Clinical Pathways

annaedRN, RN · Aug 4, 2009

We too as an agency have played around with that idea. It sounds as things start to change to reimbursement being based on meeting outcomes that clinical pathways will be a must...more so than writing a few goals on the 485. I think that it is good in concept but since numerous nurses coming in and out of homes is less structured than in a hospital, that using them would have to have a very cut and dry application so that everyone is on the same page. Does that make sense? just some thoughts...if it could be added on to the routine charting... and updated as you download new info into the computer, so that the things taught, goals met would be checked off..anyways, would need alot of fine tuning and planning to make all staff utilize them properly

KateRN1 · Aug 4, 2009

Good points to consider, thanks. Here's what I'm thinking, or at least along these lines. Cert pd is 60 days, assume frequency is 3xwk for 1 wk, 2xwk for 3-4 wks (depending on how it falls), then 1xwk for 4 wks. The pathway would look similar to what's in the hospital. Let's take a newly insulin dependent diabetic.

Goals:

(long-term) Pt demonstrates fasting blood glucose within range of 70-120 5/7 days per week and/or HgbA1C

(short-term) Pt. demonstrates ability to draw up and self-administer insulin injection within 3 visits.

(long-term) Pt verbalizes understanding of diabetic diet teaching and/or glycemic index scale.

(long-term) Pt. verbalizes understanding of pathophysiology of diabetes including possible outcomes of non-compliance.

So then your pathway would be something along these lines:

visit 1--nurse demonstrates proper procedure to draw up and administer insulin as patient watches; assess pt's understanding of dx; provide daily log for blood sugar monitoring; provide handout: How to Self-Administer Insulin

visit 2--nurse provides visual and verbal cuing to assist patient with drawing up and self-administering insulin; brief overview of diabetic teaching including handout: Now You Need Insulin [i made that one up]; review daily blood sugar log

visit 3--nurse observes patient draw up and self-administer insulin providing cuing as needed; mark short-term goal met if applicable; begin diet teaching including handout: Create Your Plate; review daily blood sugar log.

visit 4--begin ed on the pathophys of diabetes, how it occurs, how it progresses; include handout: Insulin for Type 2 Diabetics; review daily blood sugar log

visit 5--continue with ed on pathophys, include handouts: Avoiding Diabetic Complications; review daily blood sugar log

visit 6--draw HgbA1C; teaching on labs used to monitor diabetes; include handout: Diabetes and Lab Tests; review daily blood sugar log

visit 7--review results of HgbA1C; review daily blood sugar log; review previous teaching sessions, correct any misunderstandings; no new teaching/handouts at this time

visit 8--Discuss diabetic foot care; include handout: Diabetic Foot Care; review daily blood sugar log; begin discussing resources for discharge

I could keep going for the full 12-14 visits, but I think the point is clear. Anyway, the idea is to have a schedule for teaching so that everything is covered, the goals are clear and measurable, and if a fill-in nurse comes, s/he knows exactly where the patient is.

Does that sound reasonable or am I dreaming?

annaedRN, RN · Aug 5, 2009

I like it! Would take MUCH work to implement but I think it would be worth it. Would need to be sensitive to patient's learning styles, how much pt vs family providing care, and some way to document if patient is NOT following/advancing so that learning/goals for each visit could be adapted or even repeated as needed. I think it would make it so much clearer when recert time came...it could prove easily if goals are met or more teaching and assessment is required. I love having easy to read patient info to leave with the patient for reinforcement after teaching!!

Abbies · Aug 13, 2009

:yeah:

