Transcript establishing a culture of mobility in the hospital setting
ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING Continuing the Conversation
Combined Sections Meeting 2015 February 4 th -7 th , 2015 – Indianapolis, IN Michael Friedman PT, MBA Johns Hopkins Medicine - @mkfrdmn Mary Stilphen PT, DPT Cleveland Clinic - @marystilphendpt
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 - 994 Annual Admissions – 50,000 Acute Care Therapists – 65 FTEs
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
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?
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 Patient centered: Affects patient’s ability to perform activities of daily living and basic needs, which can affect a patient’s
dignity
. Our current health-care environment is emphasizing patient centered outcomes (i.e. Hospital Readmissions )
Hoyer et al., 2013
2
Why is promoting activity and mobility important?
Body Systems :
cardiovascular (orthostatic hypotension, thrombus) musculoskeletal (atrophy and contractures) urinary elimination (infection and dehydration) bowel elimination (constipation and dehydration) Co morbidity Disease Debility psychosocial (depression) respiratory (hypostatic pneumonia) integumentary (pressure ulcers) metabolic (fluid and electrolyte imbalance) 3
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.
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 • Overtreatment readmissions , avoidable complications, and declines in functional status, especially for the chronically ill.
– 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…..
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
Goal – Improve value for patients • Improve outcomes without raising costs • Lowering costs without compromising outcomes.
What does that mean for physical therapist • Patient level • System level
SYSTEMATIC USE OF DATA
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 .
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
by surrogates answered
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 OT 1. Feeding 2. O/F hygiene 3. Dressing Uppers 4. Dressing Lowers 5. Toilet (toilet, urinal, bedpan) 6. Bathing (wash, rinse, dry ) 1= Unable (Total Assist) 3= A Little (Min Assist/CGA/Sup) 2= A Lot (Mod/Max Assist) 4= None (Ind./Modified Independent)
Mobility Scale Score Table for AM-PAC
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
6 Clicks Distribution – PT / Mobility – Never go to a meeting without this info! Ideal for nursing mobility Source: Medilinks, all Acute Care PT Evaluations for all Cleveland Clinic Hospitals 2013 n = 54,532
6 Clicks Publications
Resource Utilization 2013 - 4842 patients (8.8%) had a 6 clicks score of 24
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 within institutions, 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 Time Right Place Right Skills
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
The DYS -Functional Assessment Puzzle
Fall Risk Fatigue Scale AM-PAC Glasgow FIM Tinetti
Rankin
Laps Walked Level of Assist CAM-ICU Braden PROMIS Core Measures
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
Johns Hopkins Highest Level of Mobility (JH-HLM)
patient with poor outcome Score
250+ FEET
8
WALK 25+ FEET
7
10+ STEPS
6
STAND CHAIR BED 1 MINUTE TRANSFER SIT AT EDGE TURN SELF / ACTIVITY LYING
5 4 3 2 1 Contact Johns Hopkins Medicine for permissions and instructions for use.
46
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?
Change of JH-HLM on Day of Admission at JHH
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Nurse JH-HLM to Therapist AM-PAC
Choosing Wisely – Resource Utilization Exemplars
• • JHH Neurosurgery JHH Department of Medicine
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
Critical Components to Success
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
Critical Components to Success
Set expectations with patients and family upon admission Measure, Measure, Measure Have Fun
From the ICU to Readmissions
THE JOHNS HOPKINS ACTIVITY AND MOBILITY PROMOTION (AMP) STORY
Experience in the Intensive Care Unit Critical 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
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
Dedicated Therapist 2008 Reality Check
Service Level Additional Visits per month Additional FTEs 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?
Total Incremental Cost (Salary + Benefits)
Who is the “Right” provider to mobilize patients?
