establishing a culture of mobility stilphen.friedman...property of michael friedman, pt, mba and...

Establishing a Culture of Mobility in the Hospital Setting...Continuing the Conversation

1/26/2015

Property of Michael Friedman, PT, MBA and Mary Stilphen PT, DPT. Not to be copied without permissions. 1

ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING

Continuing the Conversation

Combined Sections Meeting 2015February 4th-7th, 2015 – Indianapolis, IN

Michael Friedman PT, MBA

Johns Hopkins Medicine - @mkfrdmn

Mary Stilphen PT, DPT

Cleveland Clinic - @marystilphendpt


1/26/2015


Cleveland Clinic Rehab and Sports Therapy

Therapy Locations

Cleveland Clinic Main Campus and 8 regional

hospitals

100 IRF beds

65 SNF beds

3,277 Acute care beds

47 Outpatient locations

Rehab Team

350 Physical Therapists

100 PTA’s

135 OT’s

25 COTA’s

35 SLP

5 Audiologists

50 ATC’s

The Johns Hopkins Hospital (JHH)Baltimore, MD

Licensed Acute Beds - 994Annual Admissions – 50,000Acute Care Therapists – 65 FTEs


1/26/2015


Description

Healthcare reform has reinforced the need to transform service models to focus on value by emphasizing efficiency and efficacy. This need for system re-design, culture change and the call for innovation presents an opportunity to overcome the long-standing challenges faced implementing an interdisciplinary mobility program as a standard of care.

In this educational session, we will build on the 2014 CSM discussion and will examine opportunities, strategies and tactics to position, implement, and evaluate interdisciplinary mobility initiatives in the hospital setting.

Objectives

• Review the evidence supporting mobility in the acute care setting

• Identify the value opportunities for mobility to enhance outcomes or reduce costs along the healthcare continuum.

• Demonstrate how Hospitals can successfully integrate many types of data to inform their decision making.

• Examine specific strategies to leverage organization Healthcare Reform initiatives to drive Interdisciplinary mobility

• Discuss strategies to initiate, conduct, and evaluate an interdisciplinary mobility model

• Discuss practical strategies to measure implementation success

ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING

Highlights from CSM 2014

• Evidence Supporting Activity

• Value and Waste

• The Systematic Use of Data

• 10 Critical Components of Creating a Culture of Mobility in the Hospital Setting


1/26/2015


Our next chapter…

• Updates on Systematic Use of Data

• Functional Reconciliation

• Interdisciplinary Mobility Care Path

• Implementing at scale

THE EVIDENCE SUPPORTING ACTIVITY

Why is promoting activity and mobility in the hospital important?

Patient centered: Affects patient’s ability to perform activities of daily living and basic needs, which can affect a patient’s dignity.

Most hospitalized patients currently spend most of their time in bed.J Am Geriatr Soc. 2009; 57(9):1660‐5

Lower levels of physical fitness are directly associated with all-cause mortality and increased complications.

JAMA. 1989;262(17):2395‐2401; JAMA. 2008;300:1685–1690

2Hoyer et al., 2013

Our current health-care environment is emphasizing patient centered outcomes (i.e. Hospital Readmissions)


1/26/2015


Why is promoting activity and mobility important?

metabolic (fluid and electrolyte imbalance)

respiratory (hypostatic pneumonia)

cardiovascular (orthostatic hypotension, thrombus)

musculoskeletal (atrophy and contractures)

urinary elimination (infection and dehydration)

bowel elimination (constipation and dehydration)

integumentary(pressure ulcers)

psychosocial (depression)

Body Systems:

3

Disease

DebilityCo-morbidity

WASTE AND VALUE

The Value Equation

“Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.”– Michael Porter, PhD Harvard Business School

Value = Outcome

Cost

Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006.


1/26/2015


Examples of Waste

• Failure of care delivery – poor execution – lack of widespread adoption of best practice resulting in patient injuries, worse

clinical outcomes, and higher costs. (e.g. hospital acquired complications)• Failures of care coordination

– care that is disjointed (e.g. handoffs, discharge plans) – unnecessary hospital readmissions, avoidable complications, and declines in

functional status, especially for the chronically ill.• Overtreatment

– care that is rooted in outmoded habits, that is driven by providers' preferences– unnecessary tests or diagnostic procedures to guard against liability – use of higher-priced services that have negligible or no health benefits

over less-expensive alternatives

"Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012. http://www.healthaffairs.org/healthpolicybriefs/

www.choosingwisely.org

www.erassociety.org

The Healthcare Challenge

Value Solutions:

• Improve Outcomes

• Decrease Cost

The big wins are when we can do both together.

