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Critical Pathways: Occupational Therapists' Role in Development and Utilization
Arlene M. Andrews Susan J. Bass
Michele L. Engle Stephanie H. Estes
Jennifer J. McEachran Alexandra M. Shallers
ABSTRACT. Managed care is mandating that healthcare facilities imple- ment cost containment measures. Critical pathways are one popular tool used to meet this demand. Thc purpose of this study was to explore current involvement of occupational therapists (OTRs) in the use and creation of critical pathways.
Results of a national survey showed 70.5% of the respondents reported they are not currently using critical pathways. A majority of OTRs are not and have not taken an active role in critical pathway development. Fur- thermore, the majority indicated having no knowledge of future critical pathway implementation in their facilities.
Information gathered fiom those OTRs reporting critical path use in- cluded most common diagnoses using the paths and percentages of OTRs utilizing critical paths in specific occupational therapy areas.
The conclusions drawn by the researchers indicated the need for OTRs to becomc more involved in the developmcnt and utilization of this multi- disciplinary approach to treatment. For OTRs to maintain and enhance their positions within the allied health profession, proactive involvement
Arlene M. Andrews, Susan J. Bass, Michele L. Engle, Stephanie H. Estes, Jenni- fer J. McEachran, and Alexandra M. Shallers are affiliated with the University of Indianapolis.
The authors would like to thank their advisor, Lynn R. Surrey, PhD, for his support and guidance, Robin T. Underwood, OTWL, for her assistance with the research development, and Pamela V. Wolfe for her editorial feedback.
Occupational Therapy in Health Care, Vol. ll(3) 1998 O 1998 by The Haworth Press, Inc. All rights reserved. 53
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54 OCCUI?4TIONAL THERAPY IN HEALTH CARE
with these managed care driven quality assurance methods is essential. [Article copies available for. a fee from The Haworth Doc~unenl Delivery Service: 1-800-342-9678. E-mail address: ge/i~lfo@/~awortl~pr~sinc.com]
Health care costs are on the rise and will continue to rise as medical technology increases and as thc Amcrican population grows older. Recently, managed care models such as Health Maintenance Organizations and Pre- fcrred Provider Organizations have become popular methods uscd to de- crease medical costs while maintaining health care quality for consumers (Christiansen, 1996). Managed care approaches, which include critical path- ways, are being used in a variety of clinical settings, and limited published data shows promising results of its effectiveness (Blegen, Reiter, Goode, & Murphy, 1995). Critical pathways can also be identified as care maps, care paths, clinical guidelines, algorithms, collaborative case management plans, service strategies, and outcome management (Sinnott, 1994). Critical path- ways provide a standardized treatment approach that enables health care facilities to achieve the goal of improving care delivery while meeting man- aged care paycr requirements (Graham, Pettus, & Klava, 1995). The purpose of this study is to explore current involvement of occupational therapists in the use and creation of critical pathways.
Between 1929 and the middle 1950s, the percentage of the gross national product (GNP) expended on medical and health care remained relatively stable at about four percent. This percentage began to increase in the middle 1950s and has since continued to rise at a steady pace (Lundberg, 1994). In 1995, 14% of the GNP in the United States was spent on medical and health care (Blegen et al., 1995), which shows a 10% increase in approximately 20 years.
Health care in the United States is funded by both public and private organizations, and one of the major sources of public health care funding is Medicare. Medicare provides hospitalization insurance for persons ages 65 and older, and also aids this population in paying physician, home health care, and other health care expenses (Levy, 1993). Under Medicare, health care costs have risen from $5 billion at the inception of the program in 1965 to $110 billion in 1993 (Levy, 1993). As the medical field continues to make technological advances in diagnosis and treatment techniques, an extended life expectancy can be anticipated. The population served by Medicare will continue to increase and contribute to rising health care costs.
