Quality and Value in Home Care Introduction to Outcome-Based Pathways Wound Care (Short Stay)

Transcription

1 Quality and Value in Home Care Introduction to Outcome-Based Pathways Wound Care (Short Stay)

2 Objectives Outcome-Based Pathway What are they? How were they developed? What do they mean? Wound Care Outcome-Based Pathways What are they? What do they entail?

3 Outcome-Based Pathway Definition Outcome Based Pathways (OBPs) arrange the care plan outcomes around a specific population s needs (e.g. wound care, unilateral hip and knee replacement, hospice palliative care). The OBP identifies expected evidence-informed outcomes that will be achieved as part of best practice care/treatment delivered at specific points in a patient s care journey. Outcomes are achieved through the application of best practice guidelines, business and patient care efficiencies and innovations. 3

4 Outcome-Based Pathway These pathways have been created in an effort to ensure: Clinical best practices are applied in the provision of care/services in order to achieve optimal patient outcomes. Standardized reporting and outcome measurements based on best practice are applied provincially to evaluate sector performance in the provision of care/services. A consistent patient experience across the province when receiving CCAC services. Provider autonomy and flexibility as the clinical expert in providing care or treatment. A mechanism exists for CCACs to monitor the progress of patients receiving services for a particular condition and provide a framework for Care Coordinators to intervene when a patient s care trajectory is not meeting the anticipated outcomes. 4

5 Defining Terms Outcome-Based Pathway Clinical Pathway Focus is outcomes Focus is clinical goals Identifies indicators to measure outcomes Identifies clinical tools to Care Coordinator interventions detailed measure progress Less time-specific/ sensitive activities Clinical interventions are detailed Tends to outline multiple timespecific sequences of activities Outcome-Based Pathways do not replace Clinical Pathways but are complementary in their use 5

6 Shared Accountability for Patient Care Performance expectations are clearly defined among the care team, who share responsibility for attaining set health outcomes 6

7 Glossary Term OBP OBR FFS SPO PLO Definition Outcome-based pathway: An identified trajectory of care for a specific population or condition which identifies expected evidence-informed outcomes that are likely to be achieved as part of the best practice care provided. Care on OBP can be reimbursed via the Outcome-Based Reimbursement framework (OBR) or Fee for Service (FFS). Outcome-based reimbursement: Payment which is based on successful achievement of outcomes at identified intervals on an Outcome-Based Pathway. Fee for service: Providers are paid for visits made based on previously established rates for visits. Service Provider Organization: An organization contracted by a CCAC to provide care for a patient. Payment Linked Outcomes: Outcomes on pathways eligible for reimbursement payment type which identify which outcomes must be achieved to release a core payment. 7

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9 Short Stay Population Typically require short term education, care or support as a result of illness, injury or disability High potential to return to independence Stable and predictable care trajectory Overall very low care coordination intensity with a focus upon exceptions High capacity to transition to self-care

10 10 OBP & OBR Development Cycles

11 OBR vs. FFS Overall there are two types of payment frameworks: 1. OBR 2. FFS It is important to remember that the OBP content was developed to accommodate for either OBR or FFS SPO payment reimbursement types The payment framework does not change the way the OBPs are used in any way Currently OBR is only used within Short Stay Populations but OBPs can be used across all CCM populations using a FFS framework

12 Outcome-Based Pathways Caseload/OBP&R Eligibility Short Stay: OBP-OBR Eligible Long Stay: OBP-FFS Eligible ONLY **all OBPs are capable of being on Long Stay Caseloads the only difference is that the reimbursement is FFS instead of OBR Other: OBP-FFS Eligible ONLY OBP Diabetic Foot Ulcer Pilonidal Sinus Pressure Ulcer Surgical Wound Traumatic Wound Venous Leg Ulcer Total Hip Replacement (Post-op) Total Knee Replacement (Post-op) Arterial Leg Ulcer Maintenance Wound Non-Healing Wound Malignant Wound Assessment 12

13 Review of the Pathways: Standard Pathway Sections Pathway Name Presenting Issue or Condition Defined (Inclusion Criteria) Exclusion Criteria Overall Pathway Outcome Reason for Stoppage

14 Review of the Pathways: Standard Pathway Sections Date Created Date Reviewed Subject Matter Experts Date of Endorsement Frequency of Review

