Therapy 2011 - Updates in EvidenceBased Care and Quality Initiatives
PHA Annual Conference May 19th, 2011
Tonya Miller PT, DPT COS-C
Michelle Abeln PT, DPT WCC
OBJECTIVES
• The Learner will be able to:
– Demonstrate knowledge of the components of
evidence based medicine
– Identify evidence based tools and quality of life
measures appropriate in home health setting
– Link evidence based medicine to rehab care
planning and goals setting in the home health
setting
– Demonstrate knowledge of how evidence based
tools and quality of life measures link to outcome
measures and quality initiatives
Evidence-Based Practice
• Evidence-Based (EVB) Practices
– Definition: Comprehensive reviews of the
scientific evidence regarding the effectiveness,
risks, and benefits of specific health care services
– AHRQ
– Individualized care based upon standardized EVB
assessments
– Research utilized to determine appropriate
interventions and measure outcomes
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Evidence Based Medicine
• Best Research Evidence
– Derived from either basic science of medicine or
patient-centered clinical research
– Components
• Standardization
• Reliability
• Validity
Evidence Based Medicine
• Standardization
– The process of administering a
test under uniform conditions
– Consider
• Population
– The Medicare HH patient? - community-dwelling elderly
• Size of the Sample
Evidence Based Medicine
• Reliability: are findings reproducible?
– The process of determining that the test or
measure is measuring something in a reproducible
and consistent fashion
– Test/Retest
– Inter-rater
– Internal consistency: estimate reliability by
grouping questions in a questionnaire that
measure the same thing ( quality of life measures
Evidence Based Medicine
• Validity: the strengths of our conclusion
– Three Types
• Content Validity: Is this test comprehensive and does it
fully represent what is claims to measure
• Construct Validity: Does the test conform to prior
theoretical relationships (example: is there more than
one study that supports it)
• Criterion Validity: Does it stand up to an already
established “gold standard” - example: Berg stands up
the Tinetti
Evidence Based Medicine
• Clinical Expertise
-Ability to use clinical skills and past
experience to identify the need and
appropriateness of standardized assessment
tools such as evidence-based tools
Evidence Based Medicine
• Patient Values
– The unique preferences, concerns, and
expectations that each patient brings to the
encounter
– Must be integrated into the clinical
decision making process
Evidence Based Medicine
• Evidence-Based Medicine (EBM) is the
integration of:
– Best Research Evidence
– Clinical Expertise
– Patient Values
“When these three elements are integrated,
clinicians and patients form a diagnostic
and therapeutic alliance which optimizes
clinical outcomes and quality of life.” (Sackett)
Evidence Based Medicine- finding
resources
• Professional Organizations
– Search Engines: OVID, Pub Med, MEDLINE
– AHRQ, American Geriatric Society, Quality Net (MedQIC),
CHAMP Program, Commonwealth Fund…
– International and national
• Goggle search
– Often times you can read articles for free – be persistent
– Copy and paste full name of article in the search area and
you can often find the article in a pdf format
– Best for articles greater than one year old
Evidence Based Medicine
• Final Rule: The Role of Evidence Based
Care
“By advancing patient care, improving quality and fighting
fraud, this final rule addresses important concerns shared by
the home health industry and all Medicare stakeholders .
“This final rule will help us ensure more accurate payments
and retain prudent financial stewardship of the Medicare trust
funds,” said Jonathan Blum, director of the Center for
Medicare and deputy administrator for CMS.
Evidence Based Medicine
• Final Rule: The Role of Evidenced Based Care
– Re-evaluation by a qualified therapist on 13 and 19th visit
• Increased focus on reasonable and necessary at defined
time frames during the episode of care
– Plan of care includes treatment goals
• In accordance with clinical accepted standards of
practice
– Functional Assessment and Re-assessment
• Include successive objective measurements
– Interventions include clinically effective interventions
• How do we support clinically effective intervention
Evidence-Based Medicine (cont.)
