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Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 1
ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING
Continuing the Conversation
Combined Sections Meeting 2015February 4th-7th, 2015 – Indianapolis, IN
Michael Friedman PT, MBA
Johns Hopkins Medicine - @mkfrdmn
Mary Stilphen PT, DPT
Cleveland Clinic - @marystilphendpt
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 2
Cleveland Clinic Rehab and Sports Therapy
Therapy Locations
Cleveland Clinic Main Campus and 8 regional
hospitals
100 IRF beds
65 SNF beds
3,277 Acute care beds
47 Outpatient locations
Rehab Team
350 Physical Therapists
100 PTA’s
135 OT’s
25 COTA’s
35 SLP
5 Audiologists
50 ATC’s
The Johns Hopkins Hospital (JHH)Baltimore, MD
Licensed Acute Beds - 994Annual Admissions – 50,000Acute Care Therapists – 65 FTEs
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 3
Description
Healthcare reform has reinforced the need to transform service models to focus on value by emphasizing efficiency and efficacy. This need for system re-design, culture change and the call for innovation presents an opportunity to overcome the long-standing challenges faced implementing an interdisciplinary mobility program as a standard of care.
In this educational session, we will build on the 2014 CSM discussion and will examine opportunities, strategies and tactics to position, implement, and evaluate interdisciplinary mobility initiatives in the hospital setting.
Objectives
• Review the evidence supporting mobility in the acute care setting
• Identify the value opportunities for mobility to enhance outcomes or reduce costs along the healthcare continuum.
• Demonstrate how Hospitals can successfully integrate many types of data to inform their decision making.
• Examine specific strategies to leverage organization Healthcare Reform initiatives to drive Interdisciplinary mobility
• Discuss strategies to initiate, conduct, and evaluate an interdisciplinary mobility model
• Discuss practical strategies to measure implementation success
ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING
Highlights from CSM 2014
• Evidence Supporting Activity
• Value and Waste
• The Systematic Use of Data
• 10 Critical Components of Creating a Culture of Mobility in the Hospital Setting
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 4
Our next chapter…
• Updates on Systematic Use of Data
• Functional Reconciliation
• Interdisciplinary Mobility Care Path
• Implementing at scale
THE EVIDENCE SUPPORTING ACTIVITY
Why is promoting activity and mobility in the hospital important?
Patient centered: Affects patient’s ability to perform activities of daily living and basic needs, which can affect a patient’s dignity.
Most hospitalized patients currently spend most of their time in bed.J Am Geriatr Soc. 2009; 57(9):1660‐5
Lower levels of physical fitness are directly associated with all-cause mortality and increased complications.
JAMA. 1989;262(17):2395‐2401; JAMA. 2008;300:1685–1690
2Hoyer et al., 2013
Our current health-care environment is emphasizing patient centered outcomes (i.e. Hospital Readmissions)
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 5
Why is promoting activity and mobility important?
metabolic (fluid and electrolyte imbalance)
respiratory (hypostatic pneumonia)
cardiovascular (orthostatic hypotension, thrombus)
musculoskeletal (atrophy and contractures)
urinary elimination (infection and dehydration)
bowel elimination (constipation and dehydration)
integumentary(pressure ulcers)
psychosocial (depression)
Body Systems:
3
Disease
DebilityCo-morbidity
WASTE AND VALUE
The Value Equation
“Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.”– Michael Porter, PhD Harvard Business School
Value = Outcome
Cost
Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006.
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 6
Examples of Waste
• Failure of care delivery – poor execution – lack of widespread adoption of best practice resulting in patient injuries, worse
clinical outcomes, and higher costs. (e.g. hospital acquired complications)• Failures of care coordination
– care that is disjointed (e.g. handoffs, discharge plans) – unnecessary hospital readmissions, avoidable complications, and declines in
functional status, especially for the chronically ill.• Overtreatment
– care that is rooted in outmoded habits, that is driven by providers' preferences– unnecessary tests or diagnostic procedures to guard against liability – use of higher-priced services that have negligible or no health benefits
over less-expensive alternatives
"Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012. http://www.healthaffairs.org/healthpolicybriefs/
www.choosingwisely.org
www.erassociety.org
The Healthcare Challenge
Value Solutions:
• Improve Outcomes
• Decrease Cost
The big wins are when we can do both together.
