Simple changes adapt CHF path for home care
Adding home care aids hospital program
When Patricia Sparacino, RN, MS, FAAN, studied the effects of implementing clinical pathways for inpatients with congestive heart failure (CHF), she had no idea that her findings would translate to home care patients, too. Sparacino is a clinical nurse specialist at University of California San Francisco Stanford Health Care and an associate professor in the UCSF School of Nursing.
The initial project, which began 21 months ago, involved using a nationally recognized best practice guideline Sparacino chose the one developed by the Agency for Health Care Policy and Research (AHCPR) in Washington, DC and adapting it for patients at UCSF’s Mount Zion Medical Center.
The results were fewer readmissions within 60 days of hospital discharge, a reduction in costs of 17%, and a decrease in length of stay from 6.6 days to 5 days. "From that we found we have other areas of work," says Sparacino. "We realized the importance of implementing a clinical pathway in home care as well."
Over the last few months, Sparacino has done just that, and although much of her data have yet to be compiled, she tells Homecare Quality Management she thinks hospital admissions are down even further, patient satisfaction has improved, and nurses are more confident taking care of these patients with the pathway in place.
"These were mainly frail and elderly people," she says of the inpatients. "They were the oldest and the sickest patients, and most were getting referred to our home care division afterwards."
With so much talk about a continuum of care, Sparacino says it was a natural progression for her to consider the impact of putting a pathway in place for home care patients, too.
Her first step was to talk with the home care nurses. "They thought it was a great idea," says Sparacino. "They have to be generalists in home care, but this is an age of specialization. A clinical pathway would help them to be specialists in a way."
Adapting the guidelines
In developing a pathway appropriate for home care, Sparacino used a prepackaged manual of clinical paths currently on the market. But she had to make changes so it would address the needs of her patients.
Among the changes she made: expanding the assessment portion of the pathway, including a section for a baseline assessment, and putting the first instruction about medication in the first visit.
Sparacino also added sections to list educational materials that are given to patients, and added space for the caregiver to list barriers to care "so that it was up front, especially if the barrier was cognitive impairment, or a cognitively impaired spouse or caregiver," she says.
"I also tried to code the CHF document so that anything that is CHF-specific is documented on the pathway, and other aspects of care are documented on the usual forms," says Sparacino. She cross-referenced those usual forms to the pathway for cardiovascular documentation. "There was nothing before, other than standard cardiovascular documentation, which had no guidelines or structure."
While Sparacino says she wanted to include a good number of visits in her pathway, she could find no hard data on outcomes as they relate to the number of visits to CHF patients. "The only thing I have been able to find were cited in CARING Magazine in 1994," she says. That recommendation was 10 to 18 visits. "Yet Milliman & Robertson reimbursement guidelines say only three home visits," Sparacino adds.
She selected nine visits. "It was somewhat arbitrary, but we were trying to balance what seemed reasonable until we have some clinical outcomes data."
Each visit on the path was "packaged" to include what a nurse should cover from simple items such as blood pressure and pulse rates to patient education. "The nurses really wanted cues that organized their care better," says Sparacino.
The result is a pathway that allows a nurse to see at a glance whether a patient is improving or failing. The pathway also makes it possible for a nurse who has not visited a particular patient before to determine what has already been covered and what areas still need to be addressed with a patient.
After all her work creating a clinical pathway (see sample pathway, inserted in this issue), Sparacino says there are four things that must be included in any path to ensure its success:
• maintenance of continuity with any inpatient clinical pathway that exists;
• provision for the capture of outcomes data;
• tracking education or attempts at education;
• provision of cues to the health care provider a template that will guide the caregiver in his or her work.
Sparacino says one of the biggest benefits of the pathway has been to help nurses assess patient understanding. "The nurses have seen a real impact from cues we gave them on questioning patients," she says. "Before, they asked if the patient had any questions. That usually didn’t get a response. But if they ask, Share with me what we discussed about your medication when I visited you last Tuesday,’ the patient is forced to give a response."
The program, implemented in March 1996, was refined in June 1997. "We eliminated one visit by moving pieces of it to other visits. It was really more a tweak than a revision." The biggest change was to move some of the patient education and information on medications from the second visit into the first visit. "We felt that some vital content shouldn’t wait until the second visit."
Hopes for the future
Now, Sparacino says she wants to look at outcomes based on payer sources. One payer uses the Milliman & Robertson guidelines for CHF patients, Sparacino explains. "But that is based on actuarial tables, not outcomes. We want to be able to show that that number is inadequate so that our nurses don’t have to fight for further visits. It’s not an effective use of their time."
She is currently two months into that part of the project, and will continue to collect data until she has 100 patients for each payer source being studied.
Sparacino has some tips for agencies that want to implement pathways for their patients, be it in CHF or anything else.
1. Involve physicians.
Making the effort a multidisciplinary one pays off, she says. "You get greater buy-in this way." She also recommends using a nationally recognized guideline, such as the AHCPR one. "That way, you don’t insult providers or bruise their egos. It’s based on accepted national research."
2. Share your information with inpatient caregivers.
Sometimes, the hospital staff needs to know what you find out. For instance, Sparacino and her staff found that physicians were ordering up to eight different medications for CHF patients, each of which had to be taken three times a day. While that is fine in an inpatient setting, asking very frail sick people to remember to take 24 pills a day is asking for non-compliance.
Physicians are also often unaware of the costs of some of the medications they prescribe. "These patients will either not take the medications, or they won’t take all the doses because it’s just too expensive," says Sparacino. "The doctors, when you tell them this, are astounded." As a result, she devised a chart that lists drug names, dosages, average cost per month of the medication, and major adverse reactions. (See sample chart, inserted in this issue.)
"They loved it," says Sparacino, noting that they asked to have the chart reduced to a pocket notebook size for easy reference.
3. Revisit the project regularly.
With so many changes in health care clinical, administrative, managerial, and organizational Sparacino says it’s easy to forget about a particular project. You have to be sure you look over your pathway regularly; Sparacino says quarterly is a good time frame. "It’s frequent enough to keep people alert, but not so frequent that they stop listening." The purpose of the reviews, she adds, is to make sure the project takes account of any new treatments.
4. Make your pathway part of a research project.
Sparacino says that by making her CHF pathway into a research project, it becomes easier to capture whether any difference was made. "It is a way of quantifying change," she says. In addition, you can often find out things of importance to your patients that you might not otherwise know. For instance, when she was working on the inpatient project, Sparacino discovered that many of the patients were native Russian speakers with limited understanding of English. Because there was a research project under way, this was noted, quantified, and addressed. "That was an unanticipated benefit," she says.
[Editor’s note: For copies of the AHCPR guideline on congestive heart failure, call (800) 358-9295 and ask for the heart failure clinical practice guideline.]
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