Outcomes in action: two subacute tracking systems.

Interviews with Pamela Leiter, President, Formations in Health Care, Inc., and Lea Chiaromonte, Vice President of Clinical Services, Regency Rehabilitation Management and Consulting Services 

As every astute administrator knows these days, "outcomes" has become a healthcare buzzword. In the longterm care field, ability to document subacute rehabilitative service outcomes is gaining primary importance. Clearly defined quality of care information is of concern to everyone involved in today's rehabilitative health care: from patients, physicians and nursing staff to administrators, marketing directors and third-party payers.

This rising interest in outcomes stems in part from the shift toward managed care, a trend just beginning to make itself felt in the longterm care field. Increased concern about accountability, however, is more than a matter of providers wanting to "look good on paper." Besides providing evidence to outsiders on how well longterm care facilities are doing with subacute rehab, tracking outcomes shows administrators and marketing personnel which programs are successful and what new ones might be worth instituting. With increasing competition from hospitals for subacute rehab and other services that once were the almost-exclusive domain of nursing homes, believable outcomes data can give a facility an edge.

In light of all this, Nursing Homes Associate Editor Linda Zinn spoke with representatives of two companies that, in the early 1990s, developed outcomes measurement systems for use in the subacute rehab setting: Pamela Leiter of Formations in Health Care, Inc.,(*) and Lea Chiaromonte of Regency Rehabilitation Management and Consulting Services (Regency's system was developed by its South Coast Rehabilitation Services division; Ms. Chiaromonte was with SCRS during the system's development).(**) They discussed how the outcomes "state of the art" has evolved in this field in recent years.

What is the greatest value of an outcomes measurement system to an average 100-bed nursing home providing subacute rehab, whether it is part of a chain or a freestanding facility?

Leiter: We feel that the main value of our Clinical Outcomes System is that it provides a benchmark for comparison. It allows a single facility to see how it measures up - clinically and in terms of marketability - with similar facilities around the country. Facilities that just follow outcomes internally might think their outcomes are good, but compared with what? Bringing in that broad comparison tells a much better story.

Chiaromonte: For any outcomes measurement system to be useful, it must use scales specifically designed for a facility's type of patients. Using the right measurements allows an organization to not only compare its performance on a quarterly basis with previous quarters, but also with a national database that includes like facilities and patient populations.

Can you tell our readers which measurements you consider to be absolutely vital to a good outcomes measurement system for the nursing home subacute setting?

Leiter: It's important to look at the big picture, which is reflected by the resident's length of stay and cost of treatment. Also, you can judge the quality of a program by the level of independence a patient achieves - e.g., changes in self-care skills, mobility, communications skills and independence in living at home.

Obviously, the goal of most rehabilitation programs is to get the patient back home and living as independently as possible. If you compare the percentage of patients in a program who can return home - and their lengths of stay - with a national database, you can see if you've done as well or better than the national average.

Chiaromonte: Length of stay and average improvement are the most significant overall measurements. In our system, improvement is rated on seven-point scales within physical therapy, occupational therapy, and speech therapy. For example, in occupational therapy the 14 deficit areas rated include bathing, community activities, home management, joint mobility, etc.; functional levels for these range from "Total Assistance" to "Total Independence." The clinician rates each patient on one of these scales for the three major deficit areas. Then quarterly, an average improvement level is calculated, which is compared with the national database.

What ensures that a facility's outcomes are being compared with those of facilities similar in size and service offerings?

Leiter: Our data are case-mix adjusted and take comorbid disease status into account so that like cases are compared.

Chiaromonte: We control for case-mix by putting patient records into what we call Diagnosis Classification Groups (DCGs). The DCGs are mapped similarly to DRGs (diagnosis-related groups) used in hospitals, but are more suitable for subacute patients. Also, we store data from each organization that is licensed to use our system in a separate location, so an individual facility within a chain can be sure it's comparing data derived from similar patient populations.

What elements ensure the validity of your system?

Leiter: We started out with representatives from nine subacute companies who worked with us to develop the system. Getting their input assured us that we were measuring what those treating subacute patients really wanted to know. We collected their patient data for more than two years and analyzed them repeatedly for reliability.

Chiaromonte: We continue to work with outside agencies to validate our system. It must measure what it's supposed to measure and ensure that the measurements are reliable. Reliability testing has shown that.

What safeguards are in place to make sure data are collected and recorded accurately?

Leiter: We have built-in "stages of error" checking. Our software checks for blanks in the information that is input. Then, when the data arrive at our office, we have another set of checks, during which we "cleanse the data" by verifying whether certain parameters are met. For example, if we are collecting lab data, they need to fall within a specific range of values. We also check the rater's scoring against expected ranges for that item, to see if any facilities or clinicians might be "cheating" the system.

