(

DIRECT CARE AND COORDINATING CARE

TIME STUDIES IN THE

MYELODYSPLASIA AND PEDIATRIC HEMATOLOGY CLINICS

( APRIL 21, 1988 S

Submitted to:

Harriet Bakalar A. C. S. W.Director of Social Work

Mott Women’s Holden Hospitals

By:

Wendy CarlinCassandra ErvinLisa HodgsonKaren Kelly

EXECUTIVE SUMMARY

Harriet Bakalar, Director of Social Workat Mott Women’s HoldenHospital, initiated a request for a group of Industrial and OperationsEngineering students to assist in the completion of a study undertaken byher department. This study is the DSCC/UMMC Costing Chronic Care Studythat will determine the total cost of patient care and the distribution ofthese costs through the different disease stages over time.

The two clinics studied by our student group are the PediatricHematology and the Myelodysplasia Clinics. The time study incorporatedthe coordinating care of both clinics. In addition, the direct care wasstudied in the Myelodysplasia Clinic. Direct care is considered to be thetime spent on a patient’s care during a clinic visit. The time spent on thetelephone or other mediums on a patient’s care while they are not in thehospital is considered to be coordinating care.

The sample size in the Myelodysplasia clinic for the direct carestudy was uncontrollably small (25). This sample size is not large enoughto draw conclusive results about the cost of a clinic visit in each of thedisease categories. However, when we took an average of all the patientswe observed in the clinic we found the averae cost to be $96.33.Currently this charge is only $75.

Participation levels in the coordinating care study in both clinicswere low, but this was especially true of the Pediatric Hematology ClinicStaff(44%). We feel that because we had low participation levels that wedid not have valid data on which to base our results. The cost that wewere able to calculate from our limited data was $143.06 formyelodysplasia and $348.28 for hematology. These figures are stated on aper patient per year basis.

Although the results from this study are very inconclusive, we feelthat the methodologies that were developed for the study are important.We feel that these methodologies are appropriate for the situation athand The method of collecting and analyzing the data could easily be usedagain in the future if the study were ever to be continued or done again

C

TABLE OF CONTENTS

Page

INTRODUCTION 1

MYELODYSPLASIA 2DIRECT CARE 4COORDINATING CARE 8

HEMATOLOGY COORDINATING CARE 11

MYELODYSPLASIA AND HEMATOLOGY CLINICS 15

(.-‘.APPENDICES

APPENDIX A 16APPENDIX B 20APPENDIX C 21

INTRODUCTION

The project presented in this paper assists in the completion of theDSCC/UMMC Costing Chronic Care Study. The objective of the CostingChronic Care Study is to establish a total cost of patient treatment andthe distribution of these costs through the disease stage over time. In thecourse of establishing this total cost, it is essential that the servicesprovided and the cost of these services remain distinct. By keeping themseparated, it will be simpler when treatment technology or costs changeto alter the overall cost of the disease.

The project addresses that part of the Costing Chronic Care Studythat concerns the outpatients of the Myelodysplasia and PediatricHematology/Oncology Clinics. In the Myelodysplasia Clinic, we studiedboth direct care and coordinating care time. The Hematology Clinic’s onlyfocus was the time spent on coordinating care. The direct care portion inthe Myelodysplasia Clinic is aimed at capturing the amount of time eachprofessional spends with a patient. This will enable us to better assign amore accurate cost of a clinic visit, It is felt that the current cost of $75for the clinic visit is not reflective of the amount of patient care that isreceived by each patient. Coordinating care is the amount of time anyproject related professional spends on patient-related phone calls,letters, and consultations while the patient is not in the hospital. This issomething that was not previously reflected anywhere. Since it isbelieved that the coordinating care time is considerable it needed to beinvestigated. This paper documents what people are involved, how muchtime is involved, and what costs are involved for each of the mentionedactivities.

We divided our group of four between the two clinics at the outsetof this project to better handle its scope. The Pediatric HematologyClinic time study was handled by Lisa Hodgson and Karen Kelly. WendyCarlin and Cassandra Ervin worked with the staff of the MyelodysplasiaClinic.

