How to cover the gap between acute, home care
How to cover the gap between acute, home care
Guidelines -- not pathways -- guide care
Acute care and home care case managers at Holston Valley Medical Center in Kingsport, TN, recently teamed up to pilot a six-month surgical guideline program that promises to improve outcomes, enhance the quality of care across the continuum, and strengthen communication between hospital case managers and the providers in other settings.
The project's initial development, however, did not begin with clearly defined goals. The project, which was implemented in June, involves the use of guidelines -- which are formatted like pathways -- and completion of a patient medical profile form prior to hospitalization.
"When we started working on this project, we did not have any idea what [type of tools] would evolve," recalls Keltie Kerney, BSN, RN, A-CCC, MPH, director of the hospital's home care services, who worked closely with the case managers in developing the guidelines. (See related story describing how acute and home care case managers were cross trained to use the guidelines, p. 124.)
"We didn't have [pathways] as one of our objectives when we started. Basically, we wanted to look at our time frames of processing patients from the physician's office to preadmission, through the hospital and home and to improve every single aspect of their stay," explains Kerney. Lack of continuity in care and communication among providers were commonly cited concerns among the hospital's physicians and led to the project's development, she adds.
Kerney credits a simple meeting of the minds between physicians and Holston's 10 inpatient and eight home health case managers. She first observed that some physicians were concerned about communication across the continuum. Next, she began talking with physicians about exploring new ways to address patient needs across the continuum. "We started looking at some of the other things that people around the country have done, some of which are incorporating the guidelines developed by Milliman & Robertson," continues Kerney.
Kerney says the Milliman & Robertson guidelines were used because they are based upon current practice patterns and not considered "cookbook" -- an important concern among the hospital's physicians. Milliman & Robertson is a medical consulting and guideline development firm headquartered in Seattle.
"Our physicians, for the most part, have been real sensitive to the idea of cookbook medicine. The mere fact of what the guidelines should be called became a concern. Our physicians feel threatened by managed care, so we intentionally wanted to stay away from anything that had the flavor of a critical pathway," explains Kerney.
Surgical case management team evolves
Holston Valley's efforts at improving cross-continuum care for its surgery patients began with an organizational meeting. "We came together simultaneously based upon the needs and interests from each other's areas. Then the group evolved into a larger group, and we officially requested from administration that our group be sanctioned and chartered as a quality improvement performance team, which is now known as the Surgical Case Management Team," notes Kerney.
Included on the team, in addition to Kerney and a surgeon, is at least one representative from both the acute care and home health case management departments. Also included were staff from the inpatient surgical unit, utilization review, physical therapy, same-day-service, intensive care unit/cardiac care unit (ICU/CCU), preadmission, and enterostomal therapy nursing. In addition, one nurse from one of the hospital's managed care organizations also serves on the committee.
The team first established specific goals, including:
* improve patient, family, and physician satisfaction;
* provide true continuity of care by maximizing both inpatient and outpatient resources;
* establish outcome-based monitors;
* restructure/redesign the delivery of care;
* prepare for capitation contracts;
* increase market share;
* develop a framework or model that could be extrapolated to other physicians;
* develop and test tools for a more appropriate case management/utilization program.
Making the guidelines unique
The group then developed 10 multidisciplinary surgical guidelines which were designed to cover every aspect of the surgery patient's care. The guidelines, which outline treatments and procedures much like a critical path, were a multidisciplinary effort because "no single discipline has dominated looking at what we've developed," explains Kerney. The following 10 diagnoses were selected for guideline development based on their high volume:
* abdominoperineal resection with proctectomy;
* aortic aneurysm, abdominal repair with graft replacement;
* lysis of adhesions;
* senoralpoplietal bypass;
* colectomy without colostomy;
* esophagectomy with direct end-to-end anastomosis;
* phoracotomy with biopsy;
* small bowel resection;
* colostomy teaching;
* above-the-knee amputation.
Each guideline is one page and includes six columns including physician/office, home health initial contact; 72 hours or more preadmission; admission day; day one post-op; day two post-op; and outcomes. Under each section are the preprinted guidelines. The case managers' roles are outlined at the bottom of each section under discharge planning for either the acute or home health discipline. On the back page of the guideline are the continuing protocols for home visits, divided by visit day.
For example, on the above-the-knee amputation guideline, under the day one post-op column, the acute care case manager reviews and obtains orders for post hospital placement. On day two post-op, the acute care case manager notifies the home health case manager of the patient's transfer to either a rehabilitation facility or a skilled nursing facility.
The last section, patient outcomes, lists surgery-specific outcome goals. Above-the-knee amputees, for example, must be able to accomplish the following:
* ambulate without weight bearing with crutches or walker;
* tolerate a normal diet.
In addition, staff must remove any drains in the patients before they can be discharged to a rehab facility for further physical therapy.
"The guidelines are used among all the disciplines that work with the patient," explains Kerney. "For example, for the above-the-knee amputation guideline, we will pull the PT in for that case as needed, so [each guideline] is not just limited to certain disciplines. And with the colostomy guidelines, the enterostomal therapy nurse is very active."
The group also developed a list of outcome monitors that include such factors as the number of readmissions to the hospital within 30 days of admission to home health, number of patients developing wound infections after admission to home health, and hospital length of stay. Other outcomes will be monitored as the program progresses. "With any medical intervention, whether it is a dressing frequency change or a medication change, we want to see why it was done, what generated the change, and then once the change was made, what the outcome was as a result of the change," explains Kerney.
Case managers become involved in the patient's care prior to hospitalization by ensuring that a pre-hospital assessment is completed. A patient medical profile form is completed by the patient in the physician's office prior to hospitalization. This form allows the physician to begin assessing such information as symptoms, history of illnesses, and additional health problems.
From this information, the physician determines "what the actual procedure will be and checks to see, based upon his assessment, whether any type of home or other type of outpatient therapy, perhaps just PT, will be needed once this patient has surgery."
Results to be analyzed in December
So far, no results have been analyzed as a result of the program, which was two years in the making. "We're just now in the implementation phase of our six-month pilot study," explains Kerney, adding that she hopes to have some quantifiable results by December. "We believe that there will be a significant difference in all outcomes to include patient satisfaction, physician satisfaction, and nursing satisfaction," she predicts.
Kerney is not aware of other programs developed to the extent that Holston Valley's is because "we looked at every single piece [of the patient's care], starting in the doctor's office."
For example, when a physician gets the referral that a patient needs a thoracotomy, the physician completes a form which indicates the physician's desired discharge plan for the patient, explains Kerney.
"The top section addresses discharge plans for the patient, whether they can go home alone after surgery or whether the patient will need assistance. These needs are anticipated of course, but we know upfront that if the physician checks 'anticipates home care' then we're going to be very involved, but during the pilot study, home health nurses will make a home visit regardless," adds Kerney.
"We anticipate that there will be additional guidelines added in the surgical group as well as we expect to extrapolate this to other physician groups too," explains Kerney.
[Editor's note: For information about guidelines published by Milliman & Robertson, contact the company's corporate headquarters, 1301 Fifth Ave., Suite 3800, Seattle, WA 98101. Telephone: (206) 624-7940.] *
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