In other words…..


1/26/2015


Institute for Healthcare Improvement Triple Aim

Institute for Healthcare Improvement Triple Aim

Improve patient experience

Improve the health of populations

Reduce health care costs

www.ihi.org

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

physical therapist

SYSTEMATIC USE OF DATA


1/26/2015


2014 was a big year!

What does the mean to us

• We used data from a validated tool to give us information about patients mobility

• We used that information to drive CULTURE change in our organization– Therapist Utilization

– Patient Mobility

– Discharge Planning

Our Journey at the Cleveland Clinic

Uniform data Collection

Use information from large uniform data sets to make

decisions.


1/26/2015


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

What is Cleveland Clinic’s 6 Clicks?

• Short form of the AM-PAC (Activity Measure for Post Acute Care)

• Patient Reported Outcome Tool

• 25 years in development

• Validated across all levels of care

• 240 items – 3 domains

• Computer Adapted Test

• Can be shortened, and answered by surrogates

AM-PAC Cleveland Clinic Short Form‘Six Clicks’

PT

1. Turning over in bed

2. Supine to sit

3. Bed to chair

4. Sit to stand

5. Walk in room

6. 3-5 steps with a rail

OT1. Feeding2. O/F hygiene3. Dressing Uppers4. Dressing Lowers5. Toilet (toilet, urinal,

bedpan)6. Bathing (wash, rinse,

dry)

1= Unable (Total Assist) 2= A Lot (Mod/Max Assist)

3= A Little (Min Assist/CGA/Sup) 4= None (Ind./Modified Independent)


1/26/2015


Mobility Scale Score Table for AM-PACMobility Scale Score Table for AM-PAC


1/26/2015


PT 6 Clicks Data Volume – CCHS Hospitals

2011 2012 2013 Total

Evaluation 27,876 43,132 54,876 125,884

Follow up 0 67,219 86,290 153,509

Total Visits 27,876 110,351 141,166 279,393

How does Cleveland Clinic use 6 Clicks data to demonstrate value and improve functional mobility of our patients?

Use of 6 clicks Data

Discharge Recs

Guide therapist resource

utilization

Improve patient

mobility


1/26/2015


Source: Medilinks, all Acute Care PT Evaluations for all Cleveland Clinic Hospitals 2013 n = 54,532

Ideal for nursing mobility

6 Clicks Distribution – PT / Mobility – Never go to a meeting without this info!

6 Clicks Publications

Resource Utilization

2013 - 4842 patients (8.8%) had a 6 clicks score of 24


1/26/2015


Expanding the conversation to Interdisciplinary Functional Assessment achieving Functional Reconciliation?

And the Lord said, Behold, the people is one, and they have all one language; and this they begin to do: and now nothing will be restrained from them, which they have imagined to do.

Go to, let us go down, and there confound their language, that they may not understand one another's speech. —Genesis 11:4–9

Functional Reconciliation

…the comparison of a patient’s functional ability prior to hospitalization with their current status.

To occur at all transitions in level of care withininstitutions, and between institutions and out-patient / community resources.

similar to medication reconciliation

Elliot, D, et al. Exploring the Scope of Post-Intensive Care Syndrome Therapy and Care: Engagement of Non-Critical Care Providers and Survivors in a Second Stakeholders Meeting. Critical Care Med. 2014 Jul 31.

System Approach Value Opportunities

• Targeted intervention

• Protocol development

• Discharge planning

• Acquired complication risk

• Resource utilization

• Patient functional trending

• Predictive modeling

• Reconciliation across setting

Right Skills

Right Time

Right Place


1/26/2015


The Problem

Solving the Outcome Measurement Dilemma:

• Need many items or many condition-specific instruments to cover all the relevant functional outcomes across a broad range of patients

• The traditional administration of extensive instruments is burdensome to patient and clinician

• Instruments lack the comprehensiveness needed to track patient progress across settings throughout an episode of care.

