Need to freshen up or revise critical pathways?
Colorado agency offers these guidelines
(Editor’s note: This new Home Care Case Management section will be a recurring feature in Homecare Quality Management. HQM will provide practical guidance to home care managers who are both quality and case managers, and who need to make case management and quality management work together toward cost containment and improved patient care.
While quality management deals primarily with compliance, process improvement, and measuring and reporting outcomes, the case management section will focus more on clinical improvement and outcomes management. Quality management and case management are integrally intertwined. We hope you like our new section. Your feedback is encouraged. To suggest topics for this section, give feedback, or volunteer a successful case management program at your agency, contact: Managing Editor Cheli Brown, P.O. Box 740056, Atlanta, GA 30374. Or e-mail: [email protected])
A Denver home care agency wanted to revamp its delivery of care process by creating new critical pathways. These had to be pathways that would replace care plans and have enough detail to satisfy Medicare and HMO requirements.
The Visiting Nurse Corp. of Colorado in Denver succeeded in its goal, and now has critical pathways that have made documentation and patient care more uniform.
"The new critical pathways help us standardize care, so when we look at outcomes we can have a better idea of how to alter our care to create better outcomes," says Sandra Fragleasso, RN, MS, director of clinical programs and quality improvement for the nonprofit agency, which serves 13 counties in central Colorado and has more than 20,000 visits per month.
"We’ve been looking at critical pathways for four years, and the quality care team’s big criterion was simplicity," says Beverly Kruse, RN, BS, CRRN, rehabilitation nurse clinician.
"We looked at other people’s critical pathways, and they didn’t meet our needs of simplicity," Kruse adds.
So the agency created its own critical pathways, starting with a one-page outline that can be adapted to each diagnosis. The result is a blueprint that field nurses can use to document that they’ve accomplished all of the teaching and care goals needed for each patient.
The agency has used the format to develop critical pathways for preoperative and postoperative home care visits for several surgeries. These critical pathways have documented how home care teaching differs from education the patient receives in outpatient and hospital settings. This has helped the agency convince insurers that home care visits were necessary, Kruse says.
Flexibility was the key to developing the pathways, says Stephanie Prock, RN, MSN, nurse manager for Visiting Nurses Corp. of Colorado.
"Because we’re a freestanding agency we work with multiple hospital providers, including university hospitals," Prock explains. "We had to create a system that was flexible."
Prock and Kruse give these suggestions on how quality and case managers can develop their own critical pathways:
1. Form a task force.
Members included administrators, case managers, rehabilitation therapists, clinical specialists, discharge planners, and a pediatric nurse. "We wanted an agencywide buy-in and needed to get the right people on the task force," Prock says.
The group met monthly at first. As the work grew, meetings were held every two weeks. Prock became the project leader, and she set the pace.
"First we called it the Critical Pathway Quality Care Team. Then it evolved into other things. Now it’s called the Disease State Management Quality Care Team," Prock says. "Critical pathways were one of our first steps into disease state management."
2. Select diagnoses according to priorities.
The task force decided to start with patients who had one of these diagnoses:
• congestive heart failure;
• pressure ulcer wounds;
• chronic obstructive pulmonary disease;
• pneumonia.
The group chose these patient populations because the diagnoses were more common and they had clear outcomes.
"It’s always easier to start with a surgical diagnosis when you create critical pathways," Kruse says. "We’re working on critical pathways for other diagnoses, and we’ve found that pathways for strokes and asthma are harder to write."
Kruse says the agency has a list of 45 top diagnoses, listed in order of frequency, and that’s how the task force selected its first critical pathways.
Later, the group added pathways for other diagnoses, including presurgery and postsurgery care of lumpectomy, mastectomy, and hip replacement patients. The agency also did a postoperative critical pathway for anterior cruciate ligament repair. These were written to meet the needs of a local hospital and physician’s group that wanted to hire the agency to visit surgery patients at home.
3. Create a critical pathway outline.
Task force members brainstormed and did research, looking at existing critical pathways.
