SSM’s CARE PATHWAYS® boost patient compliance, lower readmission rates

Physician-as-champion approach encourages buy-in

St. Louis-based SSM Health Care (SSMHC), a not-for-profit health system, has instituted a series of case management CARE PATHWAYS that have improved outcomes in several initiatives over the past five years. Results of the programs are shared systemwide to encourage benchmarking and modeling.

Leaders in these efforts see a direct link between case management and quality. "Our basic tenet is they are one and the same; both are directed at what is best for the patient," says Dan Hoffman, MD, administrative medical director at St. Mary’s Good Samaritan, Inc., in Centralia and Mt. Vernon, IL. "One of the foundations of CARE PATHWAYS is that the best quality of care happens to be the most efficient. If you keep a patient too long in the hospital, complication rates go up. Utilization of services is part of what we look at in terms of quality."

When it comes to quality, the folks at SSMHC know whereof they speak; SSMHC recently became the first health care organization to win the coveted Malcolm Baldrige National Quality Award.

Around this basic foundation, Hoffman explains, SSMHC has identified high-risk areas such as congestive heart failure (CHF), pneumonia, chronic lung disease, myocardial infarction, and strokes. The health system designed CARE PATHWAYS to help streamline the care delivered.

"Doing it the same way is better than doing it the right’ way," he asserts. "Every physician thinks they are right. If we can get them to do things the same way, it standardizes care and helps in all ancillary services departments. Everyone knows what is expected of them in terms of patient care."

SSMHC’s case managers work to ensure compliance with the CARE PATHWAYS, identify outliers and their potential causes, and discuss their findings with attending physicians on a one-to-one basis in what Hoffman calls a "friendly" atmosphere. "We seek to avoid adversarial situations; you get more flies with honey," he explains. "We’re all trying to do what’s best for the patient."

This emphasis on teamwork is carried across departments. "Quality and case management are two separate departments," says Joby Glenn, RN, BSN, director of case management, "but they work closely together. Case managers will route important issues to quality management for special studies, and answer questions and conduct special studies on what the quality management department does. Then they forward that information to Dr. Hoffman and his committees."

"The basic principles for feeding information to other departments applies across the system," adds Shelley Niemeier, BSN, MHA, the quality resource center consultant. "Case management directors from every entity in the system meet on a quarterly basis to share issues they have identified. Each medical center also has a quality director, who gets feedback from the case managers. So we have forums across the system where these disciplines work closely and share ideas."

About five years ago, St. Mary’s Hospital Medical Center in Madison, WI, began developing CARE PATHWAYS in order to promote a coordinated, patient-centered approach to care delivery. (For a sample page of a CARE PATHWAY, click here.) The intent was to optimize the value of care processes through several mechanisms:

  • enhanced communication and collaboration among members of the interdisciplinary health care team;
  • support and encouragement for the patient and family to become active members of the team;
  • promotion of "continuum of care" thinking;
  • the streamlining of resource utilization through the adoption of consistent outcomes-based practices.

To facilitate the overall development and implementation processes, a CARE PATHWAYS Advisory Group was formed at St. Mary’s. This committee included staff nurses and clinical nurse specialists in pathway leadership roles, representatives from rehab services, utilization review, and health information services.

Over the years, the structure evolved. At the Feb. 5, 1998, meeting, the CARE PATHWAYS Advisory Group formalized its name change to the Integrated Patient Care Council. In addition, the following mission statement was developed: "The purpose of the Integrated Patient Care Council is to increase the value of care and services we deliver. We will accomplish this by facilitating: 1) integration across disciplines and settings within our system, and 2) by development and management of outcomes-based health care practices."

A closer look at one specific pathway — the CHF care path — helps illustrate how the SSMHC system works. The impetus for this particular initiative came from SSMHC’s strategic plan.

"It was identified in late 2000 as an opportunity for quality improvement; we had a high readmission rate," explains Tina Garrison, CARE PATHWAYS coordinator.

"In our JOA [Joint Operating Agreement] with Good Samaritan, it was also identified as one of the top areas of financial loss in the hospital," adds Hoffman. "One way to address the problem was through CHF, which was also tied to the readmission rate, as well as to losses in Medicare margin."

