Kitty WU, Ph.D., M. Soc. Sc (Clin. Psy)

HOCS PM(AH)

*

Structure survey

Process-Outcome survey

CQI Projects on AH Services for Stroke & Hip Fracture

2

Frontline staff

*

To nurture the use of standardized outcome

measures for service planning

SSF(Rehab) discussion

Appropriateness of care

Performance monitoring

Structure Survey

I. Process-Outcome Survey

II. CQI Report & 4-page Summary

III. Outcome Workshop

Process-outcome survey- Aims

To take a snapshot of AH services (Ax, Rx & pre-post outcome) in different settings via standardized minimal

data set for patient care & performance monitoring

5

Needs stratification for appropriate care

Performance monitoring to promote optimal services

Acute C/R DAY/OPD/COM

Methods

6

Identify Minimal Data Set for AH services in Stroke & #Hip Rehab

based on international references

& rational principles

e.g., international reference

8

Algorithm B:

Inpatient Rehab

9

Determine level of care based on: 1. Medical status 2. Function (motor & cognitive) 3. Social Support 4. Access to care

Assessment of Rehab Progress: 1. General (med status) 2. Functional status Mobility ADL Communication Nutrition Cognition Mood / motivation 3. Family Support Resources Caretaker Transportation 4. Patient & Family Adjustment 5. Reassessment of goals 6. Risk for recurrent CVA

Principles Outcome is contributed by the whole team

Meaningful for patient care

Evidence-based

Existing common practice

Readily captured in D/C summary

Service provision based on patient needs (as usual), not for completing the whole data set

from ~2,200 data fields to a minimal data set of…

Maximum data fields for each AH discipline

Assessment Intervention Outcome

either / or

Assessment Intervention Outcome

Assessment Intervention Outcome

CP Diet MSS OT P&O PT ST Focus 1 Emotional Functioning

Malnutrition Risk (with / without Dysphagia)

Emotion Functioning (Patient) Self Care Joint Maintenance Impaired Mobility Swallowing

Assessment 1 Mood / Suicidal Risk Ax Nutritional Diagnosis - Malnutrition Risk - Low / Medium / High

Behavioral / Emotional / Personality Problem

Orthotic Tx - Supportive Dysphagia

Intervention 1 Cognitive / Cognitive-behavioral Therapy

Diet Prescription Counseling - Acceptance of Illness

ADL / Self Care Ax & Training Ankle Foot Orthosis Functional Training Compensatory Swallowing Strategies

Intervention 2 Mood Management / Emotion Management

Enteral Nutrition Counseling- Acute Stress Reaction

Hand Function Ax & Training Shoulder Immobilizer Therapeutic Exercise Diet Modification

Intervention 3 Mindfulness-based Therapy Nutrition Education Others Knee Extension Splint Walking / Mobility Training Swallowing Ex

Outcome 1 Hospital Anxiety and Depression Scale (HADS) 0 to 21

Energy Gap: Estimated Intake - Estimated Requirement (kCal)

Acceptance of Illness (Patient) - Good / Fair / Poor / Not Applicable

Barthel Index (BI) 0 to 100

Modified Rivermead Mobility Index (MRMI) 0 to 40

Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) 1 to 10

Outcome 2 Geriatric Depression Scale (GDS) 0 to 15

Functional Independence Measure (FIM) 18 to 126

Elderly Mobility Scale (EMS) 0 to 20

Focus 2 Cognitive Function Secondary Prevention Social Care (Discharge Planning) Cognitive / Perceptual Protection Impaired Balance Communication Difficulties

Assessment 1 Neuropsychological Ax Nutritional Diagnosis - Malnutrition Risk - Low / Medium / High

Discharge Problem Clinic / Special Session Acquired Language Disorder

Intervention 1 Wechsler Adult Intelligence Scale - III (WAIS-III)

Diet Prescription Discharge Planning - Community Support

Cognitive Ax & Training Heel Protector Therapeutic Exercise Aphasia Therapy

Intervention 2 Hong Kong List Learning Test (HKLLT)

Nutrition Education Discharge Planning - Placement Arrangement

Adaptive Coping Strategies Helmet Manual Therapy Cognitive Communication Training

Intervention 3 Symbol Digit Modality Test (SDMT)

Financial Assistance - Disability Allowance

Sensory Re-education Seat / Back Cushion Other - Prescription of Walking Aid Ø AIDU or AIDS or AIDQ or AIDF

