ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING Continuing the Conversation Combined Sections Meeting 2015 February 4th-7th, 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 Rehab Team 350 Physical Therapists 100 PTA’s 135 OT’s 25 COTA’s 35 SLP 3,277 Acute care beds 5 Audiologists 47 Outpatient locations 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 Disease 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) Comorbidity 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 valuebased 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 readmissions, avoidable complications, and declines in functional status, especially for the chronically ill. • Overtreatment – 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 What does that mean for physical therapist • Improve outcomes without raising costs • Lowering costs without compromising outcomes. • 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 answered by surrogates AM-PAC Cleveland Clinic Short Form ‘Six Clicks’ 1. 2. 3. 4. 5. 6. PT Turning over in bed Supine to sit Bed to chair Sit to stand Walk in room 3-5 steps with a rail 1. 2. 3. 4. 5. 6. OT Feeding O/F hygiene Dressing Uppers Dressing Lowers Toilet (toilet, urinal, bedpan) Bathing (wash, rinse, dry) 1= Unable (Total Assist) 2= A Lot (Mod/Max Assist) 3= A Little (Min Assist/CGA/Sup) 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 Place Right Time 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 Glasgow 6 Min Walk Glascow Tinetti AM-PAC Rankin Level of Assist Laps Walked Fatigue Scale CAM-ICU FIM 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 25+ FEET 7 10+ STEPS 6 STAND 1 MINUTE 5 CHAIR TRANSFER 4 SIT AT EDGE 3 TURN SELF / ACTIVITY 2 LYING 1 MOBILITY LEVEL WALK BED 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 49 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 Translating Research into Practice (TRIP) Identify opportunities to integrate “culture of mobility” concepts with existing hospital initiatives March 23, 2010 The Activity and Mobility Promotion Initiative (AMP) Reimbursement and Regulatory ICU Innovation Patient Centered Care Readmissions Surveillance of Cancer Or Cancer Recurrence EMR Design Interdisciplinary Care Coordination Activity Mobility Promotion Preventable Harms (DVT, Pressure Ulcers, etc) Population Health Value and Choosing Wisely 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 Feb Mar Apr May Data Collection Data Reporting Provider Education Workflow Re-Assessment Build in EMR Develop Education Tools Barriers Survey Initial Workflow QI Team Meeting Jun 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. Hoyer EH, et al. Am J Phys Med Rehabil. 2014 Aug 15. Contact Johns Hopkins Medicine for permissions for use. Number responses Agree or Strongly Agree 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: – Activity: What activity did the patient do? – Barriers: What barriers does the patient have to be mobilized? – Continue: 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) 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. Completed (Date) Comments 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? Goal….. Nursing Therapy Patient Centered 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 M – Myocardial/Hemodynamic O – Oxygenation Adequate Stability • No evidence of active myocardial ischemia x 24 hours • No dysrhythmia requiring new anti-dysrhythmia agent x 24 hrs. • FiO2 < 0.6 • PEEP < 10 cm H2O (Evaluate inclusion criteria for OOB daily) V – Vasopressor(s), Hemodynamics E – Engages to Voice • No increase of any vasopressor x2 hours • Patient responds to • No sustained BP ∆ > 20mmHg for > 10min verbal stimulation • No sustained HR ∆ > 20 bpm (exception: patients in for > 3 min, HR < 140, HR > 40. neurological ICU • No symptoms with ∆ in BP or HR STEP #2 – complete functional assessment, total score. Functional Assessment: within Normal Limits (WNL): Patient independently performs ADL or needs minimal assistance Bathing 1-Assist of 2 or more (Total) 1-Assist of 2 or more (Total) Oral Care 4-No Assist (None) 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 3-Supervised - Min Assist of 1 (A Little) (A Little) Up to Bathroom 2-Mod-Max Assist of 1 (A Lot) 2-Mod-Max Assist of 1 (A Lot) Walk in Halls 1-Assist of 2 or more (Total) Total Score/ Functional Level 1-Assist of 2 or more (Total) 13 Current Score 12 Yesterday O – Other N – Neurological • > 24 hour post tPA • SAH secured for stroke, PE, MI • ICP < 20 • No femoral line, unless • Secured/stable permanent tunneled spine dialysis catheter • Stable neuro exam • Other contraindications FUNCTIONAL LEVEL I MOVE-ON S AFETY CRITERIA NOT MET FUNCTIONAL LEVEL II SCORE 6-11 B EDREST The patient’s physical participation is deemed unsafe d/t hemodynamic instability, sedation or other factors requiring Bedrest. TOTAL ASSIST 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. M OD-M AX ASSIST 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. M IN ASSIST 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. NO ASSIST The patient is able to perform the activity safely without supervision or assistance Consider the following activities and indicate those completed. Consider the following activities and indicate those completed. Consider the following activities and indicate those completed. Consider the following activities and indicate those completed. 