Case management and critical pathways: links to quality care for persons with spinal cord injury.

Changes in the healthcare environment and reimbursement practices have resulted in profound restructuring of traditional healthcare delivery and practice patterns throughout the country (Messler, 1994). The development of systems of cost-effective quality health service is the challenge the healthcare industry faces. One such system, a frequently used model of nursing care delivery in acute care settings, is case management (American Hospital Association, 1990). The purpose of this article is to share our approach to the development of this innovative system.

At the Medical College of Virginia Hospitals/Virginia Commonwealth University (MCV/VCU), the development and implementation of a case management/critical pathway system grew out of a desire to improve patient care services to patients with spinal cord injury (SCI).

Overview of Case Management/Critical Pathways

Case management is designed to promote patient and customer satisfaction through the use of clinically expert case managers who can balance patient and family needs with efficacious and cost-effective use of resources while continually monitoring, evaluating, and modifying the treatment plan to achieve optimal patient outcomes (Mercy Healthcare Arizona, 1994). The goals of case management are to optimize patient self-care, decrease fragmentation, provide quality care across the continuum, enhance quality of life, and promote the effective use of resources.

A review of the literature demonstrates that case management has become a synonym for cost-effective quality care (Girard, 1994). Case management has been implemented by many healthcare agencies and professionals across various practice settings. It has proven to decrease length of stay and provide quality care within cost constraints (Sterling, 1994). The complex needs of the spinal cord injured patient warrant the coordinated, timely efforts of many human and material resources within different practice settings. The delivery of such care is likely to be disjointed, and outcomes of care less than optimal (Bejciy-Spring, 1994), hence the natural place for a case manager to support care transitions and team communication.

Under the traditional healthcare delivery system, the provision of care to the SCI patient is often a complicated, cumbersome, time consuming process that lends itself to a case management approach (Strong, 1991). The literature clearly demonstrates that case management has been successfully implemented for patients or populations who have significant needs, have predictably unpredictable hospital stays, and are high volume and high cost (Girard, 1994). It has been suggested that case management of the SCI patient could serve as a means to enhance quality rehabilitation outcomes, increase patient satisfaction, enhance interdisciplinary relationships, and improve continuity from intensive care to community settings (Bejciy-Spring, 1994). Currently, however, there are no studies that demonstrate the effectiveness of a case management approach to the spinal cord injured patient population.

One aspect of the case management approach involves the development of critical pathways. A critical pathway is an interdisciplinary document that communicates planned interventions for a specific population within a specific timeframe (Mercy Healthcare Arizona, 1994). Pathways organize, sequence, and time "critical" patient interventions (Bergman, 1994).

Critical pathways:

* reduce variations in treatment (Lumsdon, 1993);

* are educational tools for new practitioners;

* reduce re-work and redundancy in care;

* assist with quality improvement work;

* decrease fragmentation in care, which is possible with complex populations such as SCI;

* strengthen collaborative practice and improve teamwork;

* are outcome focused and quality driven;

* allow for the analysis of services to the patient; and

* prevent gaps or delays in required patient services.

The most important goal of case management and the use of critical pathways is to improve patient outcomes. Implementing clinical pathways and analyzing the variance data from pathways are key to reaching expected outcomes, timely discharge of patients, and appropriate utilization of resources. Data such as this would be particularly helpful with the complex medical and treatment issues of patients such as those with spinal cord injury.

The Environment

MCV/VCU, a 700-bed urban university medical center located in the heart of Richmond, Virginia, is a Level 1 trauma center and a federally designated regional model system of care for patients with traumatic brain and spinal cord injury. Contained within the MCV complex is the complete continuum of care for patients with SCI, including a state-of-the-art neuroscience intensive care unit, a neuroscience progressive care unit, a neurosurgery unit, and a CARF-accredited SCI rehabilitation program.

Early in 1991, the nursing director of the Neuroscience Center proposed that the spinal cord injury program be examined for opportunities to improve services. An invitation was extended to the medical director of the spinal cord injury service to co-lead the efforts for improved services. With the medical director's acceptance of the co-leader role, an interdisciplinary group was formed to begin the work of improving services to SCI patients.

The Climate for Change

At the same time the nursing and medical directors were forming a group to improve spinal cord injury services, three major organizational initiatives were in development. These initiatives, which included the development of Product (Service) Line Management, continuous quality improvement, and managed care, provided additional momentum to improve the continuum of services for SCI patients.

