1. 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

2. Appalachian Regional Healthcare, Inc. l Integrated healthcare network n 8 hospital n 8 hospital based home health agencies n 15 DME stores n 6 clinics l Service area n Southern West Virginia n Eastern Kentucky

4. Transdisciplinary Healthcare Delivery and the Continuum l Case management is practice across the continuum. n 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).

6. Historical Perspective: Manual Clinical Pathway Development l Determination of need n Assessment of prevalence and incidence of diseases in central Appalachia n Disease state selection –COPD, CHF, and IDDM selected on the basis of retrospective chart reviews. (click on each acronym for sample Guideline)COPDCHFIDDM –Physician participation in review process.

7. Historical Perspective: Manual Clinical Pathway Development l Clinical pathway development team selection n Project leader: clinical nurse specialist in community health. n 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. n Agency communications process –Clinical pathway development team members communicated project progress at monthly staff meetings; Solicited staff input throughout the development process.

8. Historical Perspective: Manual Clinical Pathway Development l Each clinical pathway was developed using research and evidenced based reference sources. l Each clinical pathway was reviewed by clinical experts with current expertise in the particular disease state. l Preliminary review was performed by the clinical pathway development team and the director of clinical services.

9. Historical Perspective: Manual Clinical Pathway Development l Clinical pathway testing and rollout n Each clinical pathway was initially tested in a “sponsoring agency”. n Results of the test were communicated with the other agencies through the clinical pathway development team. n Revisions were made and ALL agencies were then included in the testing process. n Clinical pathways were included as of the the medical record.

10. Historical Perspective: Transition to Automated Clinical Pathways l Review of current Clinical Pathway System. n Made an analysis of Path variances; revised paths where necessary. l First construction: Used “Care 2000” clinical pathway content. l Clinical pathways constructed for: n Fractured Hip, IDDM, Non-IDDM, and Depression. n CHF, COPD, Co-morbidity CHF/COPD, and CVA. n CA, Hypertension, Alzheimer's, Schizophrenia, and Wound Prevention.

11. Historical Perspective: Transition to Automated Clinical Pathways l NANDA, NIC, and NOC added to Nursing Knowledge Base in “Pathway Components” as an “experiment”. (Click on each acronym for website) NANDANICNOC l 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.

14. Historical Perspective: Transition to Automated Clinical Pathways l Second construction: “translation” effort was undertaken for each of the clinical pathways. l 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.

15. Example of Automated Pathway Construction

17. Point of Care Use of Clinical Pathways l The clinical pathways are individualized for each home health patient based upon: n Clinical and Functional Severity, n Care giver status, n Ability and willingness to be participatory in their own care. l Clinical data is collected by the home health nurse using a Fujitsu Life Book computer with “touch screen” data entry capability.

18. Example of Point of Care Clinical Pathway Use

30. Historical Perspective: Transition to Automated Clinical Pathways l Test n 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. n Full implementation pending copyright/licensure agreement.

31. Future Perspective: l Pilot Project n 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?” n Produce meaningful and useful interpretation of data analysis at the most important level of data utility: THE STAFF LEVEL.