1

MYELODYSPLASIA

INTRODUCTION

The focus of the studies in the Myelodysplasia Clinic was on thedirect care time and the coordinating care time spent by professionalswith outpatients. The two studies were conducted simultaneously byCassandra Ervin and Wendy Carlin, with the objectives of determining thetypes of profesionals involved, the amount of time spent by theseprofessionals with patients, and the costs associated with theprofessionals’ time. These studies do not concern themselves with theactual procedures associated with the treatments. The team ofprofessionals involved is listed below:

Neurosurgeon(2) Occupational Therapist Orthopedic Surgeon(2)Orthotist Pediatrician Physical Therapist(2)Registered Nurse Rehabilitation Engineer Social Worker

Direct care was defined as the services that were provided toC patients ki clinic rooms during scheduled visits. Coordinating care was

defined as the services that were provided to patients outside of clinicroom time. Coordinating care was the activities related to patient careother than that recorded as direct care. This includes, but is not limitedto, phone calls (to the family, to other facilities such as school districtsand health care facilities, etc...), written correspondences (to schooldistricts, to local 1iealth care facilities, etc...), direct interdisciplinaryconsultations, and time spent reviewing a patient’s case. It is importantto note that ALL activities performed on behalf of Myelodysplasiapatients by the professionals involved were to be classified as eitherdirect care or coordinating care in order to ensure that the total timespent on patient care was captured.

Myelodysplasia (or spina bifida) is a birth defect in the spinalcolumn resulting from the failure of the spine to close properly during thefirst month of pregnancy. The condition results in varying degrees ofparalysis and loss of sensation in the lower limbs, and most often resultsin bowel and bladder complications. Because of the above variables, thepatients involved in the direct care study were classified according to thefollowing age groups and neurological levels (location and severity ofspinal defect):

2

Ae Grpu ULQijQLLv1

1. Neo-natai- includes initial 1. T12 or higher

hospitalization 2. L1 - L32. Infancy

- beginning with first 3. L1. - L5

discharge up to age 2 4. S1 - S23. Toddler Years- age 2 to 54. Early School Years - age 6 to 125. Adolescence

- age 13 to 176. Adult - age 18 and older

The remainder of the Myelodysptasja section will further discuss themethodology, the results, and the problems encountered during the courseof the project in both the direct care and the coordinating care studies.

3

DIRECT CARE

I NTRODUCT1ON

Currently, a $75 flat rate fee is charged to the patient per visit tothe clinic. It is felt that the charge for the clinic does not accuratelyreflect the care that is received by the patient. The revised costingsystem needs to reflect the service time spent by each professional witheach patient. Therefore, the objective of the direct care study was todetermine the amount of time each professional spent on direct care (asdefined above) for patients in the various classifications.

We considered several alternative methods to use in gathering thedata. After considering the advantages and disadvantages of each, wedecided to use self-reported data and time studies. The self-reporteddata has obvious disadvantages; however, it has one overriding advantage,Which is that the treatment procedures, which are extremely variable, donot need to be defined. We conducted time studies to validate theself-reported data. During each clinic, students recorded the amount oftime the professionals spent with patients. Again, this did not require adefinition of the treatment procedures.

MEfl-RDDCLOGY

The direct care study was conducted for three weeks (March 21 thruApril 11). Prior to starting the study, we sent each professional a memoexplaining what we proposed to do. We also held a meeting on March 21 toexplain the data sheets and answer questions. The self-reported datasheets were centrally located in the staff room and we requested theprofessionals to record the time they spent with patients during clinicvisits immediately after their consultation with the patient. Weconducted time studies in which we recorded the amount of time weobserved the professionals consulting with patients. This dual method oftracking the time helped to verify the data we used in the cost model.

4

RESULTS

The overall average cost per patient per visit is $96.33. This doesnot take into account disease level. Calculations are explained inAppendix A.

The average cost per patient per visit by disease stage is given inTablet.