In other words…..
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 7
Institute for Healthcare Improvement Triple Aim
Institute for Healthcare Improvement Triple Aim
Improve patient experience
Improve the health of populations
Reduce health care costs
www.ihi.org
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
physical therapist
SYSTEMATIC USE OF DATA
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 8
2014 was a big year!
What does the mean to us
• We used data from a validated tool to give us information about patients mobility
• We used that information to drive CULTURE change in our organization– Therapist Utilization
– Patient Mobility
– Discharge Planning
Our Journey at the Cleveland Clinic
Uniform data Collection
Use information from large uniform data sets to make
decisions.
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 9
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
What is Cleveland Clinic’s 6 Clicks?
• Short form of the AM-PAC (Activity Measure for Post Acute Care)
• Patient Reported Outcome Tool
• 25 years in development
• Validated across all levels of care
• 240 items – 3 domains
• Computer Adapted Test
• Can be shortened, and answered by surrogates
AM-PAC Cleveland Clinic Short Form‘Six Clicks’
PT
1. Turning over in bed
2. Supine to sit
3. Bed to chair
4. Sit to stand
5. Walk in room
6. 3-5 steps with a rail
OT1. Feeding2. O/F hygiene3. Dressing Uppers4. Dressing Lowers5. Toilet (toilet, urinal,
bedpan)6. Bathing (wash, rinse,
dry)
1= Unable (Total Assist) 2= A Lot (Mod/Max Assist)
3= A Little (Min Assist/CGA/Sup) 4= None (Ind./Modified Independent)
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 10
Mobility Scale Score Table for AM-PACMobility Scale Score Table for AM-PAC
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 11
PT 6 Clicks Data Volume – CCHS Hospitals
2011 2012 2013 Total
Evaluation 27,876 43,132 54,876 125,884
Follow up 0 67,219 86,290 153,509
Total Visits 27,876 110,351 141,166 279,393
How does Cleveland Clinic use 6 Clicks data to demonstrate value and improve functional mobility of our patients?
Use of 6 clicks Data
Discharge Recs
Guide therapist resource
utilization
Improve patient
mobility
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 12
Source: Medilinks, all Acute Care PT Evaluations for all Cleveland Clinic Hospitals 2013 n = 54,532
Ideal for nursing mobility
6 Clicks Distribution – PT / Mobility – Never go to a meeting without this info!
6 Clicks Publications
Resource Utilization
2013 - 4842 patients (8.8%) had a 6 clicks score of 24
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 13
Expanding the conversation to Interdisciplinary Functional Assessment achieving Functional Reconciliation?
And the Lord said, Behold, the people is one, and they have all one language; and this they begin to do: and now nothing will be restrained from them, which they have imagined to do.
Go to, let us go down, and there confound their language, that they may not understand one another's speech. —Genesis 11:4–9
Functional Reconciliation
…the comparison of a patient’s functional ability prior to hospitalization with their current status.
To occur at all transitions in level of care withininstitutions, and between institutions and out-patient / community resources.
similar to medication reconciliation
Elliot, D, et al. Exploring the Scope of Post-Intensive Care Syndrome Therapy and Care: Engagement of Non-Critical Care Providers and Survivors in a Second Stakeholders Meeting. Critical Care Med. 2014 Jul 31.
System Approach Value Opportunities
• Targeted intervention
• Protocol development
• Discharge planning
• Acquired complication risk
• Resource utilization
• Patient functional trending
• Predictive modeling
• Reconciliation across setting
Right Skills
Right Time
Right Place
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 14
The Problem
Solving the Outcome Measurement Dilemma:
• Need many items or many condition-specific instruments to cover all the relevant functional outcomes across a broad range of patients
• The traditional administration of extensive instruments is burdensome to patient and clinician
• Instruments lack the comprehensiveness needed to track patient progress across settings throughout an episode of care.
