Clinical pathways offer better outcomes
February 1, 1999 7 minutes read
Clinical pathways offer better outcomes
Process is difficult and time-consuming
With their system contribution under fire, hospital home health agencies are now struggling for ways to get their wagons in a circle and prove their worth. Developing clinical pathways that help reduce the length of, or totally avoid, hospitalizations is an excellent way to justify one’s existence, according to providers.
While designing pathways in collaboration with your affiliated hospital may ultimately save your hide, it may cause bumps and bruises along the way, sources warn. The combination of involving and scheduling many already overcommitted players, gaining consensus on treatment protocols and establishing patient control and hand-off points can take months or even years.
"It’s a complex, difficult process. It’s not as easy as people think," says Cynthia Runner-Heidt, RN, MSN, administrator of patient care services at Lehigh Valley Hospital in Allentown, PA. "It may be easier in a smaller hospital with fewer players."
"The time varies. It depends on the number of places on the continuum, the number of people involved, the volume of patients. Some [can be finished] in six months; others take years," adds Greg Solecki, vice president of home health care at Henry Ford Health System in Detroit.
The challenge starts with determining which pathways to develop. As a general rule, high volume, length of stay, or cost diagnoses offer the most hospital cost savings, home care value and patient benefit opportunities. Exceptions, however, abound.
Some of the most common hospitalization-related diagnoses do not easily lend themselves to pathway development, states Rita Bendekovits, RN, MSN, ONC, CRRN, rehabilitation clinical specialist with Lehigh Valley Home Care. For example, stroke patients have widely varied complications, with possible physiatrist, neurologist, or family practitioner physician management. Standardizing treatment with so many variables and care directors is more difficult.
Although the idea for total joint replacement, one of Lehigh Valley’s first clinical pathways, originally came from a performance improvement study evaluating cost savings and therapy increase opportunities, the diagnosis lends itself to pathway development, according to Bendekovits. "It’s an elective surgery, it’s consistent with complications and post-op procedures, and though it’s multidisciplinary, with only orthopedic surgeon physician management, it’s easier to get standardized discharge orders from physicians."
Clinical pathways that conserve the most hospital resources also offer home care the greatest opportunities, but providers may have to lower their sites, at least initially. Hospital-based professionals may understand little of home care’s capabilities, so winning converts with small successes may be necessary to advance the overall program. "We’ve worked on quite a few with not a lot of patients, but if you maintain a positive approach, people will see you as a willing collaborator and call you back to the table," Solecki reports.
In addition to working on pathways involving few patients or resources, you can also gain support by taking key hospital players on home visits, Solecki advises. "It’s hard to look beyond your place on the continuum," but a personal experience may help train hospital eyes on home care, he notes.
Hospital-to-home care pathways that involve many departments may have a multidisciplinary steering committee to guide the process. The appropriate home care representatives depend on the scope of the project and your institution’s politics, Solecki advises. He often attends at the start of pathway development to "talk up home care," but leaves the details to "people who own the process, know the best about the process and well-represent the home health agency — maybe a manager or clinical specialist," he says.
The real fun of clinical pathway development begins after you’ve selected a disease target, sources report. To eventually develop standardized protocols, affected hospital and home care departments should each separately identify current practices, Bendekovits says.
- Outline home care practices.
In home care, staff from each discipline involved should meet alone to develop a consensus treatment. This is no simple matter, even for conditions with common curative interventions, such as joint replacement, Bendekovits notes.
"There is not a consistent approach in home care. It is an independent practice no matter what you do. It is very hard for anyone to sit down and identify [what they do] in any visit. Once you can accomplish that, the rest is easier," she explains.
"The flowcharting is very long and time- consuming, but it helps identify [the care components]," Solecki agrees.
Expect resistance initially. Wary field staff may first ask, "How can you tell us what to do?" Bendekovits reports. However, once participants understand that "writing down what [they] do doesn’t mean you’re taking away [their] independence," the discussion moves on. As individuals begin describing their normal practice, differences quickly become apparent.
"After sitting down and hearing [each other’s interventions], you hear a lot of, Do you really do that? I don’t usually do that,’" she says.
- Conduct chart audits.