Acknowledge Dr. Alan Jette for slide

Rankin

Braden

AM-PAC

Glascow

The DYS-Functional Assessment Puzzle

6 Min WalkGlasgow

Tinetti

Fall Risk

Level of Assist

Fatigue Scale FIM

Core Measures

CAM-ICU

PROMIS

Laps Walked


1/26/2015


JHH Data Strategy – Tool Selection

• Interdisciplinary

• Documentation efficiency

– EMR design

– Regulatory requirements

• Meaningful across settings

• Meaningful across initiatives

• Composite and specific measures

– Meaningful clinical difference

– Ceiling and floor

• Drive Intervention

JHH Data Strategy – Execution

• “Interdisciplinary Functional Assessment” Policy• Hospital-wide workflow

– Johns Hopkins – Highest Level of Mobility (JH-HLM) for Nursing

– AM-PAC Inpatient Mobility and Activity Scales (6 Clicks)• Nursing (frequency under re-evaluation) • PT and OT (every visit)

– Interdisciplinary diagnosis specific measures – Population specific workflows for outliers

(OB/GYN, Psychiatry, Inpatient Rehab, Pediatrics)• Electronic data entry as part of the EMR • Data System Infrastructure design and build• Reports

The System Architecture was determined


1/26/2015


Johns Hopkins Highest Level of Mobility (JH‐HLM)

BED

CHAIR

STAND

WALK

250+ FEET

25+ FEET

10+ STEPS

1 MINUTE

TRANSFER

SIT AT EDGE

TURN SELF / ACTIVITY

LYING

MO

BIL

ITY

LE

VE

L

8

7

6

5

4

3

2

1

Score

46

patient with poor outcome

Contact Johns Hopkins Medicine for permissions and instructions for use.

With each JH-HLM document:

• This information provides additional detail of the highest level of movement you are documenting: – Level of Assistance needed

• None= Modified Independence/Independent

• A lot= Max/Mod Assist

• A little= Min/Contact Guard Assist/Supervision

• Total= Total/Dependent Assist

– Assistive Device

– Number of Assistive Persons

– Exercises (i.e. bed exercises, chair exercises)

– Ambulation Distance (i.e. patient walked several laps around the unit)

How does Johns Hopkins use data to demonstrate value and improve functional mobility of our patients?


1/26/2015


Change of JH‐HLM on Day of Admission at JHH

49

Nurse JH-HLM to Therapist AM-PAC

Choosing Wisely – Resource Utilization Exemplars

• JHH Neurosurgery

• JHH Department of Medicine


1/26/2015


10 Critical Components to Creating Value Establishing a Culture of Mobility in the Hospital Setting

Critical Components to Success

Be able to clearly articulate to all members of the team the benefits of mobility and harmful affects of immobility while the patient is in the hospital setting.

Identify opportunities to integrate “Culture of Mobility” concepts within existing hospital initiatives (e.g. LOS, ICU, readmissions)

Physician and nursing support – Identify engaged physician and nurse champions with influence over practice with their peer groups


Identify barriers to implementation

Assess workflow and hardwire operations and accountability

Have a good understanding of your baseline metrics. What do you want to achieve – have data to support it.

Develop an Education and Training Strategy


1/26/2015



Set expectations with patients and family upon admission

Measure, Measure, Measure

Have Fun

THE JOHNS HOPKINS ACTIVITY AND MOBILITY PROMOTION (AMP) STORY

From the ICU to Readmissions

Experience in the Intensive Care UnitCritical Care Rehabilitation Quality Improvement Project 2007

Shown decrease in:

• Medical ICU (MICU) days in patients with benzodiazepine and narcotic use and improved delirium status.

• Average length of stay in the MICU (4.9 vs. 7.0 days) and hospital (14.1 vs. 17.2) compared to the prior year.

Needham DM et al. (2010, July). Top Stroke Rehab 2010;17(4):271–281


1/26/2015


MICU LOS sustained success

Needham DM et al. (2010, July). Top Stroke Rehab 2010;17(4):271–281

Potential Benefits to Hospital

Why so many empty MICU beds? patients are awake and moving, patients are better

Versus same 4-month period in 2006:• 20% increase in MICU admissions• 10% reduction in hospital mortality• 30% (2.1 day) reduction in MICU LOS• 18% (3.1 day) reduction in hosp LOS

For details on ICU Financial Modeling see:Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM. ICU early physical rehabilitation programs: financial modeling of cost savings. Critical Care Medicine. 2013 Mar;41(3):717-24.

Is a therapist driven model sustainable across all units?