Acknowledge Dr. Alan Jette for slide
Rankin
Braden
AM-PAC
Glascow
The DYS-Functional Assessment Puzzle
6 Min WalkGlasgow
Tinetti
Fall Risk
Level of Assist
Fatigue Scale FIM
Core Measures
CAM-ICU
PROMIS
Laps Walked
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 15
JHH Data Strategy – Tool Selection
• Interdisciplinary
• Documentation efficiency
– EMR design
– Regulatory requirements
• Meaningful across settings
• Meaningful across initiatives
• Composite and specific measures
– Meaningful clinical difference
– Ceiling and floor
• Drive Intervention
JHH Data Strategy – Execution
• “Interdisciplinary Functional Assessment” Policy• Hospital-wide workflow
– Johns Hopkins – Highest Level of Mobility (JH-HLM) for Nursing
– AM-PAC Inpatient Mobility and Activity Scales (6 Clicks)• Nursing (frequency under re-evaluation) • PT and OT (every visit)
– Interdisciplinary diagnosis specific measures – Population specific workflows for outliers
(OB/GYN, Psychiatry, Inpatient Rehab, Pediatrics)• Electronic data entry as part of the EMR • Data System Infrastructure design and build• Reports
The System Architecture was determined
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 16
Johns Hopkins Highest Level of Mobility (JH‐HLM)
BED
CHAIR
STAND
WALK
250+ FEET
25+ FEET
10+ STEPS
1 MINUTE
TRANSFER
SIT AT EDGE
TURN SELF / ACTIVITY
LYING
MO
BIL
ITY
LE
VE
L
8
7
6
5
4
3
2
1
Score
46
patient with poor outcome
Contact Johns Hopkins Medicine for permissions and instructions for use.
With each JH-HLM document:
• This information provides additional detail of the highest level of movement you are documenting: – Level of Assistance needed
• None= Modified Independence/Independent
• A lot= Max/Mod Assist
• A little= Min/Contact Guard Assist/Supervision
• Total= Total/Dependent Assist
– Assistive Device
– Number of Assistive Persons
– Exercises (i.e. bed exercises, chair exercises)
– Ambulation Distance (i.e. patient walked several laps around the unit)
How does Johns Hopkins use data to demonstrate value and improve functional mobility of our patients?
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 17
Change of JH‐HLM on Day of Admission at JHH
49
Nurse JH-HLM to Therapist AM-PAC
Choosing Wisely – Resource Utilization Exemplars
• JHH Neurosurgery
• JHH Department of Medicine
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 18
10 Critical Components to Creating Value Establishing a Culture of Mobility in the Hospital Setting
Critical Components to Success
Be able to clearly articulate to all members of the team the benefits of mobility and harmful affects of immobility while the patient is in the hospital setting.
Identify opportunities to integrate “Culture of Mobility” concepts within existing hospital initiatives (e.g. LOS, ICU, readmissions)
Physician and nursing support – Identify engaged physician and nurse champions with influence over practice with their peer groups
Critical Components to Success
Identify barriers to implementation
Assess workflow and hardwire operations and accountability
Have a good understanding of your baseline metrics. What do you want to achieve – have data to support it.
Develop an Education and Training Strategy
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 19
Critical Components to Success
Set expectations with patients and family upon admission
Measure, Measure, Measure
Have Fun
THE JOHNS HOPKINS ACTIVITY AND MOBILITY PROMOTION (AMP) STORY
From the ICU to Readmissions
Experience in the Intensive Care UnitCritical Care Rehabilitation Quality Improvement Project 2007
Shown decrease in:
• Medical ICU (MICU) days in patients with benzodiazepine and narcotic use and improved delirium status.
• Average length of stay in the MICU (4.9 vs. 7.0 days) and hospital (14.1 vs. 17.2) compared to the prior year.
Needham DM et al. (2010, July). Top Stroke Rehab 2010;17(4):271–281
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 20
MICU LOS sustained success
Needham DM et al. (2010, July). Top Stroke Rehab 2010;17(4):271–281
Potential Benefits to Hospital
Why so many empty MICU beds? patients are awake and moving, patients are better
Versus same 4-month period in 2006:• 20% increase in MICU admissions• 10% reduction in hospital mortality• 30% (2.1 day) reduction in MICU LOS• 18% (3.1 day) reduction in hosp LOS
For details on ICU Financial Modeling see:Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM. ICU early physical rehabilitation programs: financial modeling of cost savings. Critical Care Medicine. 2013 Mar;41(3):717-24.
Is a therapist driven model sustainable across all units?
