Clinical Management Nutr 564: Management Summer 2003

Clinical Management

Objectives: Review the functions of managementReview the functions of management Identify unique challenges of clinicalIdentify unique challenges of clinical management in nutrition/ dietetics Review Nutrition Care ProcessReview Nutrition Care Process Review Care PathwaysReview Care Pathways

Clinical Management Functions Resource management Allocation of resources Time, Physical resources, $ Patient acuity

Clinical Management Acuity Acuity: Decisions about acuity are based on sensitivity and specificity models not on universal principles. May be determined by: Diagnosis Screening Clinical Status

Clinical Management Functions Administrative dutiesAdministrative duties Budget Planning Strategic Plan Goals & Objectives

Clinical Management Functions Personnel managementPersonnel management Teams/ Leadership/ Organizational behavior Culture of Health Care and Dietetics Change management Risk management Recruitment/ Training Performance Evaluations Retention

Clinical Management Objectives: Review the functions of management Identify unique challenges of clinicalIdentify unique challenges of clinical management in nutrition/ dietetics Review Nutrition Care Process Review Care Pathways

Clinical Management Challenges Organizational Structure Health Care Ancillary service

Clinical Management Objectives: Review the functions of management Identify unique challenges of clinical management in nutrition/ dietetics Review Nutrition Care ProcessReview Nutrition Care Process Review Care PathwaysReview Care Pathways

Nutrition Care Process Nutrition Care Process and Model: ADA adopts road map to care and outcomes management Lacey K, Pritchell E, JADA 2003;103:

Nutrition Care Process Four Distinct Steps Not a linear relationship but based on critical thinking Nutritional Assessment Nutrition Diagnosis Nutrition Intervention Nutrition Monitoring and Evaluation

Nutrition Care Process Lacey K, Pritchell E, JADA 2003;103:

Nutrition Care Process Consistent components and formats: Definition and Purpose Key components or substeps with examples as appropriate Critical thinking characteristics Documentation elements Considerations for continuation, discontinuation, or discharge of care

Nutrition Care Process How does this differ from MNT? Some commonalities: Consistent Standardized Four-step process Process implemented differently in MNT types of service MNT always involves comprehensive assessment and individualized care

Nutrition Care Plans Internal documents to support patient care Summary of relevant patient information Problem oriented Problem #1 - Medication induced Diabetes Problem #2 - Uncontrolled HTN Problem #3 - Social Support

Nutrition Care Plans Documentation should support the Nutrition Care Process What information needs to be consistently tracked and recorded?

Nutrition Care Plans Patient Management: Information management Goals and Objectives

Clinical Pathways

Also known as: Critical paths Critical pathways Care paths

Clinical Pathways “Management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency” Every NR et al. Circulation 2000;101:461-5.

Clinical Pathways  Select the best practice when practice varies unnecessarily  Defining the standards for the expected duration of hospital stay and for the use of tests and treatment  Examining the interrelations among the different steps in the care process to find ways to coordinate or decrease the time in the rate-limiting step  Giving all hospital staff a common game plan from which to view and understand their various roles in the overall care process  Providing a framework for collecting data on the care process so that providers can learn how often and why patients do not follow an expected course during their hospitalization  Decreasing documentation burdens  Improving patient satisfaction with care by educating patients and their families about the plan of care Pearson SD, et al.: Ann Intern Med 1995;123:941-8.

Clinical Pathways Care delivery tool similar diagnoses Identify level of care Members of Health Care Team Specifies time of intervention Incorporates discharge planning and education

Clinical Pathways Benefits Uniform care / reduces variation in care Improves communication Facilitates documentation Supports quality assurance efforts

Clinical Pathways Limitations Only useful if properly used in a timely fashion Flexibility Often many of the processes have not been tested Not all variation is negative Not an end in itself Allow for identification of problems

Clinical Pathways Steps in developing a care pathway Select a topic Select a team Evaluate the current process of care Evaluate medical evidence and current practice Determine the critical pathway format Algorithm Include documentation on the pathway Document and analyze variance Pathway implementation Continuous Quality Improvement

Clinical Pathways Examples: Information on patient’s nutritional care Admission: Screening - Baseline data - Ht, Wt, IBW, Nutritional Assessment - at risk statement During hospitalization: Interactions * Diet Instruction * Nutrition Support

Clinical Pathways Examples: Information on patient’s nutritional care Discharge Planning: Education Plan for follow-up