Brave new world: Case managers and the future of clinical pathways

Current paths focus too much on length of stay, experts say

When clinicians at New England Medical Center in Boston developed the first clinical pathways in 1985, no one expected the sweeping effect these tools would have on acute patient care in America. Thirteen years later, pathways have become synonymous with the profession of case management. And as pathways continue to evolve in both scope and complexity, your role will evolve along with them, experts say.

"When pathways first came along, they were the panacea of all time," says Sue Sedaka, RN, a case manager at MedSmart International, a consulting firm specializing in pathway development in Costa Mesa, CA. "But I think we've gotten to the point where we've realized that putting a pathway together is not a panacea any more than getting a trip book from the auto club is a panacea. Because once you buy the trip book, you still have to confront the weather, the traffic conditions, and all of those issues."

Specifically, Sedaka says, pathways must be flexible enough to be consistently updated and customized to individual needs because each patient is different. But most paths continue to fall short of that goal. "I had a facility tell me recently, `We did our pathway 18 months ago. Why should we change it?'" Sedaka says. "My response was, `Eighteen months? Eighteen minutes may have been too long ago!'"

Karen Zander, RN, MS, CS, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA, was a member of the team that first developed clinical pathways at New England Medical Center. She says part of the problem is that many institutions have lost sight of the original intent of pathways.

"They were invented to solve the problem of, how are we going to get patients to outcomes and be more efficient?" Zander says. "What happened was that, because they represented a simple enough solution, there was a very fast acceptance and experimentation period after we introduced them. But there was too much attention to the solution and not enough attention to what the problem was in the first place."

As a result, Zander says, many institutions simplified the issue to reducing length of stay, instead of looking at how to achieve positive clinical outcomes more efficiently. "It's still the way people think about paths - that it's a way to cure lengths of stay, or to get standardization or decreased variability in practice," she says. "But the reason we came up with [the idea] in the first place was to guarantee that while we were trying to be more efficient, we didn't lose sight of measurable patient outcomes."

Zander stresses that by patient outcomes, she doesn't mean patient satisfaction but rather clinical indicators such as functional ability, patient knowledge, and absence of complications. And in order to get a handle on such outcomes, Zander notes, the pathway should become the core of the medical record itself. (For more about the origin of clinical pathways, see related story, p. 67.)

At Thomas Jefferson University Hospital (TJUH) in Philadelphia, case managers have addressed that issue by incorporating severity adjustment into their pathways. For example, they have added the New York Heart Associa tion's four-tiered severity classification system to TJUH's congestive heart failure pathway, says Kimberly Jungkind, RN, MPH, CCM, a case manager at TJUH.

Jungkind and her colleagues also have tried to make their pathways more specific, to the point of including pharmaceuticals, target doses, and telephone numbers of specific clinicians, either on the pathway itself or as an attachment. "We think it's important to allow everyone to know, for example, which ACE inhibitor is on the formulary and what the target dose and starting dose should be," she says.

This increased specificity underscores the need to build in a process by which pathways can be updated on short notice, Sedaka says. "New technologies, new modalities, and new treatment protocols come out on a daily basis," she says. "So your pathway has to be interactive. It has to be able to absorb those changes so that when you do go and customize to a patient's needs, you have all the latest options available."

Options can change from week to week

But building such a process is easier said than done, especially when your degree of flexibility depends on the decisions of hospital administrators. For example, hospitals often negotiate purchasing options with a particular vendor to secure discounts on drugs or other products. "That's all well and good if your pathway says, `When you get to this point, we're going to use brand X,'" Sedaka says. "But what happens next week when brand Y comes out, and it's actually the better product, or the better service or modality, and it's not part of the buying option?"

Given the rapid pace of new drug development and clinical research, even receiving timely information about recent changes can pose a problem, Sedaka notes. Indeed, many patients with chronic conditions are accessing the latest information about treatments for their diseases via the Internet before the clinicians who treat them. "We're about to go through a big flip-flop as to who is managing whom," Sedaka says. "Soon, the baby boomers are going to be telling the provider industry what they will and won't accept. I know that I'm not going to have a doctor tell me that I'm stuck with yesterday's mashed potatoes because he didn't read the latest update."

The solution is to take the plunge into automation, using computer systems to access the latest information and to more easily adapt pathways to reflect that information. Although there's nothing wrong with manual systems, "they can require that things go through 150 iterations before they finally get to the end user," Sedaka says. "Meanwhile, there are those of us who are on-line with a research department that is constantly updating the pathways, providing addendums to help you understand what came out last week in the New England Journal of Medicine. That allows me instantaneously to suggest to the physician and the patient that these new options are now available and approved." (For more about the future of automated pathways, see related story, p. 68.)

While the future of clinical pathways - and of case management - certainly involves increased automation, other changes are likely in store as well. One significant change will be the continued expansion of pathways across the continuum of care, Zander says.

At TJUH, case managers have already revised the congestive heart failure pathway to reflect such a continuum focus, and Jungkind believes other systems will soon follow suit, particularly larger hospitals. "You're going to see more integrated pathways, so that when a patient enters the physician's office or the ED, they will already have that part of the pathway started," she says. "Then the paperwork ideally should follow through with that patient if they get admitted, or if they don't. There should be phone numbers for who to call for subacute care or for transfers to home health."

One obstacle currently in the way of such fully integrated paths, however, is that many physician groups "haven't come around to the need to standardize or look at a population and follow it through the whole system," Jungkind says. A challenge at some institutions may be how to rework job descriptions so that the responsibilities of different clinicians don't overlap more than necessary as patients move through the continuum.

"It depends on what the case manager is able to do and how much freedom they have," Jungkind says. "And do the case managers then bridge the continuum of care? Because if they and the pathways bridge the continuum of care, you've got a good match."

Because of the need for such a continuum focus, Zander says she believes the term "discharge" has become a barrier. "I want the concept of discharge to go away," she says. "We should think about patients being on journeys - patient transitions, where they move from one venue to another. I like to think that paths will help that."

Although pathways in the future will "look different and act different," pathways and the concept of structured health care are here to stay, Zander contends. "Once you start to think about outcomes and using the most powerful interventions earlier in time, you can never quite go back," she says. She even envisions that within 10 years it may well become illegal not to treat patients on some kind of pathway.

"To say you have no concept of where you're going with a patient will be unacceptable," Zander says.

For more information on the future of clinical pathways, contact the following:

Kimberly Jungkind, RN, MPH, CCM, case manager, Thomas Jefferson University Hospital, 111 South 11th St., Philadelphia, PA 19107. Telephone: (215) 955-6000.

Sue Sedaka, RN, case manager, MedSmart International, 1675 Scenic Ave., Costa Mesa, CA 92626. Telephone: (800) 652-1134.

Karen Zander, RN, MS, CS, FAAN, principal and co-owner, Center for Case Management, 6 Pleasant St., South Natick, MA 01760. Telephone: (508) 651-2600.