• Long MICU and overall LOS

• $$$ per MICU day

• Higher skill to mobilize

• Therapist underutilization

• Significant ROI potential


1/26/2015


Dedicated Therapist 2008 Reality Check

Service Level Additional Visits per month

Additional FTEs

Total Incremental Cost

(Salary + Benefits)

Meet therapist recommended treatment frequency

Meet acute care provider expectation – Provide same level of therapy every day, during patient stay, 7 days a week

Everyone agrees people need to move?Does it take a therapist?

If not then who and how?

Who is the “Right” provider to mobilize patients?

Therapist

Complexity to Mobilize PatientMax Complex Mod. Complex Independent

Nurse/Tech/Other

Tra

nsl

atin

g R

esea

rch

into

P

ract

ice

(TR

IP)

Identify opportunities to integrate “culture of mobility” concepts with existing hospital initiatives


1/26/2015


March 23, 2010

ICU Innovation

Surveillance of Cancer Or Cancer Recurrence

Value and Choosing Wisely

Patient Centered Care

Length of Stay

Preventable Harms (DVT, Pressure Ulcers, etc)

Activity Mobility

Promotion

InterdisciplinaryCare Coordination

Readmissions

The Activity and Mobility Promotion Initiative (AMP)

Cancer Survivorship

Population Health

65

Reimbursement andRegulatory

EMR Design

Johns Hopkins AMP Initiative

Phase I –AMP Inpatient Care Coordination Bundle Development and Pilot

Phase II – Expansion of AMP Bundle and Adult Inpatient Functional Reconciliation

Phase III – Homecare, Pediatrics, Ambulatory Specialty Practice and Primary

Care Functional Reconciliation


1/26/2015


Johns Hopkins AMP - Readmissions

Johns Hopkins Health System Goal to reduce 30-day readmissions 10% below state

mandated cap

Value of Rehab was to champion the importance of function in reducing

readmission risk

Focused to 2 General Medicine units initially

Post-Hospital Syndrome

• post-hospital syndrome, an acquired, transient period of vulnerability

• During hospitalization …. receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity.

• more assertively apply interventions aimed at … promoting practices that reduce the risk of delirium and confusion, emphasizing physical activity and strength maintenance or improvement, and enhancing cognitive and physical function.

Krumholtz. Post-Hospital Syndrome. Patient physical functioning is associated with their risk for hospital readmission. NEJM. 2013; Jan 10;368(2):100-2.

JHH Care Coordination “Bundle”

• ED Care Management• Risk screening—Early and periodic• Patient family education

– Self-care management– Condition-Specific Education Modules– “Teach-back”

• Interdisciplinary care planning– Multidisciplinary team-based rounds:

every day, every patient– Activity and Mobility Promotion (AMP) – Projected discharge date on every

patient• Transition of Care and Follow Up

Resources


1/26/2015


Initial Workflow

Barriers Survey

JunMayAprMarFebJanNovOctSep Dec

TIMELINE – AMP Project Plan

Build in EMR

Data Collection

Provider Education

QI Team Meeting

GO LIVE

Develop Education Tools

Data Reporting

Workflow Re-Assessment

CHAMPIONS REQUIRED

JHM Activity and Mobility Barriers Survey

Statement/QuestionNumber responses Agree or

Strongly Agree

My inpatients are NOT too sick to be mobilized.

I have received training on how to safely mobilize my inpatients.

I DO have time to mobilize my inpatients during my shift/work day.

Nurse-to-patient staffing is adequate to mobilize inpatients on my unit(s).

I DO feel confident in my ability to mobilize my inpatients.

Increasing the frequency of mobilizing my inpatients DOES NOT increase my risk for injury.

Inpatients who can be mobilized usually have appropriate physician orders to do so.

My inpatients are NOT resistant to being mobilized.

I believe that my inpatients who are mobilized at least three times daily will have better outcomes.

Hoyer EH, et al. Am J Phys Med Rehabil. 2014 Aug 15.

Contact Johns Hopkins Medicine for permissions for use.

Sample questions and response from a nursing unit


1/26/2015


Overcoming Barriers

• Engagement:

– Finance – therapist dedicated time to rounds

– Administrators – Furnishings, resources.

– Physicians – orders, walk patients or examine at chair-side, patient engagement, facilitate interdisciplinary rounds.

– Nursing Staff – documentation, co-education, mobilize patients

– Therapists – train nurses, facilitate interdisciplinary rounds.

– Clinical staff – help with documentation and mobilizing patients.