Product (Service) Line Management is a method to integrate all disciplines involved in the production of a specific product, such as spinal cord injury care. It provides a framework for ongoing monitoring and analysis of the work being undertaken, it is amenable to changes in the market place, and it is best developed by the service provider. The key is to foster vertical and horizontal integration within the system (O'Malley, 1991). We found ourselves with "units" caring for SCI patients when what we wanted was a seamless continuum of care. Service lines allowed us to all focus on the single product: excellent patient outcomes for SCI patients.

Service line management is collaborative, multidisciplinary, and always customer focused, and it attempts to group related services to satisfy the customer. The success of a service line perspective is directly related to the organization's ability to focus on the needs of the patients and how those needs are marketed and priced (Flynn, 1991).

Continuous Quality Improvement (CQI) is a tool to analyze service delivered to specific customer groups and to find ways to deliver that service more effectively. It allows the observation of patient care initiatives with a careful analysis of the accuracy, completeness, correctness, cost, and timeliness of interventions. Areas where there is a gap between what is desired and what is delivered can be corrected (Kralovec, 1991). By using the pathway to look at SCI care, we are able to perform just such a quality analysis.

In managed care strategies, the provider of service teams up with the payor in ways that produce quality care in a cost-effective way. The goal of managed care should not be thought of only in financial terms. Rather, the goal is to maximize the value of a service: the quality delivered for the costs incurred (Hicks, 1992). Again, using the pathway as a CQI tool, we could examine the value of the service we delivered, recognize the areas where we needed to improve, and support these initiatives with data.

Creating the Vision

As with most projects or plans, it is prudent to begin with a vision of how the product should appear once completed. The vision should then guide the decisions made in each step of the process.

The MCV/VCU interdisciplinary SCI team began with such a vision, which was formed by asking the team two questions:

* What should our spinal cord injury customers be able to expect from a service perspective when they enter the MCV spinal cord injury program?

* How can quality service be assured through the MCV continuum of care?

It was decided by the group that patients should be able to expect the following:

* adequate information regarding SCI;

* involvement in the planning of care;

* smooth and timely transitions within the continuum;

* freedom from hospital acquired problems; and

* care from a highly skilled team.

A necessary step in bringing the vision to reality was a thorough discussion of the current program: its strengths and its weaknesses.

The program's strengths included:

* the existence of a highly skilled team of professionals with expertise in the care of patients with spinal cord injury

* strong communication links within the acute and rehabilitations teams.

Weaknesses included:

* unclear service delivery goals,

* fragmented patient transitions, and

* the lack of an interdisciplinary focus across the continuum of care.

Examination of the current spinal cord injury program led to productive discussions regarding ways to address problems. The dominant issue was how to link the improvements in the program in a way that would most effectively meet the needs of patients.

The nursing director of the Neuroscience Center suggested the development of a critical pathway as a framework for coordinating care across the continuum and as a tool for program development. This innovative strategy for improving patient care was just beginning to be addressed in the literature as the MCV team was forming. Critical pathways had been developed in predictable illnesses, such as coronary artery bypass; however, pathways on traumatically injured patients--such as SCI--had not yet been developed.

Development of the Pathway

Pathway development involved an 18-month process of education, negotiation, collaboration, and communication, which began with education of the interdisciplinary team regarding the elements and purposes of a critical pathway. Most of the team members were unfamiliar with the critical pathway concept; the educational process was therefore necessary in beginning our work.

Following the education process, negotiation began on the layout of the pathway. Because the process of care varies for the acute and rehabilitation phases of a patient's hospital experience, such things as the titles of each section (i.e., systems vs. function) of the pathway and the timeframes (daily goals vs. weekly goals) had to be determined through negotiations with the team.

The most challenging phase of the development of the pathway came with the decision on which "critical" interventions to include in the pathway and the timing of those interventions. As healthcare professionals, we wanted to include every detail of care as critical. This, however, would have made the pathway much too cumbersome for use.

The pathway development team attempted to use the current literature to guide the development of the interventions for the pathway. While the literature reflected the current standard of care for spinal cord injury, it did not contain information on the interventions that were crucial in moving the patient toward important outcomes. In addition, the literature provided no specific information on the timing of the standard interventions for patients.