Therapist Nurse/Tech/Other
Max Complex Mod. Complex Independent
Complexity to Mobilize Patient
Identify opportunities to integrate “culture of mobility” concepts with existing hospital initiatives
March 23, 2010
The A ctivity and M obility P romotion Initiative (AMP) Reimbursement and Regulatory ICU Innovation Patient Centered Care Readmissions EMR Design Surveillance of Cancer Or Cancer Recurrence Interdisciplinary Care Coordination Activity Mobility Promotion Value and Choosing Wisely Population Health Preventable Harms (DVT, Pressure Ulcers, etc) Cancer Survivorship Length of Stay 65
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
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
TIMELINE
– AMP Project Plan GO LIVE Sep Oct Nov Dec Jan
Initial Workflow Provider Education Build in EMR Develop Education Tools Barriers Survey QI Team Meeting
Feb Mar Apr May
Data Collection Data Reporting
Jun
Workflow Re-Assessment
CHAMPIONS REQUIRED
JHM Activity and Mobility Barriers Survey
Sample questions and response from a nursing unit
Statement/Question 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.
Number responses Agree or Strongly Agree
Hoyer
EH,
et al
. Am J Phys Med Rehabil. 2014 Aug 15.
Contact Johns Hopkins Medicine for permissions for use.
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: –
A
ctivity: What activity did the patient do?
–
B
arriers: What barriers does the patient have to be mobilized?
• • –
C
ontinue: 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
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 Shift
Expectation 1. Review service specific presentation and algorithms for provision of therapy care specific to service. (TL/Mgr) Completed (Date) Comments 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
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
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
Development of an Interdisciplinary Mobility Care Path
THE CLEVELAND CLINIC STORY AS TOLD BY KAREN GREEN, PT, DPT
Who owns Mobility?
Patient Centered
Goal…..
Nursing Therapy Medical Team
How we got (are getting) there…
Culture of Mobility Safe Patient Handling Ongoing Education Nursing Mobility Care Path
Step One…
Culture of Mobility • Partnered with Nursing Leaders to create a culture change on 4 medical nursing units then expanded to multiple units and hospitals
How …
Culture of Mobility
– Revised Nursing Documentation – Changed PT and OT orders to Consults – Provided Nurse Training – Provided Physician Training
Therapy Consult…
Culture of Mobility
Therapy Consult…
Culture of Mobility
Outcomes…
Culture of Mobility
Outcomes…
• Patient Education Video Culture of Mobility
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
Step 3… • Mid Level Providers • Nurse Residency Students • Nursing Floors • Pediatric ICU Staff • Regional Hospital Staff
Ongoing Education
Step 4…
Nursing Mobility Care Path
• 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
Nursing Mobility Care Path
STEP #1 – complete safety screen. MOVE-ON SAFETY SCREEN (Evaluate inclusion criteria for OOB daily) M – Myocardial/Hemodynamic Stability
• No evidence of active myocardial ischemia x 24 hours • No dysrhythmia requiring new anti-dysrhythmia agent x 24 hrs.
O – Oxygenation Adequate
• FiO2 < 0.6
• PEEP < 10 cm H2O V –
Vasopressor(s), Hemodynamics
• No increase of any vasopressor x2 hours • No sustained BP ∆ > 20mmHg for > 10min • No sustained HR ∆ > 20 bpm for > 3 min, HR < 140, HR > 40.
• No symptoms with ∆ in BP or HR E –
Engages to Voice
• Patient responds to verbal stimulation (exception: patients in neurological ICU
O – Other
• > 24 hour post tPA for stroke, PE, MI • No femoral line, unless permanent tunneled dialysis catheter • Other contraindications
N –
spine
Neurological
• SAH secured • ICP < 20 • Secured/stable • Stable neuro exam
STEP #2 – complete functional assessment, total score.
Functional Assessment: within Normal Limits (WNL): Patient independently performs ADL or needs minimal assistance Bathing Oral Care 1-Assist of 2 or more (Total) 4-No Assist (None) 1-Assist of 2 or more (Total) 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 Chair 3-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 Total Score/ Functional Level 1-Assist of 2 or more (Total) 1-Assist of 2 or more (Total) Current Score 13
Yesterday 12
F UNCTIONAL L EVEL I MOVE ON S AFETY C RITERIA NOT MET B EDREST The patient’s physical participation is deemed unsafe d/t hemodynamic instability, sedation or other factors requiring Bedrest.
