‘Express path’ gives necessary QI, PPS info
Express path’ gives necessary QI, PPS info
Agency reviewed top 20 diagnoses
Nearly a year ago, the president and quality improvement coordinator of United Home Health Services Inc. in Canton, MI, began the process of analyzing the home care agency’s top diagnoses, costs, and outcome trends.
This review led to a special project in which the agency’s staff helped to develop a list of best practices that clinical staff would follow for each patient with a specific diagnosis. These best practices or clinical pathways, called Express Paths, give nurses guidelines about how to handle patients from a clinical perspective and serve as a reminder that the agency now works in a prospective payment system (PPS) environment in which there are not unlimited funds for patient visits.
"We have always looked at the patient’s needs first, and not just look at the visits," says Gloria Bruhowzki, RN, BA, president and administrator of the freestanding, hospital-affiliated agency that serves western Michigan.
"But now we use Express Paths as a framework of where to begin," Bruhowzki adds. "Express Paths make us look at what would be more efficient for a case instead of doing visits exactly as we have done them in the past."
Pathways appear to be successful
Some of the Express Paths are complete and being used, and so far, patient outcomes are consistent with what they were under the interim payment system (IPS) and before IPS, says Lynn Lariviere, RN, CRRN, quality improvement and rehab coordinator.
Also, patient satisfaction surveys have continued to come back with 100% satisfaction ratings, so by that measurement, the pathways have been successful.
Here’s how the agency developed its clinical pathways:
1. Analyze top diagnoses.
They identified the agency’s top diagnoses and assigned them to supervisors and other staff to research for trends per diagnosis, such as the number of visits, disciplines involved, and costs.
Everyone was assigned one or two diagnoses with the instruction to look for any patterns or trends, as well as to check outcomes, whether patients met goals, whether there were problems with hospitalization, and other problems, Lariviere says.
"We estimated how much we thought we’d be paid under PPS," Bruhowzki says. "Then we determined that we needed a plan for the future and so we met with a multidisciplinary team to look at the cases from all aspects of care."
The team researched and studied best practices for each discipline, including nursing, therapy, social work, and dietary.
2. Develop profile of typical patient.
Using 23 elements of OASIS data that affect payment, they began to develop a profile of a typical patient.
"The majority of patients are Medicare age, and a lot are from rehab," Lariviere notes.
Team members wrote descriptions of the characteristics of typical patients, based on their own experience and the OASIS information about what a majority of people under a particular diagnosis would have in common. Once a description was written, the teams could begin to develop best-practice recommendations for each of those typical patients. The patient profile, called a "patient picture," is described with a brief phrase above the goals and problems on each of the Express Paths. (See sample Express Path, inserted in this issue.)
For example, a description of a typical hip fracture patient might read: a therapy patient, frail, elderly, history of falls and balance difficulties.
"Initially, we didn’t have the descriptive part in there, but we determined we needed it to know the typical patient," Bruhowzki says.
While developing the pathways, the team referred to published information about interdisciplinary care plans. The team also created additional paths for various treatment needs. For instance, the patient with congestive heart failure would be listed on one path with therapy and on another without therapy.
3. Sketch characteristics of patients with additional problems.
"We also described what a patient would look like who didn’t fit into our plan," Bruhowzki says. "For example, if the patient had a hip fracture and also an infected wound then that case wouldn’t be typical and would require more visits."
The pathways describing typical patients were used as a launching pad for determining the resources and staff that would be required for any particular case, she adds.
Express paths list potential problems that might make the patient’s care more involved and complicated, and these include infected wounds and comorbidities. Under a category for treatment, all disciplines that should be involved are listed and their duties are outlined. Each path lists a range of planned visits per episode, and the frequency and duration of these visits per discipline.
The pathway encourages efficiency and helps to eliminate duplication, Bruhowzki says. For example, on a particular case, it might be more efficient to have the occupational therapist initiate treatment first; and then a week later, the physical therapist will begin treatment, instead of having all therapists start on the same week, she explains.
The Express Paths are a page long, serving as a quick snapshot for nurses to review with each case. "We wanted the intake nurse to have all of these at her disposal, and when she was referring to a patient, she could use this template of what we expect the care might be," Bruhowzki says. "Then the nurse or therapist or whoever opens the case could come back and say whether the patient fits the profile."
4. Encourage debate over path recommendations.
During team meetings about the Express Paths, various members discussed and debated path recommendations. "We’d have a lot of dialogue between members," Bruhowzki says. "They’d say, I think physical therapy can accomplish this,’ or the OT might say, I need 12 visits, not 10, and can’t do it in less than that.’"
So the pathways were developed with input from all disciplines and were created with the goal of giving patients exactly the amount of care they needed in order to reach desired outcomes. The debate and team input into creating the pathway recommendations also helped to give the team ownership in the finished product. This way, team members could encourage other staff to follow the guidelines and trust that the recommendations were developed with the best of intentions.
The team also benefits from working together to decide what kind of care each patient needs and setting standard goals. This teamwork approach has carried over to their use of the pathways, and now therapists, nurses, and other clinical staff are communicating more closely about their schedules and treatment, Lariviere says.
For example, the agency has encouraged staff to think of patient visit scheduling in terms of Monday through Saturday instead of the same two or three days each week. Now team members may ask one another which day they will be visiting the patient so that a different discipline could make a point of visiting the patient on an entirely different day, Lariviere explains.
"We feel [as if] our care has done nothing but improve, and the statistics and patient satisfaction surveys show that to be true," Bruhowzki says. "Our supervisors feel very comfortable defending any case on why we did so many visits."
5. Use paths for both financial and clinical purposes.
In addition to the clinical Express Paths that are used by the visiting staff, the agency has a separate pathway that has additional information about reimbursement, costs, and planned episodic payment. (See pathway with reimbursement information, inserted in this issue..)
"We decided to keep the financial information within the management group," Lariviere says.
During a trial period, the agency wanted to see how well the pathways would work for both clinical and financial purposes; only managers didn’t want the staff’s judgment to be contaminated by the reimbursement information, she explains.
"They might not be as objective if they knew that if they made one or two more visits, the agency wouldn’t be paid," Lariviere says. "We didn’t want the staff to make decisions in that way."
Managers, however, go over the income statement and balance sheet and talk about the typical case and what it would cost based on various disciplines providing care, Bruhowzki says.
"The key to managing under PPS is you have to have more involvement with the supervisor than you would under other systems," Bruhowzki says. "The supervisor needs to say to an employee, Most staff that care for a patient with this diagnosis are able to reach an outcome within 20 visits, and I notice you’re already at 30, and you are only two weeks into the case. So what’s going on here?’"
In this example, the nurse might explain that the patient in question has an infected wound, and this would lead the supervisor to ask for the documentation for the wound and to suggest the patient see a wound care specialist, Bruhowzki says.
Each case will have some variations off the pathway, and this is expected, Lariviere says.
However, it’s the overall picture that is important and the Express Paths help to make this clearer. The computerized pathway financial information provides managers with a comprehensive look at the disciplines involved in each case, the number of visits that were made, the reimbursement paid, and other pertinent data, Lariviere says. "So you can see how much you were paid and with the information about the number of visits made you can see how much you’ve already spent."
• Gloria Bruhowzki, RN, BA, President and Administrator, United Home Health Services Inc., 2200 Canton Center, Suite 250, Canton, MI 48187. Telephone: (734) 981-8820.
• Lynn Lariviere, RN, CRRN, Quality Improvement/Rehab Coordinator, United Home Health Services Inc., 2200 Canton Center, Suite 250, Canton, MI 48187. Telephone: (734) 981-8820.
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