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The first step in creating clinical pathways is to know and understand your data. Identify your opportunities to affect quality and costs, says Tammy Corley, RN, BSN, ACM, director of care management for Premier Performance Partners, part of Charlotte, NC-based Premier, Inc.
Look at the various service lines and determine which MS-DRGs and APR-DRGs are most impacted by variations in care, she adds.
Bring together a multidisciplinary committee that includes representatives from throughout the hospital to analyze the length of stay and resource consumption for different diagnoses, and identify the DRGs where there are the most opportunities for improvement, adds Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts. Physicians must be part of the process so they will buy into the idea, she adds.
Evaluate how length of stay, cost of care, and outcomes are affected by variability in providing treatment, suggests Larry Burnett, RN, MS, managing director for Huron Healthcare, a Chicago-based healthcare consulting firm.
For instance, analyze how care differs among the various cardiologists who practice at your hospital and how it varies between the cardiologists and hospitalists and determine which methods match best practices, provide the best outcomes, and the most efficient and cost-effective care.
Corley suggests starting with your hospital’s DRGs with the highest volume and largest opportunities for improvement. Look at those with high volume, observed length of stay versus expected length of stay, cost opportunities, and variations in care that are impacting quality.
A large number of organizations are working on sepsis, which often is the No. 1 driver of length of stay, mortality, cost, and readmissions, Corley says. She adds that a large number of hospitals she works with are focused on developing sepsis pathways or protocols and standardizing their interventions around sepsis.
Using the best practices found in the literature, develop pathways and order sets, Corley says.
“Most hospitals try to make the pathways too complicated, and this affects how easily they are implemented. Our pathways are one page. They are based on a medical milestone format and focused on what is absolutely necessary to move patients through the care process, both clinically and operationally,” Burnett says.
Once the pathways are developed, send them to the hospital quality committee for review and final approval, Corley suggests.
“Hospitals don’t have to reinvent the wheel. They can replicate the guidelines available commercially, get them electronically, and drop them into the electronic medical record,” Cesta says. Hospitals need physician champions to conduct peer-to-peer education on the pathways and order sets, and on the need for standardizing care to ensure compliance, she adds.
If your hospital wants to design care pathways, don’t do it alone, advises Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management. Instead, pull in representatives from all the levels of care that provide services for each diagnosis or population. The process should be led by a facilitator who is experienced in designing pathways, she says.
Ask each of the levels of care to identify the common barriers that may get in the way of patients meeting their outcomes, she adds.
As CMS moves toward value-based purchasing and bundled payments, hospitals will need to develop standardized pathways that extend to 30, 60, and 90 days after discharge, Zander says.
“Hospitals have to collaborate with post-acute providers and know their plans,” she says.
Decide on what outcomes you want at the end of acute care — home care or a skilled nursing facility. “Outcomes in the categories of knowledge, functions, physiological, and psychological health, and the absence of complications are crucial measurements,” she says.
List the tasks that should happen in the hospital, the orders that are needed, the core measures that should be implemented, what tests and procedures should be performed, and what the results should be, Zander suggests. Then do the same for the post-discharge providers. “Care will be mostly the same in the hospital but will vary after discharge,” she adds.
Pathways that extend throughout the continuum will enable case managers to think 30, 60, or 90 days ahead, which will put the hospital in a good position when the Centers for Medicare & Medicaid Services fully implements bundled payments, she says.
“What is going to be hard is that not every patient follows the same continuum. One hip replacement patient may need to go to a skilled nursing facility, but another may be able to go straight home with home care services. This flexibility will require software that is malleable and uses more than drop-down windows. Mostly, it requires good old-fashioned care planning skills,” she says.
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