Managed health care is increasing in popularity as an effective method of
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cost containment for the health carc industry. Managed care is an organized system that oversees care for an enrolled population by controlling the selec- tion and utilization of health services in a high quality, cost-effcctive manncr (Doolan, 1995). True managed carc involves payment of a prenegotiated flat fee to a health care provider for each person enrolled in the health care plan (Lanute, 1994). Under this capitated system the health care provider agrees to perform all necessary services for the prenegotiated monthly fee. As services are eliminated, or dcemed unnecessary, profit margins increase (Undcrwood, 1995). Annual growth rates of managed care have risen from 5 to 15 percent between 1986 and 1994, which demonstrates physicians' willingness to ac- cept such plans (Heinen & Chase, 1994). According to Shatistein and Beigel, managed care companies investigate the need for admissions and continued hospital stay according to strict criteria (as cited in Gibson & Richert, 1993). The purpose of managed care is to cut costs paid to hospitals and practitioners and to shorten the length of hospital stays (Gihson & Richert, 1993). Man- aged care organizations choose to contract with physicians and hospitals that demonstrate cost-efFective care delivery or a willingness to follow the prac- tices dictated by managed carc organizations (Heincn & Chase, 1994).
A central issue in the selection of care providers by managed care opera- tors is knowing the planned course of rccovery for specif-ic diagnoses and estimated costs in advance (Graham, Pettus, & Klava, 1995). Critical path- ways are capable of providing managed care organizations with this informa- tion. Coffey et al. (1992) definc critical pathways as an optimal sequencing and timing of interventions that is developed by a multidibciplinary team for a particular diagnosis. Underwood (1995, paragraph 22) stated:
Critical pathways are an indication of the course of patient treatment on a time line, with an outcome orientation, and with prompts for a multi- disciplinary staff to perform important interventions so that costs arc contained and quality, as defined by the consumers, is assured.
The critical path method was i h t introduced to the health care industry in the early 1970s, but was not well received (Coffey et al., 1992). The following three paragraphs outline the three main factors stated by Undcrwood (1995) that have causcd the health care community to reevaluate the use of critical paths as a method of planning care.
Foremost, according to Spath, quality control programs such as W. Ed- ward Deming's Total Quality Management (TQM) wcre implemented in American industries during the 1970s (as cited in Underwood, 1995). Dem- ing believed that 94% of all industrial errors were system errors (Gillcm, 1988). Deming's TQM concept focuses attention on a systems approach to process management that increases effectiveness of operations and reduces costs associated with error (Martin, 1990). Recently, health care institutions
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56 OCCUPATIONAL THERAPY IN HEALTH CARE
have been facing many of the same pressures as industry, such as escalating costs with sharper competition and rising quality concerns (Lopresti & Whet- stone, 1993). By evaluating treatment mcthods for various diagnoscs and creating critical pathways, the hcalth carc industry is closely paralleling the TOM approach being used in other industries.
Additionally, in 1983 the Joint Commission on Accreditation of Health Care Organizations mandated quality assurance activities centering around patient care problems be coordinated and implemented by hcalth care organi- zations (Fain & Wahlen, 1992). According to Sinnott (1994), critical path- ways can bc used as a total quality management strategy in any setting. The critical path method contributes to quality assurance by decreasing delays and duplication of services, improving professional collaboration, and expos- ing inconsistencies in care (Sinnott, 1994).
Finally, the Prospective Paymcnt System was introduced in 1983 for Medicarc reimbursement of inpatient acute hospitalization (Underwood, 1995). Currently, hospitals are paid one rate per Diagnosis Related Group. This rate is fixed, regardless of procedures or services the patient receives, or how long the patient is hospitalized (Underwood, 1995). To assurc profitabil- ity, hospitals devised systems to assess and adjust patients' lengths of stay and treatment protocols (Underwood, 1995).
These factors have led to the increased use of case management and thc reintroduction of critical pathways as an instrument used in the case manage- mcnt approach to patient care. The case management approach is defined by Ovretveit (1992) as a method of patient care that is designed to provide a clear plan that specifically defines the objectives of each disciplinc. This approach ensures that health care services are coordinated, the care plan is rcviewed and updated as needed, and that !he patient obtains the best value of service for fees rendered.