• Examples:
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Timed up and Go (TUG)
Berg Balance Scale (BBS)
Braden Scale
Borg RPE
Geriatric Depression Scale
Gait Velocity
Two Minute Step Test
MOCA
EVB Tools: Description and Utilization
• Timed Up and Go (TUG)
 Measure of functional mobility impairment
 Equipment: Chair, tape measure,
stopwatch, assistive device (prn)
 Completion time: varies with patient ability
 Scoring: <10 seconds- high mobility
10-19 seconds- typical mobility
20-29 seconds- slower mobility
>=30 seconds- diminished mobility
 Correlation to falls >13.5 seconds
 Mod-high correlation with Berg and gait velocity
EVB Tools: Description and Utilization
• Berg Balance Scale (BBS)
 Measure of balance and falls risk
 Equipment: chair, ruler, stopwatch,
shoe/slipper, step/stepstool;
no AD can be used
 Completion time:15-20 minutes
 Scoring: 41-46= low fall risk
21-40=moderate fall risk
0-20= high fall risk
 Change in 6 points=90% confidence that change has
occurred
EVB Tools: Description and Utilization
• Braden Scale
 Identifies patients at increased risk for pressure ulcer
development
 Categories: Sensory, moisture, activity, mobility,
nutrition, friction/shear
 Completion time: <1 minute once
patient assessed
 Scoring: 15-16= low risk
13-14= moderate risk
<12 = high risk
EVB Tools: Description and Utilization
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BORG Rate of Perceived Exertion (RPE) Scale
Measures level of fatigue felt during activity
Correlates to heart rate and VO2
Used to determine if exercise intensity
is enough to improve endurance and
lung function
 Scoring: 6-20 scale
greater number = greater exertion
: goal: maintain 13-14
: stop: if increase to 15
EVB Tools: Description and Utilization
• Modified BORG scale
 Measures level of breathlessness
 Used to determine safe progression of exercise
programs
 Can easily be taught to pt/caregiver for
logging dyspnea level with ADLs
 Scoring: 0-10 scale;
greater number = greater exertion
: stop if >4 (somewhat severe or worse)
http://www.well-quest.org/
EVB Tools: Description and Utilization
BORG RPE
Modified BORG
• Measures overall level
of fatigue
• Scoring: 6-20 scale
• Caution with frail,
severely deconditioned,
or certain cardiac pts
• Used to determine if
exercise intensity is
sufficient
• Specifically measures
level of breathlessness
• Scoring: 0-10 scale
• Appropriate for any pt,
specifically cardiopulmonary pts
• Used to show when
program needs to be
modified
EVB Tools: Description and Utilization
• Geriatric Depression Screening
 Measurement of depression in patient’s with dementia
 Equipment: Questionnaire
 Completion time: <10 minutes
 Scoring: 0-4: typically no cause for concern
5-8: mild depression
9-11:moderate depression
12-15: severe depression
EVB Tools: Description and Utilization
• Gait Velocity Test
 Measure of gait
 Equipment: stopwatch, measuring tape,
assistive device (prn)
 Completion time: <2 minutes
 Scoring: Time it takes leading limb (toe) to cross start
line and end line (10 meters); factor in
acceleration/deceleration time
<=0.6m/second- household ambulation
0.6-1.0m/second- limited community ambulation
>1.0m/second- full community ambulation
EVB Tools: Description and Utilization
• 2- Minute step test
 Measure of strength and aerobic capacity
 Equipment: stopwatch
 Completion time: <5 minutes to set up
2 minutes to complete test
 Scoring: total # of times ® knee reaches correct
height during marching for 2 minutes
EVB Tools: Description and Utilization
• MoCA (Montreal Cognitive Assessment)
 Measures mild cognitive impairment
 Uses attention & concentration, executive functions,
memory, language, visiuoconstructual skills,
conceptual thinking, calculations, and orientation
 Equipment: paper test sheet, pencil/pen
 Time to administer: 10 minutes
 Scoring: Total: 30 points; Normal: >=26 points
 Free for clinical, educational, and research use; can
use WITHOUT permission by health
professionals/hospitals/clinics/public health institutes
Link between EVB tools and QOL
Measures
• Choosing appropriate EVB tools to
develop plan of care for patient
• Better outcomes
• Improved QOL measures
Quality of Life Measures(QOL)
• Definition
– Measures the general well-being of an individual
and how one may be affected by chronic disease
or disability
– Multi-dimensional
• Often disease specific
• Incorporates physical, mental, emotional and
social well-being
• Effects of treatments
• Financial impacts of medical conditions
Health Related Quality of Life Measures
(HRQOL)
• More precise way of defining QOL
• Primarily concerned with how QOL may be
affected by health and disease
• Measures patient’s sense of his/her OWN
health and well-being in areas of physical,
psychological, and social functioning
Disablement Model: EVB Tools and QOL
Pathology
Disease/disorder
Impairment
Basic objective
measurements
Functional
Limitation
EVB Tools
Disability
QOL Measures
QOL Measures (cont.)