Functional Communication Training

Outcome 1 DSM Dx - Neurocognitive Disorder NCD0 to NCD3

Total Fat - Inadequate Intake / Excessive Intake (No click = Normal)

Reintegration into Community Y / N RICY or RICN

Mini-Mental State Examination (MMSE) 0 to 30

Berg Balance Scale (BBS) 0 to 56

Therapy Outcome Measure (TOM): Aphasia (Impairment Level) 0 to 5

Outcome 2 Sodium - Inadequate Intake / Excessive Intake (No click = Normal)

The Montreal Cognitive Assessment (MOCA) MOCA0 to MOCA30

Timed Up & Go Test (TUG) 0 to 100

Therapy Outcome Measure (TOM): Aphasia (Disability Level) 0 to 5

Focus 3 Cognitive Function Caregiver Transfer of Care Movement Difficulties Impaired Function Communication Difficulties

Assessment 1 Neuropsychological / Neurocognitive Rehabilitation

Orthotic Tx - Corrective Dysarthria

Intervention 1 Behavioral Modification Counseling - Acceptance of Illness

Community Re-integration Ankle Foot Orthosis Chest Physiotherapy Dysarthria Therapy

Intervention 2 Neurocognitive Rehabilitation Counseling - Carer Stress Home Ax & Modification Inversion Control Ankle Orthosis Acupuncture Oral Motor Ex

Intervention 3 Psychoeducation Financial Assistance - Fee Waiving

Life Style Re-design Orthopaedic Insole Walking / Mobility Training

Outcome 1 DSM Global Assessment of Functioning Scale (GAF) 0 to 100

Acceptance of illness (Main Carer) - Good / Fair / Poor / Not Applicable

Adapted Lawton Ø LAWTON0 to LAWTON27

Gait Y / N GAITY or GAITN

Modified Functional Ambulatory Category (MFAC) 1 to 7

Therapy Outcome Measure (TOM): Dysarthria (Impairment Level) 0 to 5

Outcome 2 Goal Attainment Scaling (GAS) GAS0 to GAS99

Functional Test for the Hemiplegic Upper Extremity (FTHUE) FTHUE1 to FTHUE7

Hand Grip Strength (HGS) 0 to 100

Therapy Outcome Measure (TOM): Dysarthria (Disability Level) 0 to 5

13 MSS - Pre-admission Residence & Discharge Destination

Minimal data set of CQI Project of AH rehab Services (Stroke)

Patient needs

Movement

Self-care

Nutrition

Swallowing

Communication

Cognition

Emotion

Community reintegration

Minimal data set of CQI Project of AH rehab Services (#Hip) HIP

CP DIET MSS OT P&O PT

Focus 1 Emotional Functioning Malnutrition Risk Emotion Functioning (Patient) Self Care Risk Management Mobility

Assessment 1 Mood / Suicidal Risk Ax Malnutrition Risk - Low / Medium / High

Adjustment to Illness / Disability Referral Details - Prosthetic / Orthotic Assessment

Premorbid MFAC PREM1 to PREM7

Intervention 1 Cognitive / Cognitive-behavioral Therapy

Diet Prescription Counseling - Acceptance of Illness ADL / Self Care Ax & Training Orthotic Assessment (Footwear Assessment)

Walking / Mobility Training

Intervention 2 Mood Management / Emotion Management

Enteral Nutrition Counseling- Acute Stress Reaction Caregiver Training Gait Analysis (Fall Risk Assessment) Therapeutic Exercise

Intervention 3 Mindfulness-based Therapy Nutrition Education Treatment Compliance Aids Prescription & Training Fall Prevention FP

Outcome 1 Hospital Anxiety and Depression Scale (HADS) 0 to 21

Energy Gap: Estimated Intake - Estimated Requirement (kcal)

Acceptance of Illness (Patient) - Good / Fair / Poor

Barthel Index (BI) 0 to 100

Modified Functional Ambulatory Category (MFAC) 1 to 7

Outcome 2 Geriatric Depression Scale (GDS) 0 to 15

Functional Independence Measure (FIM) 18 to 126

Timed Up & Go Test (TUG) 0 to 100

Focus 2 Pain Management Prevention of Re-fracture - Adequacy of Dietary Calcium Intake

Discharge Planning Foundation skill Protection Function

Assessment 1 Pain Assessment Main Carer Availability Intervention - Clinic / Special Session