The research literature offers scveral examples of critical pathways being used with a wide variety of patient populations in both inpatient and outpa- tient trcatment settings, subacutc care, extended care, and home health care. According to Sinnott (1994) critical pathways can aid all health professionals in meeting the challenges of practicing under the currcnt trends of managed care. In an article entitled Case Mur~agenlent-A Bottom-Line Care Delivery Model, the development of a case management model is described that is representative of the most common developmental processes found in the literature. The model was developed at the Tucson Medical Center, a non- profit hospital, to provide quality patient care and meet tight financial restric- tions (Olivas et al., 1989).
A committee was formed by the nursing profession to develop and imple- ment an alternative care dclivery model. The members of this committee consistcd of hospital administrative personnel, nursing personnel, and other
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clinical staff including physical therapy and social services. The goal of this committee was to develop an ideal care delivery system for both total hip reconstruction patients and leukemia patients, which included critical path- ways. The committee sought to use "collective intclligence," which incorpo- rated each team member's expertise and perspective in the development of this care system (Olivas et al., 1989). Occupational therapists were not men- tioned in this article as having a place on the multidisciplinary critical path- way development team. From review of the literature, thc exclusion of occu- pational therapists is a scenario typical of other multidisciplinary teams fom~ed to develop critical pathways.
Managed care is radically changing the health care delivery system. The health care professionals and organizations who fail to understand the im- plications of managed care will not be prepared for the future. According to Landry and Knox (1996), occupational therapists will need to find new ways to provide services under the capitated managed care system. This will in- volve providing care within a fixed budget and redesigning therapy methods to reduce procedures and modalities for any given treatment or thcrapy. As previously explained, critical pathways can be developed and used as a tool to hclp occupational therapists make the needed changes to survive managed care implementation.
The literature does not clearly indicate that occupational therapists are currently involved in the development and use of critical pathways, although research has shown that critical pathways are a valuable method for contain- ing costs and maintaining quality of care for all health care professionals. The intent of this research studv was to exdore occu~ational theranists' use and knowledge of critical pathways. More specifically, the researchers antici- pated support for the following research hypotheses:
1. The majority of occupational therapists across the United States are not currently using critical pathways in their treatment settings.
2. The majority of occupational therapists across thc United States have not or are not currently taking an active role in developing the critical pathways in their facilities.
3. The majority of occupational therapists across the United States havc been informed that their facilities will be using critical pathways for treatment of one or more patient diagnoses in the future.
METHODOLOGY
The subjects for this study included 500 randomly selccted registcred occupational therapists (OTRs) from throughout the United States. These individuals were chosen from the population of occupational therapists who
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are members of the American Occupational Therapy Association (AOTA). Each randomly selectcd OTR was sent a survey by mail. The survey con- sisted of 16 questions, including both sub.jective and objectiv'e items, regard- ing the use of critical pathways. A cover letter accompanied the survey describing the intent of the research and ensuring respondcnt confidcntiality. Demographic information from the respondents is summarized in the follow- ing tables: Table 1 shows the experience level of the OTR both in the field of occupational therapy and expericnce at the current facility. Table 2 illustrates the demographic information regarding the location of the responding thera- pist, grouped by region.
RESULTS
Two hundred eight of the 500 surveys mailed were returned. Eighteen surveys were not used in the compilation of data due to inaccurate or insuffi- cient completion of the survey. Therefore, data analysis was performed on 190 surveys. The total number of responses to each question were tallied and converted to a percentage of the whole.
Of the OTRs reporting, 70.5% are not currently using critical pathways
TABLE 1. Experience Level of OTRs Surveyed
Experience Ranges from 1 Averages I
I Years in occupational Less than one year I 11 . I1 years theraov 1 to 38 veara I
I Length of time at current Less than one year 4.96 years facility to 25 years I
TABLE 2. Location of OTRs Surveyed
Western I 58 I 30.53% Northeastern 1 53 27.89%
Region
Southern I 44 I 23.16% Midwestern 34 17.89% I
I I
Number of Respondents Percentage of Respondents
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when treating their patients. Nearly 30% of the OTRs who are not currently using critical pathways reported that they are being developed in their facili- ty; 34.3% indicated they are not being developed, and 35.8% were uncertain regarding critical path usage.
