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
• mfried26@jhmi.edu
• Twitter follow:
– @mkfrdmn
Mary Stilphen PT,DPT
• Stilphm@ccf.org
• 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.