Successful Experiences with Clinical Pathways in Rehabilitation.

This article describes the interdisciplinary process utilized by a group of rehabilitation professionals at a Veteran's Hospital to integrate interdisciplinary team process and philosophy into the use of clinical pathways. Furthermore, this article outlines the framework utilized to develop the specific pathways, presents clinical pathways for the stroke and traumatic brain injury patients, and discusses successful outcomes of clinical pathways by rehabilitation professionals. The pathways presented in this article focus on outcomes rather than processes. Outcomes are the same as program evaluation outcomes and include access to programs, functional status gains, length of stay, and length of stay efficiency.

Interdisciplinary Process

Team concepts in rehabilitation evolved because of the complexity of patient care needs, the patient having medical, social, psychological and economic concerns. The involvement of multiple professionals with a patient does not guarantee coordinated delivery of care. For a team to be effective, members of the team must effectuate collaboration and realize the synergistic relationship of the whole, rather than sub-units of the team (Parker, 1972; Wendland & Crawford, 1976). The team members must realize the importance of communication, collaboration, and coordination required to avoid fragmented care, care that does not meet the needs of the patient. Interdisciplinary teams function as a unit, crossing boundaries of specialists and cooperating among disciplines to meet the complex needs of rehabilitation patients. Rehabilitation professionals must collaborate and coordinate the intensity of rehabilitation care to efficiently and effectively influence and achieve maximum patient and family outcomes. Clinical pathways provide a framework for interdisciplinary teams to focus on commonly agreed upon patient problems, coordinate treatment interventions and monitor program outcomes.

Clinical Pathways

Clinical pathways are defined as clinical management tools that organize major client care activities and interventions of an interdisciplinary team for a particular clinical diagnosis or clinical procedure. The purposes of pathways are to organize (sequence and time) client care activities and interventions; serve as clinical management tools; define major client care interventions; seek input from the client interdisciplinary team members; define particular diagnosis(es) or procedure(s); and foster flexibility dictated by client condition and client and provider preferences (Clinical Guidelines Panel, 1995).

Clinical pathways should not be confused with critical paths. Critical paths define and time essential and critical elements of clinical treatment based on patient responses during an episode of care. Critical paths are discipline-specific, process-oriented and sequenced. Critical paths are guidelines that may be used to reduce resource utilization and maintain quality of care (Ross, Johnson, & Kobernick, 1997).

Clinical pathways, in comparison, define essential patient needs and are specific to like diagnoses of patients with needs that are resolved through interdisciplinary team processes. Thus, clinical pathways are goal and outcome-oriented. They have only recently been used by rehabilitation teams (Irrang, Delitto, Hagen, Huber, & Pezzullo, 1995; Flaconer, Roth, Sutin, Strasser, & Chang, 1993; Romito, 1990). Clinical pathways promote an efficient, organized and time-managed approach to client care as a team plans to accomplish agreed upon goals and outcomes for discharge. The clinical pathways become a method to analyze and control clinical care processes. In other words, the team has a "road map/a protocol" to schedule and coordinate treatment, track client progress, and justify client variances from the pathway.

Method

The purpose of this study was to compare clinical pathway results to previous experiences of team process using the outcome measures for program evaluation. Participants selected for this study were those clients admitted to the inpatient rehabilitation unit with an admitting diagnosis consistant with the clinical pathway, such as stroke and traumatic brain injury. The focus of the study was to compare program evaluation outcomes measures which does not require informed consent.

The purposes of rehabilitation are to prevent complications, restore abilities, and facilitate community transitions. Each aspect of the rehabilitation mission is potentially measurable through program evaluation measures. Rehabilitation professionals have a long history of striving to maximize client outcomes through the most efficient and effective utilization of resources. This tradition is enhanced by program evaluation which enables rehabilitation professionals to apply an on-going system for improving program processes and better meet client needs (CARF, 1995). Examples of program components that require on-going evaluation are access to rehabilitation services, functional outcomes, patient satisfaction, and discharge planning. The clinical pathways presented in this article focus on clients' functional outcomes, access to rehabilitation programs, and length of stay efficiency. In this setting, client satisfaction is evaluated outside the parameters of the clinical pathway, as a separate and ongoing aspect of customer service evaluation.