C

C

VERAGE COST PERPATIENT STAGE PATIENT PER VISIT

NEO-NATAL T

Li -L3

L4-L5

Si-S2

INFANCY T

L1-L3 111.32

L4-L5 113.14

S1-S2

TODDLERHOOD T 1 20.23

L1-L3L4-L5 78.03

S1-S2 40.54EARLY SCHOOL T 97.14

L1-L3

L4-L5 13.51• S1-S2 72.97

ADOLESCENCE T 71.90

L1-L3 62.68

L4-L5

S1-S2

ADULT T 28.52

L1-L3 57.84

L4-L5

S1-S2

TABLE 1. AVERAGE COST PER DISEASE STAGE

5

We were able to obtain data for thirteen of the twenty-four diseasestages. However, care must be taken in the interpretation of theseresults. In some cases, the average cost was based on only oneobservation. A larger sample size , with each catagory being represented,is necessary before any valid conclusive remarks can be made.

Although participation from the professional staff was good, insome cases, we have no reported time. Reasons for this include: some ofthe nine member staff of professionals were not present for each clinic,they ran out of time before they could see the patient, or they forgot torecord their time. For this reason, we have included in Appendix A, theaverage time each professional spent with patients, catagorized bydisease level. It is important to remember that some professionals onlyneed to see certain patients. The neurosurgeon, orthopedic surgeon, andrehabilitation engineer in particular don’t see every patient that comes tothe clinic.

The time studies we conducted were used as a quality check todetermine the validity of the self-reported data. We were not familiarwith the procedures involved in the direct care of a Myelodysplasiapatient, so we recorded the time a professional spent in a clinic roomwith a patient. However, due to patient support systems, it is impossibleto know when a professional is doing somethilig classified as direct careand when they are giving support and encouragement to a patient. For thisreason, we relied on the self-reported data.

PROBLEMS ENCOUNTERED

We encountered many problems during the course of this study. Themain obstacle was the relatively small number of patients that werevisiting the clinic during the study. The clinic is only open six half days amonth. The clinic usually schedules six patients per clinic day. Wedesigned the data collection stage to observe 36 patients, over 20% oftheir active patients. However, due to cancellations, we observed 25patients, less than 15% of their active patients.

Another problem concerned the use of self-reported data.Occasionally, some professionals would forget their start or stop timeand the data would merely be an estimation of their direct care time.Also, the data collection sheet allowed for five minute intervals. Sevenminutes could be subjectively recorded as five minutes or ten minutes,depending on the professional.

6

C

U

C A problem with the time study data was in determining when theconsultation ended. Frequently, the consultation appeared to have endedonly to have the professional return moments later.

RECOMMENDATIONS

The method employed in the direct care study in the MyelodysplasiaClinic can be used to assertain the cost of direct care provided by the ninemember multidisciplinary team of professionals. The study indicated thatthe current charge of $75 does not reflect the type of care patientsreceive during clinic visits. However, before a valid cost system can bedefined, the study needs to be expanded to include patients from alldisease levels that utilize the clinic.

We recommend that the direct care study be extended so that thecosting system can be structured to cover the complete cycle of thedisease. We designed the study so that it could be continued in ourabsence. The time studies do not need to be continued. The self-reporteddata will give reliable results. The accuracy is limited to the five minutetime interval used in the study, and the desire of the professional staff toparticipate in the study.

7

COORDINATING CARE

INTRODUCTiON

The coordinating care study in the Myelodysplasia Clinic wasconducted for three weeks (March 21 11988 thru April 8, 1988). The goalof the study was: 1) to determine the amount of time each professionalspent coordinating care for patients, and 2) to calculate the costassociated with this time. As previously mentioned, coordinating care isdefined as those activities performed by professionals on behalf ofmyelodysplasia patients outside of clinic room time.

MEfl-KDOOLOGY

Coordinating care activities are performed by the professionals invarious locations at any time of the day. Because of this, a self-reporteddata collection method was used in determining the amount of time eachprofessional spent on coordinating care. Data sheets were provided to aidthose involved in recording their coordinating care time. These sheetsincluded designated spaces for the professional’s name, patient’s name,date, estimated time, and brief description of the activity performed. Theprofessionals were instructed to fill in this information immediatelyupon completion f the activity.

RESULTS

After receiving the completed data sheets, a tabulation was made ofthe total hours each professional spent coordinating care. Note, thistotal reflects the time each professional recorded having spent oncoordinating care. Some of the professionals did not record any time. (SeeTable 2).

