The Power of Data: Achieving Consistent Patient Outcomes

 

CombinedSectionsMeeting2015

February 4‐7, 2015Indianapolis, IN 

 

www.aptahpa.org HPA The Catalyst is the Section on Health Policy & Administration 

of the American Physical Therapy Association 

Speaker(s):   Dianne Jewell, PT, DPT, PhD       Heather Smith, PT, MPH       Mary Stilphen, DPT  Session Type: Educational Sessions Session Level: Intermediate  This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s).  

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The Power of Data: Achieving Consistent Patient Outcomes

Mary Stilphen PT, DPTCleveland Clinic Rehabilitation and Sports Therapy

Dianne V. Jewell, PT, DPT, PhDThe Rehab Intel Network

Heather Smith, PT, MPH APTA

Session Learning Objectives

After this session, you will be able to:• Lay the groundwork for standardized outcomes data collection • Implement a standardized outcomes tool in a consistent and

accurate manner• Analyze and share the information you collect to improve

performance at the patient, clinician and/or organizational level

ACOs, Medical Homes

PTA differential payment

Pay for performance

Functional reporting

Therapy cap, MPPR

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Practice-based Evidence

Outcomes Evaluation

• Outcome = “The end result of patient/client management…” (Guide to PT Practice, page 43)

• Why standardized???– Consistency of measurement within an episode of care– Ability to compare across patients with similar diagnoses– Ability to compare across providers who manage patients

with similar diagnoses

Standardized Outcomes Tools: Options

Performance-based• Examples…

– Aerobic capacity (6 minute walk, shuttle walk, submaximal treadmill/cycle tests…)

– Balance (TUG, FRT, Berg, Tinetti…)

– Functional performance (FCE)

– Gait (10 meter walk, DGI, Functional Ambulation Category…)

Self-report• Examples…

– Oswestry– DASH– LEFS– NDI– SF-12– FOTO– AMPAC– OPTIMAL

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What you need to know…• Is the tool reliable?

– Inter-tester, intra-tester, test-retest, parallel forms, split-half, internal consistency

• Is the tool valid?– Face, content, construct (convergent/discriminant), criterion

(concurrent/predictive)

• Is the tool sensitive to change?

• Has meaningful change been determined?

The Power of Information on a Large Scale

• Internal uses–Performance improvement–Guideline refinement–Quality reporting–Staff development

• External uses–Referral sources–Payers–Consumers

THE CLEVELAND CLINIC STORY

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• 10 Hospital nonprofit health care system (9 Ohio, 1 Florida)

*

• Unified Brand• Unified Organizational and Leadership Structure • Standard Operational and Clinical Procedures• Increased Productivity, Efficiency, and Cost Structure• Positioning for Growth

Cleveland Clinic Rehabilitation & Sports Therapy

Care Pathways

Consistency of Service

Centralized Recruiting

Outcomes Measurement

“Each time you learn something new you have to adjust the whole framework of

your knowledge”Eleanor Roosevelt

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Timeline

January 2010 – Therapy Integration

April 2010 – New EMR

July 2011 – 6 clicks

July 2013 – G Codes

September 2013 – SNF data

History

• 2010 – MediLinks implemented as the EMR for PT/OT in the inpatient setting.–Progressive rollout started at main campus in

April 2010 and moved to 8 regional hospitals–Rollout completed by May 2011

• Observations in MediLinks allow the collection of discrete data

• June 2010 – Began discussions with medical leadership on what data should we collect and what questions did we want to answer

What were our initial goals?

• Collect meaningful discrete outcome data with every patient encounter

• Utilize discrete patient data to drive clinical decisions, demonstrate value and guide resource utilization

• Use data to devise a more objective way to determine the appropriate discharge disposition from acute care

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What Cleveland Clinic was looking for in a tool?

Minimal burden on staff

Minimal burden on patients

Incorporate functional items that therapists currently evaluated

No more that 6 questions

Ability to assist with moving patients to post acute settings

Criteria for selecting/developing a tool

• Short – No more than 6 questions. We liked the sound of “6 Clicks”

• Minimal burden on therapists. Develop something that could be easily incorporated into their day.