15 Review of the Pathways: Standard OBP Sections 15

16 Diabetic Foot Ulcer OBP Pathway Name Diabetic Foot Ulcer Presenting Issue or Condition Defined Diabetic foot ulceration is a full-thickness penetration of the dermis of the foot in a person with diabetes. Ulceration is a complication of either Type I or Type II diabetes which can cause neuropathy resulting in sensory loss of protective sensation, skin changes, foot deformity, and limited joint mobility. As a result, pressure from footwear, cuts, bruises or other injury may go unnoticed. Risk for ulceration is exacerbated by peripheral arterial disease, poor glucose control, obesity, self-care deficit and improper footwear. Exclusion Criteria o Acute Charcot foot o Gangrene (tissue ischemia) o Known osteomyelitis or upon initial assessment, ability to probe to bone o Intact skin (without visible injury or opening e.g. cellulitis) Overall Pathway Outcome o Wound closed 16

17 Pilonidal Sinus OBP Pathway Name Presenting Issue or Condition Defined Pilonidal Sinus Pilonidal sinus (cyst, Sacro-coccygeal Pilonidal Sinus): is an abscess near or at the natal cleft of the buttocks in the midline of the sacrococcygeal area of the back. This acquired condition is caused by one or more factors: body hairs entering the natal cleft or previous incision site causing a foreign-body reaction or keratin plugs in hair follicles causing folliculitis/ abscess. Exclusion Criteria o Intact skin (without visible injury or opening e.g. cellulitis) Overall Pathway Outcome o Wound closed 17

18 Pressure Ulcer OBP Pathway Name Presenting Issue or Condition Defined Pressure Ulcer (Decubitus ulcer or bedsore): is a localized area of tissue damage or necrosis that results when soft tissue is compressed (pressure, shear, and friction) between a bony prominence and an external surface. Contributing factors include moisture (i.e. perspiration, stool and urine), external friction, nutritional deficiencies, immobility, impaired sensory perception, lack of activity and decreased levels of consciousness. Pressure ulcers are staged based on degree of tissue injury. Pressure ulcers are never reverse staged. Exclusion Criteria o Suspected Deep Tissue Injury: purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Overall Pathway Outcome o Wound closed o Stage I Pressure Ulcer: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. 18

19 Surgical Wound OBP Pathway Name Presenting Issue or Condition Defined Surgical Wound Surgical Wound (Post-Surgical Wound): is a wound caused by a surgical incision that is intentionally left to heal by secondary intention or when primary wound closure with staples or stitches is unsuccessful with subsequent dehiscence. Surgical wounds are made in optimal conditions but failure to heal may be a result of infection. These wounds may be referred to as surgical site infections (SSI). Exclusion Criteria o Closed surgical incision with or without a drain o Skin grafts/donor sites o Intact skin (without visible injury or opening e.g. cellulitis) Overall Pathway Outcome o Wound closed 19

20 Traumatic Wound OBP Pathway Name Presenting Issue or Condition Defined Traumatic Wound Traumatic wound: is an acute wound caused by external injury such as friction, shear or blunt trauma (i.e. skin tear, burn) The layers of the skin are separated with a variable degree of tissue damage. They may be referred to as partial or full thickness wounds and may occur anywhere on the body. Exclusion Criteria o Intact skin (without visible injury or opening e.g. cellulitis) Overall Pathway Outcome o Wound closed 20

21 Venous Leg Ulcer OBP Pathway Name Presenting Issue or Condition Defined Venous Leg Ulcer (venous stasis ulcer, venous insufficiency ulcers) a wound caused by impairment in the flow of venous blood from the legs to the heart. This impairment is associated with venous hypertension as a result of one or a combination of the following: valve dysfunction (reflux) blockage of the veins (i.e. clot) "failure of the calf muscle pump function" (i.e. paraplegia, MS or altered gait) Exclusion Criteria o Intact skin (without visible injury or opening e.g. cellulitis) Overall Pathway Outcome o Wound closed 21

22 Assessment Pathway Pathway Name Presenting Issue or Condition Defined Exclusion Criteria Overall Pathway Outcome Assessment Pathway Patients admitted to CCAC services with a wound of unknown etiology which cannot be determined by the Care Coordinator requiring a comprehensive wound assessment to determine the underlying cause. NB: once wound etiology has been identified, appropriate interventions should be initiated by the service provider in accordance with the correct outcome-based pathway in addition to notifying the Care Coordinator of the correct pathway assignment. Patients with a wound of known etiology either indicated on the medical referral or determined by the Care Coordinator upon their assessment. o Moved to appropriate outcome-based pathway upon determination of wound etiology. o OR Initiation of treatment as per best practice and clinicians assessment if not appropriate for a pathway. 22