Rehabilitation clinical pathways apply an interdisciplinary, systematic approach to targeted high volume and complex client populations: stroke, traumatic brain injury, pain and amputation. This interdisciplinary approach invests all members of the rehabilitation team, including physicians, in the delineation of prescriptions and outcomes for the care of specific client populations.

Outcomes Measures

Three elements provided the structural framework for each of the clinical pathways for rehabilitation: client needs, length of stay, and functional/program outcomes. A client's needs list was generated by the rehabilitation professionals for each diagnosis, i.e., stroke and traumatic brain injury. To validate the client needs list for each diagnosis, each clinical team conducted a literature search on priority rehabilitation needs specific to the diagnosis and the defined clinical outcomes. Through a refinement process, each client needs list was finalized. For example, the client needs listed for stroke rehabilitation are: medical management (medical problems, stroke risk factors, potential for altered skin integrity, and medication administration); communication (comprehension and expression); cognition (memory, problem solving and safety skills); activities of daily living (self care needs); dysphagia; continence (bowel and bladder); mobility and fall prevention (balance, transfers, wheelchair mobility, and gait/ambulation); sexuality; equipment needs; psychosocial needs (spiritual, leisure, and vocational); and education. These core needs comprise the team plan of care for the client admitted for stroke rehabilitation. Team members select and individualize the needs list specific to the client's problems. For example, the client admitted without dysphagia does not have dysphagia on the team treatment plan. For a client admitted with dysphagia, the type of dysphagia is further defined (such as oral or pharyngeal).

The second element of the clinical pathway framework is length of stay. Program evaluation data for length of stay from 1990-1992 provided the benchmark for targeted length of stay for each diagnostic group using national data from the Uniform Data System for Medical Rehabilitation (UDSMR) (Uniform Data System for Medical Rehabilitation, 1992). Clinical pathways have just recently been used in clinical settings, yet program evaluation has been required of rehabilitation programs seeking Commission of Accreditation of Rehabilitation Facilities (CARF) accreditation for 20 years. Having the opportunity of being the first Veterans Hospital to participate in program evaluation through the UDSMR, team members had reliable client outcome data for six years. Over the years, team members had continually examined and integrated findings from program evaluation data into quality improvement processes, incorporating principles of continuous quality improvement (CQI). Using the most current program evaluation data for length of stay and functional outcomes per diagnoses, the average length of stay was subdivided per week and functional outcomes were written for each predetermined interval.

Functional outcomes, the third element of the framework for the clinical pathways, are measured by the Functional Independence Measure (FIM). The FIM was developed by the UDSMR. The FIM is a standardized, performance-based, observer-rated assessment of 18 functional items for activities of daily living: eating, grooming, bathing, dressing upper body, dressing lower body, toileting, bladder control, bowel control, transfers to/from bed/wheelchair/chair; transfers to/from tub/shower; transfers to/from toilet; locomotion, stair climbing; comprehension, expression, social cognition, problem solving, and memory. Each FIM item is scored using a scale from 1 (dependent) to 7 (independent). Integrated within the scoring guidelines are considerations for assistive/adaptive equipment, set-up of supplies and/or supervision, and physical assistance in order to measure burden of care and severity of disability.

Appropriate FIM items and outcome scores were selected for each of the pathways based on a three year review of our clients' functional outcome scores compared to private sector functional outcome scores for the same diagnosis. Private sector outcome scores served as the benchmark for comparison.