• Minimal Burden on patients

Could we use AM-PAC

• Activity Measure for Post Acute Care• 25 years in development• Validated across all post acute levels of care• Patient reported outcome tool • 249 items – 3 domains

– Basic Mobility– Daily Activity– Applied Cognitive

• Could be shortened and answered by surrogates

• Had not been validated for use in Acute care

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On Therapy evaluation, each discipline completes a functional measure assessment.

MOBILITY (PT):

1. Turning over in bed2. Supine to sit3. Bed to chair4. Sit to stand5. Walk in room6. 3-5 steps with a rail

SELF CARE (OT):

1. Feeding2. O/F hygiene3. Dressing Uppers4. Dressing Lowers5. Toilet (toilet, urinal, bedpan)6. Bathing (wash/rinse/dry)

Scale: 1= Unable (Total Assist) 2= A Lot (Mod/Max Assist)

3= A Little (Min Assist/CGA/Supervision) 4= None (Ind./Modified Independent)

Cleveland Clinic’s 6 ClicksCleveland Clinic’s 6 Clicks

Use of 6 clicks Data

Guide discharge recommendation

Guide therapist resource

utilization

Improve patient

mobility

PT 6 Clicks Data Volume – CCHS Hospitals

2011 2012 2013 2014 Total

Eval 27,876 43,132 54,876 57,606 183,490

Follow up 0 67,219 86,290 93,498 247,007

Total Visits

27,876 110,351 141,166 151,104 430,497

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Improve Patient Mobility

Ability to collect, aggregate and display functional data in a way that is meaningful to all members of the medical team has changed behavior and contributed to a “all hands on deck”

philosophy around patient mobility

6 Clicks Distribution – All Hospitals 2014

Ideal for nursing mobility

GUIDE DISCHARGE RECOMMENDATIONS

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Using 6 Clicks to guide discharge recommendations

Data over the past three years has been consistent

Home with no services –19.48

Home with home care –17.81

SNF/IRF –13.95 – 14.0

LTAC – 11.25

6 Clicks Predicts D/C Destination

• 83% of patients had recommendation and actual d/c placement match

• ROC analysis allowed us to define the best cutoff score for determining discharge to home on the basis of the highest sensitivity and specificity associated with the various scores.

• Cutoff scores of 42.9 for basic mobility and 39.4 for daily activity at the first visit provided fair to good accuracy for predicting discharge destination.

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IMPROVE THERAPIST UTILIZATION

80% 88%

10%5%10%5%

1% 2%

0%

20%

40%

60%

80%

100%

120%

PT (N = 5419) OT (N = 3075)

Patients with a 6‐Clicks score of '24' (highest level of function):Therapist Discharge Recommendation ‐ Combined

Inpatient Rehab Home care Home ‐ with outpatient PT/OT Home ‐ without skilled needs

Inappropriate Consults

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0%

2%

4%

6%

8%

10%

12%

14%

16%

18%PT & OT ICU Visits as % of Total Visits

Mandatory Functional Outcome Reporting

Journey at the Cleveland Clinic

Uniform data collection in all

settings

Use information from large uniform data sets

to make decisions.

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Opportunity at Cleveland Clinic

• Uniform Data Collection from all 47 outpatient locations into one database– Use that data to provide information back to policy makers– Is there a benefit of using a single “generic” outcome tool.– Useful starting point to increasing the accountability of rehabilitation

professionals– Represents a foundation for establishing a universal system of

reporting

Outpatient Outcome Tools

Outpatient

• AM-PAC Short Forms both Basic and Adapted versions

• Diagnoses specific Tools• LEFS• QuickDash• Oswestry• NDI• FactB +4

Benefits of Using a Single Outcome Tool

Ability to Develop Large Data Sets

Measure function on the same scale across multiple settings

Begin to have a consistent measurement of “function”

Using a single tool to measure VALUE

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Outpatient AM-PAC Data

• Data available for patients seen between 7-1-13 to 6-30-14– Patients must have at least 2 AM-PAC to be included

• 13,000 matched patients by MRN in Database• 6,000 additional patients with 2 AM-PACS that are not

identified by MRN

What did the data tell us?