8

COORDINATING CARE RESULTS

TOTAL HRS. AVER. HRS. AVER. COST PERPROFESSIONAL RECORDED PER YEAR PATIENT PER YEAR

NBJRLR3BDN 0.17 2.95 $ 1.40

OCCUPATIONALTHERAPIST 758 131.39 $21.99

ORThOPEDIC SURGECN - - -

ORTHOTIST 10.50 182.00 $24.41

PEDIATRICIAN 8 25 143 00 $67 94

PHYSICALTHERAPIST 0.92 15.95 $ 2.10

REGISTERED NURSE 0.58 10.05 $ 1.73

REHABlLATION ENGINEER - -

SOCIAL VK)RKER 10.42 180.61 $23.49

TOTAL

$143.06

Table 2.

The goal was to determine the average coordinating care time perpatient per year. The calculations used to determine this value can befound in Appendix B. The cost value we arrived at is $143.06 per patientper year.

9

PROBLEMS ENCOUNTERED

There were significant problems encountered during the course ofthis study. The method of data collection created certain difficulties.Because of self-reported data, there was no way to verify the number andtime duration of the activities each professional performed. Also the datawas recorded using five minute intervals, which allows for somesubjectivity on the individual involved in determining the amount of timehe/she spent on each activity. For example, an activity requiring sevenminutes could have been subjectively recorded as five minutes or tenminutes.

Another problem in conducting the study was in the amount ofparticipation from the professionals. Of the twelve professionalsinvolved (two neurosurgeons, an occupational therapist, two orthopedicsurgeons, an orthotist, a pediatrician, two physical therapists, aregistered nurse, a rehabilitation engineer, and a social worker), onlyseven (58%) of them filled out data sheets. For those who did notcomplete the data sheets, it was not possible to determine whether theyspent no time on coordinating care during the three week period, orwhether they just did not record their time.

RECOMMENDA11ONS

The data generated in this study was not complete due to the abovedifficulties. However, the methodology developed can be used toeffectively detemine the amount of time each professional spends oncoordinating care for patients, and further to calculate the costassociated with this time. To accomplish this, a few recommendationsshould be made to ensure the accuracy of the desired outcomes.

1. A slight modification in the data collection sheets is needed. Insteadof using five minute intervals in recording the time spent on eachcoordinating care activity, a designation of “start time” and “end time”should be made. This will ensure the accuracy of the recorded time andeliminate any chances of subjectivity.

2. The duration of the study should be lengthened beyond three weeks.This will allow time for the professional involved to get accustomed tofilling out the data sheets in hopes that they will not forget to recordtheir times. This also allows for a more accurate average of time spentper year.

10

HEMATOLOGY COORDINATING CARE STUDY

INTRODUCTION

Lisa Hodgson and Karen Kelly were asked to find the amount of timebeing spent by physicians and nurse practitioners on coordinating care.Coordinating care is defined as that time spent on a patient’s case whilethat patient is not at the hospital receiving care. This can be in the formof telephone calls, letters, or consultations, but is most generally atelephone call. This paper will further discuss the data collectionmethod, the results from the data we collected, the problems encounteredin the study, and the recommendations based upon the results.

METHODOLOGY

We decided that a self reporting method was the best availablealternative for the hematology coordinating care time study. Althoughthere are numerous drawbacks to this method we felt that it was the onlyone that was feasible for the project. The drawbacks that wereconsidered are the following:

-people forget to write down what is requested of them.-it requires time and effort on the part of the people

involved in the study.-self reported data is inherently inaccurate.

However, any other method would have been infeasible for the followingreasons:

-coordinating care can be performed at any location duringany part of the day.

-it is not reasonable for two people to keep track of thefifteen involved in this study.

-it is not possible for others to determine when the taskbeing performed could be considered coordinating care.

•11

We distributed to the physicians and nurse practitioners a sheet onwhich to record the necessary information. Attached to these sheets wasan informational letter explaining the project and the sheets. The sheetasked forthe patient name and the amount of time spent performing thecoordinating care activity. A tally sheet was also provided for theclerical staff to record all incoming calls. In addition, the sheet alsoasked the clerical staff to record how many daily calls each personinvolved in the study received. This was intended to be a check as to howmany calls the doctors and nurse practitioners were making inrelationship to how many they had received. Both of these project sheetswere to be completed over the course of a three week period.

