pha annual conference may 19 th, 2011 tonya miller pt, dpt cos-c michelle abeln pt, dpt wcc therapy...
TRANSCRIPT
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
3
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.)
14
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
41
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
42
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
60
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
61
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.