• Usually in survey or questionnaire format
• Self administered or clinician administered
• Variety of surveys exist to measure impact
of treatment on QOL based on past patient
experiences
• The two most used in Healthcare:
– Generic: such as SF-36 (Short form with 36 questions)
– Disease or Disorder specific: Visual Functioning
Questionnaire or Minnesota Living with HF
questionnaire
• Can be used before, during or after treatment
QOL Measures (cont.)
• Why so important
– Growing trend in research to develop and study
the effects that chronic disease and different
treatment options have on QOL
– Help determine appropriate cost effective
treatment options for improving quality of life
– Help determine treatment areas that need to be
improved
– Strong predictor of prognosis
Determining the appropriate QOL
Measure
1) What are you looking to measure?
2) Is tool reliable, valid, and responsive?
3) Is tool practical?
QOL measures (cont.)
• Free QOL surveys:
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Clinical COPD Questionnaire
COPD Assessment Test (CAT)
36-Item Short Form Health Survey
Nottingham Health Profile
• Fee required:
– Minnesota Living with Heart Failure
Questionnaire
– The Kansas City Cardiomyopathy
Questionnaire
QOL Measures (cont.)
• Overview of The Clinical COPD
Questionnaire (CCQ)
-3 domains: symptoms, functional state and mental
state
-10 items equally weighted
-available in 2 versions: 7 day and 24 hour
-self administered
- a seven-point scale where 0 = asymptomatic/no
limitations and 6
- extremely symptomatic/totally limited
QOL Measures (cont.)
• Overview of COPD Assessment Test (CAT)
– Questionnaire for COPD patients to measure
impact of COPD on person’s life and how it
changes over time.
– Free
– Self administered
– 8 questions
– Scoring 0-5 each question
– Total range 0-40 with lower score better
QOL Measures (cont.)
• Overview of 36-Item Short Form Health
Survey
– Set of generic, coherent, and easily administered
quality-of-life measures.
– questions comprise eight health scales measuring
three aspects of health (functional status, wellbeing, and 'overall evaluation of health'); also
includes an unscaled assessment of change in
health status
– Free
QOL Measures (cont.)
• Overview of Nottingham Health Profile (NHP)
- Provides brief overview of individual’s perceived
emotional, social, and physical health
- 2 sections with a total of 45 questions:
>Part 1: energy level, pain, emotional reaction,
sleep, social isolation, physical abilities
> Part 2: seven life areas affected
- self-administered
- Free
QOL Measures (cont.)
• Overview of Diabetes Quality of Life
Measure (DQOL)
- designed for individuals with IDDM
- evaluates relative burden of an intensive diabetes
treatment regimen
- 46 core items with 4 major dimensions
- most widely used for assessment of
diabetes- specific HRQol
- self-administered
QOL Measures (cont.)
• Overview of Type 2 Diabetes Symptom
Checklist
- 34-item scale designed to evaluate 6 categories
of diabetes-related symptoms
>hyperglycemia, hypoglycemia,
cardiac ,neuropathic,pyschological,
and vision-related
- higher scores associated with poorer
glycemic control
- self-administered
QOL Measures (cont.)
• Overview of Minnesota Living with Heart
Failure Questionnaire ( MLHFQ)
– Evaluates heart failure’s effects on the patient’s
physical, emotional, social and mental dimensions
of quality of life.
– Need to purchase
– Self administered
– 21 items
– 6 pt Likert (0-5) scoring range 0-105
– The higher the score, the worse
QOL Measures (cont.)
• Overview of The Kansas City
Cardiomyopathy Questionnaire (KCCQ)
– 23-item questionnaire for patients related to
physical function, symptoms, social function, selfefficacy and knowledge, and quality of life.
