinical pathways that will lead to critical process improvement as well as advance the strategic mission of the organization Identify measurement tools that integrate outcomes, practice patterns, and cost data to achieve maximum impact of pathways of care Develop clinical pathways that span and link the entire continuum of care, including PCP offices and community resources 4

5 Children s Hospital of Pittsburgh of UPMC 315-bed free-standing quaternary care pediatric hospital - 41 bed ED and Trauma Center - 36 Bed PICU - 12 Bed Cardiac ICU - 55 Bed NICU 21,800 Admissions - Inpatient - Observation - Same-Day Surgery Extended Recovery 80,000 ED visits 23,500 Surgical procedures >1 million outpatient visits 5

6 Primary Care and Referral Network Children s Community Pediatrics (CHP) - 40 locations - More than 150 pediatricians - Primary care - Same-day sick appointments - Embedded behavioral health services Children s Express Care (CHP) - 7 locations - Walk-in, after-hours care - Pediatricians from CCP - Evenings and weekends Other pediatric primary care groups - Pediatric Alliance, Kids Plus Pediatrics 6

7 7 More than 30 academic, community, and specialty hospitals in Pennsylvania and New York State Hospitals and partnerships in more than 9 countries Integrated health care delivery and finance system, with a health plan covering more than 3.2 million members

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9 High-variability between episodes of care and across the continuum of care Limited measurement of reliability to guidelines Minimal outcomes data Opportunities to improve patient and family satisfaction due to perceived care discordance 9 Quality outcomes, patient safety, satisfaction, and cost are driven by standardized delivery of care across the continuum Delivery of consistent, high-value, evidence-based care Meaningful and actionable data available in realtime to frontline caregivers

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11 High-Value Care at CHP Evidenced-based and technology-enabled Clinical Pathways Pre, during, and postadmission High-cost and high-volume pediatric conditions 11

12 Reduce Unnecessary variation in care Unplanned Readmissions Acute care Length of Stay (LOS) Desired Outcomes Improve Outcomes (Quality, Safety & Financial metrics) Continuity of care (pre and post admission) Patient, Family & Provider satisfaction 12 Eliminate Non-value added testing Waste

13 President CMIO/CIO VPMA Manager, Clinical Resource Management, Analytics, Data Science Medical Director, Clinical Resource Management Analytics Team DataWarehouse & Clinical Applications Team Nursing Informatics Clinical Champions Finance 13

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15 Clinical Effectiveness Guideline Evidence-Based Limited Education Variable interdisciplinary collaboration Focused settings of Care Clinical Pathway Evidence and consensus-based Formal education and rollout Inter- and Multi-disciplinary Across the Continuum Real-time measurement & feedback loop Strategic Alignment 15

16 Impact Health of Patients Organizational Systems of Care Hospital and Health System Individual Patients i.e. Reducing readmissions, LOS, infection rates, central line utilization Population i.e. Reduce exposure to unnecessary care, focus on health promotion & wellness Processes, workflow, patient flow i.e. Improving throughput, decrease bed utilization, enhance medication delivery Economics i.e. Improve revenue and decrease at-risk revenue, reduce variability of controllable costs Strategy i.e. Create buy-in for additional pathways, promote and support service-lines, grow market 16

17 Hospital- Peer LOS LOS Evaluation and Selection Process Predicting potential impact through the analysis of actual clinical & financial data, per CHP DataWarehouse, Cost Management System, & PHIS Hospital-Peer ALOS COST Volume Internal Analysis Decision: Clinical Pathway or Guideline Peer Benchmarking Expected LOS/Observed Hospital-peer CH CMI (LOS Based) Hospital-peer CH CMA LOS 17

18 Additional Considerations Is this potential pathway practical at this time? Do we have the capacity? Would all of the stakeholders have buy-in? Do we have the resources to support this potential pathway? To perform an analysis of the current state/weigh pros and cons To develop and support the pathway - includes data analysis, PowerPlan development & QlikView dashboard What evidence is available? Is this an existing (In-house) clinical effectiveness guideline? Is there peer-reviewed, published evidence? Do any of our peer institutions have a clinical pathway or guideline? 18

19 1 Idea Generation 2 Identify Team 3 Gather Evidence 4 Design & Development 5 IT Build 6 Education & Rollout 7 Measurement & Feedback 8 Disseminate Knowledge 19

20 Process 1. Idea Generation What is the projected Impact Is it practical? Is it the right time? Identify Team Pathway Champions Nursing, Physician & Ancillary Stakeholders Gather Evidence Literature Research Benchmarking Market Survey Design & Development Define Patient Population Inclusion & Exclusion Criteria Define On vs Off Pathway Select KPIs, outcome, and balancing measures 20

21 Process IT Build 5. PowerPlan (Order set) Dashboard Clinical decision support Education and Rollout Pathway Champions and key stakeholders Coordinators and Educators Measurement and Feedback Pathway champions and key stakeholders Leaders Frontline staff, including nurses, residents, fellows Dissemination of Knowledge Internal and external sharing of process and impact Publication Patient and family materials 21

