PHA Annual Conference May 19 th, 2011 Tonya Miller PT, DPT COS-C Michelle Abeln PT, DPT WCC Therapy 2011 - Updates in Evidence- Based Care and Quality.

PHA Annual Conference May 19th, 2011

Tonya Miller PT, DPT COS-C

Michelle Abeln PT, DPT WCC

Therapy 2011 - Updates in Evidence-Based Care and Quality Initiatives

OBJECTIVES

• The Learner will be able to:– Demonstrate knowledge of the components of

evidence based medicine– Identify evidence based tools and quality of life

measures appropriate in home health setting– Link evidence based medicine to rehab care

planning and goals setting in the home health setting

– Demonstrate knowledge of how evidence based tools and quality of life measures link to outcome measures and quality initiatives

Evidence-Based Practice

• Evidence-Based (EVB) Practices– Definition: Comprehensive reviews of the

scientific evidence regarding the effectiveness, risks, and benefits of specific health care services – AHRQ

– Individualized care based upon standardized EVB assessments

– Research utilized to determine appropriate interventions and measure outcomes

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Evidence Based Medicine

• Best Research Evidence– Derived from either basic science of medicine or

patient-centered clinical research

– Components • Standardization• Reliability• Validity

• Standardization– The process of administering a

test under uniform conditions

– Consider

• Population – The Medicare HH patient? - community-dwelling elderly

• Size of the Sample

Evidence Based Medicine

• Reliability: are findings reproducible?– The process of determining that the test or

measure is measuring something in a reproducible and consistent fashion

– Test/Retest– Inter-rater – Internal consistency: estimate reliability by

grouping questions in a questionnaire that measure the same thing ( quality of life measures

Evidence Based Medicine

• Validity: the strengths of our conclusion– Three Types

• Content Validity: Is this test comprehensive and does it fully represent what is claims to measure

• Construct Validity: Does the test conform to prior theoretical relationships (example: is there more than one study that supports it)

• Criterion Validity: Does it stand up to an already established “gold standard” - example: Berg stands up the Tinetti

Evidence Based Medicine

• Clinical Expertise

-Ability to use clinical skills and past experience to identify the need and appropriateness of standardized assessment tools such as evidence-based tools

Evidence Based Medicine

• Patient Values – The unique preferences, concerns, and

expectations that each patient brings to the encounter

– Must be integrated into the clinical

decision making process

Evidence Based Medicine

• Evidence-Based Medicine (EBM) is the integration of:– Best Research Evidence– Clinical Expertise– Patient Values

“When these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life.” (Sackett)

Evidence Based Medicine

• Professional Organizations– Search Engines: OVID, Pub Med, MEDLINE– AHRQ, American Geriatric Society, Quality Net (MedQIC),

CHAMP Program, Commonwealth Fund… – International and national

• Goggle search– Often times you can read articles for free – be persistent– Copy and paste full name of article in the search area and

you can often find the article in a pdf format– Best for articles greater than one year old

Evidence Based Medicine- finding resources

• Final Rule: The Role of Evidence Based Care

“By advancing patient care, improving quality and fighting fraud,  this final rule addresses important concerns shared by the home health industry and all Medicare stakeholders . “This final rule will help us ensure more accurate payments and retain prudent financial stewardship of the Medicare trust funds,” said Jonathan Blum, director of the Center for Medicare and deputy administrator for CMS.  

Evidence Based Medicine

• Final Rule: The Role of Evidenced Based Care– Re-evaluation by a qualified therapist on 13 and 19th visit

• Increased focus on reasonable and necessary at defined time frames during the episode of care

– Plan of care includes treatment goals • In accordance with clinical accepted standards of

practice– Functional Assessment and Re-assessment

• Include successive objective measurements– Interventions include clinically effective interventions

• How do we support clinically effective intervention

Evidence Based Medicine

• Examples:– Timed up and Go (TUG)– Berg Balance Scale (BBS)– Braden Scale – Borg RPE – Geriatric Depression Scale– Gait Velocity– Two Minute Step Test – MOCA

Evidence-Based Medicine (cont.)