In view of the lack of literature, the team pooled its collective expertise to decide upon the critical interventions and the timing of these interventions. This effort required hours of collaboration, negotiation, and communication. Countless hours of work resulted in an interdisciplinary document that would hopefully guide SCI patients within our system toward positive outcomes.

Implementation/Pilot Project

Implementation of the SCI critical pathway began in July 1992 and included a 6-month pilot project to determine the efficacy of its use. The plan required several important steps.

Education was the key component in the first phase of the implementation. All disciplines were given in-service training on the purposes and use of the pathway for SCI patients. The process was made easier because, during pathway development, the team members communicated with their respective disciplines regarding the upcoming implementation of the tool and the need for their input.

Once the pathway was in use, the neuroscience clinical nurse specialist worked with staff on the units within the continuum to resolve issues with implementation. One important issue involved the recording of variance data and how that process should occur. In addition, logistical issues, such as where to keep the document and how to get it printed, needed to be addressed.

The implementation process/pilot project required continual feedback. The SCI critical pathway was the first pathway implemented at the hospital, therefore the staff had no frame of reference from which to work. The entire interdisciplinary team played pivotal roles in integrating the document into the care of the spinal cord injury patients through demonstration of the use of the tool as they delivered care and through feedback to their peers.

Evaluation

Evaluation of the effectiveness of the critical pathway occurred in several ways. First, data was collected to examine if there were differences in the length of stay and cost between patients placed on the pathway during the pilot project and those that had been patients prior to the implementation of the pathway. Significant decreases in length of stay and cost were noted in the postimplementation groups. In particular, length of stay in the Intensive Care Unit was decreased by 14 days and cost was dramatically reduced.

The examination of variance data was a second level of evaluation that occurred in the postimplementation phase. All of the pathways were reviewed and variances examined. Pain management was noted to be an important variable in whether or not SCI patients progressed steadily toward their goals. This data was confirmed by clinicians who had had numerous encounters with pain management issues with patients. As a result of the pathway variance data, pain management has received more attention in spinal cord injured patients.

During the evaluation phase, the nursing staff identified the need for a "champion" of the process who would assure unit and continuum monitoring of pathway use. It was at this point that we added the role of unit-based SCI case manager to the program. Through collaboration and discussion with the interdisciplinary team, a model for the implementation of case management was conceptualized. The model links the continuum of care, data analysis, and the process of improving organizational outcomes by using a continuum case manager and a unit case manager (see illustration).

Benefits of the Process

Certainly, the evaluation data noted above indicate some of the positive influences that the use of critical pathways can have for the organization and, most importantly, for the patient. However, it is the unmeasurable benefits of going through the development process that may have a more lasting impact on the overall quality of the spinal cord injury program. For the MCV team these included increased knowledge, an improved interdisciplinary approach to the patient, and increased team cohesion.

Prior to the development of the pathway, each of the team members were expert clinicians in their own phase of care delivery. However, after the process of pathway development each team member believed that they had gained a broader knowledge of spinal cord injury care. The team members from the acute phase of care came to understand the important rehabilitation concepts that needed to be integrated into the acute care of the patient. Rehabilitation team members gained knowledge of the acute management of patients that was helpful to them in managing acute issues occurring in rehabilitation.

A second benefit of the development process included an improved interdisciplinary approach to the care of the patient. Before the team formed to develop the pathway, the practice of the acute care team was multidisciplinary. Rehabilitation practiced in interdisciplinary care was highly proficient, but we needed to strengthen the links within the continuum. The process of the development of the pathway demonstrated to the acute team the difference in interdisciplinary and multidisciplinary practice. For the rehabilitation team the process improved their interdisciplinary performance.

Finally, and perhaps most importantly, a bond developed between the members of the team. We learned respect for each other as clinicians as we worked together to meet a common goal, a goal that often seemed as if it would not be met. The end result of the bonding that occurred was a more cohesive interdisciplinary team that could communicate more effectively regarding SCI patients across the entire continuum of care.

Outgrowth of the Pathway

As a result of the original development of the spinal cord injury critical pathway, several important projects have emerged.

First and foremost, the pilot data from the original pathway led to the development of a research project in the Model Systems for Spinal Cord Injury. The objectives include determining the influence of case management and critical pathways on positive outcomes for SCI patients. These outcomes, in addition to length of stay and cost, also include looking at the influence of interventions on reducing complications and promoting increased function.