• Long MICU and overall LOS
• $$$ per MICU day
• Higher skill to mobilize
• Therapist underutilization
• Significant ROI potential
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 21
Dedicated Therapist 2008 Reality Check
Service Level Additional Visits per month
Additional FTEs
Total Incremental Cost
(Salary + Benefits)
Meet therapist recommended treatment frequency
Meet acute care provider expectation – Provide same level of therapy every day, during patient stay, 7 days a week
Everyone agrees people need to move?Does it take a therapist?
If not then who and how?
Who is the “Right” provider to mobilize patients?
Therapist
Complexity to Mobilize PatientMax Complex Mod. Complex Independent
Nurse/Tech/Other
Tra
nsl
atin
g R
esea
rch
into
P
ract
ice
(TR
IP)
Identify opportunities to integrate “culture of mobility” concepts with existing hospital initiatives
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 22
March 23, 2010
ICU Innovation
Surveillance of Cancer Or Cancer Recurrence
Value and Choosing Wisely
Patient Centered Care
Length of Stay
Preventable Harms (DVT, Pressure Ulcers, etc)
Activity Mobility
Promotion
InterdisciplinaryCare Coordination
Readmissions
The Activity and Mobility Promotion Initiative (AMP)
Cancer Survivorship
Population Health
65
Reimbursement andRegulatory
EMR Design
Johns Hopkins AMP Initiative
Phase I –AMP Inpatient Care Coordination Bundle Development and Pilot
Phase II – Expansion of AMP Bundle and Adult Inpatient Functional Reconciliation
Phase III – Homecare, Pediatrics, Ambulatory Specialty Practice and Primary
Care Functional Reconciliation
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 23
Johns Hopkins AMP - Readmissions
Johns Hopkins Health System Goal to reduce 30-day readmissions 10% below state
mandated cap
Value of Rehab was to champion the importance of function in reducing
readmission risk
Focused to 2 General Medicine units initially
Post-Hospital Syndrome
• post-hospital syndrome, an acquired, transient period of vulnerability
• During hospitalization …. receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity.
• more assertively apply interventions aimed at … promoting practices that reduce the risk of delirium and confusion, emphasizing physical activity and strength maintenance or improvement, and enhancing cognitive and physical function.
Krumholtz. Post-Hospital Syndrome. Patient physical functioning is associated with their risk for hospital readmission. NEJM. 2013; Jan 10;368(2):100-2.
JHH Care Coordination “Bundle”
• ED Care Management• Risk screening—Early and periodic• Patient family education
– Self-care management– Condition-Specific Education Modules– “Teach-back”
• Interdisciplinary care planning– Multidisciplinary team-based rounds:
every day, every patient– Activity and Mobility Promotion (AMP) – Projected discharge date on every
patient• Transition of Care and Follow Up
Resources
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 24
Initial Workflow
Barriers Survey
JunMayAprMarFebJanNovOctSep Dec
TIMELINE – AMP Project Plan
Build in EMR
Data Collection
Provider Education
QI Team Meeting
GO LIVE
Develop Education Tools
Data Reporting
Workflow Re-Assessment
CHAMPIONS REQUIRED
JHM Activity and Mobility Barriers Survey
Statement/QuestionNumber responses Agree or
Strongly Agree
My inpatients are NOT too sick to be mobilized.
I have received training on how to safely mobilize my inpatients.
I DO have time to mobilize my inpatients during my shift/work day.
Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).
I DO feel confident in my ability to mobilize my inpatients.
Increasing the frequency of mobilizing my inpatients DOES NOT increase my risk for injury.
Inpatients who can be mobilized usually have appropriate physician orders to do so.
My inpatients are NOT resistant to being mobilized.
I believe that my inpatients who are mobilized at least three times daily will have better outcomes.
Hoyer EH, et al. Am J Phys Med Rehabil. 2014 Aug 15.
Contact Johns Hopkins Medicine for permissions for use.
Sample questions and response from a nursing unit
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 25
Overcoming Barriers
• Engagement:
– Finance – therapist dedicated time to rounds
– Administrators – Furnishings, resources.
– Physicians – orders, walk patients or examine at chair-side, patient engagement, facilitate interdisciplinary rounds.
– Nursing Staff – documentation, co-education, mobilize patients
– Therapists – train nurses, facilitate interdisciplinary rounds.
– Clinical staff – help with documentation and mobilizing patients.
Through Documentation
• Accountability: Interdisciplinary documentation of function
• Sustainability: Using IT to automate data extraction
Have a strong understanding of baseline metrics you hope to influence.