Chiaromonte: Each facility using our computerized system (Pulse Point Technology) is provided with technical support and programming services, whether that facility is using Regency's South Coast Rehabilitation Services (SCRS) or not. Their databases don't interact, and not even SCRS has access to their information. Pulse Point handles all questions, comments and issues.

Of course, clients can compare themselves to our national database via our quarterly Outcomes Trends Report and a discharge destination report - but as far as information going into the system, it is kept completely separate.

Do you concern yourself with how compliant a facility is in terms of data gathering and reporting, or do you consider it the organization's responsibility to police itself?

Leiter: If our client is using our software package, we're alerted if there are insufficient data. If they're using the pen-and-paper version, it's up to whoever is coordinating the system on the facility's staff to urge compliance. (When the pen-and-paper system is used, data are recorded manually and then input on the facility's computer for transfer to us via modem.) If a facility doesn't have good processes in place for managing paperwork, they might have trouble ensuring that they' re getting complete data. Therefore, it's important when organizations are looking at adopting an outcomes measurement system that they examine their day-to-day processes. They have to answer such questions as: When will they complete their data studies? How can the outcomes function be fit into their routine without being intrusive? It should be viewed as part of doing their medical record documentation, except that for outcomes they need to start at the beginning of treatment.

Chiaromonte: We take a "train the trainer" approach to ensure compliance. Initially, managers and lead clinicians are trained to train their therapists in using the system. If a client has multiple facilities and wants to use our system in all of them, they usually have a person in each facility who becomes the facility expert. The same is true of single-facility organizations - one person is usually in charge of training and troubleshooting.

If there's a technical problem, Pulse Point Technologies provides a "help desk" accessible via modem and telephone support. PPT staff can remotely examine a computer to see what's wrong with it and either walk the facility's person through resolving it or resolve it for them. If there's a clinical issue in a facility for which we provide rehabilitation services, such as how to rate a particular patient, the SCRS area managers can help with that determination. It is ultimately the facility expert and the area manager's responsibility to ensure compliance, but we check for compliance at the corporate level, as well.

Since your outcomes measurement system has been in use for several years, have you identified the need for some adjustments?

Leiter: We just completed a major revision, deleting unnecessary items and clarifying others. For example, in the original version we gave 20 different choices of wound sites on the body, to determine whether any particular sites were associated with difficult wound healing. We discovered that differentiating among five major sites (ankle, heel, coccyx, elbow and occiput) was adequate and that listing 20 was not necessary.

Chiaromonte: After our system was in place for about one and a half years, we began asking our users what we needed to change. In response to their input, we have added more deficit areas in physical therapy and occupational therapy - such as joint mobility and physical restraints in both physical and occupational therapy, and skin integrity in physical therapy - and made the definitions of some deficit areas clearer and more specific, especially for speech therapy.

We've also changed our training approach for individuals being certified to use our system. The training method we used initially, although it produced very good results, was somewhat difficult to manage, so we developed a self-study approach. We've tested the users trained in this way and found them to be as well trained as with the original one.

In developing subacute rehab outcomes, are there other changes you can foresee being needed?

Leiter: We plan to expand the clinical topics addressed in the Clinical Outcomes System. In fact, we added nutrition and infection instruments recently, and we're working on developing cardiac and oncology instruments.

Chiaromonte: We're working toward making the Rehabilitation Outcomes Measure even more functionally based, because the more globally we can look at patients, the better we'll be able to tell payers what outcome we expect for a specific patient. To do that we'll need to not only rate patients at the start of treatment and at discharge, but also within the therapeutic environment. In other words, we want to be able to predict to the payer, "If you allow this treatment modality for this duration, the patient will be likely to achieve X level of functioning. If you allow this other treatment modality or a shorter duration of treatment, the outcome is likely to be Y. You choose."

* Formations in Health Care, a division of Medirisk, Inc., was established in 1992 to address a need for outcomes measurement specifically geared to subacute care. The result was their Clinical Outcomes System, which is licensed to 80 subacute and another 40 longterm care facilities. The system is listed by the Joint Commission for use by its accredited LTC facilities.

** Regency, through its South Coast Rehabilitation Services division, provides contract rehabilitation services - primarily to subacute/long-term care facilities - in 15 states. Its Rehabilitation Outcomes Measure (ROM) is used by many of those facilities and is also licensed to more than 200 facilities that do not contract with SCRS. Approximately 400 organizations altogether are using the system. It is currently being reviewed by the Joint Commission for use in accredited LTC facilities.