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EVB Tools: Description and Utilization • Timed Up and Go (TUG)

Measure of functional mobility impairment Equipment: Chair, tape measure,

stopwatch, assistive device (prn)Completion time: varies with patient abilityScoring: <10 seconds- high mobility

10-19 seconds- typical mobility

20-29 seconds- slower mobility

>=30 seconds- diminished mobilityCorrelation to falls >13.5 secondsMod-high correlation with Berg and gait velocity

EVB Tools: Description and Utilization • Berg Balance Scale (BBS)

Measure of balance and falls risk Equipment: chair, ruler, stopwatch,

shoe/slipper, step/stepstool;

no AD can be used Completion time:15-20 minutes Scoring: 41-46= low fall risk

21-40=moderate fall risk

0-20= high fall risk Change in 6 points=90% confidence that change has

occurred

EVB Tools: Description and Utilization • Braden Scale Identifies patients at increased risk for pressure ulcer

development Categories: Sensory, moisture, activity, mobility,

nutrition, friction/shear Completion time: <1 minute once

patient assessed Scoring: 15-16= low risk

13-14= moderate risk

<12 = high risk

EVB Tools: Description and Utilization • BORG Rate of Perceived Exertion (RPE) Scale Measures level of fatigue felt during activity Correlates to heart rate and VO2 Used to determine if exercise intensity

is enough to improve endurance and

lung function Scoring: 6-20 scale

greater number = greater exertion

: goal: maintain 13-14

: stop: if increase to 15

EVB Tools: Description and Utilization • Modified BORG scale Measures level of breathlessness Used to determine safe progression of exercise programs Can easily be taught to pt/caregiver for

logging dyspnea level with ADLs Scoring: 0-10 scale;

greater number = greater exertion

: stop if >4 (somewhat severe or worse)

http://www.well-quest.org/

EVB Tools: Description and Utilization

BORG RPE

• Measures overall level of fatigue

• Scoring: 6-20 scale• Caution with frail,

severely deconditioned, or certain cardiac pts

• Used to determine if exercise intensity is sufficient

Modified BORG

• Specifically measures level of breathlessness

• Scoring: 0-10 scale• Appropriate for any pt,

specifically cardio-pulmonary pts

• Used to show when program needs to be modified

EVB Tools: Description and Utilization

• Geriatric Depression ScreeningMeasurement of depression in patient’s with dementiaEquipment: QuestionnaireCompletion time: <10 minutes

Scoring: 0-4: typically no cause for concern

5-8: mild depression

9-11:moderate depression

12-15: severe depression

EVB Tools: Description and Utilization • Gait Velocity Test Measure of gait Equipment: stopwatch, measuring tape,

assistive device (prn) Completion time: <2 minutes Scoring: Time it takes leading limb (toe) to cross start line

and end line (10 meters); factor in acceleration/deceleration time

<=0.6m/second- household ambulation

0.6-1.0m/second- limited community ambulation

>1.0m/second- full community ambulation

EVB Tools: Description and Utilization

• 2- Minute step test Measure of strength and aerobic capacityEquipment: stopwatchCompletion time: <5 minutes to set up

2 minutes to complete testScoring: total # of times ® knee reaches correct

height during marching for 2 minutes

EVB Tools: Description and Utilization • MoCA (Montreal Cognitive Assessment) Measures mild cognitive impairment Uses attention & concentration, executive functions,

memory, language, visiuoconstructual skills, conceptual thinking, calculations, and orientation

Equipment: paper test sheet, pencil/pen Time to administer: 10 minutes Scoring: Total: 30 points; Normal: >=26 points Free for clinical, educational, and research use; can use

WITHOUT permission by health professionals/hospitals/clinics/public health institutes

Link between EVB tools and QOL Measures

• Choosing appropriate EVB tools to develop plan of care for patient

• Better outcomes

• Improved QOL measures

Quality of Life Measures(QOL)

• Definition – Measures the general well-being of an individual

and how one may be affected by chronic disease or disability

– Multi-dimensional• Often disease specific• Incorporates physical, mental, emotional and

social well-being• Effects of treatments• Financial impacts of medical conditions

Health Related Quality of Life Measures (HRQOL)

• More precise way of defining QOL• Primarily concerned with how QOL may be

affected by health and disease• Measures patient’s sense of his/her OWN

health and well-being in areas of physical, psychological, and social functioning

Disablement Model: EVB Tools and QOL

QOL Measures (cont.)

