GA rehab center SCORS’ better outcomes data
New indicators suit spinal/brain trauma patients
Like many other medical rehabilitation facilities, Shepherd Center in Atlanta uses Functional Independence Measures (FIM) to assess patient outcomes and benchmark against other facilities. But because many of Shepherd’s patients are paraplegics, FIM was not adequate to measure their progress. To meet these paralyzed patients’ needs for assessment, Shepherd developed its own outcome measurement standards.
The need for such functional outcome measures has become paramount, both in terms of payer reimbursement and monitoring patient progress. Under managed care, patients can no longer spend months in rehabilitation. Instead, stays are limited to 30 days, which, in turn, can limit progress.
FIM data just weren’t working
FIM data work well in determining outcomes and improvements in less severely injured patients and stroke patients who typically respond well to rehabilitative therapy. However, they proved too limiting for the 60% of Shepherd’s patient population those with traumatic and permanently debilitating spinal cord injuries. Because many of its patients would never be able to walk again or dress themselves, Shepherd automatically ranked lower on FIM scores than other facilities.
Each month, 555 rehabilitation facilities nationwide send patient demographics, diagnostic, treatment, and FIM data to Uniform Data System (UDS) in Buffalo, NY, the most widely used outcomes database for medical rehabilitation. UDS then compiles the data and generates quarterly reports that compare each hospital to other participating facilities regionally and nationally in areas such as length of stay and FIM score change throughout the hospital stay.
"Overall, FIM is a good measuring tool. It looks at 18 indicators and ranks each on a scale of one to seven, with a total score of 18 being totally dependent and 126 being completely independent," explains Mike Jones, PhD, director of Shepherd Center’s Virginia C. Crawford Research Institute in Atlanta. "But where it becomes limiting is for patients with a C1 spinal injury, for example, who will never be able to [perform some of the tasks] measured on the FIM on their own."
"We specialize in spinal cord injuries, and we have more volume than other facilities, which makes us a little different. We focus on assisted technology to help them become more mobile and learn to live effectively, but those [types] of improvements aren’t measured on the FIM," he adds.
"So in some ways, it’s like comparing apples to oranges. We wanted to come up with [supplemental data] that was more specific to our patient population," Jones says.
Expanding outcomes research data
To supplement FIM, Jones created Shepherd Center Outcomes Research System (SCORS), an internal comprehensive data collection tool that demonstrates patient outcomes and service value in terms of health care dollars invested in each patient. Each month, various treatment departments access the hospital’s internal database and update information in five functional outcomes categories:
patient functional status, including living setting, need for assistance (based on the FIM score), medical acuity, and productive activity;
patient and family satisfaction with service responsiveness, treatment delivery, and outcomes achieved;
accuracy in predicting treatment outcomes and efficiency;
patient satisfaction with quality of life;
cost, which includes immediate value of treatment in terms of outcomes achieved vs. health care dollars invested, and long-term savings resulting from quality treatment.
"With SCORS, we can look at a patient’s situation pre-morbidity, at admission, at discharge and then follow up with the patient at nine months, one year, two years, or even up to five years after discharge," notes Kristen Soukup, MPH, quality improvement manager. "It not only lets us look at improvements but the durability of those outcomes. While we don’t expect to see many changes in a multiple sclerosis patient or [spinal injury patient], for example, we do want to make sure all our patients are either staying where they are or making progress after discharge," she adds.
Taking a team approach
Collecting and translating the data requires ongoing team effort. As patients make their way through the treatment process, each department is responsible for inputting outcomes data into Shepherd’s internal information system database. That data is then compiled and evaluated by Soukup.
"I use SCORS to generate trends and see how our treatment program is working," Soukup says. "The only way to accurately monitor outcomes and improve quality of care is by making [outcomes data collection] a continuous process. If we spot a trend, we can go to our performance improvement council and see how we can improve it."
Reports generated from the data showed that the percentage of Shepherd’s spinal injury patients being treated for pressure sores was increasing a problem that corresponded with decreased length of stay (LOS). In 1986, when average LOS totaled about 75 days, the percentage of patients presenting with ulcers was approximately 11%. But when LOS fell to about 50 days in 1995, that percentage soared to nearly 18%. In 1996, Shepherd’s average rehab LOS tumbled to just 33 days. (See table, p. 158.)
"Before managed care really set in and length of stay was cut, we had more time to educate patients and show them things to look out for," says Jones.
"But when you are [limited to] about 30 days, it can really have a negative impact for us and the patient. Treating a skin wound can run about $40,000, depending on the severity and keep a patient [down] for months."
PCASSO system keeps patient in the picture
To keep the problem in check, Shepherd implemented the PCASSO system (Patient-Centered Access to Secure Systems On-line), a type of telemedicine technology that allows physicians to diagnose skin wounds from a distance. The system, which looks much like a standard office phone, hooks to a video monitor in the patient’s home.
The hospital is also equipped with the PCASSO system, which enables both parties to see one another in a still photo during the phone conversation. Shepherd’s nurses travel to the patient’s home with the system, photograph early stage pressure wounds, and electronically send the images back to the hospital.
"We use PCASSO so we can spot skin wounds in their earliest stages and keep patients from having to come back to the hospital for treatment," Jones says.
"The [program] also allows the nurses to show them what to look for on their own. Since [spinal injury] patients can’t feel the wounds, they have to know how to spot early signs in order to prevent them."
The system appears to be working. In its testing phase, none of the patients who had access to the system suffered skin wounds. Two out of 15 patients in the control group were readmitted for skin sores six months after discharge, however.
"PCASSO is just one more element to Shepherd’s [quality improvement] program that is making a difference," Soukup notes. "If we didn’t have these [outcomes data tools] in place, we wouldn’t have as clear of a picture of what is really working and what needs to be improved. Information really is power."
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