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23 Physician A Physician B Physician C Physician D 23

24 Physician A Physician B Physician C Physician D 24

25 Physician A Physician B Physician C Physician D Physician E Physician F Physician G Physician H Physician A Physician A Physician Physician B Physician C Physician D Physician E Physician F Physician G Physician H Physician B Physician A Physician B 25

26 LOS (hours) Complicated Appendicitis Median LOS/month (hours) Consensus for Management Obtained PowerPlan Available Consensus for Management Obtained Median LOS UCL Average LCL

27 Uncomplicated Appendicitis LOS (hours) Median LOS/Month (hours) Consensus for Management Obtained PowerPlan Available Median LOS UCL Average LCL

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29 LOS (hours) Planned Cholecystectomy Median LOS/month (hours) Consensus for Management Obtained PowerPlan Available Median LOS/month (hours) UCL Average LCL

30 Isolated Neonatal Hyperbilirubinemia All Peer Hospitals Select Peer Hospitals CHP 1020 patients out of 3865 (26%) spent at least 1 day in a NICU 171 patients out of 625 (27%) spent at least 1 day in a NICU 41 patients out of 87 (47%) spent at least 1 day in the NICU 30 Patients with Principal Dx Hyperbilirubinemia 7/1/14-6/30/15

31 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 LOS (hours) LOS (hours) LOS for IHB patients admitted to Neonatal Service* (includes ED LOS) Internal Comparison LOS for IHB Patients Admitted to General Pediatrics** (includes ED LOS) *Represents 78 IHB Patients admitted to the Neonatal Service between Jan15-April16 **Represents 42 IHB Patients admitted to a General Pediatrics Service between Jan15-April16

32 Maybe the patients we admit to the NICU are sicker? 32 *American Academy of Pediatrics, Clinical Practice Guideline, Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation, PEDIATRICS Vol. 114 No. 1 July 2004

33 Isolated Neonatal Hyperbilirubinemia LOS (hours) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov UCL 23 Median LOS/Month (hours) Consensus for Management Obtained PowerPlan Available LCL Data1 UCL Average LCL 33

34 Dissemination of Data Frontline Staff (Nurses, APPs, Residents, Fellows, Attending Physicians) Clinical Champions Physician Leadership (Division Chiefs, Clinical Directors) Nursing Leadership (Unit Directors, Senior Nurse Leaders) Residency Program Leadership Hospital Leadership 34

35 Summary Stats Surgical Pathway Metric FY15 FY16 FY17 FYTD18 (July17-Nov17) Complicated Appendicitis Pathway Number of Encounters Percentage of Patients that went to IR Post-Op 23 (18%) 16 (15%) 12 (10%) 6 (9%) Percentage of Patients "On Pathway" Pre-Op 66% 75% 80% 82% Percentage of Patients "On Pathway" Post-Op 47% 50% 60% 66% LOS (hours) 130 hours 101 hours 99 hours 89 hours Readmissions within 30 days not available not available 15.52% 12.9% Uncomplicated Appendicitis Pathway Number of Encounters Percentage of Patients that went to IR Post-Op Percentage of Patients "On Pathway" Pre-Op 76% 79% 84% 81% Percentage of Patients "On Pathway" Post-Op 10% 36% 46% 44% LOS (hours) 33 hours 30 hours 27 hours 28 hours Readmissions within 30 days not available not available 8.97% 0.7% Planned Cholecystectomy Pathway Number of Encoutners Percentage of Patients "On Pathway" Pre/Intra-Op NA NA 71% 55% Percentage of Patients "On Pathway" Post-Op NA NA 92% 94% LOS (hours) 27 hours 26 hours 9.5 hours 9 hours Readmissions within 30 days not available 6 (6%)

36 Clinical Condition Metric Pre- Pathway Post- Pathway Pre vs Post Complicated Appendicitis Uncomplicated Appendicitis Planned Cholecystectomy Isolated Hyperbilirubinemia Cellulitis/Simple Abscess 36 Median Length Of Stay (hours) hours 21% decrease % Patients Requiring Interventional Radiology Procedures Post-Op 17% 11% -6% 35% decrease Median Length of Stay (hours) hours 12% decrease % Patients receiving post-op Antibiotics 13% 9% -4% 31% decrease Median Length of Stay (hours) hours 65% decrease 30-day Readmissions 6% 0% -6% Median Length of Stay (Admitted Patients; hours) Median Length of Stay (Pts discharged from the ED; minutes) 100% decrease hours 22% decrease min 13% decrease Admission percentage (based on ED visits) 31% 25% -6% 19% decrease Imaging Utilization (beyond X-Rays & US) 12% 7% -5% 42% decrease