Prescription of Walking Aid AIDU or AIDS or AIDQ or AIDF or AIDE

Intervention 1 Cognitive / Cognitive-behavioral Therapy

Diet Prescription Discharge Planning - Placement Arrangement

Cognitive Ax & Training Heel Protector Functional Training

Intervention 2 Mindfulness-based Therapy Nutrition Education (High Calcium Diet)

Discharge Planning - Community Support Service Information / Application

Mobilization & Strengthening Hip / Femoral Orthosis (Hip Protector) Home Discharge Support (HDS) HDS

Intervention 3 Relaxation Training Financial Assistance - Comprehensive Social Security Assistance (CSSA)

Others (Complication Prevention) Lower Limb Supporting Orthosis (Compression Stocking)

Chest Physiotherapy

Outcome 1 DSM Global Assessment Functioning Scale (GAF) 1 to 100

Calcium - Inadequate Intake / Excessive Intake (No click = Normal)

Reintegration into Community Yes / No RICY or RICN

Mini-Mental State Examination (MMSE) 0 to 30

Elderly Mobility Scale (EMS) 0 to 20

Outcome 2 Subjective Units of Distress Scale (SUDS) 0 to 10

Berg Balance Scale (BBS) 0 to 56

Focus 3 Cognitive Function Adequate Protein for Anabolism - Muscle Metabolism

Family Caregiver Community Re-integration Movement Difficulties Pain

Assessment 1 Neuropsychological Assessment Protein - Inadequate Intake / Excessive Intake (No click = Normal)

Counseling - Carer Stress Intervention - Orthotic Tx - Corrective

Intervention 1 Wechsler Adult Intelligence Scale-III (WAIS-III)

Diet Prescription Community Support - Rehabilitation Service

IADL / Household Tasks Ax & Training Orthopaedic Boots (Raise Sole / Heel / Shoe Modification)

Pain Modulation

Intervention 2 Hong Kong List Learning Test (HKLLT) Enteral Nutrition Counseling - Carer Stress Home Ax & Modification Hip / Femoral Orthosis (Hip Spica) Manual Therapy

Intervention 3 Symbol Digit Modality Test (SDMT) Nutrition Education Counseling - Acceptance of Illness Fall Prevention & Intervention Therapeutic Exercise

Outcome 1 DSM Dx - Neurocognitive Disorder NCD0 to NCD3

Body Mass Index(BMI) - 1.0 to 99.0 (unit in kg/m2)

Continuity of Social Care Yes / No CSCY or CSCN

Adapted Lawton LAWTON0 to LAWTON27

Pelvic Level Yes / No PLY or PLN

Numeric Pain Rating Scale (NPRS) 0 to 10

Outcome 2 Muscle Mass MM0.0 to MM99.0 (unit in kg)

Acceptance of Illness (Main Carer) - Good / Fair / Poor

Fall Efficacy Scale FES0 to FES100

Note:

1. Pre-admission Residence & Discharge Destination will be captured by MSS in the d/c summary as part of the minimal data set for the CQI project of allied health services for hip fracture.

2. An “either-or” principle will be adopted when two outcome measures exist for a focus area (i.e., only one of the two outcome measures will be captured for the survey).

3. Use free text space for data entry of discharge condition only.

Patient needs

Movement

Self-care

Nutrition

Pain

Communication

Cognition

Emotion

Community reintegration

Minimal data set of CQI Project of AH rehab Services (#Hip) HIP

CP DIET MSS OT P&O PT

Focus 1 Emotional Functioning Malnutrition Risk Emotion Functioning (Patient) Self Care Risk Management Mobility

Assessment 1 Mood / Suicidal Risk Ax Malnutrition Risk - Low / Medium / High

Adjustment to Illness / Disability Referral Details - Prosthetic / Orthotic Assessment

Premorbid MFAC PREM1 to PREM7

Intervention 1 Cognitive / Cognitive-behavioral Therapy

Diet Prescription Counseling - Acceptance of Illness ADL / Self Care Ax & Training Orthotic Assessment (Footwear Assessment)

Walking / Mobility Training

Intervention 2 Mood Management / Emotion Management

Enteral Nutrition Counseling- Acute Stress Reaction Caregiver Training Gait Analysis (Fall Risk Assessment) Therapeutic Exercise

Intervention 3 Mindfulness-based Therapy Nutrition Education Treatment Compliance Aids Prescription & Training Fall Prevention FP