– Need to purchase
– Self administered
– 5-7 pt Likert scoring range 0-100
– The higher the score, the better
EVB Tools and QOL: Connecting To OASIS-C
• Heart Failure (M1500,
M1510)
– The Minnesota Living with
Heart Failure
Questionnaire
– The Kansas City
Cardiomyopathy
Questionnaire
• Depression (M1730),
(2250d), (2400c)
– Geriatric Depression
Screening Tool
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QOL: Connecting To OASIS-C (cont.)
• Diabetes (M2250b, 2400a)
– Diabetes Quality of Life
Measure (DQOL)
• COPD (M1400, M1410)
– Clinical COPD
Questionnaire
– COPD Assessment Test (CAT)
• Wounds
– Address underlying issue
• 36-Item Short Form Health
Survey
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Evidence-Based Medicine:
OASIS-C Connections (cont.)
• Process Measures
– Depression: Has the patient been screened for
depression using a standardized depression
screening tool?
– Falls: Has this patient had a multi-factor fall risk
assessment?
– Pain: Has the patient had a formal pain assessment
using a standardized assessment tool?
– Pressure Ulcers: Was this patient assessed for risk
for developing pressure ulcers?
• Yes- using a standardized tool
EVB and QOL: Treatment interventions
• BERG- pt at moderate risk for falls with difficulty on
all transfer sections.
o Treatment: specific interventions to work on sit><stand
transfers, strengthening of LEs, and to assess need for
liftchair
• Gait Velocity Test- gait speed shows pt only safe for
household ambulation, as pt not using AD and not
clearing feet from floor during swing phase.
o Treatment: strengthening of LEs (specifically dorsiflexors),
training with appropriate AD, assess need for ankle-foot
orthosis
EVB and QOL: Treatment interventions
• Modified BORG- pt scored 5/10 when ambulating 35’
with standard walker
o Treatment: educate pt on use of rolling walker, educate pt on
diaphramatic breathing, educate pt/caregiver on use of chart
to log pt’s dyspnea with ADLs.
EVB Tools and QOL: Rehab Plan of care
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TUG score on SOC= 29 seconds.
POC: Ambulation with wheeled walker
in home on level and unlevel surfaces;
static and dynamic balance exercises.
Re-assess TUG every 2 weeks.
GOAL: Pt will increase TUG score to
15-20 seconds with wheeled walker in
4 wks for decreased fall risk and
typical mobility.
EVB Tools and QOL: Rehab Plan of care
• Modified BORG on SOC= 5/10 with ambulation
without AD on 2 steps to leave home.
POC: training with use of cane on steps, LE
strengthening exercises, educate pt/CG on use of chart
to log breathlessness with ambulation. Re-assess
BORG every 2 weeks.
GOAL: Patient will ambulate independently with cane
outdoors to get to car with Modified BORG rating of
3/10 so patient can begin outpatient PT in 5 wks.
EVB Tools and QOL: Rehab Plan of care
Gait Velocity: 0.8 seconds with cane on SOC
s
.
POC: static and dynamic balance exercises,
strengthening, training on sequencing with
use of cane. Re-assess gait velocity weekly
GOAL: Gait velocity will improve to 1.2 m/sec for safe
community ambulation with cane in 4 weeks.
Turning the Wheels of Health Care
Turning the Wheels of Health Care Quality
Quality
Objective
Measurement
& Goals
Improved Scores on OASISC
Evidence-Based Interventions/Goal
Achievement Impact on Patient
Turning the Wheels of Health Care
Quality
Quality
of life
Patient
satisfaction
Value -Based
Healthcare
EVB Tools QOL: Outcomes and Quality
Connection
• OB QM
– Reducing re-hospitalization
• Gait velocity and connection to increase morbidity and
morality – the “6th vital sign”
• OBQI
-Functional and clinical
OASIS outcomes connectors
EVB Tools QOL: Outcomes and Quality
Connection
• PBQI:
– Direct correlation to disease processes using
quality of life measures
• HHCAPS
– Compare changes in QOL to HHCAPS
– Great way to set goals for clinicians that will
impact publically reported data
EVB Tools QOL: Outcomes and Quality
Connection
• Value Based
Purchasing
– Referral sources
– Payors
• Positioning to be the
agency of choice in
collaborative care and
ACO models
I have all of these tools
And
Great Info!
