Presentation Creating Care Title Pathways Committees December 12, 2012 December 12, 2012 Creating Care Pathways Committees LeadingAge Indiana Integrated Care & Payment Executive Series 1 2012 Health Dimensions Group Page 1
Your Presenter Ellen First, RN, MSN, RAC-CT Senior Consultant Health Dimensions Group 2 Clinical Pathway Development Clinical pathways were first utilized in the early 1990s in the United States and United Kingdom in attempt to best implement practices in standardized and reproducible manner 3 2012 Health Dimensions Group Page 2
Clinical Pathway Development Definition Document outlining standardized, evidencebased, multidisciplinary management plan, which identifies appropriate sequence of clinical interventions, time frames, milestones, and expected outcomes for homogeneous patient group Source: Quality Improvement & Enhancement Programme Clinical Pathways Board 4 Basics of Clinical Pathway Development Cochrane Review meta-analysis (27 studies surveying 11,398 participants) revealed that the use of clinical pathways reduced 1 : Overall length of stay Cost of care Number of complications experienced Research across 15 states noted 30-day hospital readmission for patients diagnosed with chronic obstructive pulmonary disease (COPD): 7.1% rate for patients with primary diagnosis of COPD 17.3% rate for patients with secondary diagnosis of COPD 2 1 Rotter, et. al., n.d. 2 AHRQ, 2011 5 2012 Health Dimensions Group Page 3
Why Clinical Pathways? Improve patient care through consistent management based upon best practices Maximize efficient use of resources Reduce unnecessary variation in care processes, stimulate a collaborative approach, and promote continuity of care for patients with a common condition Improve communication with patients and families with regard to the expected course of treatment Promote effective clinical audit and continuous quality improvement Source: Audimoolam, et. al., 2005 6 Why Clinical Pathways? (continued) Beginning October 1, 2012, hospitals in the highest quartile for readmissions for patients with congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia will be penalized up to 1% of their total Medicare reimbursement 7 2012 Health Dimensions Group Page 4
Set the Stage Commitment at senior management level and stakeholder involvement Ability to commit necessary time, resources, and effort Successful clinical pathway implementation 8 Clinical Pathway Steering Committee Clinical pathway steering committee is charged with responsibility for shepherding the process of development through the full Plan-Do-Study-Act quality management cycle Use of a project plan that assigns all needed action items to a specific person or group with expected dates of completion will help the team to stay on track 9 2012 Health Dimensions Group Page 5
Clinical Pathway Steering Committee (continued) Membership Considerations Who will be the members? When, where, and how often will members meet? What roles will various members fill, and what skills will they need? Multidisciplinary Collaboration Assure physician inclusion in all phases of planning, implementation, and revision 10 Clinical Pathway Steering Committee (continued) Requirements for effective steering committee include: Identify one or more physician sponsors Designate committee leader Agree on master template that provides ability to tailor to individual patient needs and choices Determine where/how the pathway will reside (paper, electronic, or combination?) Promote multidisciplinary approach Maintain records of meetings and activities Collaborate with IT from the beginning of the process forward Develop pathway review process that encourages direct provider input Develop communication and education plan that includes all stakeholders 11 2012 Health Dimensions Group Page 6
Clinical Pathway Steering Committee (continued) Determine under what circumstances changes will be made to the pathway Consider frequency of change and expediency of change into the process: Resources in time and material to change the pathway Incorporation of quality improvement information based upon variance analysis Evaluation of changes to evidence-based practice and methods for its applied use 12 Key Components Established timelines Categories of care with specific interventions Standards for patient/caregiver education Educational materials are standardized and accessible Outcomes criteria and monitoring Variance identification, analysis, and response 13 2012 Health Dimensions Group Page 7
Established Timelines Defines when intervention begins, how often it is provided, and when it is expected to be completed Assures that all key components are completed prior to discharge 14 Interventions Describes key elements of care in terms of expected outcome Begins with review of relevant scholarly literature to assure that basis is in research and evidence-based best practice Provides evidence that daily skilled care provided was needed in order to move patient along the pathway toward goal Assures that key goals are achieved when possible and that variances are analyzed when not 15 2012 Health Dimensions Group Page 8
Interventions (continued) Starting with the outcomes of care, determine what actions (interventions) are needed that best assure achievement of the stated outcome Interventions are based on scholarly research, not the way we have always done it here, but this sentiment might be the hardest obstacle to overcome in practice Clinical practice guidelines are often the basis of pathways, in that they represent best practices in prevention, diagnosis, therapies, risk, and cost Clinical pathway creates a system for implementation of this information in a consistent, reproducible way that allows for identification of variance 16 Outcomes, Criteria, and Monitoring Essential task of the pathway development steering committee is framing of clear, quantifiable, and realistic outcome statements that encompass essentials of best practice for problem under review In framing outcome statements, ask: how will I know that I have achieved this? Review of discharge plan should be included in all days of the pathway 17 2012 Health Dimensions Group Page 9
Example Outcomes for a COPD Care Pathway Increased prevalence of patients with COPD who have up to date immunizations for flu and pneumococcal pneumonia Increased number of patients with COPD who have received disease-specific education prior to discharge Increased number of patients with COPD who can correctly demonstrate use of their inhaler/nebulizer prior to discharge Decreased unplanned hospital readmissions Decreased incidence of respiratory infections in patients with COPD 18 Variance Identification, Analysis, and Response If we deviated from the pathway, what was the reason? If reason was preventable, how could the team have better executed the plan? What changes could be put in place to more effectively achieve the expected outcome? It will be necessary to determine methodology for identifying, collating, analyzing, responding, and reporting of variances The more embedded the process can be into the electronic record, the greater consistency variance review team can expect 19 2012 Health Dimensions Group Page 10
Variance Identification, Analysis, and Response (continued) Variances generally fall into one of three major categories System variance Health professional variance Patient variance Would include staffing, equipment, and training issues Clinical judgment Complications, comorbid conditions, and choice 20 Variance Identification, Analysis, and Response (continued) Assign discrete categories to variance groupings to promote ease in collating and analysis i.e. 1.1 Patient condition, 1.2 Patient choice, 2.1 Clinical decision, 3.1 Other Create standardized processes for identification, documentation, and reporting of variances Additionally, create documentation fields that allow elaboration on reasons for and follow up to the identified variance 21 2012 Health Dimensions Group Page 11
Challenges to Pathway Implementation Clinician acceptance: bias, time, staff turnover, priorities Multiply comorbid patients/residents who might fit into multiple pathways Focus: time, multiple projects Information technology infrastructure Training: varied and numerous stakeholders, external team members 22 Review Characteristics of effective pathway include Basis in evidence-based best practices Clear and concise definitions and language Cues interventions Statements are outcome-based Interdisciplinary input to development and implementation plans Promotion of streamlined documentation methods including development of standardized fields in electronic medical record (EMR) systems 23 2012 Health Dimensions Group Page 12
Review (continued) Goals of effective clinical pathway include: Promotion of evidence-based practice Defined standards, interventions, timelines, and goals Assurance of interdisciplinary collaboration within framework of pathway Decreased variance occurrences Consistent initiation of discharge planning on admission day one Improved outcomes and satisfaction for patients and families 24 Questions? 25 2012 Health Dimensions Group Page 13
Contact Ellen First, RN, MSN, RAC-CT Senior Consultant, Health Dimensions Group 4400 Baker Road, Suite 100 Minneapolis, MN 55343 ellenf@hdgi1.com 908.208.7454 cell 763.537.9200 fax 26 Presentation Title 27 2012 Health Dimensions Group Page 14