CVA paths give specifics for each discipline
Take quick look at stroke pathway program
Milford (DE) Memorial Hospital Home Health created clinical pathways for stroke patients with a specific goal of cutting the length of stay in home care from three-plus months to three weeks.
It has worked, with the average LOS now totaling 22 days, says Barbara Peterson, RN, MSN, EDD, manager of home health.
One key to the QI project’s success has been the development of clinical pathways for each home care discipline involved in treating patients who have had cardiovascular accidents (CVA).
Here’s their program, in a nutshell:
• Skilled nursing: The goal was to promote understanding of the disease process within three weeks.
"The nurse had a protocol for each visit, saying this was the minimum he or she was to do," Peterson says. "And these were measurable through charting."
Longer visits, shorter LOS
The visits usually last an hour and 15 minutes, which is about 30 minutes longer than nursing visits were before the change. "We had to schedule these nurses for longer visits, although that doesn’t help with reimbursements since you’re reimbursed for visits, not for the length of time," Peterson says. "But we thought that if we could shorten the LOS, it would be marketable to managed care companies."
Visits were daily for the first three days, and then every other day for two visits. Finally, visits were two times a week for two weeks or longer.
"We expected the patient to be compliant with the medication regime in two weeks’ time," Peterson says. "Within three weeks, we were hoping they’d be returned to an optimum level of functioning and be well on their way to their maximum level of functioning post-stroke."
The pathway includes a checklist for the assessment that is done on every visit. This includes the following:
check temperature;
check pulse and respirations;
check lung sounds;
check heart sounds;
check eyes for neurological assessment.
During the first week, nurses also would do whatever they could to make sure the patients’ pressure areas were protected because the potential for skin breakdown was great.
Goals for the last visits included teaching the patients how to modify their lifestyles, such as using special devices for cooking, for example.
• Physical therapy: The goals were to help the patient live in a safe, barrier-free environment and achieve independence, whether through walking or using a wheelchair or walker.
We will not walk out if they’re not ready’
The physical therapists were expected to meet with the patient three times a week for three weeks. On the third week, the number of visits would be dropped to two visits if possible. If the patient still needed help after a third week, physical therapy would be extended to a fourth week.
"We tell patients that we will not abandon them, and we will not walk out if they’re not ready by the end of three weeks," Peterson says. "The patients have input. If they say it’s too aggressive, then we’ll back off."
But so far, Peterson says, patients have not resisted the shortened LOS. Their bigger shock has been over being released from the hospital after three days, so they have been appreciative of any home care services they receive.
Since the agency started the program last year, it has needed more physical therapists to handle the influx of new stroke patients. Rather than hire new employees, Milford Home Health has contracted with physical therapists at the rehabilitation and transitional care facilities to moonlight for home health care. This gives the patient a greater continuity of care between providers.
"If the physical therapist has a good relationship with the patient in rehab or transitional care or the hospital physical therapy department, then we offer that therapist a contract to moonlight with us," Peterson explains.
• Occupational therapy: The goals are similar to those of physical therapy. "They were to evaluate their function in normal living, which means to see if they could cook if they needed to do that," Peterson says.
Occupational therapists also teach patients how to take their baths and how to re-enter the community.
These visits are kept to two times a week for two weeks whenever possible.
• Speech therapy: The goals are to help the patient regain control of swallowing, breathing, and speaking or communicating in some fashion.
"If the patient couldn’t talk, maybe he could write or communicate in another way," Peterson explains.
Speech therapists often have the patients call an agency nurse to see how well they could be understood while the therapist helps them converse.
If the patient was referred to home care from rehabilitation or transitional care, then the speech therapist was expected to complete therapy with two visits a week for three weeks. If the patient was referred to home care straight from the hospital, then therapy might continue for six weeks, Peterson says.
• Social worker: The goal would be to treat post-stroke depression when needed. Peterson says the agency rarely uses social workers for CVA patients, but when they are used, the visits may number up to three.
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