The Power of Data: Achieving Consistent Patient Outcomes Combined Sections Meeting 2015 February 4‐7, 2015 Indianapolis, IN www.aptahpa.org HPA The Catalyst is the Section on Health Policy & Administration of the American Physical Therapy Association Speaker(s): Dianne Jewell, PT, DPT, PhD Heather Smith, PT, MPH Mary Stilphen, DPT Session Type: Educational Sessions Session Level: Intermediate This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s). Page 1 of 19 total pages
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The Power of Data: Achieving Consistent Patient Outcomes
CombinedSectionsMeeting2015
February 4‐7, 2015
Indianapolis, IN
www.aptahpa.org HPA The Catalyst is the Section on Health Policy & Administration
of the American Physical Therapy Association
Speaker(s): Dianne Jewell, PT, DPT, PhD
Heather Smith, PT, MPH
Mary Stilphen, DPT
Session Type: Educational Sessions
Session Level: Intermediate
This information is the property of the author(s) and should not be copied or otherwise used without the
express written permission of the author(s).
Page 1 of 19 total pages
2/10/2015
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The Power of Data: Achieving Consistent Patient Outcomes
Mary Stilphen PT, DPTCleveland Clinic Rehabilitation and Sports Therapy
Dianne V. Jewell, PT, DPT, PhDThe Rehab Intel Network
Heather Smith, PT, MPH APTA
Session Learning Objectives
After this session, you will be able to:
• Lay the groundwork for standardized outcomes data collection
• Implement a standardized outcomes tool in a consistent and accurate manner
• Analyze and share the information you collect to improve performance at the patient, clinician and/or organizational level
ACOs, Medical Homes
PTA differential payment
Pay for performance
Functional reporting
Therapy cap, MPPR
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Practice-based Evidence
Outcomes Evaluation
• Outcome = “The end result of patient/client management…” (Guide to PT Practice, page 43)
• Why standardized???– Consistency of measurement within an episode of care
– Ability to compare across patients with similar diagnoses
– Ability to compare across providers who manage patients with similar diagnoses
– Gait (10 meter walk, DGI, Functional Ambulation Category…)
Self-report• Examples…
– Oswestry
– DASH
– LEFS
– NDI
– SF-12
– FOTO
– AMPAC
– OPTIMAL
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What you need to know…
• Is the tool reliable?– Inter-tester, intra-tester, test-retest, parallel forms, split-half,
internal consistency
• Is the tool valid?– Face, content, construct (convergent/discriminant), criterion
(concurrent/predictive)
• Is the tool sensitive to change?
• Has meaningful change been determined?
The Power of Information on a Large Scale
• Internal uses–Performance improvement
–Guideline refinement
–Quality reporting
–Staff development
• External uses–Referral sources
–Payers
–Consumers
THE CLEVELAND CLINIC STORY
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• 10 Hospital nonprofit health care system (9 Ohio, 1 Florida)
*
• Unified Brand• Unified Organizational and Leadership Structure • Standard Operational and Clinical Procedures• Increased Productivity, Efficiency, and Cost Structure• Positioning for Growth
Cleveland Clinic Rehabilitation & Sports Therapy
Care Pathways
Consistency of Service
Centralized Recruiting
Outcomes Measurement
“Each time you learn something new you have to adjust the whole framework of
your knowledge”
Eleanor Roosevelt
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Timeline
January 2010 – Therapy Integration
April 2010 – New EMR
July 2011 – 6 clicks
July 2013 – G Codes
September 2013 – SNF data
History
• 2010 – MediLinks implemented as the EMR for PT/OT in the inpatient setting.–Progressive rollout started at main campus in
April 2010 and moved to 8 regional hospitals–Rollout completed by May 2011
• Observations in MediLinks allow the collection of discrete data
• June 2010 – Began discussions with medical leadership on what data should we collect and what questions did we want to answer
What were our initial goals?
• Collect meaningful discrete outcome data with every patient encounter
• Utilize discrete patient data to drive clinical decisions, demonstrate value and guide resource utilization
• Use data to devise a more objective way to determine the appropriate discharge disposition from acute care
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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
Criteria for selecting/developing a tool
• Short – No more than 6 questions. We liked the sound of “6 Clicks”
• Minimal burden on therapists. Develop something that could be easily incorporated into their day.