Through Documentation

• Accountability: Interdisciplinary documentation of function

• Sustainability: Using IT to automate data extraction

Have a strong understanding of baseline metrics you hope to influence.

• Length of Stay

• Readmissions

• Therapist Overutilization

• Fall Rates

• Hospital Acquired Complications

• Daily documentation compliance

• Call Bells

• % of patients discharged home

Assess workflow and hardwire operations and accountability

• Hand off and care coordination rounds ABC’s:

– Activity: What activity did the patient do?

– Barriers: What barriers does the patient have to be mobilized?

– Continue: How can we continue to progress activity with the patient?

• Nurse Daily documentation

– Johns Hopkins Highest Level of Mobility Scale

– AM-PAC Inpatient Short Forms (Mobility and ADL)

• Therapist documentation

• AM-PAC Inpatient (6-Clicks) each visit

• Mobilize all patients three times per day to out-of-bed or ambulating (twice during day, once at night)

• JH-HLM Interdisciplinary Goal Setting

• JH-HLM Progression Protocol


1/26/2015


Develop an education and training strategy

• Nurses:– Online: My-Learning for

Nurses– Huddles with Therapists– Curbside Consult– Mobility instructional videos

• Physicians:– Contraindications to

mobilizing patients– Engaging Patients– Orders to Mobilize Patients

Therapist Delivery of Care Paradigm ShiftExpectation Completed (Date) Comments

1. Review service specific presentation and algorithms for provision of therapy care specific to service. (TL/Mgr)

2. Review materials on readmissions program and rounds coverage. (TL/Mgr)

3. Review algorithm for provision of co-treatment. (TL/Mgr)

4. Review “Discharge Planning for ACS” (CS/TC)

5. Documentation (3 samples) reflects correct leveling for patients.

6. Audit (3 samples) reflects completion of activity status forms and calendars.

7. Shadow (3x) rounds coverage with TC or CS.

8. Observation of staff member at rounds reflects proactive communication for therapy.

9. Complete mylearning module on Teach Back Patient Education Method v. 1.0.

10. Complete learning packet quiz.

Patient and Family Engagement

• Video intro “Get up and Move”

• Admission scripting

– Importance of mobility

– Activity Status and Calendar

– Patient and Family Choices

• Interactive tablets – provider directed

• Pediatrics


1/26/2015


Measure, Measure, Measure

• Accountability – Nurse documentation compliance to three times per day increased during the project

• Safety – there was no change in falls with implementing the AMP project

• Communication - Nursing utilization of JH-HLM and Therapists (PT, OT) use of “Six Clicks” directly correlated

• Nurse Utilization – correlation between JH-HLM and call bell utilization

Association between JH‐HLM and LOS, D/C Home, Costs, and Readmission

Encourage creativity and fun

• Promotion

• Competition– Provider

– Patient

• Rewards


1/26/2015


Strategies to Improve the patient JH-HLM Trajectory

• Formalize and integrate the common “Interdisciplinary Functional Assessment” as part of care planning and EMR

• Patient and provider compliance reports

• Physician engagement of patient/family in mobility

• Patient specific daily mobility goals

• Target Therapy resources (i.e. Choosing Wisely)

• Optimize resources within nursing infrastructure to best execute mobility

• Formal internal messaging campaign

PASSING THE TORCH

What I learned this year…

• Physical Therapy can influence but we can’t drive Culture Change

• Data and the Medical Team need to drive culture change in the Hospital


1/26/2015


THE CLEVELAND CLINIC STORY AS TOLD BY KAREN GREEN, PT, DPT

Development of an Interdisciplinary Mobility Care Path

Who owns Mobility?

Goal…..

Patient Centered

Nursing

Therapy

MedicalTeam


1/26/2015


How we got (are getting) there…

Culture of

Mobility

Safe Patient

Handling

Ongoing

Education

Nursing Mobility Care Path

Step One…

• Partnered with Nursing Leaders to create a culture change on 4 medical nursing units then expanded to multiple units and hospitals

Culture of Mobility

How…

–Revised Nursing Documentation

–Changed PT and OT orders to Consults

–Provided Nurse Training

–Provided Physician Training

Culture of Mobility


1/26/2015


Therapy Consult… Culture of Mobility

Therapy Consult… Culture of Mobility

Outcomes…Culture of Mobility


1/26/2015


Outcomes… Culture of Mobility

• Patient Education Video

Step Two… Safe Patient

Handling

• Partnered with the Safe Patient Handling Committee to provide a therapy perspective as well as assist with education and training.

