Home Care Case Management
Fine-tune micro-indicators for use on care maps
Agency uses these to track diabetes cases
If you use care maps or clinical pathways solely to reduce patient visits, then you may be missing some crucial benefits of implementing these instruments. Care maps are the perfect vehicles for collecting data on patient populations and disease problems, as well as for measuring outcomes, according to a Georgia quality manager.
The CareSouth/Advantage/Quality Home Health Agency in Savannah, GA, has developed care maps that meet several needs by including micro-indicators on each day's plan. (See micro-indicators for type 1 diabetes, new onset, p. 54.)
"The main difference between our care map vs. what we found out on the market is we are able to measure outcomes with ours," says Deborah Jennings, RN, continuous quality improvement specialist with the hospital-affiliated agency that has home health offices serving southeastern South Carolina and coastal Georgia.
"Our agency reviewed many clinical pathways or care maps available in the home health market," Jennings says. Most lacked documentation and outcomes measurements.
"You need to prove that what you did worked," she adds. "So with our care maps, we're going to be able to prove to Medicare or whoever that this will work for this population, but maybe this other population needs more visits because of problems, such as blindness, poor hearing, or less support in the home."
In a year's time, Jennings says, the agency should have some strong data that measure the following factors:
· cost of patients who are using care maps vs. patients who are not (this will be broken down into cost per episode, supply costs, etc.);
· trends regarding problems with patients meeting a particular goal by a certain day;
· trends regarding patient/caregiver compliance with disease maintenance while on the care plan.
Agencies that wish to combine outcomes measurements with care maps can do so more easily by including those measurement indicators on the actual care maps. This way the nurse is reminded with each visit of exactly what is tracked and expected in the way of teaching and demonstration, Jennings says.
Rhonda Costner, RN, MN, office director for Interim Healthcare's Spartanburg, SC, office, says each InterPath critical path used by Interim has a face sheet with patient goals. Interim's elaborate InterPath system collects data for outcomes management and benchmarking. The company then uses these data to prove results to payers and physicians and for quality improvement projects. For example, Interim was able to generate outcomes from its nonsurgical cardiac program that showed the average number of visits per patient went down from 20 to 11; unexpected discharge from home health because of rehospitalization decreased from 15% to 6%; and the episode goals for the patient were being met 89% of the time, vs. 77% of the time before.
To create your own micro-indicators for care maps, Jennings offers the following suggestions:
· Get input from field nurses and physicians.
The agency's chief objective in creating care maps and micro-indicators was to achieve consistency when different nurses teach patients about their disease, Jennings says. "A lot of times we found that patients would be taught some things over and over again, but other things would be left out of the teachings."
The micro-indicators should reflect these chief daily goals for each visit, she says.
So the agency asked field nurses and quality improvement nurses to meet weekly for five months to discuss what these goals should be.
"We based it on our past experience, while thinking of new ways to teach because they were going to be expected to learn more and get more family support from the beginning," Jennings says.
The group also made sure the goals met home health standards of care and basic diabetic standards.
The home health agency has a medical director who also helped with the goals, and the team received input from the agency's affiliated hospital.
Some of the goals build on goals presented in the hospital's own diabetic care map, Jennings says. For example, the hospital team expected diabetic patients to have a blood sugar level of less than 200 mg/dl when they were discharged. "So when they got home, we expected it to be less than 200 mg/dl on the first day."
Therefore, one of the micro-indicators for the first day of a diabetic patient's home care reads: "Fasting finger stick blood sugar reading falls between 70 mg/dl and 200 mg/dl."
When nurses use the care map, Jennings adds, they will stay in contact with physicians to make sure the daily goals correspond to the physician's orders.
· Create outline of goals and tasks per visit.
The agency chose to focus on five chief areas of concern when creating the care map and goals outline. These include cost, relief of suffering, restoration of function, safe and pleasant environment, and patient satisfaction.
The categories selected were:
- assessment and monitoring;
- tests and diagnostics;
- treatment;
- medications;
- consults;
- nutrition;
- activity and safety;
- patient and family instructions;
- discharge planning.
"On each visit the patient or caregiver will be required to demonstrate or verbalize specific actions and facts that will enable them to become independent in their health care," Jennings says.
Reducing visits in stages
The care map team wrote 22 of these goals and then pared them down to 20 micro-indicators and incorporated them into 11 visits. Although this number of visits is higher than what some commercial care maps recommend, Jennings says it will work as a starting point.
"We had been seeing patients for 28 to 30 visits," Jennings says. "We couldn't just go to three visits, but we hope to get this number down from 11 visits to three visits, maybe next year."
So the outline lists tasks and patient teaching goals for each visit, including such details as this instruction on visit 3: "Instruct on use of medical ID bracelet/necklace/card." (See care map outline, pp. 56-57.)
· Stick to the care map's goals.
The micro-indicators should reflect the chief goals of each day, although it probably would work best to limit the number to one to four micro-indicators for a particular day, Jennings says.
The CareSouth/Advantage/Quality Home Health Agency's care map for type 1 diabetic, new onset, for example, has 25 tasks and instructions that must be completed on the first day. These include, under the education category:
- Complete the Diabetic Education Assessment Tool
- Instruct what diabetes is
- Instruct hand washing technique
- Instruct use of glucose monitor machine
- Instruct three signs and symptoms of hypo/hyperglycemia and two interventions
- Instruct to draw up and inject insulin
- Instruct proper disposal of sharps
- Instruct 911/emergency response
- Teach environmental hazards (See day one diabetic care map, p. 58.)
However, the micro-indicator relating to these instructions simply states: "Patient verbalizes learning needs with completion of the Diabetic Education Assessment Tool."
It was not necessary to include more detailed teaching goals in the day one micro-indicator because most of those instructions will be repeated for the next few days, Jennings says.
"A lot of items on day one will appear on days two and three and four, because you give them five days to learn about the glucose monitoring machine and other items," Jennings explains.
So on day two, the micro-indicator relating to patient teaching reads: "Patient/caregiver verbalizes knowledge of hypo/hyperglycemia by stating symptoms, causes, and treatments for each."
On day three, the micro-indicators discuss proper disposal of sharps and having the patient verbalize doses and side effects of insulin.
Also, starting on day two, the care map begins to list a variety of goals under the category of "progress toward key patient outcomes." The nurse may check either the "met" or "not met" box and then write under the "variance" category why an outcome was not met. (See day two diabetic care map, pp. 59-60.)
· Develop tracking system.
"A coding system should be developed so that variances can be used to improve care through analysis and problem solving," Jennings states.
The three categories for potential variances are: clinician, patient and family, and system.
"For each category we chose one to 12 items that could be potential problems," she explains.
Under the clinician category, for example, a variance might be caused by inadequate documentation and response time.
The patient and family category includes the possibility that inadequate social support at home and condition complications caused a variance. Another type of variance, under the system category, might be caused by a lack of supplies or equipment availability, or by inadequate staffing.
Each micro-indicator is given a code, such as D2M1, which stands for day two, micro-indicator one. The same codes are used to track the outcomes by computer, a process that the agency's information systems employees are preparing, Jennings says.
"We can use the micro-indicators to change the care map for future use," Jennings adds. "If there is a consistent reason why they haven't met the micro-indicators by visit three, then we can change the care map."
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