Outcome 1 Hospital Anxiety and Depression Scale (HADS) 0 to 21

Energy Gap: Estimated Intake - Estimated Requirement (kcal)

Acceptance of Illness (Patient) - Good / Fair / Poor

Barthel Index (BI) 0 to 100

Modified Functional Ambulatory Category (MFAC) 1 to 7

Outcome 2 Geriatric Depression Scale (GDS) 0 to 15

Functional Independence Measure (FIM) 18 to 126

Timed Up & Go Test (TUG) 0 to 100

Focus 2 Pain Management Prevention of Re-fracture - Adequacy of Dietary Calcium Intake

Discharge Planning Foundation skill Protection Function

Assessment 1 Pain Assessment Main Carer Availability Intervention - Clinic / Special Session

Prescription of Walking Aid AIDU or AIDS or AIDQ or AIDF or AIDE

Intervention 1 Cognitive / Cognitive-behavioral Therapy

Diet Prescription Discharge Planning - Placement Arrangement

Cognitive Ax & Training Heel Protector Functional Training

Intervention 2 Mindfulness-based Therapy Nutrition Education (High Calcium Diet)

Discharge Planning - Community Support Service Information / Application

Mobilization & Strengthening Hip / Femoral Orthosis (Hip Protector) Home Discharge Support (HDS) HDS

Intervention 3 Relaxation Training Financial Assistance - Comprehensive Social Security Assistance (CSSA)

Others (Complication Prevention) Lower Limb Supporting Orthosis (Compression Stocking)

Chest Physiotherapy

Outcome 1 DSM Global Assessment Functioning Scale (GAF) 1 to 100

Calcium - Inadequate Intake / Excessive Intake (No click = Normal)

Reintegration into Community Yes / No RICY or RICN

Mini-Mental State Examination (MMSE) 0 to 30

Elderly Mobility Scale (EMS) 0 to 20

Outcome 2 Subjective Units of Distress Scale (SUDS) 0 to 10

Berg Balance Scale (BBS) 0 to 56

Focus 3 Cognitive Function Adequate Protein for Anabolism - Muscle Metabolism

Family Caregiver Community Re-integration Movement Difficulties Pain

Assessment 1 Neuropsychological Assessment Protein - Inadequate Intake / Excessive Intake (No click = Normal)

Counseling - Carer Stress Intervention - Orthotic Tx - Corrective

Intervention 1 Wechsler Adult Intelligence Scale-III (WAIS-III)

Diet Prescription Community Support - Rehabilitation Service

IADL / Household Tasks Ax & Training Orthopaedic Boots (Raise Sole / Heel / Shoe Modification)

Pain Modulation

Intervention 2 Hong Kong List Learning Test (HKLLT) Enteral Nutrition Counseling - Carer Stress Home Ax & Modification Hip / Femoral Orthosis (Hip Spica) Manual Therapy

Intervention 3 Symbol Digit Modality Test (SDMT) Nutrition Education Counseling - Acceptance of Illness Fall Prevention & Intervention Therapeutic Exercise

Outcome 1 DSM Dx - Neurocognitive Disorder NCD0 to NCD3

Body Mass Index(BMI) - 1.0 to 99.0 (unit in kg/m2)

Continuity of Social Care Yes / No CSCY or CSCN

Adapted Lawton LAWTON0 to LAWTON27

Pelvic Level Yes / No PLY or PLN

Numeric Pain Rating Scale (NPRS) 0 to 10

Outcome 2 Muscle Mass MM0.0 to MM99.0 (unit in kg)

Acceptance of Illness (Main Carer) - Good / Fair / Poor

Fall Efficacy Scale FES0 to FES100

Note:

1. Pre-admission Residence & Discharge Destination will be captured by MSS in the d/c summary as part of the minimal data set for the CQI project of allied health services for hip fracture.

2. An “either-or” principle will be adopted when two outcome measures exist for a focus area (i.e., only one of the two outcome measures will be captured for the survey).

