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Eliminating care variation is vital today
In many hospitals, clinical pathways were all the rage 20+ years ago. Everybody was developing them, but they rarely were completely implemented and many of them fell by the wayside over the years.
But with the growing emphasis on reimbursement that is based on value and not volume, clinical pathways — also called practice guidelines, critical pathways, or CareMap® tools — are making a comeback, and they’re bigger and better than ever.
Standardized care pathways, order sets and protocols are nothing new, says Tammy Corley, RN, BSN, ACM, director of care management for Premier Performance Partners, part of Charlotte, NC-based Premier, Inc. “Many hospitals have developed them but have been challenged with rolling them out and getting practitioners to use them for a number of reasons.
Pathways fell out of favor because of the difficulties in implementing them and monitoring their use. The doctors didn’t buy into the concept because they thought it was “cookbook medicine” and hospitals stopped using them, adds Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
“The concept was right, but without an electronic method to implement the pathways and monitor compliance, it was a difficult tool to use. It’s hard to monitor compliance or document variation in a paper chart. The electronic medical record offers a new opportunity to implement practice guidelines and order sets. Guidelines can be automated, and now there is a way to monitor their use,” she adds.
The changes in reimbursement being implemented as part of healthcare reform are bringing a revival of clinical pathways, says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management. “The new programs from the Centers for Medicare & Medicaid Services (CMS) mean that hospitals need to focus on efficiency measures and resource consumption as well as costs along the continuum of care. To do so, they need to ensure that patients are receiving evidence-based care, and they need tools that allow them to monitor and control how they are spending money,” she says.
For instance, the CMS Value-based Purchasing Program rewards hospitals for providing quality of care. Medicare spending-per-beneficiary, which bases hospitals’ scores on spending during an entire episode of care starting three days before admission through 30 days after discharge, makes up 20% of hospitals’ value-based purchasing score.
Then, there’s the Bundled Payments for Care Improvement pilot project, which pays a fixed price for a wide range of health services by multiple providers over a specified period of time or episode of care, Zander says. (For details on bundled payments, see Hospital Case Management, October 2014, Vol. 22 No. 10, pages 135-137.)
“Bundled payments are going to be a game changer because in many markets, cost and utilization per case will replace length of stay as a primary goal. Since bundled payments provide a lump sum for 30, 60, or 90 days of care, pathways must stretch beyond what acute care does and include what outcomes are expected if the patient goes to inpatient rehab, a skilled nursing facility, or home with home health,” Zander says.
Practice guidelines or pathways are a tool to help providers follow recommendations for evidence-based care, Cesta says. “The more you standardize, the more you reduce variations and reduce costs,” she says.
In the past, nobody was trying to control resource consumption, such as the use of antibiotics, and testing such as MRIs and CT scans, Cesta points out.
For instance, at one time, physicians typically ordered a chest X-ray every day for pneumonia patients. “Now we know that patients with improving signs and symptoms don’t need a chest X-ray every day and we can build into the guidelines and order sets when X-rays are recommended. Practice guidelines are an idea whose time has come,” she says.
Today’s technology makes it much easier for pathways to be utilized than when they were all on paper, Corley says. “Certain diagnoses can electronically drive the clinical pathways associated with them so you are not relying on an individual to go find, pull, and place on the patient’s record in order to initiate,” she says.
Research supports the idea that evidence-based clinical pathways can improve the processes of care that affect quality and financial outcomes, Corley adds.
“There’s definitely a need to standardize care. Fragmented care and lack of evidence-based care can result in devastating costs and, most importantly, suboptimal clinical outcomes,” Corley says.
Healthcare’s shift to new payment models along with the need to deliver high-quality care at a reduced cost has increased concerns about clinical variation in patient care, says Larry Burnett, RN, MS, managing director for Huron Healthcare, a Chicago-based healthcare consulting firm.
Clinical variation frequently occurs in hospitals, Burnett points out. “Individual clinicians often follow different practice patterns for the same diagnosis,” he says. There is generally as much variation between physicians in the same practice as there is among physicians nationally, he adds.
“Many variations in care are medically unnecessary and don’t positively impact quality and cost. Reducing variability results in better care, and that’s what the pathways do. When hospitals put evidence-based pathways in place, care improves, length of stay decreases, patient satisfaction scores increase statistically, and readmissions, complications, and mortality decrease, in our experience,” he adds.
Physician selection and practice patterns play a large part in determining length of stay and costs, Burnett says. But don’t fall into the trap of focusing exclusively on physician behavior to reduce care variation because other systems, processes, and people factors can affect care delivery, he says.
For instance, a heart failure patient may stay an extra day because the physician didn’t adjust his diuretic, because the nurse didn’t record the patient’s weight gain, which would have triggered a dosage adjustment. Or, the physician made the change but the pharmacy was slow in filling the prescription.
“All members of the entire care team—physicians, nursing, case management, lab, pharmacy, and other ancillary services—play a role in determining patient care. To succeed in managing care variations, hospitals have to include all clinicians and clinical services,” he says.
Physicians want to do the right thing, but there are substantial differences in training among physicians and their understanding of best practices in clinically complex patients, Burnett says.
“It’s up to the RN case manager to partner with physicians and make sure they are following the recommended standards of care,” he says.
Historically, physicians resisted using pathways, saying they were “cookbook medicine,” Corley says. “I don’t see that resistance today. The term evidence-based medicine has been used more and more over the years, and physicians understand the importance of following the best practices,” she says.
The choice about whether to implement evidence-based protocols is always at the discretion of the physician, Burnett points out. “The pathways cannot dictate medical care,” he says.
Pathways do not take away physician decision-making, Corley points out. They outline the best practices/interventions and they can, and should, be tailored to meet the needs of individual patients.
For instance, a 40-year-old-patient with pneumonia may not necessarily need the same treatment as an elderly patient with multiple comorbidities who also has pneumonia. In the case of the elderly patient, the physician might have to adjust the treatment plan while still using the clinical pathway as the guiding practice, she says.
The practice guidelines are just that — guidelines, Cesta adds. “Providers still have to look at patients as individuals and adapt the guidelines to meet their needs. Physicians should use order sets and guidelines as a foundation but treat each patient as an individual,” she says.
Clinical pathways are the best practices that work well for a lot of people. “But even if the pathways are standardized and look the same for all patients, the care will have to be individualized, and it is the job of the case manager to make sure the standard path is individualized for each patient,” Zander says.
The pathways being developed today are still medically driven and most have built-in order sets, Zander says. The best ones outline what other disciplines should be doing independently of what needs a doctor’s orders, Zander says. For instance, physicians have to write an order for a patient to have physical therapy, but orders are not needed for a social work consult or for the nurse or case managers to begin patient education.
“The new clinical pathways are still going to be centered around what the doctor orders, but they must stretch past acute care into skilled nursing facility stays and home care services. It’s the same patient in every setting, and the education needs to be the same and the plan of care needs to mesh. Everybody has to be more consistent and better organized,” she says.