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Therapy 2011 - Updates in Evidence-Based Care and Quality Initiatives

Therapy 2011 - Updates in Evidence-Based Care and Quality Initiatives. PHA Annual Conference May 19 th , 2011 Tonya Miller PT, DPT COS-C Michelle Abeln PT, DPT WCC. OBJECTIVES. The Learner will be able to: Demonstrate knowledge of the components of evidence based medicine

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Therapy 2011 - Updates in Evidence-Based Care and Quality Initiatives

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  1. Therapy 2011 - Updates in Evidence-Based Care and Quality Initiatives PHA Annual Conference May 19th, 2011 Tonya Miller PT, DPT COS-C Michelle Abeln PT, DPT WCC

  2. 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

  3. 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

  4. Evidence Based Medicine • Best Research Evidence • Derived from either basic science of medicine or patient-centered clinical research • Components • Standardization • Reliability • Validity

  5. Evidence Based Medicine • Standardization • The process of administering a test under uniform conditions • Consider • Population • The Medicare HH patient? - community-dwelling elderly • Size of the Sample

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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)

  11. Evidence Based Medicine- finding resources • 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

  12. Evidence Based Medicine • 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.  

  13. 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

  14. Evidence-Based Medicine (cont.) • Examples: • Timed up and Go (TUG) • Berg Balance Scale (BBS) • Braden Scale • Borg RPE • Geriatric Depression Scale • Gait Velocity • Two Minute Step Test • MOCA

  15. 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 ability • Scoring: <10 seconds- high mobility 10-19 seconds- typical mobility 20-29 seconds- slower mobility >=30 seconds- diminished mobility • Correlation to falls >13.5 seconds • Mod-high correlation with Berg and gait velocity

  16. 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

  17. 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

  18. 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

  19. 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/

  20. EVB Tools: Description and Utilization BORG RPE 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 • 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

  21. EVB Tools: Description and Utilization • Geriatric Depression Screening • Measurement of depression in patient’s with dementia • Equipment: Questionnaire • Completion time: <10 minutes • Scoring: 0-4: typically no cause for concern 5-8: mild depression 9-11:moderate depression 12-15: severe depression

  22. 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

  23. EVB Tools: Description and Utilization • 2- Minute step test • Measure of strength and aerobic capacity • Equipment: stopwatch • Completion time: <5 minutes to set up 2 minutes to complete test • Scoring: total # of times ® knee reaches correct height during marching for 2 minutes

  24. 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

  25. Link between EVB tools and QOL Measures • Choosing appropriate EVB tools to develop plan of care for patient • Better outcomes • Improved QOL measures

  26. 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

  27. 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

  28. Disablement Model: EVB Tools and QOL

  29. 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

  30. 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

  31. Determining the appropriate QOL Measure 1) What are you looking to measure? 2) Is tool reliable, valid, and responsive? 3) Is tool practical?

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. EVB and QOL: Treatment interventions • BERG- pt at moderate risk for falls with difficulty on all transfer sections. • 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. • Treatment: strengthening of LEs (specifically dorsiflexors), training with appropriate AD, assess need for ankle-foot orthosis

  45. EVB and QOL: Treatment interventions • Modified BORG- pt scored 5/10 when ambulating 35’ with standard walker • 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.

  46. 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.

  47. 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.

  48. 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.

  49. Turning the Wheels of Health Care Quality Turning the Wheels of Health Care Quality

  50. Turning the Wheels of Health Care Quality

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