Now What??
Integrating into Organizational Practice
• Barriers:
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Documentation Systems
Time constraints
Coordination PT and PTA
Organizational policies and processes
• Example: established falls assessments
processes
– Clinician Buy –in
Integrating into Organizational Practice
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Education
– Staff meetings
• Presenting basics of evidence based care
• Presenting one new tool per month
– Preceptor process
• One on one training
• Train the trainer
– Incorporate into new staff orientation
Documentation Strategies
– Work with Vendors for modifications
– Cut and Paste addendums to add specific Test
– Mixed Paper and computer documentation if needed
– Not having the tool available in documentation will not be an
excuse for auditors
Integrating into Organizational Practice
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Performance Improvement Team
– Discuss how Evidence Base Practice Correlates to:
• OBQI
• OBQM
• PCOI
• HHCAPS
Administration
– Discuss how Evidence Based Tool Integration Effects the bottom
line
• RAC Audits
• Value Based Purchasing
• Collaborative Care with Referral Sources
• Accountable Care Organizations – the Agency of Choice
Key Points:
• Evidence Based Medicine can improve
quality of outcomes and the patient
experience
• EVB Tools and QOL measures can be
easy to use and incorporate into everyday
clinical practice
• The use of EVB tools and QOL measures
can help to position agencies for future
success
Questions
Resources
• CMS Outcome Based Quality Improvement Manual
– https://www.cms.gov/HomeHealthQualityInits/
downloads/HHQIOASISOBQIImplimentationManual
.zip
• Home Health Quality Improvement National Campaign
– www.homehealthquality.org
• CMS Process Based Quality Improvement Manual
– http://www.cms.gov/HomeHealthQualityInits/Downl
oads/HHQIOASIS-PBQI.pdf
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Resources (cont.)
• Law, M. (2008). Evidence Based Rehabilitation: A
Guide To Practice.
• List of QOL measures: http://www.proqolid.org/
• Agency for Healthcare Research and Quality
(AHRQ) http//www.ahrq.gov
• http://www.homehealthquality.org
• http://www.champ-program.org
• Parissis, JT, et al. Comparative prognostic value
of the Kansas City cardiomyopathy and the
Minnesota living with heart failure questionaires
in chronic heart failure. Attikon University
Hospital, Athens, Greece
61
Resources (cont.)
• Klocek M,Kubinyl, et al.; Effects of physical
training on quality of life and oxygen
consumption in patients with Congestive Heart
Failure Int J Cardiol 2005; 103(3):223-329.
• Polansky, W; Understanding and Assessing
Diabetes-Specifc Quality of Life. Diabetes
Spectrum; 2000; 13:36-49.
• http://www.sciencedaily.com/releases/2007/06/07
0614105308.htm
Resources (cont.)
• Centers for Disease Control and Prevention
http://www.cdc.gov/
• American Diabetes Association Home Page
http://www.diabetes.org
• University of Missouri-Columbia (2007, June 15).
Exercise Helps People With Diabetes, Study
Says. ScienceDaily. Retrieved December 30,
• Nursing Economics, Jan-Feb, 2002
• jama.ama-assn.org
Resources (cont.)
• Jette, Alen M. Using Health Related Quality of Life
Measures in Physical Therapy Outcomes
Research; Physical Therapy,73:8:44-53.
• http://cvoutcomes.org/topics/3038
• http://www.license.umn.edu/Products/MinnesotaLiving-With-Heart-FailureQuestionnaire__Z94019.aspx
• http://www.champprogram.org/search?q=Geriatric+Depression+Sca
le+&x=15&y=17
Resources (cont.)
• http://www.rand.org/health/surveys_tools/mos/mo
s_core_36item.html
• Home Health Care CAHPS (Official)
– http://www.homehealthcarecahps.org/
• www.qualitynet.org
• Van der Molen, T. Clinical COPD Questionnaire,
University Medical Center Groningen, The
Netherlands, 1999.
Thank you for attending this session.
millert@celtichealthcare.com
ablenm@celtichealthcare.com