Group consists of:– Nursing Managers– Clinical Nurse Specialists– Director of Safety– Ergonomist– Director of Rehab

Outcomes… Safe Patient

Handling

• Teach portions of the Safe Patient Handling and Mobility Champions class

• 3 Therapy Staff Members are SPHM Champions


1/26/2015


Step 3…

• Mid Level Providers

• Nurse Residency Students

• Nursing Floors

• Pediatric ICU Staff

• Regional Hospital Staff

Ongoing

Education

Step 4…

• Developing a standard of care that included nurse driven mobility for the hospitalized patient

• Goal is to have all patients appropriate for mobility mobilize early and often by the most appropriate caregiver




1/26/2015


MOVE‐ON SAFETY SCREEN (Evaluate inclusion criteria for OOB daily)

M –Myocardial/Hemodynamic

Stability •Noevidenceofactivemyocardialischemiax24hours

•Nodysrhythmiarequiringnewanti‐dysrhythmiaagentx24 hrs.

O– OxygenationAdequate

•FiO2<0.6•PEEP<10cmH2O

V– Vasopressor(s),Hemodynamics•Noincreaseofanyvasopressorx2hours•NosustainedBP∆>20mmHgfor>10min•NosustainedHR∆ >20bpmfor>3min,HR<140,HR>40.

•Nosymptomswith∆ inBPorHR

E– EngagestoVoice•Patientrespondstoverbalstimulation(exception:patientsinneurologicalICU

O– Other•>24hourposttPAforstroke,PE,MI

•Nofemoralline,unlesspermanenttunneleddialysiscatheter

•Othercontraindications

N– Neurological•SAHsecured•ICP<20•Secured/stable

spine•Stableneuro exam

STEP #2 – complete functional assessment, total score.

STEP #1 – complete safety screen.

Functional Assessment: within Normal Limits (WNL): Patient independently performs ADL or needs minimal assistance

Bathing 1‐Assist of 2 or more (Total) 1‐Assist of 2 or more (Total)

Oral Care 4‐No Assist (None)

3‐Supervised ‐ Min Assist of 1

(A Little)

Turn and Position 2‐Mod‐Max Assist of 1 (A Lot) 2‐Mod‐Max Assist of 1 (A Lot)

Up in Chair3‐Supervised ‐ Min Assist of 1

(A Little)

3‐Supervised ‐ Min Assist of 1

(A Little)

Up to Bathroom 2‐Mod‐Max Assist of 1 (A Lot) 2‐Mod‐Max Assist of 1 (A Lot)

Walk in Halls 1‐Assist of 2 or more (Total) 1‐Assist of 2 or more (Total)

Total Score/

Functional Level 13 12

Current Score Yesterday

FUNCTIONAL LEVEL IMOVE-ON SAFETY

CRITERIA NOT MET

FUNCTIONAL LEVEL

IISCORE 6-11

FUNCTIONAL LEVEL

IIISCORE 12-17

FUNCTIONAL LEVEL

IVSCORE 18-23

FUNCTIONAL LEVEL VSCORE 24

BEDREST

The patient’s physical

participation is deemed unsafe d/t hemodynamic instability, sedation

or other factors requiring Bedrest.

TOTAL ASSIST

The patient’s physical participation

is minimal, caregivers are providing assistance with up to 75% of the

task. Patient is not able to safely support his/her weight and may not

be able to consistently follow commands.

MOD-MAX ASSIST

The patient requires physical

assistance from one person up to 50% of the activity. The patient is

participating in the activity but requires a lot of help to safely

perform the task.

MIN ASSIST

The patient requires supervision for

safety or up to 25% physical assistance of one person. The

patient is actively participating in the activity, able to bear some

weight and maintain balance without more than a little bit of

assistance.

NO ASSIST

The patient is able to perform the

activity safely without supervision or assistance

Consider the following activities

and indicate those completed.