Results

Client outcome variances based on the Uniform Data System (UDS) Functional Independence Measures (FIM) were examined in relation to changes in program processes or organizational trends. Four domains comprised this analysis: access (measured as time post onset [TPO]); functional status outcome (measured as discharge [DC] FIM); cost (measured as length of stay [LOS]); and efficiency and effectiveness (measured as LOS efficiency). Table 1., Comparison of Key Outcomes for Stroke and TBI, shows improvements in access (TPO), DC functional status measures, decreasing LOS (measured in days), and improvements in LOS efficiency (improving functional outcomes while decreasing resource expenditures) over the four years of pathway implementation.

Table 1. Comparison of Key Outcomes: Stroke and Traumatic Brain Injury

KEY OUTCOMES             1993        1994       1995
                       1/1-12/31   1/1-12/31   1/1-12/31

Total Stroke
Sample Size                 49          49          49
DC FIM                    93.6        95.7        92.9
LOS/days                    32          30          26
LOS/efficiency             .69         .78         .92
Time Post Onset Days        32          28          20

Total TBI

Sample Size                27           37          31
DC FIM                     93.       102.0       103.7
LOS                        62           57          39
LOS efficiency            .54          .56         .67
Time Post Onset Days       71           82          83

KEY OUTCOMES             1996
                       1/1-12/31
Total Stroke
Sample Size                 61
DC FIM                    93.6
LOS/days                    18
LOS/efficiency            1.07
Time Post Onset Days        26

Total TBI

Sample Size                 47
DC FIM                    98.9
LOS                         35
LOS efficiency             .53
Time Post Onset Days        88

Process outcomes have also been analyzed through quality improvement methods to improve the efficiency and responsiveness of the team to critical processes: referral to admission decision; time to complete initial client staffing meetings; time to complete progress client staffing meetings; time to complete discharge client staffing meetings; and cost savings. Process outcome measures (Table 2) reveals a progressive improvement in team meetings and team member efficiency, producing a cost savings related to team meetings. Time utilization is decreased, while the content focuses on individualized client needs and outcome goals. The indirect cost savings from team meetings is transferred back to the client and family care in direct care activities. Requirements for documentation are clear and concise, yet specific to the client. The above outcomes reveal evidence of rehabilitation professionals' continued success in using clinical pathways.

TABLE 2. COMPARISON OF KEY PROCESS OUTCOMES

Key Processes            1993             1994

Point of Referral to
Admission Decision     5-7 Days        3-5 Days
(days)

Time to Complete       30-45 minutes   20-30 minutes
Initial Reports

Time to Complete       20 minutes      15 minutes
Progress Reports

Time to Complete       10 minutes      10 minutes
Discharge Reports

Key Processes             1995            1996

Point of Referral to
Admission Decision     1-2 Days        1 Day
(days)

Time to Complete       10-15 minutes   10 minutes
Initial Reports

Time to Complete       5-10 minutes    5-10 minutes
Progress Reports

Time to Complete       5 minutes       5 minutes
Discharge Reports

Discussion

Use of clinical pathways positively influenced professional behavior of team members. The rehabilitation team reaffirmed commitment to several goals: shared goal-achievement, improved time-management, improved collaboration, and client-centered care. Together, team collaboration and treatment planning improved through a proactive interdisciplinary approach to a set of core patient needs and outcomes. The team's focus was now on client needs rather than discipline-specific clinical problems. The display of specific client needs per diagnosis and measurable outcomes at predetermined intervals across a time line established a plan of care. This plan of care was easily individualized, and collaboration was facilitated among team members. The outcomes and time frames defined for each pathway are individualized, based on the client's needs, complexity of psychosocial issues and severity of disability. Team members work together to achieve agreed upon outcomes within a predetermined time-frame. Shared commitment for mutually agreed upon outcomes has been realized by all members of the rehabilitation team.

Improved time-management is a second commitment shared by team members. The framework provided by the pathways for conducting team meetings enabled each team member to focus on clients' needs, issues, and plans that need to be shared by all team members. This focus reduced team meeting time by 10-20 minutes per client initial treatment planning, 5-10 minutes per client progress meeting, and 10 minutes per client discharge meeting. Documentation of team meetings has been streamlined by developing team meeting forms based on each clinical pathway. As a result, team meetings are facilitated (rather than delayed) by an interdisciplinary documentation system, improving time-management.

