Strengthening Information Capture in Rehabilitation Discharge Summaries An Application of the Siebens Domain Management Model

Transcription

1 Strengthening Information Capture in Rehabilitation Discharge Summaries An Application of the Siebens Domain Management Model Mario Perez MD, Woojae Kim MD, Beny Charchian MD MS, Eric Y Chang MD, Li-Jung Liang PhD, Armen Dumas MD, Hilary C. Siebens MD, Hyung Kim MD Department of Physical Medicine and Rehabilitation, VA GLA Healthcare System, Los Angeles CA Department of Medicine, UCLA School of Medicine, Los Angeles, CA and Siebens Patient Care Communications, Seal Beach, CA AAPM&R Annual Assembly, San Diego, CA Nov 15, 2014

2 Acknowledgements Harriet Aronow, PhD Carol Stein, OTR Crystal Barker, RN Agnes Wallbom, MD Milena Zirovich, MD Steve Figoni, RKT, PhD

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4 Introduction Limitations in medical communication Lengthy reports, obscure essential clinical issues Lack of standardized discharge summary formats Lack of clear organization Unstructured, with inadequate information capture

5 Introduction Siebens Domain Model Management SDMM (2001) Provides a framework for organizing the documentation of care Consistent with Engel s biopsychosocial model (1977) and Stineman s biopsycho-ecological model (2007) Organizes patient s health-related strengths, problems and issues into four domains See final slide for references.

6 SDMM: The Four Domains I. Medical/Surgical Issues Symptoms Diseases Prevention II. Mental Status/ Emotions/ Coping Communication Cognition Emotions Coping/ Behavioral Symptoms Spirituality Personal Preferences/ Advance Directives III. Physical Function Basic ADLs: Home Mobility, Self Care Intermediate ADLs: Medication management, meals, community mobility Advanced ADLs: Vocational, Avocational IV. Living Environment Physical - Type of Home Social - Family Support/ Coping Financial & Community Resources Hilary C Siebens MD 2005

7 Hypotheses 1) Reliable and valid scoring of SDMM domains and sub-domains in discharge summaries is possible 2) Traditional inpatient discharge summaries do not adequately communicate important aspects of rehabilitation care 3) Use of the SDMM will improve organization and documentation of rehabilitation care through increased capture of relevant care items

8 Methods Setting: Acute Rehabilitation Unit Design: retrospective chart review In July 2008, residents started using the SDMM in the inpatient rehabilitation unit Discharge summaries randomly chosen from final week of residents inpatient rotation 20 traditional (historical controls) reports 20 SDMM reports scored using SDMM Documentation Review Form

9 Methods The research team established scoring rules and a scoring methodology for the SDMM Documentation Review Form Review form Inter-rater reliability established with % agreement and Fleiss kappa statistic Global Scores and Individual Domain Scores (4) reflecting % of items present were calculated for each report

10 Methods Descriptive statistics (mean, standard deviation) for these 5 scores compared between traditional and SDMM reports using 2-group t-test Main outcome measures: Global Scores and Domain Scores

11 Documentation Review Form Yes = mentioned No = not mentioned N/A = not applicable

12 Documentation Review Form Yes = mentioned No = not mentioned N/A = not applicable

13 Case Demographics Historical Control 1 female, 19 male (N=20) 75% orthopedic 15% neurologic 10% medical complexity Post-SDMM Implementation 1 female, 19 male (N=20) 80% orthopedic 15% neurologic 5% medical complexity

14 Results: Global and Domain Scores Traditional Reports (N=20) % of items present SDMM Reports (N=20) % of items present p value Global Score <

15 Results: Global and Domain Scores Traditional Reports (N=20) % of items present SDMM Reports (N=20) % of items present p value Global Score < Domain I Score I. Medical/Surgical Issues

16 Results: Global and Domain Scores Traditional Reports (N=20) % of items present SDMM Reports (N=20) % of items present p value Global Score < Domain I Score Domain II Score < II. Mental Status/ Emotions/ Coping

17 Results: Global and Domain Scores Traditional Reports (N=20) % of items present SDMM Reports (N=20) % of items present p value Global Score < Domain I Score Domain II Score Domain III Score < III. Physical Function

18 Results: Global and Domain Scores Traditional Reports (N=20) % of items present SDMM Reports (N=20) % of items present p value Global Score < Domain I Score Domain II Score Domain III Score Domain IV Score < < IV. Living Environment

19 Results Improvement in overall information captured, the Global Score, was observed (34% to 53% for Traditional vs. SDMM reports, respectively; p<.0001) Information captured within each domain was also improved from traditional reports

20 Results: Individual Items In Domain I, 1 item showed significant change: mention of lifestyle risk factors (29% to 72%) In Domain II, increased mention of cognitive/communication status (35 to 80%), emotions (15 to 60%), and coping (5 to 45%) Power of attorney for health and medical directive remained low, but showed some increase in SDMM reports (5 to 15% and 5 to 30%, respectively)

21 Results: Individual Items In Domain III, items discussed regularly in both report types: basic ADLs (95% to 100%) and home mobility (90 to 84%) Improvement seen in IADLs (5% to 35%) and community mobility (15 to 30%), but all other items remained <15% In Domain IV, most items 20% or lower except increased mention of physical home setting (35 to 56%) and social supports (45 to 75%) Very few items scored as not applicable (4% in traditional, 7.5% in SDMM reports)

22 Conclusions Reliable and valid scoring of SDMM domains was possible through physician use of standardized scoring form Traditional rehabilitation discharge summaries lacked information relevant to rehabilitation care

23 Conclusions Traditional reports emphasized medical aspects of hospitalization, but often lacked discussion on mental status, emotions, coping, physical function, living environment Using the SDMM in discharge summaries led to significant increase in overall information capture, with the greatest increase in areas of mental status/emotion/coping and environment

24 Implications SDMM can serve as teaching framework for rehabilitation residents and as a simple checklist of topics to be considered in documentation Facilitates efficient and comprehensive organization of relevant information Improve patient care, safety, and communication between providers

25 References Siebens H. Applying the Domain Management Model in treating patients with chronic disease. Jt Comm J Qual Improvement 2001;27: Siebens H. Proposing a Practical Clinical Model. Topics in Stroke Rehabilitation 2011;18: Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977;196: Stineman MG. Untangling function: measuring the severity, type and meaning of disabilities. Eura Medicophys 2007;43: Provincial Interim Report, Regional Geriatric Programs Geriatric Emergency Care. rgp.toronto.on.ca. Weed LL. Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record As a Basic Tool. Chicago:Year Book Medical Publishers; Clark GS, Kortebein P, Siebens HC. Aging and Rehabilitation. In: DeLisa J,Gans B, eds. DeLisa s PM&R: Principles and Practice. 5th Edition. Wolters Kluwer Health: J.B. Lippincott Company 2010, pp