Mobility / Self-care progression⃝ Normalize environment

⃝ HOB 30°-45° as tolerated⃝ Active / Passive ROM 3

times/day

⃝ Turn/ Reposition every 2 hours⃝ Encourage patient to assist w/

ADL’s

⃝ Other:



Mobility / Self-care progression⃝ Encourage patient & family to

assist with ADL’s⃝ HOB 45° with legs dependent BID

⃝ Active / Passive ROM 3 times/day

⃝ Turn / Reposition every 2 hours⃝ OOB to Chair at least daily

⃝ A/AAROM anti-gravity⃝ PROM paraplegic extremity

⃝ Extremity strengthening

⃝ Trunk stabilization/strengthening

⃝ Other:




assist w/ ADL’s w/ progressive independence

⃝ HOB 65° with legs dependent

⃝ Sit at edge of bed w/ min support⃝ Sit / Stand / Pivot

⃝ Active / Passive ROM 3 times/day⃝ Turn / Reposition every 2 hours

⃝ OOB to Chair at least daily

⃝ A/AAROM anti-gravity⃝ PROM paretic/pelagic extremity


⃝ Other:




assist w/ ADL’s w/ progressive independence

⃝ HOB 60°-90° with legs dependent

as patient desires⃝ Active / Passive ROM 3 times/day

⃝ OOB to Chair at least daily⃝ Consider OOB to chair w/ meals


⃝ Independent sitting⃝ Balance activities

⃝ Ambulation w/ assistance

⃝ Other:

Consider the following activities and

indicate those completed.

⃝ Independent ADL’s⃝ Out of bed to chair AD LIB

⃝ OOB to chair during meals⃝ Walk in halls ≥ 4 times per day

⃝ Other:

Consider the following Safe

Patient Mobility Aids & Indicate those used.

⃝ Bed Features

⃝ Slide sheets (Sally Tube)⃝ Turn & Position System (TAP)

⃝ HoverMatt™ or Air Pal™

⃝ Lift Device (portable or ceiling lift)

⃝ Stretcher Chair

Consider the following Safe Patient

Mobility Aids & Indicate those used.

⃝ Bed Features

⃝ Slide sheets (Sally Tube)⃝ Turn & Position System (TAP)

⃝ HoverMatt™ or Air Pal™

⃝ Lift Device (portable or ceiling lift)

⃝ Stretcher Chair



⃝ Bed Features

⃝ Sit to Stand Lift⃝ Caregiver 2 person assist

⃝ Slide Sheet (Sally Tube)

⃝ Turn & Position System (TAP)⃝ HoverMatt or Air Pal

⃝ Lift Device (portable or ceiling lift)⃝ St t h Ch i



⃝ Bed Features

⃝ Gait Belt⃝ Walker

⃝ Caregiver Stand-by Assist

⃝ Other:



Any device with which patient has reached a level of independent safe

use.

⃝ Cane

⃝ Crutches⃝ Walker

⃝ Oth


1/26/2015


"THE MOMENT OF CRITICAL MASS, THE THRESHOLD, THE BOILING POINT“-MALCOLM GLADWELL

Health Care is Changing in Fundamental Ways

SYSTEM SKILLS

Interest in Data

Devise Solutions for System Problems

Develop an Ability to Implement at Scale

Acknowledge Dr. Alan Jette for slide

How we got (are getting) there…

Culture of

Mobility

Safe Patient

Handling

Ongoing

Education



1/26/2015


Johns Hopkins Highest Level of Mobility (JH‐HLM)

BED

CHAIR

STAND

WALK

250+ FEET

25+ FEET

10+ STEPS

1 MINUTE

TRANSFER

SIT AT EDGE

TURN SELF / ACTIVITY

LYING

MO

BIL

ITY

LE

VE

L

8

7

6

5

4

3

2

1

Score

106

Contact Johns Hopkins Medicine for permissions and instructions for use.

Institutional Change is Hard…

….It is easy to say NO!

Ability to Implement at Scale

Tra

nsl

atin

g R

esea

rch

into

Pra

ctic

e (T

RIP

)


1/26/2015


ICU

Medicine Pilot

Neurosurgery Choose Wisely

PT/OT AMPAC

Homecare AMPAC

Peds AMP

Medicine Choose Wisely

Surgical Pathway(ERAS)

Care Coordination

CommunityHospital LOS

JHM AMP BundleEPIC

Accountability4 E’s

4 E’sReinforcement

Workflow/EMR

4 E’s

Cleveland Clinic to Scale

Johns Hopkins to ScaleERAS and EPIC pushing AMP 2.0

• Resource Assessment and Business Plan

• Required Champions (RN, MD, Admin)

• Pre-op and post-op visit AM-PAC (in process)

• Required common functional assessment

• JH-HLM progression protocol

• Interdisciplinary Mobility Goals (JH-HLM)