Fifty-six OTRs (29.5%) indicated that they are currently using critical pathways when treating their patients. These individuals were instructed to answer five additional questions specifically related to the use of critical pathways in thcir facility. When asked if they were consulted about or in- volved in the development of critical pathways in their facility, the following responses were obtained:: thirteen (23.2%) indicatcd they were personally involved, 16 (28.6%) indicated another OTR at their facility was involved, 15 (26.8%) indicated another OTR and himherself were involved, 3 (5.4%) indicatcd that no OTR in their facility was involved, and 9 (16.1%) were uncertain. Thosc' individuals who indicated that they were a part of critical path development were then asked what role thcy played in the development of the pathway. Seven (16.0%) stated thcy were the team leader; 29 (67.0%) stated they were a team membcr; and 6 stated they played another role, such as consultant.
DISCUSSION
It has becn established that as health care costs continue to rise, so has the usc ol'managed care as an effective form of cost containment. Managed care organizations choose to contract with hospitals and physicians that conform to their guidelines. The health care professionals and organizations that fail to understand the impact of managed care, with emphasis on cost containment strategies, will jeopardize their active participation in the hcalth care arena. A rapidly emerging mcthod of cost containment that can aid all health profcs- sionals, including occupational therapists, in the challenge of reducing treat- ment cost is the development and use of critical pathways.
Of the 190 OTRs surveyed, 70.5% rcported that they are not currently using critical pathways when treating their patients. This strongly supports our first research hypothesis.
In addition, research hypothesis number two was supportcd as the findings in the results section indicate. A majority of OTRs are not taking or have not taken an activc role in developing critical pathways.
Furthermore, the majority of OTRs have not been informed that their facilities will be using critical pathways for treatment of one or more patient diagnoses in the future, which docs not uphold the anticipated results as staled by hypothesis number three. Since approximately one third of the OTRs are unaware of critical pathway dcvelopment in the facility in which they work, it is the belief of the researchers that this is an cxample of thc
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OTRs' need to educate themselves and become proactive in their profession. OTRs must actively scek opportunities to work with multidisciplinary teams in development of critical pathways.
For those participants indicating that the paths were currently being devel- oped in their facility, 55% reportcd that, if asked, they would participate in the development, 17.5% reported that they would not participate, and 27.5% reported that they were uncertain. For those OTRs cmployed at facilities not currently developing the paths, 70% of the therapists said they would partici- pate given the opportunity, 4% reported they would not, and 22% indicated unccrtainty. These findings indicate that between 26-45% of occupational therapists will not participate or are uncertain about taking an active role in developing critical paths. This is cause for concern. If occupational therapy does not take an active part, then its services may bc excluded from these paths. This, in turn, may lead to occupational therapy services not being utilized or reimbursed.
Most troubling, however, is that a vast majority of occupational therapists are not participating in the use of critical pathways for a variety of reasons. There were numerous individuals who made comments on their surveys indicating that they did not use critical pathways because they currently do not apply to the settings or patient populations with which they work. Others commented that critical pathways are restrictive and would severely limit the role of the occupational therapist in treatment.
The researchers feel it is important that those OTRs who are familiar with critical pathways become educatcd about thc benefits provided by this tool. In today's managed care cnvironment OTRs need to realize that they can use critical pathways as a way to ensure those patients who can benefit from their services receive them.
The following are additional findings from this research study that are not directly related to the hypotheses. First, the most conunon diagnoses for which critical paths are used include: total hip replacement, total knee re- placement, hip fractures, cerebral vascular accidents, and traumatic brain injuries (see Table 3). This indicates that the pathways are utilized mainly with orthopedic and physical dysfunction diagnoses and are not utilized as frequently with mental health diagnoses. Similarly, of the survey respondents who work with physical disabilities, 50% use critical paths. Thirty-nine per- cent of the respondents in hand therapy utilize the paths, while only 14% of thc therapists in mental health use them (see Table 4).
