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Triage, pathways and outcomes
This three-pronged approach is helping one facility assess care and modify treatment plans. Can it work for you, too?
By John Melvin, MD, Mary Segal, PhD, and John Whyte, MD, PhD
It's hard not to notice managed care's ever-increasing forces--
especially when they're causing inpatient rehab providers to revise once-standard practices. As a result, many services traditionally delivered in inpatient settings are now transferred to the community.
In addition, rehab hospitals are increasingly entering into contractual arrangements that capitate fees to cover patients' total care needs. To negotiate wisely, managers must know how diagnoses and variables within each diagnostic category, such as age or chronic illness, affect costs. Among other things, they also must determine which rehab services can be most effectively delivered in an outpatient setting.
Rehabilitation providers at MossRehab in Philadelphia are answering these questions by piloting projects to learn more about patient care processes. Our data, accumulated as part of a hospital program called the Clinical Management System (CMS), document how patients with various diagnoses recover, not only during the inpatient stay, but also after several months at home. We expect this information to help us develop predictive models to classify patients.
These models will enhance our ability to project outcomes, calculate the resources specific patients use, and ultimately, move selected services from the inpatient to the outpatient setting in a way that corresponds to the patients' clinical needs.
The CMS has three major components: triage, pathways and outcomes. In addition, it includes a feedback process that culminates in needed changes. To help clinicians and staff become oriented to the program, we introduced these components in phases, beginning with discharge and post-discharge outcomes in January 1996 and followed by development of stroke pathways in July 1997. Triage decision rules are now also under development for stroke patients. By rolling out the CMS in stages and by initially limiting components to one diagnosis, we could test our processes and make any necessary adjustments on a small scale before adding the next step. Below are the stages:
- Triage. Before admission, each stroke patient will be evaluated to determine the required treatment program: subacute care, acute care, home health services, day program services or skilled nursing care. The decision-tree takes into account patients' functional, medical, social support and insurance status. We expect the triage instrument to provide guidelines that can be broadly applied to about 90 percent of our patients, recognizing that some patients will not fit the model. As we progress, we will examine who these patients are, and use this information to continue to refine the triage process.
- Pathways. On the patient care unit, a computerized database tracks performance indicators for each stroke inpatient on admission and at weekly intervals until discharge. During the pilot year, these indicators have been limited to walking (or wheelchair maneuvering), lower body dressing, toilet transfer, toileting self-care, bladder management and medication management. Once we have accumulated enough data, we can begin to identify the time range when patients' skills plateau in these areas.
This information will help us predict when stroke survivors, and eventually, those with a range of other diagnoses, can be expected to regain various levels of function. Over the next few months, we plan to expand this database to include patients receiving pulmonary rehab.
- Outcomes. Measured for all of our inpatients, outcomes have traditionally been assessed with the FIM. This instrument is administered upon admission and again at discharge. To determine function along a more comprehensive continuum of care, however, we have augmented the FIM with questions about function in the community at six months post-admission. A 30-minute telephone survey is conducted on a random sample of patients representing all diagnoses. This elicits information about disability level (using FIM scores), community mobility, home/community health and safety, social activities, quality of life and caregiving requirements, and also includes a brief screening for depression. This database, operational as of January 1996, now contains information on more than 1,200 patients.
- Feedback. Ideally, outcomes data provide feedback to improve the standard of care. Predicting patient progress and outcomes is at the core of CMS. When we first assess patients for their rehabilitation potential, we would like to project what their broad outcomes--including functional status, community integration and quality of life--will be. The feedback loop built into CMS provides for the kind of refinement and fine-tuning necessary in any such comprehensive effort. Here are some issues that have emerged for further consideration:
Caregiver training/patient education. Within six months of discharge, about one-third of our stroke survivors fall one or more times, most often in the home. We are reviewing selected charts to determine whether changes in our education program might reduce the incidence of these post-discharge falls.
For example, should safety education begin earlier in the patient's stay? Is adequate time spent on specific ways to eliminate in-home falling hazards? Patients with lower extremity amputations have also experienced a significant, though lower (11 percent), rate of falls, which we also hope to reduce.
Medical acuity. Certain underlying chronic conditions may be associated with higher-than-average costs. We expect further investigations to confirm that renal dialysis is one of these conditions. Such information should be helpful when we negotiate future managed care contracts, and will enable us to identify and adjust for these conditions. Similarly, we will be able to review costs associated with other patient care requirements, such as feeding tubes or wound care.
Transfer of services. Stroke survivors with aphasia and other speech deficits typically plateau in their recovery well after discharge. For this reason, we are now beginning to move speech therapy services for these people to the outpatient setting.
Because we can now examine data on individual patients, as well as combined averages, we can study the medical records of those who performed better or worse than expected. For example:
- About 10 percent of our patients with lower extremity amputations tell us post-discharge that they didn't wear their prostheses or pylons. The team may contact these patients again to determine why. We will also examine the inpatient record for possible predictors of nonuse. If this pattern persists, the team may consider changing its ordering protocols for certain patients or developing extensive follow-up programs to encourage prostheses use in this group.
- Some 10 percent of patients with a diagnosis of medical deconditioning tell us they do not receive expected post-discharge services. The team may opt to contact these patients for more information. If a gap in providing appropriate services truly exists, we will monitor patients in this category to ensure that they receive all needed outpatient services.
- Upon admission, 25 inpatient stroke survivors couldn't walk independently. At discharge, 10 were walking independently with assistive devices, requiring only supervision. Six patients regained this skill in fewer than 20 days; however, four took between 21 and 40 days to reach this level. We want to know why it took some patients longer to attain this level of function, given that all were admitted with equal levels of disability. Now, we can examine the charts and admission profiles of our higher- and lower-functioning patients for possible explanations.
This spring, our first CMS stroke inpatients from fall 1997 will be contacted to participate in the six-month post-admission survey. For this group of patients, we will have high-quality demographic, functional and medical information that spans admission through the rehab stay. When the post-discharge survey is completed, we will also have the patients' descriptions of continued resource use and their detailed post-discharge outcomes. We, therefore, can retrospectively link our patients' post-discharge status with their experiences during the inpatient stay, and thus, refine our patient care processes.
With the CMS, we're initiating a response to far-reaching changes that mandate shorter lengths of stay, documentation of patient outcomes, and a careful financial assessment of all care delivered.
All authors are with MossRehab, Philadelphia. John Melvin, MD, is vice president of medical affairs. Mary Segal, PhD, is a research scientist, and John Whyte, MD, PhD, is director of Moss Rehabilitation Research Institute.
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