Automating Evidence-Based Clinical Pathways Across the Continuum: Appalachian Regional Healthcare’s

Evolving Experience

Presenter:

Russell C. McGuire, MSN, RN

Director of Clinical Services

System Center – Home Services

Appalachian Regional Healthcare, Inc.

Integrated healthcare network 8 hospital 8 hospital based home health agencies 15 DME stores 6 clinics

Service area Southern West Virginia Eastern Kentucky

Transdisciplinary Healthcare Delivery and the Continuum

Case management is practice across the continuum. Acute care, home health, clinics: each entity

has a transdisciplinary team responsible for:– Evidenced-based clinical pathway development and

implementation.– Routine, clinical case management planning

sessions.– Automation of clinical pathways (HBOC’s care

manager and pathways homecare).

Appalachian Regional HealthcareLexington, Kentucky September 1998

Care Delivery ThroughProfessional Practice

TheARH CareDeliveryModel

Historical Perspective:Manual Clinical Pathway Development

Determination of need Assessment of prevalence and

incidence of diseases in central Appalachia

Disease state selection– COPD, CHF, and IDDM selected on the basis of

retrospective chart reviews. (click on each acronym for sample Guideline)

– Physician participation in review process.

Historical Perspective:Manual Clinical Pathway Development

Clinical pathway development team selection Project leader: clinical nurse specialist in

community health. Team participation based upon:

– Members selected from agency staff.– Willingness and interest to participate in a practice change.

– Interest and expertise in a particular disease state. Agency communications process

– Clinical pathway development team members communicated project progress at monthly staff meetings; Solicited staff input throughout the development process.

Historical Perspective:Manual Clinical Pathway Development

Each clinical pathway was developed using research and evidenced based reference sources.

Each clinical pathway was reviewed by clinical experts with current expertise in the particular disease state.

Preliminary review was performed by the clinical pathway development team and the director of clinical services.

Historical Perspective:Manual Clinical Pathway Development

Clinical pathway testing and rollout Each clinical pathway was initially tested in a

“sponsoring agency”. Results of the test were communicated with the

other agencies through the clinical pathway development team.

Revisions were made and ALL agencies were then included in the testing process.

Clinical pathways were included as of the the medical record.

Historical Perspective:Transition to Automated Clinical Pathways

Review of current Clinical Pathway System. Made an analysis of Path variances; revised paths where

necessary.

First construction: Used “Care 2000” clinical pathway content.

Clinical pathways constructed for: Fractured Hip, IDDM, Non-IDDM, and Depression. CHF, COPD, Co-morbidity CHF/COPD, and CVA. CA, Hypertension, Alzheimer's, Schizophrenia, and Wound

Prevention.

Historical Perspective:Transition to Automated Clinical Pathways

NANDA, NIC, and NOC added to Nursing Knowledge Base in “Pathway Components” as an “experiment”. (Click on each acronym for website)

Core team members translated “Care 2000” clinical path language into NANDA, NIC, and NOC, verifying the translation with clinical experts for content validity and accuracy.

Historical Perspective:Transition to Automated Clinical Pathways

Second construction: “translation” effort was undertaken for each of the clinical pathways.

The new NANDA, NIC, and NOC clinical paths are currently being shared with our colleagues implementing “Care Manager” in the ARH Hospitals as a part of the total effort to manage care across the continuum.

Example of Automated Pathway Construction

Point of Care Use of Clinical Pathways

The clinical pathways are individualized for each home health patient based upon: Clinical and Functional Severity, Care giver status, Ability and willingness to be participatory in their

own care.

Clinical data is collected by the home health nurse using a Fujitsu Life Book computer with “touch screen” data entry capability.

Example of Point of Care Clinical Pathway Use

Historical Perspective:Transition to Automated Clinical Pathways

Test Each clinical pathway has been tested for

accuracy and efficacy.– Testing was performed by members of the

Implementation Core Team.– Review of Clinical Pathways is a continuos

process and function of the Division’s Clinical Pathway Development Team.

Full implementation pending copyright/licensure agreement.

Future Perspective:

Pilot Project Blend Clinical Pathway methodology with

outcomes measurement.– OASIS as the central measurement tool.– Use of inferential techniques to ask the question

“Does this really make a difference?”

Produce meaningful and useful interpretation of data analysis at the most important level of data utility: THE STAFF LEVEL.