• Usually in survey or questionnaire format• Self administered or clinician administered• Variety of surveys exist to measure impact

of treatment on QOL based on past patient

experiences• The two most used in Healthcare:

– Generic: such as SF-36 (Short form with 36 questions)

– Disease or Disorder specific: Visual Functioning Questionnaire or Minnesota Living with HF questionnaire

• Can be used before, during or after treatment

QOL Measures (cont.)

• Why so important– Growing trend in research to develop and study

the effects that chronic disease and different treatment options have on QOL

– Help determine appropriate cost effective treatment options for improving quality of life

– Help determine treatment areas that need to be improved

– Strong predictor of prognosis

Determining the appropriate QOL Measure

1) What are you looking to measure?

2) Is tool reliable, valid, and responsive?

3) Is tool practical?

QOL measures (cont.)

• Free QOL surveys: – Clinical COPD Questionnaire– COPD Assessment Test (CAT)– 36-Item Short Form Health Survey– Nottingham Health Profile

• Fee required:– Minnesota Living with Heart Failure

Questionnaire– The Kansas City Cardiomyopathy

Questionnaire

QOL Measures (cont.)

• Overview of The Clinical COPD

Questionnaire (CCQ)

-3 domains: symptoms, functional state and mental state

-10 items equally weighted

-available in 2 versions: 7 day and 24 hour

-self administered

- a seven-point scale where 0 = asymptomatic/no limitations and 6

- extremely symptomatic/totally limited

QOL Measures (cont.)

• Overview of COPD Assessment Test (CAT)– Questionnaire for COPD patients to measure

impact of COPD on person’s life and how it changes over time.

– Free– Self administered– 8 questions– Scoring 0-5 each question– Total range 0-40 with lower score better

QOL Measures (cont.)

• Overview of 36-Item Short Form Health Survey– Set of generic, coherent, and easily administered

quality-of-life measures. – questions comprise eight health scales measuring

three aspects of health (functional status, well-being, and 'overall evaluation of health'); also includes an unscaled assessment of change in health status

– Free

QOL Measures (cont.)

• Overview of Nottingham Health Profile (NHP)

- Provides brief overview of individual’s perceived

emotional, social, and physical health

- 2 sections with a total of 45 questions:

>Part 1: energy level, pain, emotional reaction,

sleep, social isolation, physical abilities

> Part 2: seven life areas affected

- self-administered

- Free

QOL Measures (cont.)• Overview of Diabetes Quality of Life

Measure (DQOL)

- designed for individuals with IDDM

- evaluates relative burden of an intensive diabetes

treatment regimen

- 46 core items with 4 major dimensions

- most widely used for assessment of

diabetes- specific HRQol

- self-administered

QOL Measures (cont.)

• Overview of Type 2 Diabetes Symptom Checklist

- 34-item scale designed to evaluate 6 categories

of diabetes-related symptoms

>hyperglycemia, hypoglycemia,

cardiac ,neuropathic,pyschological,

and vision-related

- higher scores associated with poorer

glycemic control

- self-administered

QOL Measures (cont.)• Overview of Minnesota Living with Heart

Failure Questionnaire ( MLHFQ)– Evaluates heart failure’s effects on the patient’s

physical, emotional, social and mental dimensions of quality of life.

– Need to purchase– Self administered– 21 items– 6 pt Likert (0-5) scoring range 0-105– The higher the score, the worse

QOL Measures (cont.)