Another important objective of the project will be to determine what interventions are critical and what the timing of those interventions should be in promoting positive outcomes. For example, we plan to examine the relationship between the timing of interventions, such as physical therapy/occupational therapy, and outcomes, such as length of stay and functional improvements. Other significant areas of examination will include the relationship between substance abuse history, level and type of pain, degree of spirituality, and the afore mentioned outcome measures. As noted earlier, no literature exists that suggests "critical" interventions and the timing of those interventions as they relate to positive outcomes for patients with spinal cord injury.

Along with the Model Systems research project, a second research study has been developed by the nursing staff of the Neuroscience Intensive Care Unit that will involve a qualitative approach to exploring the experience of SCI patients in intensive care. This data then can be used to enhance the acute phase of care for patients with SCI.

Finally, a continuous quality improvement project has arisen from the focus on SCI in the institution. The neuroscience quality improvement group has embarked on a project to elucidate the factors that contribute to the breakdown of skin in patients with SCI. The group is exploring nutrition and length of time on backboards as possible variables in the skin breakdown problem.

Conclusions

Critical pathways are tools to achieve patient or programmatic outcomes. They are not an end in themselves, and attempts to develop pathways without interdisciplinary collaboration and a programmatic vision will not meet with complete success. It is the process of team collaboration that ultimately produces quality outcomes and strong links in the continuum of care.

Case management is critical to the success of pathways in populations that are complex, multivariant, and have high resource utilization. By guiding the process of pathway implementation and variance analysis, the case manager can assure value to the SCI patient throughout the continuum of care.

Value can also be provided to other customers of the organization via the use of pathway data. Through variance analysis the case manager can focus the team on outcomes of their practice and on methods to enhance those outcomes. This same data can be used to provide managed care organizations benchmarking information on the value of the institution's services and can simultaneously provide hospital administration additional opportunities for service improvement. It is with the service improvement vision fully in focus that case management/critical pathways systems become powerful tools to link clinicians, healthcare organizations, and payors in providing quality services to persons with spinal cord injury.

This ongoing study is supported by Grant H133N50015 from the National Institute on Disability and Rehabilitation Research to the Regional Spinal Cord Injury Center of the Medical College of Virginia/Virginia Commonwealth University.

References

[1.] American Hospital Association. (1990). Report of the hospital nursing personnel survey. American Hospital Association, Chicago.

[2.] Bejciy-Spring, S.M., Neutzling, E., & Newton, E. (1994). Nursing case management: Enhancing interdisciplinary care of the spinal cord injured patient. SCI Nursing, 11, 70-73.

[3.] Bergman, R. (1994) Gathering the goods on guidelines. Hospitals and Health Networks, 70-74.

[4.] Flynn, M. Product-line management: Threat or opportunity for nursing? Nursing Administration Quarterly, 15, 21-32.

[5.] Girard, N. (1994). The case management model of patient care delivery. AORN, 60, 403-412.

[6.] Hicks, L., Stallmeyer, J., & Coleman, J. (1992). Nursing challenges in managed care. Nursing Economics, 10, 265-266.

[7.] Kralovec, O., Huttner, C., & Dixon, M. (1991). The application of total quality management concepts in a service-line cardiovascular program. Nursing Administration Quarterly, 15, 1-9.

[8.] Mercy Healthcare Arizona (1994). CNS to case manager: Broadening the scope. Nursing Management, 25, 44-46.

[9.] O'Malley, J., Cummings, S., & Serpico, D. (1991). Pragmatic strategies for product-line management. Nursing Administration Quarterly, 15, 10-15.

[10.] Sterling, Y.M., Noto, E.C., & Bowen, M.R. (1994). Case Management roles of clinicians: A research case study. Clinical Nurse Specialist, 8, 196-201.

[11.] Strong, A.G. (1991). Case management of the patient with multisystem failure. Critical Care Nurse, 11, 10-13.

Sherry W. Fox, RN, MS, CNRN Barbara J. Anderson, RN, MS William O. McKinley M.D.

Ms. Fox is the Neuroscience Clinical Nurse Specialist, Ms. Anderson is the Nursing Director of the Department of Neuro/Psych/Rehab, and Dr. McKinley is Medical Director of the Spinal Cord Injury Rehabilitation Unit at the Medical College of Virginia, Virginia Commonwealth University.