• Minimal Burden on patients
Could we use AM-PAC
• Activity Measure for Post Acute Care• 25 years in development• Validated across all post acute levels of care• Patient reported outcome tool • 249 items – 3 domains
Ability to collect, aggregate and display functional data in a way that is meaningful to all members of the medical team has changed behavior and contributed to a “all hands on deck”
philosophy around patient mobility
6 Clicks Distribution – All Hospitals 2014
Ideal for nursing mobility
GUIDE DISCHARGE RECOMMENDATIONS
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Using 6 Clicks to guide discharge recommendations
Data over the past three years has been consistent
Home with no services –19.48
Home with home care –17.81
SNF/IRF –
13.95 – 14.0
LTAC – 11.25
6 Clicks Predicts D/C Destination
• 83% of patients had recommendation and actual d/c placement match
• ROC analysis allowed us to define the best cutoff score for determining discharge to home on the basis of the highest sensitivity and specificity associated with the various scores.
• Cutoff scores of 42.9 for basic mobility and 39.4 for daily activity at the first visit provided fair to good accuracy for predicting discharge destination.
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IMPROVE THERAPIST UTILIZATION
80% 88%
10%5%
10% 5%1% 2%
0%
20%
40%
60%
80%
100%
120%
PT (N = 5419) OT (N = 3075)
Patients with a 6‐Clicks score of '24' (highest level of function):Therapist Discharge Recommendation ‐ Combined
Inpatient Rehab Home care Home ‐ with outpatient PT/OT Home ‐ without skilled needs
Inappropriate Consults
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0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
PT & OT ICU Visits as % of Total Visits
Mandatory Functional Outcome Reporting
Journey at the Cleveland Clinic
Uniform data collection in all
settings
Use information from large uniform data sets
to make decisions.
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Opportunity at Cleveland Clinic
• Uniform Data Collection from all 47 outpatient locations into one database– Use that data to provide information back to policy makers
– Is there a benefit of using a single “generic” outcome tool.
– Useful starting point to increasing the accountability of rehabilitation professionals
– Represents a foundation for establishing a universal system of reporting
Outpatient Outcome Tools
Outpatient
• AM-PAC Short Forms both Basic and Adapted versions
• Diagnoses specific Tools• LEFS• QuickDash• Oswestry• NDI• FactB +4
Benefits of Using a Single Outcome Tool
Ability to Develop Large Data Sets
Measure function on the same scale across multiple settings
Begin to have a consistent measurement of “function”
Using a single tool to measure VALUE
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Outpatient AM-PAC Data
• Data available for patients seen between 7-1-13 to 6-30-14– Patients must have at least 2 AM-PAC to be included
• 13,000 matched patients by MRN in Database
• 6,000 additional patients with 2 AM-PACS that are not identified by MRN
What did the data tell us?
• Worked with Diane Jette to analyze data
• Manuscript submitted to PTJ– Change of severity modifier codes was heavily dependent on patients’
initial functional status
– The odds of improving at least one severity level was 4.42 (95% CI 3.38, 5.78) times greater for those with initial AM-PAC scores in the upper end of the range than for those with initial scores in lower end of the range of scores.
Aiming for Value Transformation
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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
PT/OT/ST
“Value” of PT/OT
• Systematic utilization of PRO’s for every patient in every setting.
Outcome
• Resources consumed during service deliveryCost
Should we start measuring patient reported functional outcomes longitudinally across an episode of care
• Validity of the AM-PAC ''6-Clicks'' Inpatient Daily Activity and Basic Mobility Short Forms. Diane U. Jette, Mary Stilphen, VinothK. Ranganathan, Sandra D. Passek, Frederick S. Frost and Alan M. Jette. PHYS THER. Published online November 14, 2013
• AM-PAC “6-Clicks” Functional Assessment Scores Predict Acute Hospital Discharge Destination. Diane U. Jette, Mary Stilphen, Vinoth K. Ranganathan, Sandra D. Passek, Frederick S. Frost and Alan M. Jette. PHYS THER. published ahead of print April 24, 2014
• A Sample of Private-Sector Hospital Discharge Tools: Case studies of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. American Hospital Association. 2015.