• Smart Order Sets

• Patient Pre-op and Admission education

• Patient/nurse/unit incentives

• Internal messaging campaign


1/26/2015


ICU QI

.gov

Dr. Porter

6-Clicks

ERASAMP 2.0

Functional Reconciliation

AMP 3.0

Policy Functional Assessment

Budget Alignment

EMR Design

Choosing Wisely

Post-hospital syndrome

Mobility Bundle QI

The AMP Expedition

Therapist POC

Meaningful Use

JH-HLM

Other Resources

• Health System Rehabilitation Community– www.apta.org/HSRC

• Johns Hopkins Resources– OACIS web-site

– JH-HLM and Barriers Survey permission for use– @icurehab, @drdaleneedham

• Boston Rehabilitation Outcomes Center– www.bu.edu/bostonroc

Contact

Michael Friedman, PT, MBA

• [email protected]

• Twitter follow:– @mkfrdmn

Mary Stilphen PT,DPT

• [email protected]

• Twitter follow:– @marystilphendpt


1/26/2015


ReferencesPorter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006

"Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012.

Jette DU, Stilphen M, Ranganathan VK, et al. Validity of the AM-PAC “6 Clicks” inpatient daily activity and basic mobility short forms. Phys Ther. 2014;94: 379-391

Jette DU, Stilphen M, Ranganathan VK, et al. AM-PAC “6 Clicks” functional assessment scores predict acute hospital discharge destination. Phys Ther. 2014;94: 1252-1261

Bentley, Tanya G.K., Rachel M. Effros, Kartika Palar, and Emmett B. Keeler, "Waste in the US Health Care System: A Conceptual Framework," Milbank Quarterly 86, no. 4 (2008): 629-59

M.E. Porter. What is value in health care? N Engl J Med, 363 (26) (2010), pp. 2477–2481

Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. (2010, July). Top Stroke Rehab 2010;17(4):271–281.

Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM. ICU early physical rehabilitation programs: financial modeling of cost savings. Critical Care Medicine. 2013 Mar;41(3):717-24.

Bogardus ST Jr, Towle V, Williams CS, Desai MM, Inouye SK. What does the medical record reveal about functional status? A comparison of medical record and interview data. J Gen Intern Med. 2001;16:728-36

Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685–1690.

Korupolu R, Gifford J, Needham DM. Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Contemp CritCare 2009;6:1–12

Erik H. Hoyer; Daniel J. Brotman; Kitty Chan; Dale M. NeedhamrfAmerican Journal of Physical Medicine and Rehabilitation. 2014.

ReferencesKrumholtz. Post-Hospital Syndrome. Patient physical functioning is associated with their risk for hospital readmission. NEJM. 2013; Jan 10;368(2):100-2.

Andres PL, Haley SM, Ni PS. Is patient-reported function reliable for monitoring post acute outcomes? Am J Phys Med Rehab. 2003;82(8):614-621.

Cre Care http://www.crecare.com/am-pac/ampac.html. Accessed 6/15/2011.

Haley SM, Ni P, Coster WJ, Black-Schaffer R, Siebens H, Tao W. Agreement in functional assessment: graphic approaches to displaying respondent effects. Am J Phys Med Rehab. 2006;85(9):747-755.

Brown CJ, Redden DT, Flood KL, Allman RM. The under recognized epidemic of low mobility during hospitalization of older adults. 2009. J Am Geriatric Soc;57, p. 1660.

Murphy EA. A key step for hospitalized elders. Arch Intern Med. 2011;171(3), p. 269.

Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52, p. 1269.

de morton, N., Keating, JL., Jeff, K., (2009) Exercise for acutely hospitalized older adults (Review) The Cochrane Collaboration issue 1.

Drolet, A., DeJulio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, EA, Lloyd, JM., Warers, C., Williams, S., (2012) Move to Improve: the feasability of using an early mobility protocol to increase ambulation in the intensive and immediate care settings. Physical Therapy 93(2):197-207

Convertino, VA., Bloomfield, SA., Greenleaf, JE. (1997) An overview of the issues.: physiological effects of bedrest and restricted physical activity. Medical Science and Sports Exercise 29:187-190

Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16), p. 1782.

Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660-5.

Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337

Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil. 2013.

Cabana, Rand, Powe, Wu, Wilson, Abboud, Rubin. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20; 282(15):1458-65.

establishing a culture of mobility stilphen.friedman...property of michael friedman, pt, mba and...

Documents