Consider the following activities and indicate those completed. Mobility / Self-care progression Normalize environment HOB 30°-45° as tolerated Active / Passive ROM 3 times/day Turn/ Reposition every 2 hours Encourage patient to assist w/ ADL’s Other: F UNCTIONAL L EVEL II S CORE 6-11
T OTAL A SSIST 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.
F UNCTIONAL L EVEL III S CORE 12-17
M OD -M AX A SSIST 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.
Consider the following activities and indicate those completed. Mobility / Self-care progression Encourage patient & family to assist with ADL’s HOB 45° with legs dependent BID Active / Passive ROM 3 times/day Turn / Reposition every 2 hours OOB to Chair at least daily A/AAROM anti-gravity PROM paraplegic extremity Extremity strengthening Trunk stabilization/strengthening Other: Consider the following activities and indicate those completed.
Mobility / Self-care progression Encourage patient & family to assist w/ ADL’s w/ progressive independence HOB 65° with legs dependent Sit at edge of bed w/ min support Sit / Stand / Pivot Active / Passive ROM 3 times/day Turn / Reposition every 2 hours OOB to Chair at least daily A/AAROM anti-gravity PROM paretic/pelagic extremity Extremity strengthening Other:
F UNCTIONAL L EVEL IV S CORE 18-23
M IN A SSIST 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.
Consider the following activities and indicate those completed.
Mobility / Self-care progression Encourage patient & family to assist w/ ADL’s w/ progressive independence HOB 60°-90° with legs dependent as patient desires Active / Passive ROM 3 times/day OOB to Chair at least daily Consider OOB to chair w/ meals Extremity strengthening Independent sitting Balance activities Ambulation w/ assistance Other:
F UNCTIONAL S CORE L EVEL 24
N O A SSIST The patient is able to perform the activity safely without supervision or assistance
V
Consider the following activities and indicate those completed.
Independent ADL’s Out of bed to chair AD LIB OOB to chair during meals 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 Consider the following Safe Patient Mobility Aids & Indicate those used.
Bed Features Sit to Stand Lift Caregiver 2 person assist Slide Sheet (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 Gait Belt Walker Caregiver Stand-by Assist Other: Consider the following Safe Patient Mobility Aids & Indicate those used.
Any device with which patient has reached a level of independent safe use.
Cane Crutches Walker Other:
"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 Nursing Mobility Care Path
Johns Hopkins Highest Level of Mobility (JH-HLM)
WALK 250+ FEET 25+ FEET 10+ STEPS
Score 8 7 6
STAND CHAIR BED 1 MINUTE TRANSFER SIT AT EDGE TURN SELF / ACTIVITY LYING
5 4 3 2 1 Contact Johns Hopkins Medicine for permissions and instructions for use.
106
Institutional Change is Hard…
….It is easy to say NO!
Ability to Implement at Scale
Homecare AMPAC EPIC Community Hospital LOS Medicine Choose Wisely Neurosurgery Choose Wisely Surgical Pathway (ERAS) Peds AMP Care Coordination
JHM AMP Bundle
Accountability 4 E’s Medicine Pilot PT/OT AMPAC ICU 4 E’s 4 E’s Reinforcement Workflow/EMR
Cleveland Clinic to Scale
Johns Hopkins to Scale ERAS 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
Functional Reconciliation AMP 3.0
ERAS AMP 2.0
EMR Design Choosing Wisely Policy Functional Assessment Dr. Porter Budget Alignment Meaningful Use Post-hospital syndrome 6 Clicks Mobility Bundle QI JH HLM .gov
POC ICU QI Therapist
The AMP Expedition
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
References
Porter 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 Crit Care 2009;6:1–12 Erik H. Hoyer; Daniel J. Brotman; Kitty Chan; Dale M. NeedhamrfAmerican Journal of Physical Medicine and Rehabilitation. 2014.
References
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