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 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 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 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 ⃝ Independent ADL’s ⃝ Out of bed to chair AD LIB ⃝ OOB to chair during meals ⃝ Walk in halls ≥ 4 times per day ⃝ Other: ⃝ Other: ⃝ Other: ⃝ Other: FUNCTIONAL LEVEL III SCORE 12-17 FUNCTIONAL LEVEL IV SCORE 18-23 Consider the following Safe Patient Mobility Aids & Indicate those used. Consider the following Safe Patient Mobility Aids & Indicate those used. Consider the following Safe Patient Mobility Aids & Indicate those used. 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 ⃝ Bed Features ⃝ Slide sheets (Sally Tube) ⃝ Turn & Position System (TAP) ⃝ HoverMatt™ or Air Pal™ ⃝ Lift Device (portable or ceiling lift) ⃝ Stretcher Chair ⃝ 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) ⃝ Bed Features ⃝ Gait Belt ⃝ Walker ⃝ Caregiver Stand-by Assist ⃝ Other: FUNCTIONAL LEVEL V SCORE 24 ⃝ 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 "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) Score MOBILITY LEVEL WALK STAND CHAIR BED 250+ FEET 8 25+ FEET 7 10+ STEPS 6 1 MINUTE 5 TRANSFER 4 SIT AT EDGE 3 TURN SELF / ACTIVITY 2 LYING 1 Contact Johns Hopkins Medicine for permissions and instructions for use. 106 Institutional Change is Hard… ….It is easy to say NO! Translating Research into Practice (TRIP) Ability to Implement at Scale JHM AMP Bundle Homecare AMPAC Community Hospital LOS Neurosurgery Choose Wisely EPIC Medicine Choose Wisely Surgical Pathway (ERAS) Accountability 4 E’s Peds AMP Care Coordination Medicine Pilot 4 E’s Reinforcement Workflow/EMR PT/OT AMPAC ICU 4 E’s 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 ERAS AMP 2.0 Functional Reconciliation AMP 3.0 EMR Design Choosing Wisely Policy Functional Assessment Dr. Porter .gov Budget Alignment Meaningful Use Post-hospital syndrome 6Clicks ICU QI JHHLM Mobility Bundle QI Therapist POC 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 Krumholtz. Post-Hospital Syndrome. Patient physical functioning is associated with their risk for hospital readmission. NEJM. 2013; Jan 10;368(2):100-2. Andres PL, Haley SM, Ni PS. Is patient-reported function reliable for monitoring post acute outcomes? Am J Phys Med Rehab. 2003;82(8):614-621. Cre Care http://www.crecare.com/am-pac/ampac.html. Accessed 6/15/2011. Haley SM, Ni P, Coster WJ, Black-Schaffer R, Siebens H, Tao W. Agreement in functional assessment: graphic approaches to displaying respondent effects. Am J Phys Med Rehab. 2006;85(9):747-755. Brown CJ, Redden DT, Flood KL, Allman RM. The under recognized epidemic of low mobility during hospitalization of older adults. 2009. J Am Geriatric Soc;57, p. 1660. Murphy EA. A key step for hospitalized elders. Arch Intern Med. 2011;171(3), p. 269. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52, p. 1269. de morton, N., Keating, JL., Jeff, K., (2009) Exercise for acutely hospitalized older adults (Review) The Cochrane Collaboration issue 1. Drolet, A., DeJulio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, EA, Lloyd, JM., Warers, C., Williams, S., (2012) Move to Improve: the feasability of using an early mobility protocol to increase ambulation in the intensive and immediate care settings. Physical Therapy 93(2):197-207 Convertino, VA., Bloomfield, SA., Greenleaf, JE. (1997) An overview of the issues.: physiological effects of bedrest and restricted physical activity. Medical Science and Sports Exercise 29:187-190 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16), p. 1782. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660-5. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337 Hoyer EH, Needham DM, Miller J, Deutschendorf A, Friedman M, Brotman DJ. Functional status impairment is associated with unplanned readmissions. Arch Phys Med Rehabil. 2013. Cabana, Rand, Powe, Wu, Wilson, Abboud, Rubin. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20; 282(15):1458-65.