Salient factors’ decreases irrelevant ancillary Rx with patient-specific goals
What are key rehabilitation issues for this stroke patient?’
As managed care pressures push providers to quickly move patients to the next lower (and less costly) level of care, health care systems could take a lesson from Rehabilitation Services at Emory Hospitals in Atlanta. Three years ago, the center created a new care delivery system based on the "salient factors approach" developed by Connie Burgess, MS, RN, president of Connie Burgess & Associates, a Lakewood, CA, consulting firm that specializes in redesigning health care operations to compete under managed care.
With the salient factors approach, an interdisciplinary team helps the patient and family identify and focus on a single list of specific goals that reflect key rehab issues for the patient, rather than rely on the traditional mode of incorporating disparate objectives of physical, occupational, or speech therapists into the care plan. (See related story, p. 123.)
Consider the big picture
"If providers continue to treat all patients that have the same diagnosis the same way, they run the risk of using their resources and the patient’s ineffectively," Burgess says. "Yet, by concentrating on goals that are important to the patient, you can decrease irrelevant treatment and its associated costs."
Fox example, if an older stroke patient is going to live with his daughter who does the cooking, the staff shouldn’t spend valuable rehabilitation resources on teaching the patient how to prepare meals.
"In this model, a stroke is not a stroke is not a stroke. Just because a group of patients has the same ICD-9 codes, doesn’t mean they need exactly the same type of rehab. You have to ask yourself, What are key rehabilitation issues for this stroke patient?’" Burgess says.
Instead, teams who work out of one central area rather than separate departments assess patients to establish a single, specific list of rehabilitation goals that reflect the patients’ needs. "This list can’t come from one discipline," she says. "The list must be based on where the patient is going after discharge and what resources are available there," Burgess says.
The list acts as an "index" to be addressed by all team members regardless of discipline and allow the treatment plans to center on the patients’ functional goals. "It reminds team members to address these issues 24 hours a day," she says.
For example, Burgess cites the case of a 47-year-old man who felt strongly he didn’t want to have a bedside commode. "So one of this man’s main rehabilitation goals was to be able to walk to the bathroom at night. That meant the care plan had to reflect that the night nurse who answered his call light at 2 a.m. needs to make sure he walked as independently as possible."
No more departments
Because teamwork is so important in this model, Emory eliminated departmental boundaries such as nursing and physical, speech, and occupational therapies. Instead, interdisciplinary teams work together in offices dedicated to four patient categories: spinal cord injuries, brain injuries, stroke and general rehabilitation, and outpatient. Renovation cost was minimized by using the space the facility already had and installing cubicles and counter tops instead of desks and walls.
Mark Rosenthal, FACHE, assistant administrator of rehabilitation services, points out the benefits of the streamlined system:
• Teams communicate better as they become a highly interactive and cohesive unit.
Working together side by side every day facilitates ongoing discussions of patient care, Rosenthal says. "We have lots of curbside’ chats," he says. "We don’t have to wait for a weekly staffing conference to update each other."
• Teams work toward the same goal, rather than protecting territory.
Because of the teams’ enhanced communication, providers can better meet their goal of moving patients to the next level of care. "For example, a physical therapist may notice Mrs. Jones is perking up and is able to tolerate more therapy. So the team would know it was time to move her out of the subacute track," Rosenthal says.
Because the salient factors approach demands that all team members assume accountability for outcomes, "turf battles are virtually eliminated," he says.
• Teams offer intervention based on the patient needs and what is consistent for that patient.
Because team members work together, members can teach each other more easily how to perform those tasks consistently and according to the standardized practice of the appropriate discipline, Rosenthal says. "That means if a patient has to transfer in the middle of the night, it gets done the same way," he says.
Let staff lead the way
Be forewarned: traditional staff attitudes may be difficult to dissolve if you don’t involve them from the beginning, says Rosenthal. "It’s an entrenched notion that more therapy is better, every patient is treated equally, and that the only good therapy is one-on-one therapy," warns Rosenthal.
But Rosenthal says the change to patient-focused rehab is inevitable.
"Since 1993, our length of stay [at the acute hospitals] decreased from 29 to 16 days, Rosenthal says. "So patients were being admitted to rehab much quicker and much sicker. Plus, we could see the reimbursement structure moving from fee-for-service, to case rate, per diem, and eventually capitation."
Such dramatic shifts in operations must be embraced by all staff if it is to work, Rosenthal says. Together with Burgess, Rosenthal customized the approach for Emory by assigning staff to head three task forces:
1. The program design task force identified the specific model and structure of the program, determined the role of team members, and made recommendations regarding the clinical program’s organizational design.
2. The rehabilitation case management task force developed a model of care that ensured the patient would receive high quality, cost-effective medical and rehabilitation care in the appropriate setting as well as efficient use of services.
3. The documentation task force developed a system that eliminated duplication and reduced the staff’s charting time, communicated relevant information among team, patient, family, and payers, and complied with accreditation standards, while maintaining confidentiality. The task force also had to design forms compatible with the facility’s computer system.
About 114 staff from the following departments served on the teams: staff physical therapy, therapeutic recreation, communicative disorders, social services, admission/referral division, utilization management, information services, and psychiatrists.
Next, Rosenthal and Burgess "stepped back."
"We didn’t want to be perceived as managers running the show," Rosenthal says. "We did not attend task force meetings unless we were asked. Instead, we held a weekly steering committee meeting so task force chairs could discuss issues that were coming up. That way, we could help them address any problems, but we could do so at arms length."
As Rosenthal implemented the new system, he continues to remind staff that this process is not static.
"I told them and continue to tell them This doesn’t mean we’ll remain the same for the next 10 years and then change again. This system means we can continually react and adjust to the changing health care environment,’" he says.
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