Clinical pathways: a basic tool for subacute care.

Care planning must be taken to a new level

One of the many challenges of subacute care is developing a care plan for these patients that is not only clinically effective, but cost-efficient. Reimbursement sources are as demanding in this as in any other field, and when this is coupled with the increase in patient needs, finding the best path to follow is not always easy. A possible solution is offered by the concept known as clinical pathways.

Evolution

In 1985, the New England Medical Center in Boston, introduced the "critical pathway," which was the first system that attempted to incorporate expected outcomes within specified time frames. The term "critical path" meant that the plan defined the critical key events expected to happen each day of the patient's hospitalization.

Since then, critical pathways -- also called Critical Pathway Care Maps, Action Plans, Multidisciplinary Action Plans, or Clinical Pathways -- have been adapted to meet the needs of different health care organizations that are implementing so-called case management models, the basis of subacute care programs that are evolving today.

How It Works

Each organization creating these pathways must have clearcut guidelines, eg, the degree of clinical complexity, inclusion or exclusion of other disciplines, and required nursing documentation. Once the format has been decided and approved, the organization must decide which diagnoses or procedures are to be planned out first. Many begin with the diagnoses that are most common to the organization.

Creation of the clinical pathway will be completed in parts. Writing the nursing and medical plans is the most difficult to accomplish. These plans are developed from chart review consultations with experts in the field and from literature reviews. Within these overall limits, the expected nursing outcomes for each day of care are written out, although flexibility for individual patient variations must be allowed.

Once all these pieces are completed, meetings with other disciplines need to take place. When dealing with specific physicians who regularly admit to the facility, it is preferable to attempt to gear each clinical pathway to the physician's treatment approach. For example, the planners might obtain the physician's routine orders based on diagnoses.

The timing of the plan depends on State and Federal reimbursement scales. Clinical pathways can be time-lined in hours, days, weeks or months. As a rule of thumb, the shorter LOS diagnoses will be time-lined in days. The longer LOS diagnoses will be based on weeks or months. In both situations, variance time frames must also be created.

Documentation of variances is extremely important. What are variances? They are whatever causes delay in achieving an expected outcome. There are three types of variance: operational, patient and provider. Examples:

Operational Variance

* pump malfunction 

* staffing issues

Health Care Provider Variance

* change in physician's plan of treatment

* changes in provider practice patterns, level of expertise and experience

Patient Variance

* refusal to comply with recommendations

* unexpected change in status

* unavailability for specific procedures

Uses of Clinical Pathways

* Clinical pathways were created as a clinical standard for high-quality, safe and efficient care for all patients.

* Clinical pathways focus on the optimal recovery of the patient and on the optimal recovery of all other patients having reached a similar level of care. Their goal is to produce the most favorable outcomes for the patient and the caregiver.

* Clinical pathways document a reason for admission or alternatives to admission. They present guidelines to aid in the decision of whether or not a patient is kept in an acute care setting or transferred to a subacute facility or homecare. An example of how such guidelines might be applied to admission to a skilled nursing facility-based subacute unit can be found on p. 36.

* A computerized plan allows case managers the flexibility of changing the plan to correlate with the patient's changing needs. Case managers and all healthcare providers can scrutinize the pathway and make modifications, if necessary, that are appropriate for specific therapy and patient. The case manager and nursing staff can control the length of stay by overseeing the movement of the patient through the system.

* Clinical pathways clearly present the treatment plans expected to treat a condition and produce the most favorable outcome on the assumption that treatment and healing occur without significant complication.

* All of this clearly ties into the length-of-stay issues, whether relating to acute care, subacute care or home care. Determining and mapping a patient's length-of-stay before admission clearly has advantages. Clinical pathways can map out a patient's 14-day or 28-day stay in a subacute facility, allowing the managed care entity or UR managers to view clearly the expected lab work, X-ray testing, occupational therapy, physical therapy, and intravenous therapies used, as well as wound care procedures and any other specialized treatment required, before they precertify the patient. They can then work with the facility to increase or decrease services or document the clinical rationale of certain treatments. Most important from the standpoint of managed care entities, they will have a reasonably clear idea as to how much is likely to be spent on the patient's care before the patient is admitted.

* Clinical pathways assist utilization managers by making them aware of various levels of care as alternatives to costly hospital admission.

Conclusion

Clinical pathways are clearly becoming an essential tool to effective performance and survival for subacute units in a managed care setting. There are standard formats on the market that can be modified for each facility, and consultants are available to help create facility-specific clinical pathways. It is worth searching for local resources, perhaps via local managed care entities, to assist in the development of these pathways. The time to get started with them is now.

Sheryl A. Riley, RN, is National Director of Clinical Operations for Infu-Tech, Inc., a national vendor of infusion therapy equipment and training.