The goal of the study is to find the average time spent oncoordinating care per patient per year and the cost of this time. To get tothis number required that several mathematical operations be perforndon the data we received. Also of interest was the amount of time spentproportionally on coordinating care in each of the five disease stages.Fran Talsma, our project contact, provided us with the necessaryinformation to complete this aspect of the study.

RESULTS

After several mathematical manipulations we found the averagetime spent on coordinating care per provider per day to be 36.7 or about 37minutes. A provicfer is defined to be either a physician or nursepractitioner. The average cost per patient per year was calculated to be$384.28. An average number of active patients was estimated to be 500.The equations for these calculations can be found in Appendix C.

The percentages of the amount of time spent in each of the fivedisease stages can be found in Table 1. Also included in the table is thepercentage of time spent on non-hematology patients. If it were knownhow many patients are currently in each of the disease stages then itwould also be possible to find the amount of time and cost per patient peryear on coordinating care. However, this data was not available to us.

(

12

The idea of maintaining a check as to how many calls the doctorswere making compared to how many they were receiving with recordsprovided by the clerical staff never worked out. The clerical staff waskeeping good records while we were receiving no response from thephysicians and nurse practitioners. When we began receiving recordingsheets from the physicians, the clerical staff had stopped recording theirtally sheets.

PROBLEMS ENCOUNTERED

This project was plagued by a lack of participation from thephysicians and nurse practitioners. The participation level was only 44%by individuals. However, if participation was considered over the threeweek span, then the participation level was only 23%. Of those who didparticipate, it was not over the span of time that we had requested. Wewould have liked to have data from the nurse practitioners because theyoften do the coordinating care that is not done by the physicians. One ofthem, however, was not working during the time we collected data,leaving the other twice as busy. We feel that this lack of participationled to an insufficient amount of data on which to base valid results.

Percentage of Percentage of Average TimeCalls Studied Time Spent per Activity(min)Disease stage:

Induction

Maintenance

B.M.T.

Off Therapy

Terminal

Non-HematologyPatients

12.4% 10.9% 10.53

37.9% 25.6% 8.05

3.3% 2.9% 10.60

5.9% 3.9% 7.89

24.8% 44.0% 21.13

15.9% 12.7% 9.67

TabLe 3. Percentage of Time Spent

C13

RECOMMENDATIONS

Although we feel the coordinating care time is considerable andshould be taken into consideration, we are unable to make arecommendation as to how. Because of the problems we mentioned above,the participation level is too low to draw conclusive results. We do feel,however, that the method of data collection and analysis could be usefulat a later date. We received more forms toward the end of the datacollection period. Perhaps if the study could have been conducted for alonger period of time, it may have been more accurate. :

One recommendation that we would suggest does not have to dospecifically with our study, but would benefit the hematology clinic. Wefeel the clinic needs to computerize their patient list and records. Asmentioned earlier, the percentage of patients in each stage is notavailable nor is it very clear what the total number of current pediatrichematology patients is. With computerized records, these calculationswould be easier. We think that this is something that should beconsidered in the future.

14

MYELODYSPLASIA AND HEMATOLOGY CLINICS.

Before beginning our project, it was explained to our group thepolitical atmosphere that currently exists in the hospital. Because thehospital is experiencing severe budget cuts, many employees areconcerned about their futures with the hospital. When this type of tensionexists, it is natural, at least subconsciously, to let this affect them whena study is being conducted concerning their jobs. People may tend toeither write down more time for an activity than it actually took toperform it, or possibly to not participate in the study at all. This isparticularly true of self reported data.

OVERALL CONCLUSIONS

Although we believe that the data we did receive is accurate, thereis simply not enough of it to base conclusions that we would consider tobe valid. We do not feel it is appropriate for us to base any conclusionsfrom the data we received, especially in the coordinating care studies.

• However, we do feel that the methods of data collection and the analysisof this data are appropriate for the purposes of the study. We believe thatthese same methodologies could be used again if these same studies orsimilar time studies were conducted in the future.