• Length of Stay
• Readmissions
• Therapist Overutilization
• Fall Rates
• Hospital Acquired Complications
• Daily documentation compliance
• Call Bells
• % of patients discharged home
Assess workflow and hardwire operations and accountability
• Hand off and care coordination rounds ABC’s:
– Activity: What activity did the patient do?
– Barriers: What barriers does the patient have to be mobilized?
– Continue: How can we continue to progress activity with the patient?
• Nurse Daily documentation
– Johns Hopkins Highest Level of Mobility Scale
– AM-PAC Inpatient Short Forms (Mobility and ADL)
• Therapist documentation
• AM-PAC Inpatient (6-Clicks) each visit
• Mobilize all patients three times per day to out-of-bed or ambulating (twice during day, once at night)
• JH-HLM Interdisciplinary Goal Setting
• JH-HLM Progression Protocol
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 26
Develop an education and training strategy
• Nurses:– Online: My-Learning for
Nurses– Huddles with Therapists– Curbside Consult– Mobility instructional videos
• Physicians:– Contraindications to
mobilizing patients– Engaging Patients– Orders to Mobilize Patients
Therapist Delivery of Care Paradigm ShiftExpectation Completed (Date) Comments
1. Review service specific presentation and algorithms for provision of therapy care specific to service. (TL/Mgr)
2. Review materials on readmissions program and rounds coverage. (TL/Mgr)
3. Review algorithm for provision of co-treatment. (TL/Mgr)
4. Review “Discharge Planning for ACS” (CS/TC)
5. Documentation (3 samples) reflects correct leveling for patients.
6. Audit (3 samples) reflects completion of activity status forms and calendars.
7. Shadow (3x) rounds coverage with TC or CS.
8. Observation of staff member at rounds reflects proactive communication for therapy.
9. Complete mylearning module on Teach Back Patient Education Method v. 1.0.
10. Complete learning packet quiz.
Patient and Family Engagement
• Video intro “Get up and Move”
• Admission scripting
– Importance of mobility
– Activity Status and Calendar
– Patient and Family Choices
• Interactive tablets – provider directed
• Pediatrics
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 27
Measure, Measure, Measure
• Accountability – Nurse documentation compliance to three times per day increased during the project
• Safety – there was no change in falls with implementing the AMP project
• Communication - Nursing utilization of JH-HLM and Therapists (PT, OT) use of “Six Clicks” directly correlated
• Nurse Utilization – correlation between JH-HLM and call bell utilization
Association between JH‐HLM and LOS, D/C Home, Costs, and Readmission
Encourage creativity and fun
• Promotion
• Competition– Provider
– Patient
• Rewards
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 28
Strategies to Improve the patient JH-HLM Trajectory
• Formalize and integrate the common “Interdisciplinary Functional Assessment” as part of care planning and EMR
• Patient and provider compliance reports
• Physician engagement of patient/family in mobility
• Patient specific daily mobility goals
• Target Therapy resources (i.e. Choosing Wisely)
• Optimize resources within nursing infrastructure to best execute mobility
• Formal internal messaging campaign
PASSING THE TORCH
What I learned this year…
• Physical Therapy can influence but we can’t drive Culture Change
• Data and the Medical Team need to drive culture change in the Hospital
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 29
THE CLEVELAND CLINIC STORY AS TOLD BY KAREN GREEN, PT, DPT
Development of an Interdisciplinary Mobility Care Path
Who owns Mobility?
Goal…..
Patient Centered
Nursing
Therapy
MedicalTeam
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 30
How we got (are getting) there…
Culture of
Mobility
Safe Patient
Handling
Ongoing
Education
Nursing Mobility Care Path
Step One…
• Partnered with Nursing Leaders to create a culture change on 4 medical nursing units then expanded to multiple units and hospitals
Culture of Mobility
How…
–Revised Nursing Documentation
–Changed PT and OT orders to Consults
–Provided Nurse Training
–Provided Physician Training
Culture of Mobility
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 31
Therapy Consult… Culture of Mobility
Therapy Consult… Culture of Mobility
Outcomes…Culture of Mobility
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 32
Outcomes… Culture of Mobility
• Patient Education Video
Step Two… Safe Patient
Handling
• Partnered with the Safe Patient Handling Committee to provide a therapy perspective as well as assist with education and training.