All respondents were asked to identify which disciplines in their facility are utilizing or are involvcd in developing critical paths. (See Table 5 for the complete listing of the disciplines.) Thirty-nine percent of nursing depart- ments, and 35% of the physical therapy departments utilize critical pathways; 48% of the responding OTRs are employed at facilities which have no disci-
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TABLE 3. OTRs Use of Critical Pathways by Diagnosis
Diagnoses
TABLE 4. OTRs Use of Critical Pathways by Patient Population Sewed
% of OTRs Using Critical Pathways
Total Hip Replacement Total Knee Replacement
Hip Fracture Cerebral Vascular Accident
Traumatic Brain Injury Depression
Chemical Dependency Eating Disorders Schizophrenia
73.21% 62.50% 48.21 %
37.50%
17.86% 5.36%
0% 7.1 9%
0% -
I Mental Health 1 14.29% I Occupational Therapy Areas
Physical Disabilities I 50% Developmental Disabilities 9.09%
% Utilizing Critical Pathways
Work Hardening Hand Therapy
Home Health Care Education
0% 38.89% 23.53%
0%
Industrial Rehabilitation School System
Early Intervention Geriatrics
plines involved in the use of the paths. Thirty-nine percent of nursing and 38% of physical therapy departments were or are involved in developing the paths, while 45% of the facilities had no involvement in developing critical paths.
Another interesting finding is thc relation betwcen critical pathway use and the geographic location of the therapist. Of the therapists who are utiliz- ing critical pathways, 47% reside in thc Western region of the United States,
20% 16.67% 14.29% 17.02%
Other 16.67%
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TABLE 5. Critical Pathways Use and Development by Discipline
Disciplines
Recreational Therapy ( 6.84% I 7.37% Social Services I 23.16% 21.05%
Nursing Physical Therapy Speech Therapy
Respiratory Therapy
I I
% Using Critical Paths
34% in the Northeast, 23% in the South, and 18% in the Midwest. One explanation for this trend is that the east and west coasts begin to implement new ideas which then spread to the south and midwest. A secondary explana- tion may be that managed care is more prevalent on the east and west coasts, which has forced OTRs to take an active role in methods of cost containment such as critical paths.
Due to timc constraints and financial resourccs, limitations are inhercnt within this study. Occupational thcrapists surveyed are all members of AOTA, due to the accessibility of a list of names to pool for the research. The survey is completely self-reported by OTRs, with no input from COTAs regarding critical pathway usage.
The following are recommendations for further research that may prove beneficial to the field of occupational therapy. First, the cost-effectiveness of critical pathways could be addressed by looking at the diffcrences between facilities that use and do not use pathways. Critical pathways may enhance cost-effectiveness by decrcasing duplication of services, and leading to im- proved interdisciplinary collaboration. Second, since the majority of OTRs do not use critical pathways, further research may reveal the underlying reasons for this trend. Third, since critical pathway usage may be the future trend for occupational therapy, a correlation betwcen disciplines not included in pathways and the utilization of their services within the facility may show justification for using the pathways. More specifically, because the research- ers found that a low perccntage of these paths are used in mental health, research in this area may be necessary.
% Involved In Development
38.95% 35.26% 17.37% 12.11%
Medicine Teaching
Other None
38.95% 38.42%
21.05% 11.58%
21.58% 6.32% 14.74% 47.89%
23.68% 5.26% 17.37% 44.74%
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CONCLUSION
Ln conclusion, this study examined OTRs' roles in the development and implementation of critical pathways. Critical pathways are an intcrdisciplin- ary approach to achieve the goals of cost-eftective services along the continu- um of care as provided by a facility, while maintaining quality of care. Our results indicate the majority of OTRs are not currently using critical paths in patient treatment. For OTRs to maintain and enhance their position within the allied health profession, it is imperative thcy become proactive in their in- volvement with critical pathways.
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