• Overview of The Kansas City Cardiomyopathy Questionnaire (KCCQ)– 23-item questionnaire for patients related to

physical function, symptoms, social function, self-efficacy and knowledge, and quality of life.

– Need to purchase– Self administered– 5-7 pt Likert scoring range 0-100– The higher the score, the better

EVB Tools and QOL: Connecting To OASIS-C• Heart Failure (M1500, M1510)

– The Minnesota Living with Heart Failure Questionnaire

– The Kansas City Cardiomyopathy Questionnaire

• Depression (M1730), (2250d), (2400c)– Geriatric Depression

Screening Tool

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QOL: Connecting To OASIS-C (cont.)

• Diabetes (M2250b, 2400a)– Diabetes Quality of Life

Measure (DQOL)• COPD (M1400, M1410)

– Clinical COPD Questionnaire

– COPD Assessment Test (CAT)• Wounds

– Address underlying issue• 36-Item Short Form Health

Survey

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Evidence-Based Medicine: OASIS-C Connections (cont.)• Process Measures

– Depression: Has the patient been screened for depression using a standardized depression screening tool?

– Falls: Has this patient had a multi-factor fall risk assessment?

– Pain: Has the patient had a formal pain assessment using a standardized assessment tool?

– Pressure Ulcers: Was this patient assessed for risk for developing pressure ulcers?

• Yes- using a standardized tool

EVB and QOL: Treatment interventions

• BERG- pt at moderate risk for falls with difficulty on all transfer sections. o Treatment: specific interventions to work on sit><stand

transfers, strengthening of LEs, and to assess need for liftchair

• Gait Velocity Test- gait speed shows pt only safe for household ambulation, as pt not using AD and not clearing feet from floor during swing phase.o Treatment: strengthening of LEs (specifically dorsiflexors),

training with appropriate AD, assess need for ankle-foot orthosis

EVB and QOL: Treatment interventions

• Modified BORG- pt scored 5/10 when ambulating 35’ with standard walkero Treatment: educate pt on use of rolling walker, educate pt on

diaphramatic breathing, educate pt/caregiver on use of chart to log pt’s dyspnea with ADLs.

EVB Tools and QOL: Rehab Plan of care .

TUG score on SOC= 29 seconds.

POC: Ambulation with wheeled walker in home on level and unlevel surfaces; static and dynamic balance exercises. Re-assess TUG every 2 weeks.

GOAL: Pt will increase TUG score to 15-20 seconds with wheeled walker in 4 wks for decreased fall risk and typical mobility.

EVB Tools and QOL: Rehab Plan of care

• Modified BORG on SOC= 5/10 with ambulation without AD on 2 steps to leave home.

POC: training with use of cane on steps, LE strengthening exercises, educate pt/CG on use of chart to log breathlessness with ambulation. Re-assess BORG every 2 weeks.

GOAL: Patient will ambulate independently with cane outdoors to get to car with Modified BORG rating of 3/10 so patient can begin outpatient PT in 5 wks.

EVB Tools and QOL: Rehab Plan of care Gait Velocity: 0.8 seconds with cane on SOC

POC: static and dynamic balance exercises, s strengthening, training on sequencing with . use of cane. Re-assess gait velocity weekly

GOAL: Gait velocity will improve to 1.2 m/sec for safe community ambulation with cane in 4 weeks.

Turning the Wheels of Health Care Quality

Turning the Wheels of Health Care Quality

Turning the Wheels of Health Care Quality

EVB Tools QOL: Outcomes and Quality Connection• OB QM

– Reducing re-hospitalization• Gait velocity and connection to increase morbidity and

morality – the “6th vital sign”

• OBQI

-Functional and clinical

OASIS outcomes connectors

• PBQI:– Direct correlation to disease processes using

quality of life measures

• HHCAPS– Compare changes in QOL to HHCAPS – Great way to set goals for clinicians that will

impact publically reported data

EVB Tools QOL: Outcomes and Quality Connection

EVB Tools QOL: Outcomes and Quality Connection• Value Based

Purchasing– Referral sources– Payors

• Positioning to be the agency of choice in collaborative care and ACO models

I have all of these tools

And

Great Info!