Group consists of:– Nursing Managers– Clinical Nurse Specialists– Director of Safety– Ergonomist– Director of Rehab
Outcomes… Safe Patient
Handling
• Teach portions of the Safe Patient Handling and Mobility Champions class
• 3 Therapy Staff Members are SPHM Champions
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 33
Step 3…
• Mid Level Providers
• Nurse Residency Students
• Nursing Floors
• Pediatric ICU Staff
• Regional Hospital Staff
Ongoing
Education
Step 4…
• Developing a standard of care that included nurse driven mobility for the hospitalized patient
• Goal is to have all patients appropriate for mobility mobilize early and often by the most appropriate caregiver
Nursing Mobility Care Path
Nursing Mobility Care Path
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 34
MOVE‐ON SAFETY SCREEN (Evaluate inclusion criteria for OOB daily)
M –Myocardial/Hemodynamic
Stability •Noevidenceofactivemyocardialischemiax24hours
•Nodysrhythmiarequiringnewanti‐dysrhythmiaagentx24 hrs.
O– OxygenationAdequate
•FiO2<0.6•PEEP<10cmH2O
V– Vasopressor(s),Hemodynamics•Noincreaseofanyvasopressorx2hours•NosustainedBP∆>20mmHgfor>10min•NosustainedHR∆ >20bpmfor>3min,HR<140,HR>40.
•Nosymptomswith∆ inBPorHR
E– EngagestoVoice•Patientrespondstoverbalstimulation(exception:patientsinneurologicalICU
O– Other•>24hourposttPAforstroke,PE,MI
•Nofemoralline,unlesspermanenttunneleddialysiscatheter
•Othercontraindications
N– Neurological•SAHsecured•ICP<20•Secured/stable
spine•Stableneuro exam
STEP #2 – complete functional assessment, total score.
STEP #1 – complete safety screen.
Functional Assessment: within Normal Limits (WNL): Patient independently performs ADL or needs minimal assistance
Bathing 1‐Assist of 2 or more (Total) 1‐Assist of 2 or more (Total)
Oral Care 4‐No Assist (None)
3‐Supervised ‐ Min Assist of 1
(A Little)
Turn and Position 2‐Mod‐Max Assist of 1 (A Lot) 2‐Mod‐Max Assist of 1 (A Lot)
Up in Chair3‐Supervised ‐ Min Assist of 1
(A Little)
3‐Supervised ‐ Min Assist of 1
(A Little)
Up to Bathroom 2‐Mod‐Max Assist of 1 (A Lot) 2‐Mod‐Max Assist of 1 (A Lot)
Walk in Halls 1‐Assist of 2 or more (Total) 1‐Assist of 2 or more (Total)
Total Score/
Functional Level 13 12
Current Score Yesterday
FUNCTIONAL LEVEL IMOVE-ON SAFETY
CRITERIA NOT MET
FUNCTIONAL LEVEL
IISCORE 6-11
FUNCTIONAL LEVEL
IIISCORE 12-17
FUNCTIONAL LEVEL
IVSCORE 18-23
FUNCTIONAL LEVEL VSCORE 24
BEDREST
The patient’s physical
participation is deemed unsafe d/t hemodynamic instability, sedation
or other factors requiring Bedrest.
TOTAL ASSIST
The patient’s physical participation
is minimal, caregivers are providing assistance with up to 75% of the
task. Patient is not able to safely support his/her weight and may not
be able to consistently follow commands.
MOD-MAX ASSIST
The patient requires physical
assistance from one person up to 50% of the activity. The patient is
participating in the activity but requires a lot of help to safely
perform the task.
MIN ASSIST
The patient requires supervision for
safety or up to 25% physical assistance of one person. The
patient is actively participating in the activity, able to bear some
weight and maintain balance without more than a little bit of
assistance.
NO ASSIST
The patient is able to perform the
activity safely without supervision or assistance
Consider the following activities
and indicate those completed.
Mobility / Self-care progression⃝ Normalize environment
⃝ HOB 30°-45° as tolerated⃝ Active / Passive ROM 3
times/day
⃝ Turn/ Reposition every 2 hours⃝ Encourage patient to assist w/
ADL’s
⃝ Other:
Consider the following activities
and indicate those completed.