3. Use free text space for data entry of discharge condition only.

MMSE

Pre-admission residence & D/C destination

Premorbid MFAC

Comparison of age & gender for CQI & non-CQI patients

Note: CQI = Patients discharged from various settings with AH e-forms returned for the CQI project Non-CQI = Patients discharged from inpatient settings (Stroke:1 Mar to 31 May 2015); (Hip: 6 July to 5 October 2015)

Stroke

x=71 sd=15

CQI n=4252

non-CQI n=3036

x=73 sd=15

Male 53%

Female 47%

Male 55%

Female 45%

#Hip

x=80 sd=13

CQI n=2054

non-CQI n=643

x=81 sd=10

Male 30% Female

70%

Male 32%

Female 68%

Needs stratification

Results

Different patient profiles across facilities – pre-MBI (ASU)

Stro

ke –

Ho

spit

al b

ased

Figure M2.1a. Percentage of stroke patients in different stratified groups based on pre-treatment MBI score in ASU

Different patient profiles across facilities – pre-morbid MFAC (AG)

Hip

Fra

ctu

re –

Ho

spit

al b

ased

Figure O2.1a. Percentage of hip fractured patients in different stratified groups based on pre-morbid MFAC score in AG.

Outcome

Results

Stroke: MBI change [post-MBI (-) pre-MBI] in CR by hospital group, MBI group & age group

27.7

10.6 13.5 9.6

5.4 3.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

GP1 with CR

16.7

6.8 13.7 12.5

5.9 5.0

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Pre BI <40 Pre BI 41-85 Pre BI <85

Non GP1

Age <65 Age ≥65

n=15 n=21 n=7 n=62 n=65 n=15

n=23 n=20 n=9 n=119 n=73 n=9

Outcome Measure in CR(Pre-admission Residence & Discharge Destination) (MSS)

D/C destination for Pre-admission Home Residence

D/C destination

Pre-admission Residence

11.8%

12.9%

90.8%

48.4%

53.2%

9.2%

39.9%

33.8%

Hospital Home OAH & Others

47

18 74 61

14 139

74 18

10.1%

9.6%

88.4%

56.8%

63.7%

11.6%

33.0%

26.7%

Hospital Home OAH & Others

140 241 43

36 239 100

49 375

D/C destination for Pre-admission Home Residence

D/C destination

Pre-admission Residence

Stroke

#Hip

Structure Survey

I. Process-Outcome Survey

II. CQI Report & 4-page Summary

III. Outcome Workshop

http://www.ah.home

Hospital-based 4-page sample (Hospital A)

Data capturing period via AH D/C summary

CQI project on allied health services for hip fracture rehabilitation

CP, P&O 6.7.15 to 5.10.15

DIET, MSW, OT, PT 6.7.15 to 5.9.15

0% 20% 40% 60% 80% 100%0% 20% 40% 60% 80% 100%

Your Facility

HA

Your Facility

HA

Your Facility

HA

Your Facility

HA

52 (95%)

21(36%)

2 (5%) 5 (11%) 37 (84%)

38 (64%)

42 (79%) 11 (21%)

104 (82%) 20 (16%) 3 (2%)

2 (5%) 41 (95%)

6 (60%)

106 (92%)

3 (5%)

4 (40%)

9 (8%)

Pre-admission residence

Pre-treatment MBI group

Pre-treatment MMSE group

Pre-morbid MFAC group

Page 1

CR

422 (69%) 168 (27%) 26 (4%)

9 (3%) 32 (12%) 224 (85%)

246 (59%) 170 (41%)

375 (88%) 49 (12%)

413 (87%) 56 (12%) 5 (1%)

22 (5%) 88 (18%) 371 (77%)

355 (64%) 200 (36%)

138 (86%) 23 (14%)

AG

Pre-treatment MBI group

Pre-MBI ≤60

Pre-MBI 61-80

Pre-MBI >80

Pre-morbid MFAC group

Pre-MFAC 1-2

Pre-MFAC 3-5

Pre-MFAC 6-7

Pre-treatment MMSE group

Pre-MMSE ≤19

Pre-MMSE >19

Pre-admission residence

OAH & others

Home

Percentage of patients in different categories based on measures which have been used as examples in

SSF(Rehab) for needs stratification to facilitate patient flow

Structure Survey

I. Process-Outcome Survey

II. CQI Report & 4-page Summary

III. Outcome Workshop

CQI seminar & workshop 28-29 March 2017

Referencing the benchmarking workshop of the Australasian Rehabilitation Outcome Centre (AROC)

Learn to use data …

..identify good practice

..develop initiatives to improve patient care

Learning points

Multi-directional communication

The minimal data set is a breakthrough helping to promote outcome-driven service

Structure-process-outcome of the project can be replicated for other rehab conditions

That’s 1 small step 4

CQI project team, 1

giant leap 4 AH service

CQI

Small is beautiful

AH chat group

Thank you