good points to consider, thanks. here's what i'm thinking, or at least along these lines. cert pd is 60 days, assume frequency is 3xwk for 1 wk, 2xwk for 3-4 wks (depending on how it falls), then 1xwk for 4 wks. the pathway would look similar to what's in the hospital. let's take a newly insulin dependent diabetic.
goals:
(long-term) pt demonstrates fasting blood glucose within range of 70-120 5/7 days per week and/or hgba1c
(short-term) pt. demonstrates ability to draw up and self-administer insulin injection within 3 visits.
(long-term) pt verbalizes understanding of diabetic diet teaching and/or glycemic index scale.
(long-term) pt. verbalizes understanding of pathophysiology of diabetes including possible outcomes of non-compliance.
so then your pathway would be something along these lines:
visit 1--nurse demonstrates proper procedure to draw up and administer insulin as patient watches; assess pt's understanding of dx; provide daily log for blood sugar monitoring; provide handout: how to self-administer insulin
visit 2--nurse provides visual and verbal cuing to assist patient with drawing up and self-administering insulin; brief overview of diabetic teaching including handout: now you need insulin [i made that one up]; review daily blood sugar log
visit 3--nurse observes patient draw up and self-administer insulin providing cuing as needed; mark short-term goal met if applicable; begin diet teaching including handout: create your plate; review daily blood sugar log.
visit 4--begin ed on the pathophys of diabetes, how it occurs, how it progresses; include handout: insulin for type 2 diabetics; review daily blood sugar log
visit 5--continue with ed on pathophys, include handouts: avoiding diabetic complications; review daily blood sugar log
visit 6--draw hgba1c; teaching on labs used to monitor diabetes; include handout: diabetes and lab tests; review daily blood sugar log
visit 7--review results of hgba1c; review daily blood sugar log; review previous teaching sessions, correct any misunderstandings; no new teaching/handouts at this time
visit 8--discuss diabetic foot care; include handout: diabetic foot care; review daily blood sugar log; begin discussing resources for discharge
i could keep going for the full 12-14 visits, but i think the point is clear. anyway, the idea is to have a schedule for teaching so that everything is covered, the goals are clear and measurable, and if a fill-in nurse comes, s/he knows exactly where the patient is.
does that sound reasonable or am i dreaming?

sounds perfectly reasonable and well organized. these basic pathways could easily be personalized for each situation.

LuLu2008 · Aug 22, 2009

Yes, my HH agency uses Clinical Pathways for all patients from Start of Care forward. Unfortunately, they are cumbersome to use in many respects. I wish we had a computer program with which to tailor the care plan for the individual patient.

tammybjm · Aug 1, 2012

Yes, my HH agency uses Clinical Pathways for all patients from Start of Care forward. Unfortunately, they are cumbersome to use in many respects. I wish we had a computer program with which to tailor the care plan for the individual patient.

i saw your post about using clinical pathways for home health. could you tell me where you were able to find them at. thanks [email protected]

KateRN1 · Aug 4, 2012

Ha! Never found any but have toyed with the idea of making my own for several years. I worked for one national agency that used them but they were so badly written in terms of grammar, speclling, etc., that I just hated to have to use them. And they were not visually appealing for the patients at all. I would love to be able to put someting together that has graphics, small bites of information, reasonable goals, concrete teaching plans, etc. But I just don't have the creativity to do it myself.

AMN74 · Aug 12, 2012

Kate, I worked for an agency that did just this very thing with some diagnosis. CHF, CVA, Post Joints, COPD, and to some degree diabetes,(even wound care patients) but that's a tricky one. With managed care companies and less reimbursement, our agency wanted to limit visits and teach and make everything work. We would often keep them the whole cert period, front load visits and then fall into a skip pattern. Then on the "off weeks" there were disease management nurses in the office that made calls during those weeks with a check sheet of questions to ask the patient. It worked very well for most patients, problems arose with me when the patient didn't quite fit into the "box" and I would increase visits based on my assessment. I would then have to spend hours emailing the bean counters in the office trying to justify why this patient needs more visits.

The pathways had very specific things to teach at each visit, and what to assess from the past that kept the patients on track. They developed teaching books that were to be given to the patient. The books were written on a third grade level and they made them available in spanish.

Lots of education, mostly via phone conferencing and webinars went into education to the staff when a new program would roll out. You are not dreaming, it is possible. However, you must be willing to put a lot of work into it on the front end so that it can work.

By the way, I worked as a field nurse for 15 years. I just got a little burnt out with all the paperwork. Visit demands for full time staff seem much higher than what I read on this site. I case managed 25-50 patients at all times. I drove 700 miles a week. My friends called me the "road warrior". But I sadly hung up that hat 3 months ago. I miss it some, but the change has been great, I feel my life is so much more relaxed and I'm enjoying the break. I took a new job. I'm thinking of maybe going back and doing some PRN visits with them, just to keep my hands and brain in the game of home health!

xoNurseRNxo · Aug 13, 2012

I have "pocket guide to home care standards: complete guidelines for clinical practice, documentation, an reimbursement" that I go over many times when doing a SOC. It's has very useful info pertaining to various diseases with assessment, inventions, diagnosis, teachings, etc. Also towards the back is a section titled clinical pathways in home care. I came across this book because someone else is this forum recommended it.

xoNurseRNxo · Aug 13, 2012

I want to add that the clinical pathways section is kind of vague. I think it is to give you a basic idea of assessment/eval/teaching for each visit. I'm sure a lot of tailoring will have to be done to meet your pt's need.