37 Controllable Cost * Savings Patient Population FY17 Savings per Encounter Number of Encounters Complicated Appendicitis 7.30% 111 Uncomplicated Appendicitis no change 325 Planned Cholecystectomy 15% 90 Cellulitis/Simple Abscess 18% *Actual cost of medications, supplies, lab/radiology studies, nursing care hours, blood products

38 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Nov-15 Jan-16 Mar-16 May-16 Jul-16 Sep-16 Nov-16 Jan-17 Mar-17 May-17 Jul-17 Sep-17 Nov-17 Adherence (%) 100% Percentage Adherence to Complicated Appendicitis Pathway (Pre-Op & Post-Op) 80% Target: 80% 60% 40% 20% 0% 38 Pre-op Pathway Adherence Nov 17: 100% patients had all pre-op elements met Post-Op Pathway Adherence Nov 17: 1 patient did not have a clear liquid diet ordered before they arrived to the inpatient unit

39 Adherence 100% 80% 60% 40% 20% 0% Pathway Adherence: Uncomplicated Appendicitis Pathway (Pre-Op & Post-Op) Target: 80% Reasons Patients "fell off" Pre-Op Pathway Nov17 Reasons Patients "fell off" Post-Op Pathway Nov 17 Additional Labs were Collected Post-op 0 NPO not ordered pre-op Did not receive appropriate* antibiotics within 60 min prior to surgical incision 1 8 Antibiotics were ordered post-operatively Pt did not have PO Narcotics ordered before transferring to acute care No Order for Regular or Advanced Diet before transferring to Acute Care No order for Saline Lock No Order for "Out of Bed" before transferring to acute care

40 Cellulitis/Simple Abscess - Nov 2017 Imaging Lab Patients "Off Pathway" Disposition Yes = US/X-Ray only or none No = any other imaging Yes = CBC, BMP, or none No = ESR, CRP, and/or blood cultures Clindamycin Route Appropriate* Patient 1 Discharged from ED Yes No No Patient 2 Discharged from ED Yes No Yes Patient 3 Discharged from ED Yes No No 40

41 LOS (min) Cellulitis/Simple Abscess ED Median LOS/month (minutes) n= min 173 min On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway" 41

42 Cellulitis/Simple Abscess 7 Patients with C & A admitted to Pediatrics Service (1 direct, 6 from the ED) in Nov 2 (29%) On pathway 5 (71%) Off pathway Reasons Patients "fell off" Pathway Clindamycin Route*: IV was given instead of PO 0 Lab: Pt had lab work beyond CBC/BMP, including ESR, CRP and/or Blood 5 Imaging: Pt had imaging beyond US/Xray *Clindamycin PO is preferred IV only if: NPO GI symptoms/unable to tolerate PO

43 LOS (hours) Cellulitis/Simple Abscess Median LOS/month (hours) Patients admitted to the General Pediatrics Service n=246 patients admitted to Gen Peds with Simple C&A 33 hrs 23 hrs On Pathway Centerline "On Pathway" 43

44 Bronchiolitis 85 Patients with Bronchiolitis treated and released from the ED 53 (62%) On pathway 32 (38%) Off pathway Reasons Patients "fell off" Pathway Pt Received Respiratory Treatment Deep Nasal Suctioning was Performed Patient Received Steroids Patient Received Antibiotics Patient had Imaging (CXR) RSV was Collected and Sent RVP was collected and sent

45 LOS (min) 250 Bronchiolitis Median ED LOS/month (minutes) n=1,124 patients with Bronchiolitis On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway" 45 45

46 Bronchiolitis 13 Patients with Bronchiolitis admitted to Pediatrics Service from the ED (no direct admissions) 3 (23%) On pathway 10 (77%) Off pathway Reasons Patients "fell off" Pathway Patient received Respiratory treatments Deep Nasal Suctioning was Performed Pateint was placed on Continuous Pulse Oximetry on the inpt Unit Patient received Steroids (PO or IV) Patient Received Antibiotics Patient Had Imaging (CXR) RSV Collected Respiratory Viral Panel Collected

47 LOS (hours) 70 Bronchiolitis Median LOS/month (hours) Patients admitted n=208 to admitted the General to Gen Pediatrics Peds with Service Bronchiolitis On Pathway Centerline "On Pathway" Off Pathway Centerline "Off Pathway" 47 47

48 FY 18 Pathways Cellulitis/Abscess completed (Aug 1) Bronchiolitis completed (Oct 1) Asthma completed (Nov 1) Constipation Go-live Jan-18 Diabetes Mellitus Go-live Feb-18 Migraine Sepsis Pyloric Stenosis Inpatient brain MRI Vascular Access 48

49 Improving Asthma Care Across the Continuum 49

50 Improving Asthma Care Across the Continuum 50 Create consistency in definitions, workflows, management When to Step-Up / Step-Down therapy When to refer Improve the patient/family experience Common educational materials and Action Plan Appropriate expectation setting Enhance communication Mitigate barriers to optimal health

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52 52 Thank you!