Now What??

Integrating into Organizational Practice

• Barriers:– Documentation Systems – Time constraints– Coordination PT and PTA– Organizational policies and processes

• Example: established falls assessments

processes

– Clinician Buy –in

• Education– Staff meetings

• Presenting basics of evidence based care• Presenting one new tool per month

– Preceptor process • One on one training• Train the trainer

– Incorporate into new staff orientation• Documentation Strategies

– Work with Vendors for modifications– Cut and Paste addendums to add specific Test– Mixed Paper and computer documentation if needed– Not having the tool available in documentation will not be an excuse for

auditors

Integrating into Organizational Practice

• Performance Improvement Team– Discuss how Evidence Base Practice Correlates to:

• OBQI• OBQM• PCOI• HHCAPS

• Administration– Discuss how Evidence Based Tool Integration Effects the bottom line

• RAC Audits• Value Based Purchasing• Collaborative Care with Referral Sources • Accountable Care Organizations – the Agency of Choice

Integrating into Organizational Practice

Key Points:

• Evidence Based Medicine can improve quality of outcomes and the patient experience

• EVB Tools and QOL measures can be easy to use and incorporate into everyday clinical practice

• The use of EVB tools and QOL measures can help to position agencies for future success

Questions

Resources

• CMS Outcome Based Quality Improvement Manual– https://www.cms.gov/HomeHealthQualityInits/downloa

ds/HHQIOASISOBQIImplimentationManual.zip

• Home Health Quality Improvement National Campaign– www.homehealthquality.org

• CMS Process Based Quality Improvement Manual– http://www.cms.gov/HomeHealthQualityInits/Download

s/HHQIOASIS-PBQI.pdf

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Resources (cont.)• Law, M. (2008). Evidence Based Rehabilitation: A

Guide To Practice.• List of QOL measures: http://www.proqolid.org/• Agency for Healthcare Research and Quality

(AHRQ) http//www.ahrq.gov• http://www.homehealthquality.org • http://www.champ-program.org• Parissis, JT, et al. Comparative prognostic value of

the Kansas City cardiomyopathy and the Minnesota living with heart failure questionaires in chronic heart failure. Attikon University Hospital, Athens, Greece

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Resources (cont.)• Klocek M,Kubinyl, et al.; Effects of physical training on quality of life and oxygen

consumption in patients with Congestive Heart Failure Int J Cardiol 2005; 103(3):223-329.

• Polansky, W; Understanding and Assessing Diabetes-Specifc Quality of Life. Diabetes Spectrum; 2000; 13:36-49.

• http://www.sciencedaily.com/releases/2007/06/070614105308.htm

Resources (cont.)

• Centers for Disease Control and Prevention

http://www.cdc.gov/• American Diabetes Association Home Page

http://www.diabetes.org• University of Missouri-Columbia (2007, June 15).

Exercise Helps People With Diabetes, Study Says. ScienceDaily. Retrieved December 30,

• Nursing Economics, Jan-Feb, 2002• jama.ama-assn.org

Resources (cont.)

• Jette, Alen M. Using Health Related Quality of Life Measures in Physical Therapy Outcomes Research; Physical Therapy,73:8:44-53.

• http://cvoutcomes.org/topics/3038 • http://www.license.umn.edu/Products/Minnesota-

Living-With-Heart-Failure-Questionnaire__Z94019.aspx 

• http://www.champ-program.org/search?q=Geriatric+Depression+Scale+&x=15&y=17

Resources (cont.)

• http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html

• Home Health Care CAHPS (Official)– http://www.homehealthcarecahps.org/

• www.qualitynet.org• Van der Molen, T. Clinical COPD Questionnaire,

University Medical Center Groningen, The Netherlands, 1999.

Thank you for attending this session.

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