"We looked at the critical pathway literature to date and did a library search," Prock says. "Now there’s even an Internet site for critical pathways, but there wasn’t one then." (See source box at end of article for Web site information.)
They decided early on to put the pathways on one page so the nurses would have less paperwork, and the greatest amount of compliance in following them.
"It’s a grid system, and it seems to work very well," Kruse says. "We use it to replace our nursing plans of care so we don’t have duplicate efforts."
The very top of the outline has space for the patient’s name, the agency’s number, the frequency of visits, the name of the primary caregiver, the payer source, and the surgery date and team number (if applicable).
Then the grid lists these categories:
• problems;
• goals on visit number one;
• goals met;
• goals unmet;
• goals on visit number two;
• goals met;
• goals unmet.
The task force identified three core problems that needed to be included at the top of each pathway:
• Knowledge deficit. This list could include goals of helping the patient or caregiver identify activity limitations, safety risks, and safe equipment use.
"Knowledge deficit is No. 1 because that’s the nature of the business in home care," Prock says. "In home care, your goal is to assist patients to become independent or for their caregivers to become independent as soon as possible. So you want them to be safe and you’re always teaching."
• Preoperative management or disease process management. This section directly relates to the patient’s diagnosis, and changes depending on that. It might say the patient or caregiver demonstrates appropriate seating and the use of ambulatory devices. Or if the critical pathway involves a disease diagnosis, then it is targeted toward disease process assessment.
• Coping. This one may ask that the patient or caregiver verbalize risks and complications, how to avoid or minimize risk, and realistic expectations.
"The family member has to be able to cope with the patient in the home, and the patient has to be able to cope with the disease," Prock explains.
At the bottom of the critical pathway, the outline includes these categories: assessment, teaching, interventions, activity, inter-team services and community referrals, discharge plan, and tests.
"The top part includes the outcomes or goals, and the bottom part is the interventions you need to achieve the outcome," Prock explains.
Fragleasso says a future step will be to place this outline and the specific pathways on computer, which will simplify the documentation. (See story on computerized critical pathways, p. 169.)
4. Have staff experts develop specific pathways.
The agency’s clinical specialists developed the content of each critical pathway, using the outline created by the task force.
For example, the enterostomal therapist did the wound care pathway, and the rehabilitation specialist did a stroke pathway.
Other clinical specialists included nurse clinicians with expertise in infection control, nurses who were skilled in cardiac diagnoses, and IV nurses.
The specialists asked themselves, "In order for this patient to be discharged and safe, what goals have to be achieved?"
They reviewed literature about the disease to help determine those goals. Then they asked themselves a second key question: "What is a reasonable amount of time for these people to achieve these goals?" Then they divide the critical pathways into one, two, seven, or whatever number of visits is necessary, Prock adds.
Finally, Prock says, they asked, "In order for us to achieve these goals on this visit, what interventions do we need to do?"
Kruse developed several of the pathways, including one for postoperative anterior cruciate ligament repair. She included standard patient teaching guidelines and physician’s instructions.
"We did research on what is standard postoperative care, and took into consideration specific physician requests because different doctors have their own methods of what they want done," Kruse adds.
Her critical pathway for postoperative anterior crucial ligament repair has very specific details for goals listed under each of the two visits. For example, the goals for activity on visit No. 1 are as follows:
• up with splint at all times;
• crutches, toe touch, weight bearing only as tolerated;
• patient to demonstrate crutch ambulation.
Then the goals for activity on visit No. 2 are:
• weight-bearing ambulation with crutches and splint;
• family will be able to transport patient to physician appointments.
Likewise, the main category of knowledge deficit is clearly delineated, with separate goals for each visit.
Visit number one requires the patient or caregiver to follow recommendations for diet and hydration; understand crutch and other equipment, i.e., splint use and cooling device; and knowing the signs and symptoms that need to be reported to the physician.
The second visit will require the patient or caregiver to verbalize an understanding of medications, postoperative progress, and signs and symptoms of infection to report to physician. And it requires the patient or caregiver to demonstrate the use of all equipment.
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