Mobility / Self-care progression⃝ Encourage patient & family to
assist with ADL’s⃝ HOB 45° with legs dependent BID
⃝ Active / Passive ROM 3 times/day
⃝ Turn / Reposition every 2 hours⃝ OOB to Chair at least daily
⃝ A/AAROM anti-gravity⃝ PROM paraplegic extremity
⃝ Extremity strengthening
⃝ Trunk stabilization/strengthening
⃝ Other:
Consider the following activities
and indicate those completed.
Mobility / Self-care progression⃝ Encourage patient & family to
assist w/ ADL’s w/ progressive independence
⃝ HOB 65° with legs dependent
⃝ Sit at edge of bed w/ min support⃝ Sit / Stand / Pivot
⃝ Active / Passive ROM 3 times/day⃝ Turn / Reposition every 2 hours
⃝ OOB to Chair at least daily
⃝ A/AAROM anti-gravity⃝ PROM paretic/pelagic extremity
⃝ Extremity strengthening
⃝ Other:
Consider the following activities
and indicate those completed.
Mobility / Self-care progression⃝ Encourage patient & family to
assist w/ ADL’s w/ progressive independence
⃝ HOB 60°-90° with legs dependent
as patient desires⃝ Active / Passive ROM 3 times/day
⃝ OOB to Chair at least daily⃝ Consider OOB to chair w/ meals
⃝ Extremity strengthening
⃝ Independent sitting⃝ Balance activities
⃝ Ambulation w/ assistance
⃝ Other:
Consider the following activities and
indicate those completed.
⃝ Independent ADL’s⃝ Out of bed to chair AD LIB
⃝ OOB to chair during meals⃝ Walk in halls ≥ 4 times per day
⃝ Other:
Consider the following Safe
Patient Mobility Aids & Indicate those used.
⃝ Bed Features
⃝ Slide sheets (Sally Tube)⃝ Turn & Position System (TAP)
⃝ HoverMatt™ or Air Pal™
⃝ Lift Device (portable or ceiling lift)
⃝ Stretcher Chair
Consider the following Safe Patient
Mobility Aids & Indicate those used.
⃝ Bed Features
⃝ Slide sheets (Sally Tube)⃝ Turn & Position System (TAP)
⃝ HoverMatt™ or Air Pal™
⃝ Lift Device (portable or ceiling lift)
⃝ Stretcher Chair
Consider the following Safe Patient
Mobility Aids & Indicate those used.
⃝ Bed Features
⃝ Sit to Stand Lift⃝ Caregiver 2 person assist
⃝ Slide Sheet (Sally Tube)
⃝ Turn & Position System (TAP)⃝ HoverMatt or Air Pal
⃝ Lift Device (portable or ceiling lift)⃝ St t h Ch i
Consider the following Safe Patient
Mobility Aids & Indicate those used.
⃝ Bed Features
⃝ Gait Belt⃝ Walker
⃝ Caregiver Stand-by Assist
⃝ Other:
Consider the following Safe Patient
Mobility Aids & Indicate those used.
Any device with which patient has reached a level of independent safe
use.
⃝ Cane
⃝ Crutches⃝ Walker
⃝ Oth
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 35
"THE MOMENT OF CRITICAL MASS, THE THRESHOLD, THE BOILING POINT“-MALCOLM GLADWELL
Health Care is Changing in Fundamental Ways
SYSTEM SKILLS
Interest in Data
Devise Solutions for System Problems
Develop an Ability to Implement at Scale
Acknowledge Dr. Alan Jette for slide
How we got (are getting) there…
Culture of
Mobility
Safe Patient
Handling
Ongoing
Education
Nursing Mobility Care Path
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 36
Johns Hopkins Highest Level of Mobility (JH‐HLM)
BED
CHAIR
STAND
WALK
250+ FEET
25+ FEET
10+ STEPS
1 MINUTE
TRANSFER
SIT AT EDGE
TURN SELF / ACTIVITY
LYING
MO
BIL
ITY
LE
VE
L
8
7
6
5
4
3
2
1
Score
106
Contact Johns Hopkins Medicine for permissions and instructions for use.
Institutional Change is Hard…
….It is easy to say NO!
