Computerized pathways reduce redundancy

Florida agency brings clinicians on line

Administrators with Community Home Health Care in St. Augustine, FL, were concerned that nurses and therapists were unnecessarily repeating patient lessons. Plus, their paperwork appeared to be redundant.

Clearly, something needed to be done to change care plans and assessments. It also seemed like a good idea to make visits more efficient in order to help the agency meet the financial challenges of the interim payment system (IPS).

"We were not happy with the care plans we had," says Bill Hepler, RN, BSN, MSH, computer coordinator at the hospital-based agency, which serves counties surrounding St. Augustine in northern Florida. "With IPS coming in, we wanted to find a way to keep tabs on our visits and streamline them," Hepler says.

Making education follow a pattern

Also, nurses were repeating instructions after patients had indicated they understood the material, says Grace Seeman, RN, quality improvement coordinator. "I wanted to see the teaching follow a pattern to the end rather than skip around and be repeated," Seeman adds.

The agency decided the solution was to use clinical pathways. Community Home Health Care created 20 to 25 pathways, including specific ones for the agency’s social worker, physical therapists, and nurses. There are clinical pathways for each of the agency’s top 15 patient diagnoses.

The pathways for the social worker and the physical therapists have gone through a trial-and-error process and appear to be working out very well, Hepler says. The nurses’ clinical pathways have only been used for a few weeks, so some glitches still must be ironed out.

However, all of the pathways have eliminated duplication. And they will make it far easier for the agency to collect data for various quality improvement projects, Seeman and Hepler say.

Here’s how the agency developed its pathways:

• Choose a pathway model.

The agency’s nurses already had been trained to use hand-held computers for assessments and most documentation. Administrators selected a clinical pathway software program created by Patient Care Technologies in Atlanta. The program provides a format and some examples of what to put in these pathways, but leaves plenty of room for an agency to individualize the pathways, Hepler says.

"You can use their pathways or build your own in any way you want," Hepler adds. "We got away from theirs and tailored our own."

This particular software program gave the agency some flexibility. The program also made it easy for staff to take shortcuts when typing in notes, based on programmed responses that Hepler selected. For example, when a nurse wants to document a patient’s mental status, the nurse may select the one-word choice of "alert." But when the pathway is printed, it includes the narrative: "The patient is alert." This way, the hand-held computer screen is not cluttered with unnecessary text.

• Meet with clinicians.

Administrators decided to write clinical pathways for the agency’s three disciplines: social work, physical therapy, and nursing.

Hepler chose to start with social work because there was only one social worker, and that would be the easiest discipline to put through the process of trial and error. The nursing pathways are the most technical in nature, so he saved those for last.

He met with the social worker and asked her what entries she addressed with every visit. He typed as she talked and used her responses for a baseline. Then he asked her what kinds of problems she encounters and what goals she sets. "Then we looked at all of the requirements for the Medicare 485 form and grouped it together with her entries," Hepler says.

After he completed the one-page pathway, he had her try using it. They continued to work together to improve it during the trial-and-error period.

Next, Hepler met with the physical therapy supervisor and began to work on the physical therapy pathway, which would be used by five to eight physical therapists. The physical therapy pathway includes assessments related specifically to physical therapy, such as a home exercise program.

The physical therapists tried the new pathway over a three-to-four month period. They had a little more difficulty learning how to use it because they also had to learn how to use the hand-held computers. Previously, the physical therapists had used written notes and assessments, Hepler explains.

Finally, Hepler began to write the nursing clinical pathways, relying on his knowledge as an RN and on clinical information he obtained from various books and literature. For example, he referred to the book Clinical Pathways for the Multi-disciplinary Home Care Team, written by Barbara Gingerich and Deborah Ondeck and published in 1995 by Aspen Publishers of Gaithersburg, MD. He also referred to the literature and some of the software package’s suggested items when writing the pathways that cover specific diagnoses.

• Make changes per staff suggestions.

Hepler met weekly with the physical therapists in the weeks after they began to use the clinical pathway. Later, the meetings tapered off. He plans to go through a similar trial-and-error process with the nurses.

Pathways conflicted with SOAP format

The agency’s physical therapists reported early on that they did not like the format of the clinical pathways. They had been trained to use the SOAP (subjective, objective, assessment, and plan) format of assessment. And they told Hepler they wanted the clinical pathway to be ordered in that same way.

This meant the therapists wanted the pathway to start with items relating to what the patient said about his or her own condition. Then the nurses would record their own observations about the patient’s condition. Next they would document their assessment, and end with a plan for care.

"It’s almost a contradiction to use SOAP with a pathway because of the way a pathway is organized," Hepler says. "But we came up with an idea of how to do it." He changed how the pathway was organized to suit the therapists’ request, and now they’re happy with the pathway, he says.

So far, nurses have raised two issues about the pathways: One, they are concerned the pathways are adding an hour or more to their initial assessment time, Seeman says. "But that’s just growing pains," she says. "They’ve forgotten how much extra time it took them when they started on computers." Seeman expects this problem will be resolved in a few months when nurses become more proficient in using the pathways.

The second problem is that some patients have multiple diagnoses and would automatically be placed on four or more pathways. Seeman is working to solve that problem by having the intake nurse only select the physician’s top-priority diagnoses for pathways. For example, if a patient has had a heart attack, then he or she definitely would need to be placed on the cardiac pathway. But if the physician also noted a minor bedsore, the patient might not need to be placed on the wound care pathway. Instead, the nurse could conduct a brief assessment of the wound on the general pathway as part of the patient note, Seeman explains.

The agency’s goal is to place patients on no more than three pathways at one time, and preferably only one or two, Seeman adds. "We’ll see where the major problems are, and if the doctor wants certain things done, we’ll gear the pathways toward that," Seeman adds.

• Tie pathways to patient teaching materials.

The pathways are useful in helping nurses organize their patient teaching, Seeman says. Each part of the pathway lists specific teaching goals, and some refer to a specific page of a teaching handout. The agency uses patient teaching guides published by Pritchett & Hull Associates in Atlanta.

For example, in a teaching guide on diabetes mellitus (DM), the pathway states, under Teach diabetes care: Instruct/Evaluate — signs and symptoms of hypoglycemia: Page 26-28 DM handout.

If there is a problem with the teaching and the patient’s understanding, then the nurse will check the pathway’s "progressing" choice. If the patient understands it, the nurse will check "goal met." If goals are met each day of an eight-visit pathway, for instance, then the teaching items will automatically drop from the pathway, Seeman says. If the goals are not met, then the nurse may add extra visits to the pathway.

• Use pathways to chart number of visits.

Hepler says his first goal has been to make sure staff are comfortable using all of the pathways before he begins to work on assigning specific numbers of visits to each. "I didn’t want to put in a fixed number when we started with the pathways because I felt nurses would be under too much pressure," Hepler says. "I wanted them to focus on learning the pathway sessions."

However, he has begun to research how many visits each diagnosis might require. And he is collecting data on the average number of visits per diagnosis that the agency’s nurses have conducted in the past.

Even when the pathways include a set number of visits, nurses will be able to use these as a flexible guideline that may be changed according to each patient’s needs, Hepler says.


Bill Hepler, RN, BSN, MSH, computer coordinator; Grace Seeman, RN, quality improvement coordinator, Community Home Health Care, 1955 U.S. 1 South, St. Augustine, FL 32086. Phone: (904) 826-4886. Fax: (904) 826-4885.