Patient Mobility Program – Business Plan

1. Patient Mobility Program – Business Plan Roger C. Anderson, PT Director – Rehabilitation Services SJPHS East Region LDR – 609 Health Systems Management Dr. John Fick October 29, 2013

2. Executive Summary • One area that has become increasingly problematic has been in the ambulation of those patients who may not present with other functional deficits that require other skilled therapy. • A review of literature demonstrated a significant body of evidence supporting the hypothesis that prolonged immobility of acute care patients contributes to higher incidences of morbidity, increased length of stay, and especially risk of falls while in the hospital. • Even when the task of patient ambulation was made a priority for the nursing team, it became one of many such priorities, often falling after more ‘critical’ events such as medication delivery, toileting, and other basic care issues. • The proposed solution, therefore, was to dedicate a resource strictly to the task of mobilizing patients.

3. Key Assumptions • Patients were not being mobilized as frequently as needed. This was validated via physician feedback, nursing feedback, and the number of therapy orders received where, upon assessment, the patient lacked any functional needs but only needed to be ambulated • Mobilization of the patients would result in a positive impact on overall LOS. A review of literature supported this assumption • The cost of providing the service would be less than the savings achieved by decreases in the patient LOS

4. Overview • Nursing on the units identifies those patients who are not in need of skilled therapy services, but do need to be ambulated regularly in order to prevent functional decline. • The rehabilitation technicians hired for this position are trained by physical therapy staff and certified as competent in the relevant areas (transfers, patient ambulation, chart review, and patient safety). • Once a patient is identified, they are written on to a mobility list that is maintained at the nurses’ station by the Health Unit Coordinator (HUC). Prior to seeing the patient, the tech checks with the nurse to ensure ambulation is still appropriate, and then proceeds once cleared. • After ambulation, the patient is left in a chair if desired or close to meal time, and the nurse again notified. The ambulation is noted in eCare by the tech.

5. Results of 6-Month Pilot

6. Other Pilot Findings • Average LOS change on non-pilot units during same period: -0.02 D • Staff Survey: 95% with 98% of respondents feeling the program should continue on their units • Other benefits: Increased perception of safety (5.5 percentile to 27.5 percentile rank) • Fall rate trended down with 1 outlier month from Jan (5.08) to June (2.23)/1000 patient days

7. Program Implementation Based on pilot results, staffing, and feedback from partners in nursing, the following needs were identified for program expansion throughout the remaining East Region facilities: Addition of 4 Medical/Surgical Units at St. John Macomb-Oakland Hospital, Macomb Center Addition of 12 Medical/Surgical Units at St. John Hospital and Medical Center Potential addition of 2 Medical/Surgical Units at St. John Macomb-Oakland Hospital, Oakland Center

8. Expansion Units SJMOH-M: 3C, 4C, 5C, 5W, 6C, 6W, 7C, 7W SJMOH-O: 5T, 6T SJHMC: 2E, 2ELL, 3W, 4E, 4W, 4N, 4ELL, 5N, 6E, 6W, 6ELL, 6N

9. STAFFING LEVELS AND COST Based on staffing during the pilot, and process improvements made during this phase (such as moving the ordering process to eCare), the recommended staff to unit ratio is 0.4FTE per unit. SJMOH-M Target = 3.2 FTE Existing Positions: 3 @ 0.5 FTE = 1.5 FTE New Positions Recommended: 2 @ 0.5 FTE = 1.0 FTE; 1 @ 0.7 FTE = 0.7 FTE; 1 Contingent SJH&MC Target for 12 Units = 0.4 FTE x 12 = 4.8 FTE New Positions Recommended = 1@ 1.0 FTE = 1.0 FTE; 6@ 0.5FTE = 3.0 FTE; 1@ 0.8 FTE; 1 Contingent

10. Financial Projection

11. Rollout Schedule Phase I – Expand to remaining SJMOH-M Units -Communication: Nov/Dec 2013 -Hiring and Training: January 2014 -Implementation: February 2014 Phase II – Expand to SJH&MC -Communication: Nov/Dec 2013 -Planning with Nursing: January 2014 -Hiring and Training: January/February 2014 -Implementation: 1st 6 units March 2014, 2nd 6 units April 2014

12. Monitor and Control The following areas would be monitored in tandem with nursing and finance to ensure results were achieved and remained in control: • Length of Stay • Staffing Utilization • Fall Rates • Patient Satisfaction

13. References Brown, C. J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatric Society, 52, 1263-1270. Brown, C. J., Roth, D. L., Allman, R. M., Sawyer, P. P., Ritchie, C. S., & Rossman, J. M. (2009). Trajectories of life-space mobility after hospitalization. Annals of Internal Medicine, 150 (6), 372-378. Callen, B. L., Mahoney, J. E., Grieves, C. B., Wells, T. J., & Enloe, M. M. (2004). Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatric Nursing, 25 (4), 212-217. doi:10.1016/j .gerinurse.2004.06.016. Convertino, V., Bloomfield, S., & Greenlief, J. (1997). An overview of the issues: Physiological effects of bed rest and restricted physical activity. Medicine and Science in Sports Exercise, 29 (2), 187-190. Covinsky, K. E., Pierluissi, E. M., & Johnston, C. B. (2011). Hospitalization-associated disability "she was probably able to ambulate, but I'm not sure". Journal of the American Medical Association, 306 (16), 1782-1793. doi:10.1001/jama. 2011.1556 Fisher, S. R., Kuo, Y. F., Graham, J. E., Ottenbacher, K. J., & Ostir, G. V. (2010). Early ambulation and length of stay in older adults hospitalized for acute illness. Archives of Internal Medicine, 170 (22), 1942-1943. doi:10.1001/archinternmed. 2010.422 Graf, C. M. (2006). Functional decline in hospitalized older adults. American Journal of Nursing, 106 (1), 58-67. Inouye, S., Brown, C., & Tinetti, M. (2009). Medicare nonpayment, hospital falls, and unintended consequences. New England Journal of Medicine, 360 (23), 2390-2393. doi:10.1056/NEJMp0900963

14. References Moorhouse, P. K., & Rockwood, K. (2012). Function and frailty: the cornerstones of geriatric assessment. In J. M. Holroyd-Leduc, & M. M. Reddy (Eds.), Evidence-Based Geriatric Medicine: A Practical Clinical Guide (pp. 1-12). Oxford: Blackwell Publishing, Ltd. doi:10.1002/978118281796/ch1 Report: Hospital stays shorter, but more costly. (2012, February). Healthcare Financial Management, 66.2, 12. Retrieved from http://www.hfma.org Rukstele, C. D., & Gagnon, M. M. (2013). Making strides in preventing ICU-acquired weakness: Involving family in early progressive mobility. Critical Care Nursing Quarterly, 36 (1), 141-147. doi:1007.CNQ0b013e31827539cc Tucker, D., Molsberger, S. C., & Clark, A. (2004). Walking for wellness: A collaborative program to maintain mobility in hospitalized older adults. Geriatric Nursing, 25 (4), 242-245. Wojciechowski, M. (2012, May). PTs developing innovative delivery care models. PT in motion. Retrieved from http://www.apta.org/PTinMotion/2012/5/Feature/InnovativeCareDeliveryModels/ Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatric Society, 59 (2), 266-273. doi:10.111/j.1532-5415.2010.03276.x

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