Ability to Implement at Scale
Tra
nsl
atin
g R
esea
rch
into
Pra
ctic
e (T
RIP
)
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 37
ICU
Medicine Pilot
Neurosurgery Choose Wisely
PT/OT AMPAC
Homecare AMPAC
Peds AMP
Medicine Choose Wisely
Surgical Pathway(ERAS)
Care Coordination
CommunityHospital LOS
JHM AMP BundleEPIC
Accountability4 E’s
4 E’sReinforcement
Workflow/EMR
4 E’s
Cleveland Clinic to Scale
Johns Hopkins to ScaleERAS and EPIC pushing AMP 2.0
• Resource Assessment and Business Plan
• Required Champions (RN, MD, Admin)
• Pre-op and post-op visit AM-PAC (in process)
• Required common functional assessment
• JH-HLM progression protocol
• Interdisciplinary Mobility Goals (JH-HLM)
• Smart Order Sets
• Patient Pre-op and Admission education
• Patient/nurse/unit incentives
• Internal messaging campaign
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 38
ICU QI
.gov
Dr. Porter
6-Clicks
ERASAMP 2.0
Functional Reconciliation
AMP 3.0
Policy Functional Assessment
Budget Alignment
EMR Design
Choosing Wisely
Post-hospital syndrome
Mobility Bundle QI
The AMP Expedition
Therapist POC
Meaningful Use
JH-HLM
Other Resources
• Health System Rehabilitation Community– www.apta.org/HSRC
• Johns Hopkins Resources– OACIS web-site
– JH-HLM and Barriers Survey permission for use– @icurehab, @drdaleneedham
• Boston Rehabilitation Outcomes Center– www.bu.edu/bostonroc
Contact
Michael Friedman, PT, MBA
• Twitter follow:– @mkfrdmn
Mary Stilphen PT,DPT
• Twitter follow:– @marystilphendpt
Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation
1/26/2015
Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 39
ReferencesPorter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006
"Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012.
Jette DU, Stilphen M, Ranganathan VK, et al. Validity of the AM-PAC “6 Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014;94: 379-391
Jette DU, Stilphen M, Ranganathan VK, et al. AM-PAC “6 Clicks” functional assessment scores predict acute hospital discharge destination. Phys Ther. 2014;94: 1252-1261
Bentley, Tanya G.K., Rachel M. Effros, Kartika Palar, and Emmett B. Keeler, "Waste in the US Health Care System: A Conceptual Framework," Milbank Quarterly 86, no. 4 (2008): 629-59
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Erik H. Hoyer; Daniel J. Brotman; Kitty Chan; Dale M. NeedhamrfAmerican Journal of Physical Medicine and Rehabilitation. 2014.
ReferencesKrumholtz. Post-Hospital Syndrome. Patient physical functioning is associated with their risk for hospital readmission. NEJM. 2013; Jan 10;368(2):100-2.
Andres PL, Haley SM, Ni PS. Is patient-reported function reliable for monitoring post acute outcomes? Am J Phys Med Rehab. 2003;82(8):614-621.
Cre Care http://www.crecare.com/am-pac/ampac.html. Accessed 6/15/2011.
Haley SM, Ni P, Coster WJ, Black-Schaffer R, Siebens H, Tao W. Agreement in functional assessment: graphic approaches to displaying respondent effects. Am J Phys Med Rehab. 2006;85(9):747-755.
Brown CJ, Redden DT, Flood KL, Allman RM. The under recognized epidemic of low mobility during hospitalization of older adults. 2009. J Am Geriatric Soc;57, p. 1660.
Murphy EA. A key step for hospitalized elders. Arch Intern Med. 2011;171(3), p. 269.
Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52, p. 1269.
de morton, N., Keating, JL., Jeff, K., (2009) Exercise for acutely hospitalized older adults (Review) The Cochrane Collaboration issue 1.
Drolet, A., DeJulio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, EA, Lloyd, JM., Warers, C., Williams, S., (2012) Move to Improve: the feasability of using an early mobility protocol to increase ambulation in the intensive and immediate care settings. Physical Therapy 93(2):197-207
Convertino, VA., Bloomfield, SA., Greenleaf, JE. (1997) An overview of the issues.: physiological effects of bedrest and restricted physical activity. Medical Science and Sports Exercise 29:187-190
Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16), p. 1782.
Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660-5.
Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337
Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil. 2013.
Cabana, Rand, Powe, Wu, Wilson, Abboud, Rubin. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20; 282(15):1458-65.