Chart audits highlighting different approaches, as well as sometimes poorly articulated progress notes, help focus the discussion, according to Bendekovits. Conducting the initial data gathering chart audits for Lehigh Valley’s total joint replacement pathway, she discovered "it was hard to pull out what they did. They wrote these long narratives, and I would ask myself, What are they doing?’"
Balance democratic processes with forward momentum when setting focus group sizes. Lehigh Valley used two experienced therapists to distill a laundry list of joint replacement interventions into a concise activities flow chart, Bendekovits reports. Using employees rather than independent contractors may also help.
"Employees have a more vested interest and are generally more positive than independent contractors. If you only have independent contractors you may have to involve nurses more," she notes.
Combine discipline-specific intervention sequences into an overall home care activity outline. With care management responsibilities, nurses should drive visit-by-visit goal identification and progress, Bendekovits advises.
- Collaborate with hospital staff.
As pathways help reduce hospital stays, the home care components should build on and smoothly transfer from hospital practice standards, according to Bendekovits. With their interventions outlined, home care staff should meet with hospital staff to review practices and develop consistent approaches.
Intervention outlines form the basis of care standards. Developing standards of care that are neither too rigid nor detailed is another challenge. "People want to include all nursing knowledge in the standards of care. [My advice is] don’t ignore them, but put them someplace else," she says. For example, it would be inappropriate to spell out a neurovascular assessment in a standard of care because it is common nursing knowledge. Instead, include it in a separate education model, she advises.
- Obtain physician support.
Without physician support, hospital-to-home care clinical pathways simply don’t work, sources advise. But it is one of the most challenging aspects of pathway development, and one that home care often has the least control over. Physicians in private practice may have little interest in or incentive to adopt standardized discharge orders. With recent re-engineering and cost-containment initiatives, however, employed physicians at academic medical centers may be more accustomed to care protocols. In either circumstance, sources advise using physician leaders and home care champions to influence peers.
In the case of Lehigh Valley’s total joint replacement protocol, physician buy-in started with an individual meeting with the chief of orthopedics. Draft standards were subsequently distributed to and comments solicited from all orthopedists with staff privileges at the facility, according to Bendekovits.
- Develop documentation tools.
With care standards developed and physician support obtained, one of the last steps to clinical pathway development and implementation is designing documentation tools. It helps to format pathway tools like other care plans, according to Bendekovits. "We use a documentation tool and flow sheet, and our staff love it. It’s so simple, and they were writing so much before. This looks like our other care plans; it has the same sequencing, same verbiage, and it works very well," she says.
- Measure outcomes.
Documenting the impact of clinical pathways is important, both to demonstrate positive patient outcomes and to substantiate cost savings and decreased hospitalization. "You have to collect data to demonstrate that you have value and share it with other collaborators. And you have to find out why if it doesn’t demonstrate what you think it should," says Solecki.
At Lehigh Valley, the clinical pathway team is monitoring whether patients discharged directly from the hospital to home do as well under the new protocol as those who go first to a nearby rehabilitation facility, Bendekovits says. "I really do believe patients do very well at home, but you have to prove it."
- Keep communication lines open.
Establishing clinical pathways is only the start of an ongoing dialogue about care protocols and outcomes. Solecki explains that the Henry Ford Health System total joint team still meets monthly nine years after the pathway was first implemented. Members share data and work on further clinical outcome improvements.
- Conduct ongoing education.
Continuing education — with home care field staff, hospital discharge planners, and physician offices — also comes with the clinical pathway territory, according to Bendekovits. Enthusiastic field staff exert peer pressure on those who less diligently comply with the protocols. In the absence of capitated arrangements placing the facility at risk for longer hospitalizations, discharge planners may not promote home care as quickly or strongly.
Despite the challenges, clinical pathways are here to stay. They are a key ingredient in the success of hospital based agencies, sources report.
Sources
• Rita Bendekovits, RN, MSN, ONC, CRRN, Rehabilitation Clinical Specialists, and Cynthia Runner-Heidt, RN, MSN, Administrator of Patient Care Services, Lehigh Valley Home Care, 2166 S. 12th St., Allentown, PA 18103. Telephone: (610) 402-7300.
• Greg Solecki, Vice President, Home Health Care, Henry Ford Health System, One Ford Place, No. 4C, Detroit, MI 48202. Telephone: (313) 874-6539.
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