Michael Friedman PT, MBA Johns Hopkins Medicine - @ mkfrdmn Mary Stilphen PT, DPT

1. ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTINGContinuing the ConversationCombined Sections Meeting 2015February 4th-7th, 2015 – Indianapolis, IN Michael Friedman PT, MBA Johns Hopkins Medicine - @mkfrdmn Mary Stilphen PT, DPT Cleveland Clinic - @marystilphendpt

4. Cleveland Clinic Rehab and Sports Therapy

6. The Johns Hopkins Hospital (JHH)Baltimore, MD Licensed Acute Beds - 994 Annual Admissions – 50,000 Acute Care Therapists – 65 FTEs

7. 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.

8. 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

9. 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

10. Our next chapter… • Updates on Systematic Use of Data • Functional Reconciliation • Interdisciplinary Mobility Care Path • Implementing at scale

11. The Evidence supporting activity

12. 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) 2 Hoyer et al., 2013

13. Why is promoting activity and mobility important? Body Systems: cardiovascular (orthostatic hypotension, thrombus) psychosocial (depression) musculoskeletal (atrophy and contractures) respiratory (hypostatic pneumonia) integumentary (pressure ulcers) urinary elimination (infection and dehydration) metabolic (fluid and electrolyte imbalance) bowel elimination (constipation and dehydration) 3

14. Waste and Value

15. 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 perdollar spent.”– Michael Porter, PhD Harvard Business School Value = Outcome Cost Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006.

16. 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/

17. www.choosingwisely.org www.erassociety.org

18. The Healthcare Challenge Value Solutions: • Improve Outcomes • Decrease Cost The bigwinsare when we can do both together. In other words…..

19. Institute for Healthcare Improvement Triple Aim www.ihi.org

20. Strategy for Value Transformation

21. systematic use of Data

22. 2014 was a big year!

23. 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

24. Our Journey at the Cleveland Clinic

25. What Cleveland Clinic was looking for in a tool?

26. 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

27. AM-PAC Cleveland Clinic Short Form‘Six Clicks’ PT Turning over in bed Supine to sit Bed to chair Sit to stand Walk in room 3-5 steps with a rail 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)

30. Mobility Scale Score Table for AM-PAC

31. PT 6 Clicks Data Volume – CCHS Hospitals

33. Use of 6 clicks Data

34. 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

35. 6 Clicks Publications

36. Resource Utilization 2013 - 4842 patients (8.8%) had a 6 clicks score of 24

37. 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

38. 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.

39. System Approach Value Opportunities • Targeted intervention • Protocol development • Discharge planning • Acquired complication risk • Resource utilization • Patient functional trending • Predictive modeling • Reconciliation across setting

40. The Problem

41. 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

42. Fall Risk The DYS-Functional Assessment Puzzle Glasgow 6 Min Walk Tinetti AM-PAC Glascow Rankin Level of Assist Laps Walked Fatigue Scale CAM-ICU FIM Braden PROMIS Core Measures

43. 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

44. 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

45. The System Architecture was determined

46. Johns Hopkins Highest Level of Mobility (JH-HLM) patient with poor outcome Score 250+ FEET 25+ FEET 10+ STEPS 1 MINUTE TRANSFER SIT AT EDGE TURN SELF / ACTIVITY LYING 8 7 6 5 4 3 2 1 WALK STAND MOBILITY LEVEL CHAIR BED Contact Johns Hopkins Medicine for permissions and instructions for use. 46

47. 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)

49. Change of JH-HLM on Day of Admission at JHH 49

50. Nurse JH-HLM to Therapist AM-PAC