A third shared commitment is improved collaboration among members of the rehabilitation team by focusing on clients rather than disciplines. All team members discuss the severity of a client's deficits, develop communication approaches and project outcomes. Team members contribute to developing and implementing the client's plan of care, and monitoring client outcomes. They can focus on collaboration necessary for continuity of care.

Client-centered care is the most important shared commitment. The client, by becoming involved in achieving designated outcomes, is more active in the rehabilitation process. When rehabilitation specialists mutually develop goals with clients, the client becomes more active in working toward those goals. Thus, client-centered care contributes to improved utilization of resources, outcomes, and decreased length of stay.

Furthermore, the team is better able to justify clinical relevance for deviations from the clinical pathways based on individualized needs of the client and family. If the client requires additional time to achieve goals due to complications, such as medical complications during rehabilitation, the team is able to justify the extended LOS beyond that of the clinical pathway. Variances can now be explained based on outcomes and length of stay.

Summary

The application of clinical pathways to clients requiring rehabilitation resulted in an innovative, client-centered approach that focused on outcomes at predetermined intervals. The model incorporates team process, program evaluation and continuous quality improvement. Subjective feedback suggests that communication has improved, professional turf boundaries have been reduced, and a client-centered focus and mission, where clients participate and make decisions in their treatment programs, has been refined. These rehabilitation clinical pathways may serve as a model to other rehabilitation programs and specialty programs in team-oriented health care settings.

Applying the use of clinical paths to clients requiring rehabilitation is very different from a traditional service position. Clinical pathways used in rehabilitation programming combine the best qualities of team process, program evaluation, and continuous quality improvement to improve interdisciplinary communication, reduce and/or minimize professional turf boundaries, and maximize outcomes.

The concepts of total quality improvement were easily integrated with clinical expert knowledge, experience and innovation (Heacock & Brobst, 1994). The pathways are in a state of evolution and refinement, and will continue to require variance analysis as populations change, philosophy shifts and health care environments reform. Nevertheless, the authors feel that these pathways provide a useful approach to rehabilitation service programming and treatment.

Acknowledgments

Appreciation is extended to Dr. Maria Mullins and Dr. Steven Scott for your vision, support and participation in all clinical pathway efforts, and to all members of the rehabilitation teams who made these successes possible.

References

Falconer, J., Roth, E., Sutin, J., Strasser, D., & Chang, R. (1993). The critical path method in stroke rehabilitation: lessons from an experiment in cost containment and outcome improvement." QRB. January, 8-16.

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Irrang, J., Delitto, A., Hagen, B., Huber, F., & Pezzullo, D. (1995). Rehabilitation of the injured athlete. Orthopedic Clinics of North America, 26(3), 561-577.

Parker, A. (1972). "The team approach to primary health care". Neighborhood Health Center Seminar Program, monograph series no. 3. California: University Extension, Berkeley.

Romito, D. (1990). "A Critical Path for CVA Clients." Rehabilitation Nursing 15, no.3: 154-155.

Ross, G., Johnson, R., & Kobernick. M. (1997). Evaluation of a critical pathway for stoke, JAOA, 97 (5), 269-275.

Wendland, C. & Crawford, C. (1976). "Team delivery of primary health care". Los Angeles County Medical Training System.

Clinical Guidelines, Pathways, Alogrithms Position Statement. Prepared by the Clinical Guidelines Panel. Quality Management Institute & Education Center. (1995). Department of Veterans Affairs.

National Center for Cost Containment. (1997). Outcomes of the Stroke/Amputee Algorithms Implementation Project. Milwaukee, WI: Department of Veterans Affairs: Author.

Uniform Data System for Medical Rehabilitation. U.B. Foundation Activities, Inc. (1992).

Patricia A. Quigley Susan Wallace Smith John Strugar James A. Haley Veterans Hospital3