The first step involved formulating a team. "We selected a physician champion, one of the cardiologists," notes Hoffman. "If you want to get any new approach accepted, it’s very important that you have a non-administrative physician champion to try to get the other docs on board." Then the champion was joined by representatives from all affected disciplines — case management, nursing, physical therapy, respiratory therapy, dietary, home health, social services, and pharmacy.

"We have a core care path team for anything we develop — case management, nursing, and the other core departments. Then we have ad hoc members, depending on the specialty involved," Hoffman explains.

The team met and built an order set containing what the routine orders would be. From that point, they built the interdisciplinary care path that detailed how each of the services would help care for the patient.

The next step was education. Nurses, medical staff, and all ancillary services were given an evidence-based medical rationale for the pathway. Then it was rolled out.

"The case managers then looked at the cases on the floors — how many people were using the pathway, and if not, why not," notes Hoffman. "They presented data on a periodic basis to show what compliance rates were and to give reminders about using the pathway."

Clinical indicators also are assigned to the pathways, notes Glenn. "These are quality issues. Tina [Garrison] gathers information on all patients and compares those who are on and off pathways."

"When we all gather together, we actually do it in a room," adds Garrison. "Everyone has their input right there; it’s not just a paper trail."

Patient education is another important piece of the puzzle, Glenn notes. "We give the patients their own pathway — what to expect every day," she explains. "They are told what will happen each succeeding day, how long they should expect to be in the hospital, and so on. It’s been very beneficial."

Here, too, teamwork is important. Once the documents are developed, they are brought to the medical staff for their opinions. "The docs will tweak it a bit and personalize it for their own facility," Glenn says.

Benchmarking these pathways is made easy though technology. "All representative hospitals have access to each care path through our Intranet," Hoffman notes. "Why reinvent the wheel? Different facilities will, however, tweak the pathways for their unique environments."

Identifying physician champions is just one way physician support is engendered at SSMHC.

One of the other major strategies involves the educational piece created at the conclusion of the care path development, says Hoffman. "At that time, either a local speaker or an outside speaker — hopefully someone local who is also the physician champion — will present the care path to the audience that will use it."

The process is evidence-based, Hoffman notes. "The approach is: This is the best way to take care of the patient. For example, you need an ACE inhibitor, or this kind of workup, but this other procedure is not necessary, for these reasons."

Only then is the new pathway rolled out. "Those who have bought into it will use it, and then others will use it because doctors are competitive; they will feel that if they’re not using it, they are not part of the game," Hoffman explains. "We appeal to their egos and to their competitive natures."

Support for the pathway is then reinforced on an ongoing basis by sharing comparisons between on-path and off-path results in departmental meetings, newsletters, and so on.

Hoffman and his colleagues also have developed clinical teams across both campuses to present the data to those involved in a given specialty of care. "As they see on-path lengths of stay go lower and outcomes improve, care path usage rates go up," he notes. "If you show a decent doc the valid data, he will use it."

Another strategy involves placing emergency department medical directors from each facility on the team. "Considering the number of patients who present there, it’s important to get their buy-in," Garrison says.

SSMHC is continuously re-evaluating the existing CARE PATHWAYS, Garrison notes. "Each CARE PATHWAY order set is evaluated at least twice annually by the respective CARE PATHWAY team, and changes are made as necessary," she says. "In other words, when a new order set and CARE PATHWAY are released, they are not set in stone. This is an important component of our commitment to achieving the best possible care for our patients."

A prime example of this continuous pathway evolution is the newest addition to the CHF pathway. "One of the key issues we identified in terms of readmissions is patient compliance upon discharge," notes Hoffman. "We think we’ve educated them, but when they get home they often forget what they learned. So we have added a full-time nurse who does nothing but make follow-up phone calls."

During these calls, the nurse asks the patients if they are taking their meds, doing their daily weights, and so forth. "We can even get them scales if they can’t afford one," says Hoffman.

Trying to keep these patients healthy and prevent unnecessary readmissions is a top priority, he adds, and technology comes in handy here as well. "St. Mary’s at Madison uses an electronic scale that is attached to the patient’s phone line. The phone also speaks’ and reminds the patients to weigh themselves, asks them if they took their medicine, if they’re following their low-salt diet, and so on," he notes. "The information is downloaded at the hospital. The patients love it, and we hear it has really helped in post-discharge compliance." Because of its success, he notes, the technology will be expanded to other CARE PATHWAY initiatives as well.