• Worked with Diane Jette to analyze data • Manuscript submitted to PTJ

– Change of severity modifier codes was heavily dependent on patients’ initial functional status

– The odds of improving at least one severity level was 4.42 (95% CI 3.38, 5.78) times greater for those with initial AM-PAC scores in the upper end of the range than for those with initial scores in lower end of the range of scores.

Aiming for Value Transformation

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Strategy for Value Transformation

• Improve outcomes without raising costs

• Lowering costs without compromising outcomes.

Goal –Improve value for patients

• Patient level • System level

What does that mean for

PT/OT/ST

“Value” of PT/OT

• Systematic utilization of PRO’s for every patient in every setting.

Outcome

• Resources consumed during service deliveryCost

Should we start measuring patient reported functional outcomes longitudinally across an episode of care

Acute Hospital

Skilled Nursing • Hospital Based

SNF’s• Connected Care

Units

Home Care Outpatient

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Outcome Tools

Acute Hospital

• 6 Clicks Basic Mobility• 6 Clicks Daily Activity• Mini Cog

Outcome Tools

SNF’s / Connected Care Units

• AM-PAC Basic Mobility Adapted• AM-PAC Basic Mobility Adapted with

w/c• AM-PAC Daily Activity• Completed on all patients at admission

and discharge from therapy

Use of AM-PAC in SNF

• SNF – Connected Care • Compare LOS • # visits• Patient’s functional change between facilities

Can we establish a therapy efficiency measure??

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Next Steps

• We will adjust our thinking based on what we have learned.– Continue to collect “6 clicks” on EVERY patient at EVERY

visit

– Continue to collect functional outcome data as patients move to other post acute settings (SNF, IRF, Home Care)

– Standardize outcome tools that are used

– Move to diagnosis specific tools for non-Medicare patients.

Where do I start?

Lay the Groundwork

• Get the conversation started with key members of your organization– Who will be interested/impacted

• Identify your goals for outcomes collection– Questions you want/can answer– Benchmarks for performance

• Identify criteria for selecting your outcomes tools– Focus, feasibility, meaningfulness

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Lay the Groundwork

• Select your tool(s) and train your team– Accuracy, consistency

• Prepare a database– Internal v. commercial– “Minimum data set” of information to collect

Measure…Analyze…Share

• Ground rules for measurement– Frequency (intake + …)

• Ground rules for data analysis– Frequency of data review– Reviews that address the questions posed– What to do about problem cases

• Ground rules for reporting– What information will be shared– What format will be used– Who will receive the information

Effective Messaging

• Know your audience and their value priorities

• Ingredients of an effective message– Direct– Concise– Easy to remember

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APTA Tools and Resources

Evidence-Based Practice & Research• PT Now

– www.ptnow.org• Clinical practice guidelines

– http://www.apta.org/EvidenceResearch/ImplementingEBP/• Physical Therapy Outcomes Registry

– www.ptoutcomes.com

Additional Resources

• Validity of the AM-PAC ''6-Clicks'' Inpatient Daily Activity and Basic Mobility Short Forms. Diane U. Jette, Mary Stilphen, VinothK. Ranganathan, Sandra D. Passek, Frederick S. Frost and Alan M. Jette. PHYS THER. Published online November 14, 2013

• AM-PAC “6-Clicks” Functional Assessment Scores Predict Acute Hospital Discharge Destination. Diane U. Jette, Mary Stilphen, Vinoth K. Ranganathan, Sandra D. Passek, Frederick S. Frost and Alan M. Jette. PHYS THER. published ahead of print April 24, 2014

• A Sample of Private-Sector Hospital Discharge Tools: Case studies of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. American Hospital Association. 2015.