23 Asses sment DFU Piloni dal Press ure Surgic al Traum atic VLU Outcome 0 to 7 Days Wound Measurement Holistic Patient and Wound Assessment Completed Correct OBP Confirmed Wound Therapy initiated Discharge Planning Initiated for patient independence and prevention Pressure Redistribution Measures Initiated Lower Limb Assessment Completed Root Cause of Trauma Identified and Addressed Compression Therapy Initiated Referral for Vascular Assessment Initiated/Completed 21 to 28 Days 20-30% Reduction in Wound Size Chronic Disease Self-Management Plan Initiated Referral initiated for Long-Term Pressure Redistribution Referral initiated for long-term Compression System 77 to 84 Days 70-80% Reduction in Wound Size Final Interval Wound is closed by weeks Patient has obtained and is adhering to pressure redistribution system 23 Patient is independent with Long-Term Compression

24 Interval 1: 0 to 7 Days Outcome Wound Measurement Holistic Patient and Wound Assessment Completed Correct OBP Confirmed Wound Therapy initiated Discharge Planning Initiated for patient independence and prevention Pressure Redistribution Measures Initiated Lower Limb Assessment Completed Root Cause of Trauma Identified and Addressed (Traumatic) Compression Therapy Initiated (VLU) Definition Wound measurement is in cm and includes the Length x Width x Depth A patient and wound assessment completed according to SPO, CNO, RNAO Best Practice Guidelines and clinicians judgment. Verification is received from the SPO that the OBP assigned is accurate based upon their assessment of the etiology of the wound Wound care treatments have been initiated based upon the SPO clinicians assessment and Best Practice Guidelines Discharge planning should be initiated upon admission to services and should be assessed on a case-by-case basis dependent on the individual patients clinical and psychosocial needs The appropriate clinician has completed their assessment and referral to the appropriate vendor for the required long-term pressure redistribution system to facilitate wound healing and reduce the risk of wound recurrence The RNAO Best Practice Guideline, Assessment and Management of VLUs, identifies that assessments and investigations for lower leg ulcers should be under taken by a healthcare professional trained and experienced in leg ulcer management Upon identification of the cause of the trauma, the clinician takes the appropriate steps to ensure prevention of a recurrence Compression therapy has been initiated after completion of the appropriate assessments (i.e., lower limb assessment, ABPI) in accordance with Best Practice Guidelines. Compression therapy is identified as being the gold standard of care for the treatment of venous leg ulcers in the absence of arterial disease 24

25 Interval 2: 21 to 28 Days Outcome Definition 20-30% Reduction in Wound Size The benchmark for wound healing is 20-30% within four weeks. Chronic Disease Self-Management Plan Self-management support is defined as the systematic provision of Initiated education and supportive interventions by health care staff to increase patients skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem-solving support. Referral initiated for Long-Term Pressure Redistribution (DFU) Referral initiated for long-term Compression System (VLU) The appropriate clinician has completed their assessment and referral to the appropriate vendor for the required long-term pressure redistribution system to facilitate wound health and reduce the risk for wound recurrence. The appropriate clinician has completed their assessment and referral to the appropriate vendor for the required long-term compression system to facilitate wound health and reduce the risk for wound recurrence. 25

26 Final Interval The Final Interval length varies depending on the wound type: DFU - Closed by 12 weeks Pilonidal Closed by 8 weeks Pressure Ulcer Closed by 18 weeks Surgical Closed by 8 weeks Traumatic Closed by 8 weeks VLU Closed by 12 weeks, with compression by 14 weeks Outcome Wound is closed by weeks Patient has obtained and is adhering to pressure redistribution system Patient is independent with Long-Term Compression System by Week 14 (VLU) Definition Wound has 100% re-epithelialized. The clinical milestone is that the wound has closed. It will not be considered healed for up to two years. The patient has obtained the long-term pressure redistribution system as recommended and is using the system as directed. The patient has obtained the long-term compression system as recommended and is using the system as directed by week

27 For More Information Information about Quality and Value in Home Care, and the education materials developed to support the implementation of change, can be found on the CCAC public website at under the tab of Service Providers, click on Outcome-Based Care: Resources or go directly to: Information about the changes to functionality in the Health Partner Gateway can be found on the same website under the tab of Service Providers click on CCAC Procurement, and then click on Health Partner Gateway or go directly to: