Mary Stilphen, PT, DPT

Mary Stilphen, PT, DPT Mary Stilphen PT, DPT is the Senior Director of Cleveland Clinic s Rehabilitation and Sports Therapy department in Cleveland, Ohio. Over the past 4 years, she led the integration and consolidation of rehabilitation services across a health system consisting of 10 hospitals, 47 outpatient therapy centers, and more than 700 therapy professionals. This reengineering project included successful development of unified electronic documentation, productivity, compliance, and billing platforms. Dr. Stilphen received her BS in physical therapy from Marquette University and her DPT from Simmons College. She is an active member of APTA and OPTA. h received her undergraduate degree in Exercise Physiology at University of Arizona and her master s and doctorate degrees in Physical Therapy from Northern Arizona University in 1999 and 2008 respectively. She has advanced training in vestibular rehabilitation through Emory University. She has also been in trained in PWR! and Rock Steady Boxing for Parkinson s disease and NDT for stroke rehabilitation. She lectures for the University of Nevada, Las Vegas DPT program and is involved in research on the mild cognitively impaired population. Dr. Nash is has been the Manager of Rehabilitation Note: Dr. Stilphen has no relationship which, in the context of her presentation, could be Services at the Cleveland Clinic Lou Ruvo Center for Brain Health since 2012. Under her leadership, the perceived as a potential conflict of interest. clinical rehabilitation program at Cleveland Clinic Lou Ruvo Center for Brain Health strives to maximize mobility and minimize fall risk for patients with a neurodegenerative disease through skilled individualized treatments, community exercise classes and community outreach.

Using Data to Demonstrate Value in Rehabilitation Mary Stilphen PT, DPT Senior Director Cleveland Clinic Rehabilitation and Sports Therapy

Healthcare reform has reinforced the need to transform service models to focus on value by emphasizing efficiency and efficacy. This need for system re-design, culture change and the call for innovation presents an opportunity to overcome some of the long-standing challenge we have faced. We will discuss how the systematic utilization of patient reported outcome tools has allowed the therapy department in a large health system to begin this transformation.

Objectives Define the meaning of value in a therapy practice Summarize how the ability to collect, aggregate and display data is instrumental in driving system change Understand the importance of using standardized measures to minimize operational and clinical variability in a physical therapy practice

WHAT DOES VALUE IN A PHYSICAL THERAPY PRACTICE REALLY MEAN

The Value Equation Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent. Michael Porter, PhD Harvard Business School Value = Outcome Cost Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006.

Delivering the Physical Therapy Value Proposition Ability to demonstrate value is becoming a prerequisite to participate in the US Health System Consumers, referral sources, payers and policy makers no longer accept a professions anecdotal reports certifying its value PT s must engage in a coordinated approach to develop and deliver PT s value proposition Dianne Jewell, Justin Moore Marc Goldstein Delivering the Physical Therapy Value Proposition: A Call to Action PHYS THER

Strategy for Value Transformation Goal Improve value for patients Improve outcomes without raising costs Lowering costs without compromising outcomes. Michael Porter outlines 6 strategies. What does that mean for physical therapist Patient level System level

Strategy for Value Transformation Michael Porter

Michael Porter - Value Value should always be defined around the customer Value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered Shifting focus from volume to value is a central challenge.

THE VALUE EQUATION RECONSIDERED FOR HEALTH CARE Quality is a composite of patient outcomes, safety, and experiences Cost is the cost to all purchasers of purchasing care

Strategies needed to demonstrate physical therapy's value proposition. Dianne V. Jewell et al. PHYS THER 2013;93:104-114 2013 American Physical Therapy Association

Therapy Value Proposition Access to quality services At Lower cost With greater provider accountability Dianne V. Jewell et al. PHYS THER 2013;93:104-114

Opportunity for therapy? Is this a place where we can demonstrate value Standardize outcome measurement Look at that over cost of care

WHAT DATA IS IMPORTANT TO COLLECT AND WHY

Outcome Measurement is the single most important tool to drive innovation in health care

MEASURING OUTCOMES

Current state of outcome measurement leaves much to be desired. Little consensus on what constitutes an outcome Tend to focus on immediate results Fail to capture what is important to the patient Are not comparable across providers Porter ME. What is Value in Health Care?

Diane Jette study 2009 Survey sent to 1000 APTA members 498 PT s responded to a survey regarding utilization of outcomes 47.8% indicated they utilize a standardized outcome measure 35.1% of these therapists responded that they were required for all patients in their setting, 23.8% responded that they were routinely used for all patients but not mandated.

Opportunity for Improvement

What types of Outcomes can PT s Measure Patient performance (Timed Up and Go, 6 Minute Walk Test) Clinician ratings of patient performance (FIM) Patient-reported (generic, diagnosis specific)

Back to Michael Porter The only true measure of quality are those that measure to the patient There should be a systematic utilization of PRO s for every patient in every setting

Patient Reported Outcomes Implies only that the patient provides the information Umbrella term that covers a range of measurement but is used to refer to selfreports by the patient. Data may be collected by: self-administered questionnaires Interviews by proxy

Patient report measures are the most commonly used outcome tool less expensive less time intensive and reduce the number of patients lost at follow-up because they do not require a clinic visit.

Taxonomy of PROs Greenhalgh (2009) proposed a classification system for the different applications of PROs in clinical practice. This system classifies whether the PRO data are used at the individual or aggregated-level and whether the PRO data are used directly or indirectly to inform patient care.