15

APPENDIX A

MYELODYSPLASIA CL1MCDIRECT CARE STUDY

CALCULATIONS FOR AVERAGE COST PER PATIENT PER VISIT:

E=CX(1+D)

WHERE:

C=AXB

A = AVERAGE HOURS PER VISITB = AVERAGE HOURLY WAGE RATE INCLUDING FRINGEC = AVERAGE DIRECT COST PER VISITD = INDIRECT OVERHEAD RATEE = COST PER PATIENT PER VISIT

(

16

DIRECT CARE COST PER PATIENT PER VISIT FOR EACH PROFESSIONAL

OR1NOPEDPATIENT STAGE FsEJRcStflcN S1FcN PEDIATRICIAN

TN EQ-NATAL

INFANCY

a

TODDLERHOO

EARLY SCHO(

ADOLESCENC

ADULT

L1-L3

L4-L5

Si -$2

T

L1-L3 13.46 13.46 55.87L4-L5 20.19 31.64Si-S2

T 10.10 6.73 45.77

L1-L3 6.73 33.21

L4-L5 6.73 34.10S1-S2 12.12T 10.10 16.83 29.62

L1-L3

L4-L5 6.73S1-S2 13.46 28.27

T 10.10 26.48L1-L3 6.73

- 30.96L4-L5

Si -S2

T

Li-L3 13.46 18.85L4-L5

Si-S2

17

DIRECT CARE COST PER PATIENT PER VISIT FOR EACH PROFESSIONAL

REGISTERED OCCUPATIONAL pyjPATIENT STAGE NURSE THERAPIST THERAPIST

NEO-NATAL T

L1-L3

L4-L5

S1-S2

INFANCY T

L1-L3 6.10 4.74 7.47

L4-L5 4.88 28.44 14.94

Si -S2

TODDLERH000 T 6.50 11.06 22.42

Ll-L3 732 7.11 13.08L4-L5 6.50 7.11 9.34

Si-S2-- 4.88 14.22 -

EARLYSCHOOL T 7.32 14.22 8.72Ll-L3

L4-L5 4.88Sl-S2 7.32 7.11 16.81

ADOLESCENCE T 4.88 4.74 12.14Li-L3 4.88 7.11 7.47L4-L5

Si -S2

ADULT T 12.19 7.11Li-L3 7.32 7.11 3.74L4-L5

Si-S2

18

(—.)

DIRECT CARE COST PER PATIENT PER VISIT FOR EACH PROFESSIONAL

NEO-NATAL T

L1-L3

L4-L5

19

SOCIAL REHABILITATIONPATIENT STAGE WORKER ORTHO11ST B’3R

Si -S2

INFANCY

TODpLERHOOD

EARLY SCHOOL

ADOLESCENCE

ADULT

T

L1-L3 7.37 2.85

L4-L5 8.29 4.75

Si-S2

T 12.90 4.75

Li-La 6.45 5.70

L4-L5 10.44 3.80S1-S2 5.53 3.80T 3.69 6.65Li-L3

L4-L5 1.90, Si-S2

T 11.67 1.90L1-L3 5.53

L4-L5Si -S2

T 9.21

L1-L3 7.37

L4-L5Si-S2

APPENDIX B

Myelodysp!asia Clinic: Coordinating Care Study

The figures presented for each professional listed in Table 2 weredetermined by the following calculations:

1 52wks1. average hours peryear = A x x

3wks yr

1 yr2.averagecostper= B x x D x xExF

C 2080 hrs

Where: A total hours recorded

B = average hours per year (from 1. above)

C = # active myelodysplasia patients (170)

D = professional’s average salary

E = 20% fringe benefits

F = %overhead cost

/

20

APPENDIX C

HEMATOLOGY CLINIC COORDINATING CARE STUDY

For the percentage calculations in Tablel, the total number ofactivities and the total number of time spent performing these activitieswere found from the data. The activities were then divided either into thepatient’s disease stage, or non-hematology patients. The number ofactivities in the disease stage was divided by the total number ofactivities. This was repeated for the time spent performing theseactivities.

METHOD FOR CALCULATING THE AVERAGE COORDINATING CARE TIME ANDCOST PER PATIENT PER YEAR

A*B*C=D

where

A= average time (in hrs) spent per provider per day

8= average cost per provider (including 20% fringe)

C= indirect overhead cost(as a function of direct cost)

D= averag time and cost per provider per day(for those providers who participated in the study)

then,

D*E*F G=H

where

6= total number of providers

F= number of days worked per year

G= number of active patients

H= average coordinating care time and cost perpatient per year.

21