Taxonomy of PRO s When a patient completes a PRO questionnaire and that patient s data is provided to the therapist, the data can be used at the individual level to: screen for clinical problems and identify limitations monitor progress over time, promote communication assist with goal setting If this information is aggregated across a group of patients this can be used to: inform quality improvement conduct population monitoring drive system change

Using PRO on an individual patient level

Using PRO on an aggregate level Ideal for nursing mobility

Considerations in PRO Selection What is it that you want to measure Body structure, function, activity, participation Purpose of measurement Types of measure Condition-specific, generic

Diagnosis specific PRO s Stroke Impact Scale LEFS MS Impact Scale-29 MSWS-12 PDQ 39 Neuro-QOL Modified Fatigue Impact Scale

Stroke Impact Scale

PDQ - 39

Generic PRO s PROMIS, AM-PAC Can be used across a variety of diseases and conditions as well as different treatment settings. Self-reported capability rather than actual performance of physical activities Can be administered via short forms or CAT

PROMIS PRO PROMIS PROs cover three areas, or domains: Physical (physical function, pain, fatigue) mental (anxiety, anger, cognition) social heath (physical abilities, fatigue, pain, depression, sexual function, and satisfaction with social participation (or interactions).

AM-PAC Activity Measure for Post Acute Care Activity limitations measure Developed for use across Post Acute Settings 3 domains Basic Mobility Daily Activity Applied Cognition

AM-PAC Short Forms AM-PAC short forms were created by selecting subsets of questions from the large item banks. Separate short forms were developed for each setting. Since the inpatient and outpatient short form items are derived from a larger bank of items that are scaled on the same metric Standardized scores generated from inpatient and outpatient short forms are comparable and can be used to assess patients function as they move from inpatient to outpatient settings

AM-PAC - Daily Activity

Considerations in Identifying an Outcome Tool Patient and clinical factors Patient ability, goals, clinic requirements Psychometric considerations Reliability, validity, responsiveness, sensitivity Feasibility Time, space, equipment, training, cost, burden, culture, language,

Overview of the Functional Reporting Requirement The Law: Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 Amended to require the establishment of a claimsbased data collection system for outpatient therapy services PT, OT SLP

Current state of outcome measurement leaves much to be desired. Little consensus on what constitutes an outcome Tend to focus on immediate results Fail to capture what is important to the patient Are not comparable across providers

Power of Data Collect Aggregate Display

Improve the Value of Therapy Services Standardized outcomes reported by all disciplines Be able to aggregate data for use on an individual patient level or on a system level Reported outcomes graphically to highlight trends over time Incorporates key patient reported factors into treatment planning Focus on trends and treatment modifications, not reporting

SYSTEMATIC UTILIZATION OF PATIENT REPORTED OUTCOMES

Our Journey at the Cleveland Clinic Measuring patient reported functional outcomes longitudinally across an episode of care Acute Hospital Skilled Nursing Hospital Based SNF s Connected Care Units Home Care Outpatient

Measuring patient reported functional outcomes longitudinally across an episode of care using the same tool Acute Hospital Skilled Nursing Hospital Based SNF s Connected Care Units Home Care IRF Outpatient

Acute Hospital 6 Clicks Basic Mobility 6 Clicks Daily Activity SNF s / Connected Care Units AM-PAC Basic Mobility Adapted AM-PAC Basic Mobility Adapted with w/c AM-PAC Daily Activity

Outcome Tools Outpatient AM-PAC Short Forms both Basic and Adapted versions for all neurological patients Diagnoses Specific Tools for Orthopedic Patients LEFS QuickDash Oswestry NDI FactB +4

Uniform data collection in all settings Use information from large uniform data sets to make decisions.

Data is Used to Drive Decisions Acute Hospital Discharge disposition Resource Utilization Patient Mobility SNF Connected Care Units Compare LOS, # visits, Patient s functional change between facilities Outpatient #visits Patients functional change Establish a benchmark

WHERE IS THE VALUE OPPORTUNITY

Move to Bundled Payments Move patient to the lowest cost level of care while generating the best outcome How do we use outcome data to drive decisions on when to move patients determine what level of care is best for the patients

Conclusion

Necessary Skills to Prepare for Value Based Care People and culture: The ability to instill a culture of collaboration, creativity, and accountability Business intelligence: The ability to collect, analyze, and connect accurate quality and financial data to support decision making Performance improvement: The ability to use data to reduce variability in clinical processes and improve the delivery, cost-effectiveness, and outcomes of care

Physical Therapy Outpatient AM-PAC Database

AM-PAC Neuro Visit Type

QUESTIONS

References 1. Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006. 2. What is Value in Health Care, Michael E. Porter N Eng. J Med 2010; 363:2477-2481 December 23, 2010 DOI: 10.1056/NEJMp10110241 3. Delivering the Physical Therapy Value Proposition: A Call to Action, Dianne Jewell, Justin Moore Marc Goldstein PHYS THER 2013; 93: 104-114 4. Us e of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and Applications, Jette DU, Halbert J, Iverson C,, et al. PHYS YHER l. 89 :. 125-135 5. Preparing for Therapy Required Functional Reporting Implementation in CY 2013 National Provider Call December 12, 2012 Presented by: Pamela R. West, DPT, MPH Centers for Medicare & Medicaid Services, Center for Medicare Hospital and Ambulatory Payment Group, Division of Practitioner Services 6. Greenhalgh J. The applications of PROs in clinical practice: what are they, do they work and why? Qual Life Res 2009;18:115-23 7. PROMIS Patient Reported Outcomes Measurement Information System (PROMIS www.nih.gov cited 6-15-15 8. AM-PAC Boston Rehabilitation outcomes Center Boston University; www.bu.edu/bostonroc/instruments/am-pac Cited 6-15-15 9. Utilization and Clinical outcomes of outpatient physical therapy for Medicare Beneficiaries With Musculoskeletal Conditions, Fritz JM, Hunter SJ et al Physical Therapy 2011; 91:330-345